FIRDAPSE (amifampridine)
SELF ADMINISTRATION - ORAL
Indications for Prior Authorization:
- Treatment of Lambert-Eaton myasthenic syndrome (LEMS) in adults
Patients must meet the following criteria:
- Chart note documentation is provided supporting the diagnosis of LEMS, AND
- Prescribed by or in consultation with a neurologist, AND
- Patient is age 18 years or older, AND
- Documentation of a baseline clinical muscle strength assessment (examples may include but are not limited to the Quantitative Myasthenia Gravis (QMG) score, triple-timed up-and-go test (3TUG), Timed 25-foot Walk test (T25FW)), AND
- Patient does not have a history of seizures
Reauthorization:
- Positive clinical response to therapy (e.g. improvement in dynamometry, timed 25-foot walk test, timed up and go test) as confirmed by chart note documentation
Dosing:
- Recommended starting dosage: 15 mg to 30 mg daily, taken orally in divided doses (3 to 4 times daily)
- The dosage can be increased by 5 mg daily every 3 or 4 days
- The maximum recommended total daily dosage is 80 mg
- The maximum single dose is 20 mg
Approval:
- Initial: 3 months
- Renewal: 1 year
Last review date: December 9, 2019