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    Glutamine-NutreStore

    Drug - NutreStore™ (L-glutamine powder for oral solution) Emmaus Medical

    August 2008

    Description - 5 gram powder in a packet, prescription product

    Dose - 30 gm daily in divided doses (5 gm taken 6 times each day)
                Each 5 gram dose should be reconstituted in 8-oz of water
                Supplied in packets containing 5 gm

    NDC: 42457000184

    FDA approved indication

    It is indicated only for the treatment of Short Bowel Syndrome (SBS) in patients receiving specialized nutritional support when used in conjunction with a recombinant human growth hormone (Zorbitve).

    Criteria

    The PA criteria is limited to it FDA approved indication:

    • Patient has Short Bowel Syndrome (SBS) AND
    • Is receiving Intravenous Parenteral Nutrition/Total Parenteral Nutrition (TPN) AND
    • Is concomitantly receiving human growth hormone for SBS

    Questions?

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

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