Relistor injection — United Healthcare
opioid induced constipation in patients with chronic pain related to prior cancer diagnosis or cancer treatment who do not require frequent opioid dosage escalation
Preferred products
- lubiprostone (generic Amitiza)
- Symproic
Initial criteria
- Diagnosis of opioid induced constipation in patients with advanced illness receiving palliative care OR BOTH of the following:
- ONE of the following: Diagnosis of opioid induced constipation with chronic non-cancer pain OR Diagnosis of opioid induced constipation in patients with chronic pain related to prior cancer diagnosis or cancer treatment who do not require frequent (e.g., weekly) opioid dosage escalation
- AND One of the following: patient is not able to swallow oral medications OR history of failure, contraindication, or intolerance to BOTH lubiprostone (generic Amitiza) AND Symproic
Reauthorization criteria
- Documentation of positive clinical response to Relistor injection therapy
Approval duration
12 months