Triptorelin Extended-Release (Triptodur)

OFFICE ADMINISTRATION

Indication(s) for Prior Authorization:

  • Indicated for the treatment of pediatric patients 2 years and older with central precocious puberty (CPP)

Patients must meet the following criteria for the indication(s) above:

  • Prescribed by specialist (pediatric endocrinologist), AND
  • Pediatric patient at least 2 years of age and older, AND
  • Chart note documentation confirms central precocius puberty (idiopathic or neurogenic) with onset of secondary sexual characteristics earlier than 8 years of age in females and 9 years of age in males, AND
  • Clinical diagnosis confirmed prior to initiation of therapy using the following parameters:
    • Pubertal response to a GnRH stimulation test
    • Bone age advanced one year beyond the chronological age, AND
  • Should be discontinued at the appropriate age of onset of puberty

Dosing:

  • Must be administered under the supervision of a physician
  • Given as single 22.5 mg IM injection once every 24 weeks
  • Monitor response with LH levels after a GnRH or GnRH agonist stimulation test, basal LH, or serum concentration of sex steroid levels beginning 1-2 months following initiation of therapy, during therapy as necessary to confirm maintenance of efficacy, and with each subsequent dose
  • Measure height every 3-6 months and monitor bone age periodically

Approval:

  • One year
  • Discontinue therapy at appropriate age of onet of puberty

Last review date: September 4, 2018