Limited coverage drugs – alitretinoin

Generic name	alitretinoin
Strength	10 mg, 30 mg
Form	capsule

Special Authority criteria	Approval period
For the treatment of severe chronic hand eczema in patients meeting ALL the following criteria: Refractory to 2 months of high or ultra-high potency topical steroids AND Dermatology Life Quality Index equal to or greater than 15 AND Requested by a dermatologist	24 weeks

Practitioner exemptions

• None

Special notes

1. High or ultra-high potency corticosteroids include: clobetasol proprionate 0.05%, betametasone dipropionate 0.05%, betamethasone dipropionate glycol 0.05%, desoximetasone 0.25%, fluocinonide 0.05%, halcinonide 0.1%, halobetasol propionate 0.05% and amcinonide 0.1%
2. The Dermatology Life Quality Index (DLQI) is a 10-question validated questionnaire designed to measure how dermatology-specific issues affect a patient’s quality of life. The 10 questions are measured according to a three-point scale. Sum-total DLQI scores and their meaning for patients are as follows:
   • 0-1 = no effect at all on patient's life
   • 2-5 = small effect on patient's life
   • 6-10 = moderate effect on patient's life
   • 11-20 = very large effect on patient's life
   • 21-30 = extremely large effect on patient's life
3. The need for continued alitretinoin treatment should be reassessed:
   • As soon as an adequate response (hands clear or almost clear) has been achieved
     OR
   • If the eczema remains severe at 12 weeks
     OR
   • If an adequate response (hands clear or almost clear) has not been achieved by 24 weeks
4. PharmaCare coverage is limited to one dose per day

Special Authority request form(s)

• Log in to eForms
• HLTH 5328 - Special Authority Request (PDF, 656KB)