ALLERGEN EXTRACT-HOUSE DUST MITE

Guidelines for Use

Initial Criteria (NOTE:  for Renewal Criteria see below)

Our guideline named ALLERGEN EXTRACT-HOUSE DUST MITE (Odactra) requires the following rule(s) be met for approval:

1. You have allergic rhinitis (itchy, watery eyes, sneezing) caused by house dust mites, with or without conjunctivitis (type of inflammation of eye and eyelid)
2. Your diagnosis is confirmed by in vitro testing (testing outside of your body in a tube) for IgE (Immunoglobulin E) antibodies to Dermatophagoides farinae or Dermatophagoides pteronyssinus house dust mites, or skin testing to licensed house dust mite allergen extracts
3. You are between 18 and 65 years old
4. You have tried or have a contraindication or intolerance to TWO of the following:
1. Oral antihistamine
2. Intranasal antihistamine
3. Intranasal corticosteroid
4. Leukotriene inhibitor
5. You have tried and failed subcutaneous allergen immunotherapy (SCIT) containing house dust mite allergen

RENEWAL CRITERIA

Our guideline named ALLERGEN EXTRACT-HOUSE DUST MITE (Odactra) requires the following rule is met for renewal:

1. You have history of paid claim(s) for the requested medication in the past 90 days
2. You have a previous authorization on file for the requested medication

Rationale

Promote appropriate utilization of Odactra based on FDA approved indication, dosage, and guidelines adopted from ARIA (Allergic Rhinitis and its Impact on Asthma) as well as the AAAAI (American Academy of Allergy, Asthma & Immunology) Practice Parameter on Allergen Immunotherapy.

INDICATIONS

Odactra is an allergen extract indicated as immunotherapy for house dust mite (HDM)-induced allergic rhinitis, with or without conjunctivitis, confirmed by in vitro testing for IgE antibodies to Dermatophagoides farinae or Dermatophagoides pteronyssinus house dust mites, or skin testing to licensed house dust mite allergen extracts. ODACTRA is approved for use in adults 18 through 65 years of age.

Dosage and Administration

The recommended dose is one tablet daily.

References

Odactra [Prescribing Information]. Merck, Sharp & Dohme Corp. Whitehouse Station, NJ. August 2019