As pharmacy benefit costs continue to rise, appropriate diagnosis remains a critical component of responsible specialty drug and utilization management.
Sucraid® (sacrosidase) is FDA-approved for the treatment of Congenital Sucrase-Isomaltase Deficiency (CSID), a rare genetic condition that impairs the body's ability to digest certain sugars. While the therapy can be life-changing for appropriately diagnosed patients, it is also associated with significant cost, making diagnostic accuracy especially important.
Before initiating therapy, clinical evaluation often includes:
• Consistent symptoms such as chronic diarrhea, abdominal pain, bloating, and failure to thrive or poor weight gain.
• Exclusion of more common gastrointestinal conditions that can present similarly.
• Objective diagnostic confirmation through testing such as sucrase enzyme activity assessment, genetic testing, or breath testing when clinically appropriate.
• Documentation that symptoms are consistent with CSID and expected to benefit from enzyme replacement therapy.
For plan sponsors, ensuring that high-cost therapies are supported by appropriate diagnostic evidence helps balance access to care with responsible management of healthcare resources.
At ProAct, we believe utilization management is most effective when it focuses on clinical appropriateness. The goal is not to create barriers to care, but to ensure the right patient receives the right medication for the right diagnosis at the right time.
