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Antiemetic/Antivertigo SA Form

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Antiemetic/Antivertigo SA Form COMMONWEALTH OF VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES Service Authorization (SA) Form ANTIEMETIC/ANTIVERTIGO MEDICATIONS If the following information is not complete, correct, or legible, the SA process can be delayed. Please use one form per member. MEMBER INFORMATION Last Name: First Name: Medicaid ID Number: Date of Birth: – – Gender: Male Female Weight in Kilograms: ___________________________ PRESCRIBER INFORMATION Last Name: First Name: NPI Number: Phone Number: Fax Number: – – – – DRUG INFORMATION Does NOT require SA: ondansetron (ODT/tab) (maximum quantity per fill = 60); meclizine; metoclopramide (tab/sol); prochlorperazine (tab/syrup); promethazine in members over 2 years of age. Requires submission of this SA: preferred dronabinol plus all non-preferred medications: Akynzeo® Aloxi® Antivert® Anzemet® aprepitant cap/pack Bonjesta® Cesamet® Cinvanti® Compazine® supp/tab Compro® Diclegis® dimenhydrinate doxylamine succ/vit B6 Emend® Bi Pak Emend® cap Emend® susp Emend® Tri-fold pack granisetron hydroxyzine Kytril® Marinol® metoclopramide ODT Metozolv® ODT ondansetron soln palonosetron Phenergan® prochlorperazine sup promethazine 50mg supp Reglan® Sancuso® patch scopolamine Syndros® Tigan® Transderm-Scop® trimethobenzamide Varubi® Vistaril® Zofran® ODT/soln/tab Zuplenz® film (Form continued on next page.) Virginia Medicaid Pharmacy Services Portal: http://www.virginiamedicaidpharmacyservices.com © 2017–2020, Magellan Health, Inc. All rights reserved. Revised: 5/22/2020 | Effective: 07/01/2020 Page 1 of 2 Virginia DMAS SA Form: Antiemetic/Antivertigo Medications Member’s Last Name: Member’s First Name: Drug Name/Form: ________________________________________________________________________ Strength: _________________________________________________________________________________________________________ Dosing Frequency: _________________________________________________________________________________________________________ Length of Therapy: _________________________________________________________________________________________________________ Quantity per Day: _________________________________________________________________________________________________________ DIAGNOSIS AND MEDICAL INFORMATION 1. Diagnosis of severe, chemotherapy-induced nausea and vomiting? Yes No 2. If diagnosis is AIDS-related wasting, has member tried and failed megestrol acetate oral suspension OR has a contraindication, intolerance, drug-drug interaction? Yes No 3. Nausea or vomiting related to radiation therapy, moderate to highly emetogenic chemotherapy, or post- operative nausea and vomiting? Yes No 4. Member has tried and failed therapeutic doses of, or has adverse effects or contraindications to, TWO different conventional antiemetics (e.g., promethazine, prochlorperazine, meclizine, metoclopramide, dexamethasone, etc.) Yes No 5. Member has hyperemesis (pregnancy-related nausea/vomiting)? Yes No 6. Provide clinical evidence that the preferred agent(s) will not provide adequate benefit and list pharmaceutical agents attempted and outcome. ____________________________________________________________________________________ ____________________________________________________________________________________ Prescriber Signature (Required) Date By signature, the Physician confirms the above information is accurate and verifiable by member records. Please include ALL requested information; Incomplete forms will delay the SA process. Submission of documentation does NOT guarantee coverage by the Department of Medical Assistance Services. The completed form may be: FAXED TO 800-932-6651, phoned to 800-932-6648, or mailed to: Magellan Medicaid Administration / ATTN: MAP 11013 W. Broad Street, Glen Allen, VA 23060 Virginia Medicaid Pharmacy Services Portal: http://www.virginiamedicaidpharmacyservices.com © 2017–2020, Magellan Health, Inc. All rights reserved. Revised: 5/22/2020 | Effective: 07/01/2020 Page 2 of 2 .
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    JK SCIENCE ORIGINAL ARTICLE Prophylactic Antiemetic Therapy with Ondansetron, Granisetron and Metoclopramide in Patients Undergoing Laparoscopic Cholecystectomy Under GA Vishal Gupta, Renu Wakhloo, Anjali Mehta, Satya Dev Gupta Abstract The aim of the present study was to compare the antiemetic effect of intravenous Granisetron, Ondansetron & Metoclopramide in a randomized blinded study for prophylaxis of post operative nausea and vomiting (PONV) in patients undergoing laparoscopic cholecystectomy under general anaesthesia. 60 patients (ASA I & II) undergoing laparoscopic cholecystectomy under general anaesthesia were randomly allocated into three equal groups (n=20). Emetic episodes in first 24 hours were recorded and compared in different study groups. Results were analyzed. Minimal emetic episodes were observed in early post-operative period (1-12hrs) in patients who had received intravenous granisetron in comparison to ondansetron and metoclopramide. However, after 12 hours emesis free periods were statistically insignificant between group A and B while patients in group C had no antiemetic effect. Keywords Post Operative Nausea and Vomiting (PONV), Granisetron, Ondensetron, Metoclopramide Introduction The most common and distressing symptoms, which vascular anastomoses and increased intracranial follow anaesthesia and surgery, are pain and emesis. The pressure(4). The anaesthetic consequences are aspiration syndrome of nausea, retching and vomiting is known as pneumonitis and discomfort in recovery. For institutions 'sickness' and each part of it can be distinguished as a there is increased financial burden because of increased separate entity (1). PONV (post operative nausea and nursing care, delayed discharge from Phase I and II vomiting) has been characterized as big 'little problem(2) recovery units and unexpected admissions. Hence, and has been a common complication for both in patients prophylactic antiemetic therapy is needed for all these and out patients undergoing virtually all types of surgical patients.
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    KYTRIL® (granisetron hydrochloride) INJECTION Rx only DESCRIPTION KYTRIL (granisetron hydrochloride) Injection is an antinauseant and antiemetic agent. Chemically it is endo-N-(9-methyl-9-azabicyclo [3.3.1] non-3-yl)-1-methyl-1H-indazole- 3-carboxamide hydrochloride with a molecular weight of 348.9 (312.4 free base). Its empirical formula is C18H24N4O•HCl, while its chemical structure is: granisetron hydrochloride Granisetron hydrochloride is a white to off-white solid that is readily soluble in water and normal saline at 20°C. KYTRIL Injection is a clear, colorless, sterile, nonpyrogenic, aqueous solution for intravenous administration. KYTRIL 1 mg/1 mL is available in 1 mL single-use and 4 mL multi-use vials. KYTRIL 0.1 mg/1 mL is available in a 1 mL single-use vial. 1 mg/1 mL: Each 1 mL contains 1.12 mg granisetron hydrochloride equivalent to granisetron, 1 mg; sodium chloride, 9 mg; citric acid, 2 mg; and benzyl alcohol, 10 mg, as a preservative. The solution’s pH ranges from 4.0 to 6.0. 0.1 mg/1 mL: Each 1 mL contains 0.112 mg granisetron hydrochloride equivalent to granisetron, 0.1 mg; sodium chloride, 9 mg; citric acid, 2 mg. Contains no preservative. The solution’s pH ranges from 4.0 to 6.0. CLINICAL PHARMACOLOGY Granisetron is a selective 5-hydroxytryptamine3 (5-HT3) receptor antagonist with little or no affinity for other serotonin receptors, including 5-HT1; 5-HT1A; 5-HT1B/C; 5-HT2; for alpha1-, alpha2- or beta-adrenoreceptors; for dopamine-D2; or for histamine-H1; benzodiazepine; picrotoxin or opioid receptors.
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