Pharmacy Prior Authorization Criteria

Qutenza (capsaicin)

Indications for Prior Authorization

Qutenza (capsaicin)

• For diagnosis of Neuropathic pain associated with postherpetic neuralgia
  Indicated for the treatment of neuropathic pain associated with postherpetic neuralgia (PHN).

• For diagnosis of Neuropathic pain associated with diabetic peripheral neuropathy (DPN) of the feet
  Indicated for the treatment of neuropathic pain associated with diabetic peripheral neuropathy (DPN) of the feet.

Criteria

Qutenza

Prior Authorization (Initial Authorization)

Length of Approval: 3 Month(s)
For diagnosis of Neuropathic pain associated with postherpetic neuralgia (PHN)

• Diagnosis of neuropathic pain associated with postherpetic neuralgia (PHN)
AND
• Trial and failure, contraindication, or intolerance to generic lidocaine 5% patch [A]
AND
• Trial and failure, contraindication, or intolerance to one of the following [A]:
• gabapentin
• pregabalin
• tricyclic antidepressant (e.g., amitriptyline, nortriptyline, desipramine)

Qutenza

Prior Authorization (Initial Authorization)

Length of Approval: 3 Month(s)
For diagnosis of Neuropathic pain associated with diabetic peripheral neuropathy (DPN) of the feet

• Diagnosis of neuropathic pain associated with diabetic peripheral neuropathy (DPN) of the feet
AND
• Trial and failure, contraindication, or intolerance to generic lidocaine 5% patch
AND
• Trial and failure, contraindication, or intolerance to one of the following:
• gabapentin
• pregabalin
• tricyclic antidepressant (e.g., amitriptyline, nortriptyline, desipramine)
• duloxetine

Qutenza

Prior Authorization (Reauthorization)

Length of Approval: 3 Month(s)
For diagnosis of All indications

• It has been at least 3 months since the last application/administration [B]
AND
• Patient experienced pain relief with a prior course of therapy
AND
• Patient is experiencing a return of neuropathic pain

P & T Revisions

2024-09-04, 2023-09-10, 2022-09-11, 2021-10-22, 2020-11-04, 2020-10-20, 2020-07-20

References

1. Qutenza Prescribing Information. Acorda Therapeutics, INC. Ardsley, NY. August 2022.
2. Dubinsky RM, Kabbani H, El-Chammi Z, et al. Practice parameter: treatment of postherpetic neuralgia: an evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2004; 63(6):959-965.
3. Cavalli, E., Mammana, S., et al. The neuropathic pain: An overview of the current treatment and future therapeutic approaches. Int J Immunopathol Pharmacol. 2019 Jan-Dec; 33: 2058738419838383., Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6431761/. Accessed October 1, 2021.
4. Snyder, M., Gibbs, L. Treating Painful Diabetic Peripheral Neuropathy: An Update. Am Fam Physician. 2016 Aug 1;94(3):227-234.. Available at https://www.aafp.org/afp/2016/0801/p227.html. Accessed October 1, 2021.
5. Treatment of Painful Diabetic Neuropathy. American Academy of Neurology. Available at file:///C:/Users/kdekhtaw/Downloads/Treatment%20of%20Painful%20Diabetic%20Neuropathy.pdf. Accessed October 1, 2021.
6. Cohen, K., Shinkazh, N. et al. Pharmacological Treatment Of Diabetic Peripheral Neuropathy. P T. 2015 Jun; 40(6): 372, 375-388. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450668/. Accessed October 21, 2021.
7. UptoDate. Postherpetic neuralgia. Available at: https://www.uptodate.com/contents/postherpetic-neuralgia?search=neuropathic%20pain%20postherpetic%20neuralgia&source=search_result&selectedTitle=2%7E150&usage_type=default&display_rank=2#H7. Accessed August 26, 2024.

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End Notes

1. The following agents are recommended: gabapentin, pregabalin, tricyclic antidepressants (TCAs), lidocaine patch, and controlled-release oxycodone or morphine sulfate. These agents are considered to have medium to high efficacy in managing PHN, good strength of evidence and a low level of side effects. [2]
2. Treatment with capsaicin may be repeated every three months as warranted by the return of pain (but not more frequently than every three months). [1]
3. Cavalli, E., Mammana, S., et al. The neuropathic pain: An overview of the current treatment and future therapeutic approaches. Int J Immunopathol Pharmacol. 2019 Jan-Dec; 33: 2058738419838383., Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6431761/. Accessed October 1, 2021.
4. Snyder, M., Gibbs, L. Treating Painful Diabetic Peripheral Neuropathy: An Update. Am Fam Physician. 2016 Aug 1;94(3):227-234.. Available at https://www.aafp.org/afp/2016/0801/p227.html. Accessed October 1, 2021.
5. Treatment of Painful Diabetic Neuropathy. American Academy of Neurology. Available at file:///C:/Users/kdekhtaw/Downloads/Treatment%20of%20Painful%20Diabetic%20Neuropathy.pdf. Accessed October 1, 2021.
6. Cohen, K., Shinkazh, N., et al. Pharmacological Treatment Of Diabetic Peripheral Neuropathy. 2015 Jun; 40(6): 372, 375-388. Available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450668/. Accessed October 21, 2021.

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Revision History

• 2024-09-04: 2024 Annual Review.
• 2023-09-10: 2023 Annual Review
• 2022-09-11: 2022 Annual Review
• 2021-10-22: 2021 Annual Review.
• 2020-11-04: 2020 Annual Review: no changes
• 2020-10-20: Updated guideline to include new indication of neuropathic pain associated with diabetic peripheral neuropathy (DPN ) of the feet. Updated criteria for existing condition of neuropathic pain associated with postherpetic neuralgia (PHN).
• 2020-07-20: Updated criteria to specify trial and failure through lidocaine patch

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