LUTATHERA 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
  • Histology to support diagnosis
  • Relevant prior imaging for tumor localization
  • Extent of the disease
  • All relevant laboratory tests
  • Dose order in the treatment cycle (ex. 1st, 2nd, 3rd, or 4th dose)
  • 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 radiation safety procedures
  • *Some of these items may be required during the prior authorization process

During LUTATHERA treatment

  • Pre-medication of the patient with antiemetic
    • If IV formulation is used, start and stop times of antiemetic administration
  • Start time of amino acid infusion and the individual who administered the solution
  • The start time for LUTATHERA administration and the individual who administered the solution

After LUTATHERA treatment

  • The completion time and total duration of amino acid infusion
  • LUTATHERA dose administered and the route of administration
  • Documentation of administration or referral for long-acting octreotide treatment
  • Discharge instructions for the patient
Please be informed that we have adopted new enrollment forms, starting from August 1, 2018. If you need assistance with completing the forms, please call AAA PatientCONNECT at 1-844-NETS-AAA.
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