Limited Use Note(s)

RIFAXIMIN550mg Tab

Reason For Use Code	Clinical Criteria
475	For reducing the risk of overt hepatic encephalopathy (HE) recurrence (i.e., 2 or more episodes) in patients who are unable to achieve adequate control of HE recurrence with maximal tolerated dose of lactulose alone. Rifaximin should be used in combination with a maximal tolerated dose of lactulose. For patients not maintained on lactulose, the nature of the patient's intolerance to lactulose should be documented.
	LU Authorization Period: Indefinite

Reason For Use Code

Clinical Criteria

475

For reducing the risk of overt hepatic encephalopathy (HE) recurrence (i.e., 2 or more episodes) in patients who are unable to achieve adequate control of HE recurrence with maximal tolerated dose of lactulose alone. Rifaximin should be used in combination with a maximal tolerated dose of lactulose. For patients not maintained on lactulose, the nature of the patient's intolerance to lactulose should be documented.

LU Authorization Period: Indefinite

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