Prior Authorization Information | Sucraid HCP

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Prior Authorization Information

Here is some helpful information for submitting the Prior Authorization form correctly.

1

Enter Patient Diagnosis Code (ICD-10)

Here is a list of possible ICD-10 codes that may apply to a CSID patient (may not be an all-inclusive list):

Sucrase-isomaltase deficiencyE74.31*
Other disorders of intestinal carbohydrate absorptionE74.39
Malabsorption due to intolerance, not elsewhere classifiedK90.49
Diarrhea, unspecifiedR19.7
FlatulenceR14.3
Abdominal distension (gaseous)R14.0
NauseaR11.0

*If CSID is suspected, this ICD-10 code may be required for some insurance plans and financial assistance programs.

2

Identify Patient Symptoms

Experiencing symptoms of Congenital Sucrase-Isomaltase Deficiency (CSID), including diarrhea, gas, bloating, abdominal cramping, nausea, or other.

3

Detail Patient History

  • Prior treatment
  • Medical history
  • Dietary counseling
  • Other

4

Indicate Patient Tests and Results

Evidence of deficient sucrase activity through one of the following recommended diagnoses:

  1. 13C-sucrose breath test
  2. Sucrose hydrogen-methane breath test
  3. EGD biopsy and disaccharidase assay
    • 2 extra distal duodenal biopsy samples
    • Sent to specialty disaccharidase testing lab; results evaluated
DisaccharidaseNormal Range
Lactase5 - 55 U/g protein
Sucrase26 - 110 U/g protein
Maltase105 - 380 U/g protein
Palatinase9 - 32 U/g protein

Hackenmueller SA, Grenache DG. Reference intervals for intestinal disaccharidase activities determined from a non-referenced population. J Appl Lab Med. 2016;1(2):172-80.

5

Download Authorization Form

Search your patient’s healthcare provider below to access the corresponding form.

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Important Safety Information for Sucraid® (sacrosidase) Oral Solution

  • Sucraid® may cause a serious allergic reaction. Patients should stop taking Sucraid® and get emergency help immediately if any of the following side effects occur: difficulty breathing, wheezing, or swelling of the face. Care should be taken when administering initial doses of Sucraid® to observe any signs of acute hypersensitivity reaction.
  • Do not use Sucraid® (sacrosidase) Oral Solution with patients known to be hypersensitive to yeast, yeast products, papain, or glycerin (glycerol).
  • Although Sucraid® provides replacement therapy for the deficient sucrase, it does not provide specific replacement therapy for the deficient isomaltase.
  • Adverse reactions as a result of taking Sucraid® may include worse abdominal pain, vomiting, nausea, diarrhea, constipation, difficulty sleeping, headache, nervousness, and dehydration.
  • Before prescribing Sucraid® to diabetic patients, the physician should consider that Sucraid® will enable sucrose hydrolysis and the absorption of those hydrolysis products, glucose and fructose.
  • The effects of Sucraid® have not been evaluated in patients with secondary (acquired) disaccharidase deficiency.
  • DO NOT HEAT SOLUTIONS CONTAINING SUCRAID®. Do not put Sucraid® in warm or hot fluids. Do not reconstitute or consume Sucraid® with fruit juice since the acidity of the juice may reduce the enzyme activity of Sucraid®. Half of the reconstituted Sucraid® should be taken at the beginning of the meal or snack and the other half during the meal or snack.
  • Sucraid® should be refrigerated at 36°F-46°F (2°C-8°C) and should be protected from heat and light.

Indication

Sucraid®(sacrosidase) Oral Solution is an enzyme replacement therapy for the treatment of genetically determined sucrase deficiency, which is part of Congenital Sucrase-Isomaltase Deficiency (CSID).