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OLPRUVA™ (sodium phenylbutyrate) for oral suspension Prescription Enrollment Form
To prescribe OLPRUVA, you must complete this form, sign it, and have the patient or guardian (if the patient is younger than 18 years) sign it. The form can be filled out digitally on your computer, so you just print, sign, and fax it to the pharmacy. You can also print the uncompleted form and fill it out by hand.
OLPRUVA Access Guide
This important resource takes some of the burden off you and your staff by helping you understand prescribing OLPRUVA for your patients. The guide is included in your OLPRUVA Access Toolkit, but you can also download a PDF version here.
OLPRUVA Letter of Medical Necessity example
This convenient example facilitates the process when you need to submit a Letter of Medical Necessity. A printed example is included in your OLPRUVA Access Toolkit.
OLPRUVA Payer Appeal Letter example
This convenient example facilitates the process when you need to submit a Payer Appeal Letter. A printed example is included in your OLPRUVA Access Toolkit.
OLPRUVA Patient Guide
This guide features important information to help your patients understand OLPRUVA and their treatment. The brochure is supplied in each OLPRUVA Starter Kit (see below), but you can download a PDF version here to print or email to your patients.
Other important resources available
from your OLPRUVA Representative
OLPRUVA Access Toolkit
This useful kit explains the prescription process for you and your staff to facilitate completion and submission of the OLPRUVA Prescription Enrollment Form and help everyone understand what to expect once it is submitted.
OLPRUVA Patient Starter Kit
This comprehensive kit contains resources that your patients need to start their OLPRUVA treatment. Patients will receive the kit with their first shipment of OLPRUVA, and you can also provide them to your patients.
For more information or to obtain these resources for your office, contact your OLPRUVA Representative.
Financial support and assistance available
- Copay Assistance Program—Copay assistance available for eligible patients*
- Patient Assistance Program—Patients who are uninsured or underinsured may be able to receive OLPRUVA at no cost
For more information about available programs, contact the OLPRUVA Navigator Team.
Monday-Friday, 7 AM-7 PM Central Time,
at 1-833-OLPRUVA (1-833-657-7882).
*Eligibility criteria and maximum limits apply. Contact the OLPRUVA Navigator Team for details.
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Indication and Important Safety Information for OLPRUVA
OLPRUVA [ol proo vah] (sodium phenylbutyrate) for oral suspension
Indication
OLPRUVA is a nitrogen-binding agent indicated as adjunctive therapy to the standard of care, which includes dietary management, in the chronic management of adult and pediatric patients, weighing 20 kg or greater and with a body surface area (BSA) of 1.2 m2 or greater, with urea cycle disorders (UCDs) involving deficiencies of carbamylphosphate synthetase (CPS), ornithine transcarbamylase (OTC), or argininosuccinic acid synthetase (AS).
Limitation of Use
OLPRUVA is not indicated for the treatment of acute hyperammonemia, which can be a life-threatening medical emergency that requires rapidly acting interventions to reduce plasma ammonia levels.
Important Safety Information
Warnings and Precautions
Neurotoxicity of Phenylacetate: Increased exposure to phenylacetate, the major metabolite of OLPRUVA, may be associated with neurotoxicity in patients with UCDs. If neurotoxicity symptoms of vomiting, nausea, headache, somnolence, or confusion are present in the absence of high ammonia levels or other intercurrent illnesses, consider reducing the dose of OLPRUVA.
Hypokalemia: Renal excretion of phenylacetylglutamine may induce urinary loss of potassium. Monitor serum potassium during therapy and initiate appropriate treatment when necessary.
Conditions Associated with Edema: OLPRUVA contains 124 mg of sodium per gram of sodium phenylbutyrate, and the Mix-Aid contains 5 mg of sodium per packet. Calculate the total amount of sodium based on the patient’s body surface area. If a patient develops new-onset edema or worsening edema while on treatment, discontinue administration of sodium phenylbutyrate and initiate appropriate therapy.
Drug Interactions
Valproic acid, haloperidol, or corticosteroids may increase plasma ammonia levels. Monitor ammonia levels closely. Probenecid may inhibit renal excretion of metabolites of OLPRUVA including phenylacetate and phenylacetylglutamine; monitor for potential neurotoxicity.
Use in Specific Populations
No studies with OLPRUVA have been conducted in subjects with renal or hepatic impairment. Monitor ammonia levels and in patients with hepatic impairment, it is recommended to start at the lowest dose that controls ammonia levels. Dose selection for elderly patients should be cautious, usually starting at the low end of the dosing range.
OLPRUVA should be used with caution in patients who are pregnant or planning to become pregnant. Report pregnancies to Acer Therapeutics Inc. at 1-833-657-7882. There are no data on the presence of OLPRUVA in human milk, the effects on the breastfed infant, nor the effects on milk production. This should be considered when assessing the mother’s need for OLPRUVA.
Adverse Reactions
Most common adverse reactions (incidence ≥ 3%) are amenorrhea or menstrual dysfunction (irregular menstrual cycles), decreased appetite, body odor and bad taste or taste aversion.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
This information is not comprehensive.
For additional information, please see full Prescribing Information for OLPRUVA on OlpruvaHCP.com.
Indication and Important Safety Information for OLPRUVA
OLPRUVA [ol proo vah] (sodium phenylbutyrate) for oral suspension
Indication
OLPRUVA is a nitrogen-binding agent indicated as adjunctive therapy to the standard of care, which includes dietary management, in the chronic management of adult and pediatric patients, weighing 20 kg or greater and with a body surface area (BSA) of 1.2 m2 or greater, with urea cycle disorders (UCDs) involving deficiencies of carbamylphosphate synthetase (CPS), ornithine transcarbamylase (OTC), or argininosuccinic acid synthetase (AS).
Limitation of Use
OLPRUVA is not indicated for the treatment of acute hyperammonemia, which can be a life-threatening medical emergency that requires rapidly acting interventions to reduce plasma ammonia levels.
Important Safety Information
Warnings and Precautions
Neurotoxicity of Phenylacetate: Increased exposure to phenylacetate, the major metabolite of OLPRUVA, may be associated with neurotoxicity in patients with UCDs. If neurotoxicity symptoms of vomiting, nausea, headache, somnolence, or confusion are present in the absence of high ammonia levels or other intercurrent illnesses, consider reducing the dose of OLPRUVA.
Hypokalemia: Renal excretion of phenylacetylglutamine may induce urinary loss of potassium. Monitor serum potassium during therapy and initiate appropriate treatment when necessary.
Conditions Associated with Edema: OLPRUVA contains 124 mg of sodium per gram of sodium phenylbutyrate, and the Mix-Aid contains 5 mg of sodium per packet. Calculate the total amount of sodium based on the patient’s body surface area. If a patient develops new-onset edema or worsening edema while on treatment, discontinue administration of sodium phenylbutyrate and initiate appropriate therapy.
Drug Interactions
Valproic acid, haloperidol, or corticosteroids may increase plasma ammonia levels. Monitor ammonia levels closely. Probenecid may inhibit renal excretion of metabolites of OLPRUVA including phenylacetate and phenylacetylglutamine; monitor for potential neurotoxicity.
Use in Specific Populations
No studies with OLPRUVA have been conducted in subjects with renal or hepatic impairment. Monitor ammonia levels and in patients with hepatic impairment, it is recommended to start at the lowest dose that controls ammonia levels. Dose selection for elderly patients should be cautious, usually starting at the low end of the dosing range.
OLPRUVA should be used with caution in patients who are pregnant or planning to become pregnant. Report pregnancies to Acer Therapeutics Inc. at 1-833-657-7882. There are no data on the presence of OLPRUVA in human milk, the effects on the breastfed infant, nor the effects on milk production. This should be considered when assessing the mother’s need for OLPRUVA.
Adverse Reactions
Most common adverse reactions (incidence ≥ 3%) are amenorrhea or menstrual dysfunction (irregular menstrual cycles), decreased appetite, body odor and bad taste or taste aversion.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
This information is not comprehensive.
For additional information, please see full Prescribing Information for OLPRUVA on OlpruvaHCP.com.