ESBRIET (pirfenidone)

ESBRIET (pirfenidone) 

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

• Treatment of idiopathic pulmonary fibrosis (IPF)

Patients must meet the following criteria for the indication(s) above:

• Diagnosis if IPF by pulmonologist

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:

• All non-FDA approved uses not listed in the approved indications

Dosing:

• Dose should be titrated over 14 days
• Dose is 801 mg (three 267 mg capsules) three times a day
• Doses should be administered at the same times each day
• Higher doses are not approvable
• Dose modification is required for adverse events and elevated liver function tests

Approval:

One year