Product Details

Diacomit

Stiripentol
250 mg
Capsule


DIN/PIN/NPN

02398958

Manufacturer

Biocodex Canada Inc.

Formulary Listing Date

2015-06-22  

Unit Price

5.8984

Amount MOH Pays

5.8984

Coverage Status

Exceptional Access Program Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

N03AX17

Interchangeable Products

NO  

LU Clinical Criteria

NO  

EAP Criteria

Therapeutic Class Reimbursement Criteria
Anticonvulsants

Stiripentol

  • Brand(s): Diacomit
  • Dosage Form/Strength: 250 mg capsule, 250 mg/pack powder for suspension, 500 mg capsule, 500 mg/pack powder for suspension

For the treatment of patients with severe myoclonic epilepsy in infancy (Dravet syndrome) who meet the following criteria:

  1. the patient has refractory generalized tonic-clonic seizures; AND

  1. the patient requires Diacomit (Stiripentol) for use in combination with clobazam and valproate as adjunctive therapy for the seizures; AND

  1. the patient’s seizures are not adequately controlled with clobazam and valproate alone; AND

  1. the request is submitted by a neurologist or pediatrician.

Case-by-case consideration through external review will be permitted for circumstances not meeting the above criteria.

Duration of Approval: Lifetime

EAP Drug Request Form:

Standard Form for EAP Drug Requests

Product Monograph

View Monograph