Capsaicin Patch

Capsaicin (Qutenza®) patch

OFFICE ADMINISTRATION

Indications for Prior Authorization:

• For diagnosis of Post herpetic Neuralgia (PHN)

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee:

• Any other diagnosis not listed in the approved indications

All of the following must be met:

• Inadequate response, intolerable side effect(s) or contra-indication to at least two oral drugs [e.g. tricyclic antidepressants, anticonvulsants, opioids] and a self-administered topical patch [e.g. lidocaine patch] used for PHN, OR
• If pt is ≥ 65 yrs old, inadequate response, intolerable side effect(s) or contra-indication to an oral drug [e.g. anticonvulsants, opioids] and a self administered topical patch [e.g. lidocaine patch] used for PHN

Dosing:

• Up to 4 patches per treatment session, and not more frequently than every three months
• Administration of Qutenza®:
  • Only physicians or health care professionals under the close supervision of a physician are to administer Qutenza®
  • Use only nitrile (not latex) gloves when handling Qutenza® and when cleaning treatment areas
  • Burning and erythema reported in majority of patients treated with Qutenza®

Approval:

Initial coverage for 3 months

Reauthorize yearly based upon continued response to treatment