Pharmacy Prior Authorization Criteria

Sucraid (sacrosidase) Oral Solution

Indications for Prior Authorization

Sucraid (sacrosidase) Oral Solution

• For diagnosis of Congenital Sucrase-Isomaltase Deficiency (CSID)
  Indicated for the treatment of sucrase deficiency, which is part of congenital sucrase-isomaltase deficiency (CSID), in adult and pediatric patients 5 months of age and older.

Criteria

Sucraid

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of sucrase deficiency (which is part of congenital sucrose-isomaltase deficiency [CSID])
AND
• Disease is confirmed by ONE of the following: [1, 2]
• Disaccharidase assay via a small bowel biopsy
• Carbon -13 sucrose breath test
• Molecular genetic testing confirms mutation in the SI gene
• Stool pH less than 6, an increase in breath hydrogen of greater than 10 parts-per-million (ppm) when challenged with sucrose after fasting and a negative lactose breath test
AND
• Patient is 5 months of age or older.
AND
• Prescribed by or in consultation with ONE of the following:
• Gastroenterologist
• Geneticist

Sucraid

Prior Authorization (Reauthorization)

Length of Approval: 24 Month(s)

• Patient demonstrates positive clinical response to therapy (e.g., decrease in symptoms of abdominal pain, cramps, bloating or gas; decrease in number and frequency of stools per day)

P & T Revisions

2024-10-03, 2023-11-01, 2023-10-02, 2022-11-01

References

1. Sucraid Prescribing Information. QOL Medical, LLC. Vero Beach, FL. August 2024.
2. Congenital Sucrase-Isomaltase Deficiency (CSID). International Foundation for Gastrointestinal Disorders. Available at https://iffgd.org/gi-disorders/congenital-sucrase-isomaltase-deficiency-csid/. Accessed October 24, 2022.
3. Smith, H., Romero, B., et al. The patient journey to diagnosis and treatment of congenital sucrase-isomaltase deficiency. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8298246/. Accessed October 24, 2022.
4. Chey, W., Cash, B., et al. Congenital Sucrase-Isomaltase Deficiency: What, When, and How? Gastroenterology and Hepatology. October 2020. Available at https://www.gastroenterologyandhepatology.net/files/2020/10/gh1020sup5-1.pdf. Accessed October 24, 2022.

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Revision History

• 2024-10-03: 2024 Annual Review.
• 2023-11-01: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-10-02: update guideline
• 2022-11-01: New UM PA Criteria

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