uridine triacetate oral granules (Xuriden®)

ORAL ADMINISTRATION

Indications for Prior Authorization:

  • Hereditary orotic aciduria (Xuriden): Treatment of hereditary orotic aciduria

All of the following must be met as a condition for coverage:

  • Use for uridine replacement for treatment of hereditary orotic aciduria (as documented by chart notes)

This Medication is Not Approvable for the following condition(s).

  • Any condition not listed above as an approved indication

Dosing:

  • Initial dosage: 60 mg/kg once daily
  • Maximum dose: 8 g/day

Dosage adjustment:

Increase to 120 mg/kg (maximum: 8 g) for insufficient efficacy (eg, urine orotic acid levels remaining above normal or increasing above the usual/expected range for the patient; lab values affected by orotic acid [red or white blood cell indices] worsening; worsening disease signs/symptoms)

Approval:  

One year


 

Last review date: July 25, 2016

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