LUTATHERA (lutetium Lu 177 dotatate) Treatment Checklist:

Payers may require the inclusion of the following information in the patient’s records or charts:

Prior to LUTATHERA treatment*

  • Specific diagnosis for the disease
  • Relevant prior imaging
  • Extent of the disease
  • All relevant laboratory tests
  • Dose order in the treatment cycle (ie, first, second, third, fourth)
  • Informed consent from the patient after a detailed discussion that includes both oral and written instructions, review of reasons for treatment, risk of treatment, necessary precautions to be taken, and relevant safety procedures
  • *Some of these items may be required during the prior authorization process

During LUTATHERA treatment

  • Premedication and concomitant medications of the patient and the individual who administered them
  • The start time for LUTATHERA administration and the individual who administered the solution

After LUTATHERA treatment

  • The completion time and total duration of premedication and concomitant medications
  • LUTATHERA dose administered and the route of administration
  • Documentation of administration or referral for concomitant medications
  • Discharge instructions for the patient
Please be informed that we have adopted new enrollment forms, starting from February 22nd 2021. If you need assistance with completing the forms, please call AAA PatientCONNECT at 1-844-638-7222.