PRIOR AUTHORIZATION OBESITY PHARMACOTHERAPY TEMPLATE
Phentermine / Topiramate Combination: Phentermine / topiramate extended-release capsule( Qsymia) is a fixed-dose combination of phentermine and topiramate approved for treatment of obesity in children 12 years and older. The once- daily formulation of phentermine( a sympathomimetic amine) and topiramate is designed to combat obesity by decreasing appetite and increasing satiety. Clinical trials have shown Qsymia to be effective in treatment of obesity in adolescents( 5).
GLP-1 / GIP Receptor Agonists: Tirzepatide is an FDA-approved GLP-1 / GIP dual agonist used in the treatment of adults with type 2 diabetes and obesity. Clinical studies in the adult population demonstrated significant reduction in body weight with this medication that mirror efficacy achieved with bariatric surgery. Tirzepatide demonstrated improvement in cardiometabolic factors( hemoglobin A1c, lipids, transaminases), once daily liraglutide did not show a difference in these factors compared to placebo. Given advantages in efficacy and better adherence to once weekly medication I am specifically requesting approval of coverage of Wegovy for Name.
All weight management medications should be used in conjunction with a reduced-calorie diet and increased physical activity. Name is receiving ongoing counseling on diet and activity as recommended in 2022 American Academy of Pediatrics and 2017 Endocrine Society Clinical Practice guidelines for Pediatric Obesity Management. Alternative language: All weight management medications should be used in conjunction with a reduced-calorie diet and increased physical activity. Name is participating in a multidisciplinary weight management program as recommended in 2022 American Academy of Pediatrics and 2017 Endocrine Society Clinical Practice guidelines for Pediatric Obesity Management.
I strongly urge the expedited approval of Medication for Name, as he / she clearly meets criteria for use and delay is compromising their clinical care. I appreciate your collaboration and support of his / her treatment. Thank you for partnering with me in the care of Patient Name. I am happy to set up a time to discuss his / her treatment course further. Please let me know what questions you have.
Physicians Name
1. Hampl SE, Hassink SG, Skinner AC, et al. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics. 2023; 151( 2): e2022060640.
2. Kelly AS, Auerbach P, Barrientos-Perez M, et al; NN8022-4180 Trial Investigators. A randomized, controlled trial of liraglutide for adolescents with obesity. N Engl J Med. 2020; 382( 22): 2117 – 2128.
3. Weghuber D, Barrett T, Barrientos-Pérez M, et al. Once-Weekly Semaglutide in Adolescents with Obesity. N Engl J Med 2022; 387:2245-2257.
4. Ryder, J., Kaizer, A., Rudser, K. et al. Effect of phentermine on weight reduction in a pediatric weight management clinic. Int J Obes 41, 90 – 93( 2017). https:// doi. org / 10.1038 / ijo. 2016.185.
5. Kelly AS, Bensignor MO, Hsia DS, et al Varghese for the Trial Investigators. Phentermine / topiramate for the treatment of adolescent obesity. N Engl J Med Evid. 2022; 1( 6).
6. Jastreboff AM, Aronne LJ, Ahmad NN, et al. Tirzepatide Once Weekly for the Treatment of Obesity. N Engl J Med 2022; 387:205-216. DOI: 10.1056 / NEJMoa2206038.
54