Digital Ulcers
Sildenafil
Brand(s)
- Revatio and generics
- Viagra and generics
Dosage Form/Strength
- Revatio versions: 20 mg
- Viagra versions: 25 mg, 50 mg, 100 mg
Effective Date
- September 9, 2022
Indications for Treatment
For the treatment of severe Raynaud’s phenomenon (RP) and/or digital ulcers secondary to scleroderma (systemic sclerosis) or scleroderma-like disease:
- After failure of at least one calcium channel blocker (CCB) OR without trial of a CCB in a patient who has experienced an emergency situation such as threatened ischemic digit(s) requiring hospitalization.
- Must be prescribed by a specialist (i.e., rheumatologist, general internist, vascular surgeon).
Duration of Approval
- Initial Approval: 6 months
- Renewals:
- Duration of Renewals: 1 year
- Consideration: Renewals will be considered on a case-by-case basis for patients who demonstrate benefit from treatment (e.g., positive response in the duration, frequency, and/or severity of RP and/or improvement in the size or number of digital ulcers).
Renewal Criteria
- Case-by-Case Basis: Renewals are considered for patients who demonstrate benefit from treatment, such as:
- Positive response in the duration, frequency, and/or severity of Raynaud’s phenomenon (RP).
- Improvement in the size or number of digital ulcers.
