dichlorphenamide — Medica

Initial criteria

• Patient has a confirmed diagnosis of primary hyperkalemic periodic paralysis by meeting at least ONE of the following: (a) increase from baseline in serum potassium concentration ≥ 1.5 mEq/L during a paralytic attack; OR (b) serum potassium concentration during a paralytic attack > 5.0 mEq/L; OR (c) family history of the condition; OR (d) genetically confirmed skeletal muscle sodium channel mutation
• Prescriber has excluded other reasons for acquired hyperkalemia (e.g., drug abuse, renal dysfunction, adrenal dysfunction)
• Patient has tried oral acetazolamide therapy
• According to prescriber, acetazolamide therapy did not worsen paralytic attack frequency or severity
• Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the care of patients with primary periodic paralysis (e.g., muscle disease specialist, physiatrist)

Reauthorization criteria

• Patient is currently receiving dichlorphenamide and has responded to dichlorphenamide (e.g., decrease in frequency or severity of paralytic attacks) as determined by the prescriber

Approval duration

Initial: 2 months; Reauthorization: 1 year