Getting Ready for RSV Season

The recommended palivizumab (Synagis) dosing regimen 
is 15 mg/kg body weight, given once a month during the respiratory syncytial virus (RSV) season. The MassHealth Drug Utilization Review Program calculates the amount of drug needed for the season at the time of the initial approval for the medication. If the child’s growth is significant, the provider will need to submit documentation of the new weight so that the total number of approved vials may be reviewed for appropriateness.

In Massachusetts, five monthly doses will typically provide protection for infants and children when the risk of RSV hospitalization is greatest.  Generally, use is confined to
the RSV season (October 29, 2007, to March 31, 2008). MassHealth DUR monitors RSV activity in the state and considers extra doses on a case-by-case basis secondary to reports of increased RSV activity.
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The American Academy of Pediatrics Recommend 
RSV Prophylaxis in the Following Situations:
•	Bronchopulmonary dysplasia (BPD) or chronic lung disease (CLD) (excluding asthma or reactive airway disease): Age < 24 months at start of RSV season 
plus required medication or oxygen supplementation
for CLD or BPD within last 6 months
•	Congenital heart disease (CHD): Age <24 months at 
the start of RSV season plus hemodynamically 
significant CHD
•	Gestational age < 28 weeks and current age < 12 months at the start of RSV season
•	Gestational age = 29-32 weeks and current age < six months at the start of RSV season.
•	Gestational age = 32-35 weeks and current age < six months at the start of RSV season plus  ≥ two risk factors (daycare attendance, school-aged siblings, exposure to environmental air pollutants, congenital airway abnormalities, and/or severe neuromuscular disease)

Methods to Decrease Risk of  RSV Infection 
•	Avoid passive smoking due to effects on respiratory health
•	Encourage breastfeeding due to increased immunity
•	Hand sanitation to prevent nosocomial spread 	What’s New with the Flu

Due to widespread resistance, amantadine and rimantadine 
are no longer recommended for the treatment or 
chemo-prophylaxis of influenza A in the United States; 
instead, neuraminidase inhibitors should be considered.  

PA is required for all neuraminidase inhibitor requests from June 1 to September 30. However, from October 1 to May 1 of each year, PA is only required when quantity limits are exceeded:  
•	oseltamivir 30 mg capsules > 20 units/month or 40 units/season
•	oseltamivir 45 mg or 75 mg capsules >10 units/month 
or 20 units/season
•	oseltamivir suspension > 75 ml/month or 150 ml/season
•	zanamivir > 20 inhalations/month or 40 inhalations/season

PA is required for the live, attenuated influenza vaccine (LAIV) Flumist. It is now FDA-approved for children as young as two years old.  
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Selected Updates from the 2007-2008 Influenza Prevention 
& Control Recommendations:
•	Children six months to eight years of age should initially receive two doses of trivalent inactivated influenza vaccine (TIV)  administered ≥ one month apart 
•	As an alternative to TIV, LAIV may be administered to children two to eight years of age with two doses administered ≥ six weeks apart
•	Children receiving only one dose of the influenza vaccine 
in their first year of vaccination should receive two doses in just the immediately following year
•	In addition to the A/Wisconsin/67/2005-like (H3N2) and B/Malaysia/2506/2004-like viruses, A/Solomon Islands/3/2006 (H1N1) is a new viral strain in the TIV 
for 2007-2008

	
The Prescriber e-Letter is an update designed to enhance the transparency and efficiency of the MassHealth 
drug prior-authorization (PA) process and the MassHealth Drug List. Each issue will highlight key clinical 
information and updates to the MassHealth Drug List. The Prescriber E-Letter was prepared by the
 MassHealth Drug Utilization Review Program and the MassHealth Pharmacy Program.	

The Prescriber e-Letter                                                                                                                        December 2007, Volume 1, Issue 1

Drug/Drug Class	Addition/Deletion/Change	Rationale for PA Requirement	
Antipsychotics	Addition of quantity limits  (excluding clozapine); requires PA 

	There is limited data to support the dosing of atypical antipsychotics at dosing intervals greater than those indicated 
by the FDA.  Therefore, requests for atypical antipsychotics exceeding quantity limits based on FDA-approved dosages will require PA and dosages should be consolidated where appropriate. Strong evidence shows that multiple daily dosing and complex regimens decrease medication adherence.
	
Brand antibiotics	Addition of doxycycline monohydrate (Monodox) 75 mg capsule; requires PA 	Generic doxycycline capsules (i.e., 50 mg, 100 mg) are less-costly alternatives to the branded doxycycline 75 mg capsules. The new strength is not associated with a unique indication.	
Protein C concentrate	Addition of Protein C concentrate (Ceprotin); requires PA	Therapy with protein C concentrate is costly.  Patients with 
protein C deficiency requiring life-long anticoagulation may 
be treated with low-molecular-weight heparin or warfarin.  	
Cerebral stimulants	Addition of lisdexamfetamine (Vyvanse); requires PA	There is a lack of strong clinical data supporting the place in 
therapy of lisdexamfetamine.  Other long-acting cerebral stimulants  (i.e., amphetamines, methylphenidate, dexmethylphenidate) are less-costly and their roles in the 
treatment of ADHD are better established. 	
Intranasal corticosteroids	Addition of fluticasone furoate (Veramyst) spray; requires PA	There is no data to support increased therapeutic efficacy of fluticasone furoate over the less-costly generic fluticasone proprionate for allergic rhinitis.	
Long-acting beta-2-agonists (LABA)	Addition of budesonide/formoterol (Symbicort) inhaler; requires PA	Due to increased risks of asthma-related deaths, LABAs are not recommended for first-line therapy. Rationale for use of the 
combination product budesonide/formoterol is required for 
approval.	
Neuraminidase 
inhibitors	Addition of  oseltamivir (Tamiflu) 30 mg and 45 mg capsules; seasonal 
and quantity restrictions for oseltamivir and zanamivir 	Rationale is needed for prescriptions exceeding quantity limits 
during flu season and for any quantity outside of the flu season.
Oseltamivir 45 mg and 75 mg quantity limits will be 10 units /month or 20 units/season. The 30 mg capsule will have quantity limits of 20 units/month or 40 units/season to accommodate 
dosing for members weighing between 23 and 40 kg.	
Ocular anti-allergy agents	Addition of generic OTC ketotifen (Alaway) 0.025% ophthalmic 
solution; no PA required
  
Change in the reference drug from Zaditor OTC to Alaway	Generic OTC ketotifen (i.e., Alaway) is more cost-effective than branded OTC (i.e., Zaditor OTC) or prescription (i.e., Zaditor) ketotifen.  Along with Alaway, other OTC combination 
antihistamines and vasodilators do not require PA.	
Topical antibacterials	Addition of retapamulin (Altabax) 
1% ointment; requires PA	Generic mupirocin is more cost-effective than retapamulin for treating impetigo.	
Urea-containing 
products	Addition of urea (Kerol) 50% suspension; requires PA	There is limited data on comparative efficacy between urea products. Kerol suspension costs more than other available 
urea formulations.	
Please send any suggestions or comments to: PrescriberELetter@state.ma.us