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

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

MHCP Provider Call Center 651-431-2700 or 800-366-5411