Qbrexza
Drugs - Qbrexza™ (glycopyrronium cloth) [Dermira, Inc.]
September 2019
Therapeutic area - Primary Axillary Hyperhidrosis
Initial approval criteria
Patient must:
- Be ≥ 9 years of age AND
- Documented diagnosis of primary axillary hyperhidrosis AND
- Have Hyperhidrosis Disease Severity Scale (HDSS) grade of 3 or 4 AND
- Be prescribed Qbrexza by a dermatologist AND
- Documented that diagnosis negatively impacts activities of daily living AND
- Not be diagnosed with a medical condition exacerbated by the anticholinergic effects (e.g., glaucoma, paralytic ileus, unstable cardiovascular status in acute hemorrhage, severe ulcerative colitis, toxic megacolon complicating ulcerative colitis, myasthenia gravis, or Sjögren’s syndrome) AND
- Not be taking any additional anticholinergic medications AND
- Has had a 3-month adherent trial of Xerac AC and any adverse events (e.g., skin irritation) during the 3-month trial were appropriately managed with both pharmacologic and non-pharmacologic intervention (e.g. low potency corticosteroid preparation [e.g., hydrocortisone cream], application of product to dry skin for 6 to 8 hours, etc.) AND
- All other causes of secondary hyperhidrosis must be ruled out
- Initial approval is for 3 months
Renewal criteria
Patient must:
- Report at least 1 point reduction in sweating severity using the Hyperhidrosis Disease Severity Scale (HDSS) AND
- Has no documented dysregulation of temperature control AND
- Not be taking any additional anticholinergic medications AND
- Not have any new diagnosis with a medical condition exacerbated by the anticholinergic effects (e.g., glaucoma, paralytic ileus, unstable cardiovascular status in acute hemorrhage, severe ulcerative colitis, toxic megacolon complicating ulcerative colitis, myasthenia gravis, or Sjögren’s syndrome)
- Renewal approval is for 12 months
Quantity limits
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411