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Find out how your patients respond to AMPYRA® (dalfampridine) with a 60-Day Free* Trial

60 DAY FREE* Trial

The 60-Day Free* Trial is designed so eligible MS patients can try AMPYRA and determine if they respond before they or their health plans incur any expense for the drug.

Eligibility Restrictions Apply. For Questions, call 1-888-881-1918.

3 simple steps for registration:

1
Complete the 60-Day Free* Trial Service Request Form (SRF).
  • You should obtain an estimated CrCl.
  • You may want to obtain a baseline Timed 25-Foot Walk test, which may be required for continuing therapy after your patient completes the 60-day free trial of AMPYRA.
2
Fax the completed SRF to AMPYRA Patient Support Services (APSS) at 1-888-883-3053. Or click here to submit it online via the iAssist ePrescribing portal.
  • If the report is complete and accurate, your patient can begin AMPYRA within approximately a week.
3
Give your patient the second page of the SRF, which provides information about their delivery of AMPYRA.

After your patient is registered (for your information; no action required)

  • APSS performs benefit investigation and calls the patient to provide co-pay information and the name of the specialty pharmacy.
  • The specialty pharmacy provider will contact your patient to schedule subsequent delivery of AMPYRA.

Important eligibility requirements

  • The MS patient must be an appropriate patient for AMPYRA†.
  • Patients participating in Medicaid, Medicare, or any other government-funded programs are not eligible.
  • Patients who have received a prescription for AMPYRA within the last 12 months are not eligible.

†See Full Prescribing Information.

Download a 60-Day Free* Trial Service Request Form

*Eligibility Restrictions Apply. For Questions, call 1-888-881-1918.
See more

Indication

AMPYRA® (dalfampridine) Extended Release Tablets, 10 mg, is the first and only brand medication indicated to improve walking in adults with multiple sclerosis (MS). This was demonstrated by an increase in walking speed.

Important Safety Information

AMPYRA is contraindicated in patients with history of seizure, moderate or severe renal impairment (CrCl ≤ 50 mL/min), or history of hypersensitivity to AMPYRA or 4-aminopyridine.

Indication

AMPYRA® (dalfampridine) Extended Release Tablets, 10 mg, is the first and only brand medication indicated to improve walking in adults with multiple sclerosis (MS). This was demonstrated by an increase in walking speed.

Important Safety Information

  • AMPYRA is contraindicated in patients with history of seizure, moderate or severe renal impairment (CrCl ≤ 50 mL/min), or history of hypersensitivity to AMPYRA or 4-aminopyridine.
  • AMPYRA can cause seizures. The risk of seizures increases with increasing doses. Permanently discontinue AMPYRA if seizure occurs. In the post-marketing period seizures have been reported. The majority of seizures occurred at the recommended dose, in patients without a history of seizures, and generally within days to weeks of starting therapy.
  • AMPYRA has not been evaluated in patients with history of seizures or with epileptiform activity on an EEG, as these patients were excluded from clinical trials. The risk of seizures in patients with epileptiform activity on an EEG is unknown, and could be substantially higher than that observed in clinical studies.
  • Avoid concomitant use of AMPYRA with other forms of 4-aminopyridine (4-AP, fampridine), since the active ingredient is the same. Instruct patients to discontinue use of any product containing 4-AP prior to initiating AMPYRA to reduce the potential for dose-related adverse reactions.
  • AMPYRA can cause anaphylaxis and severe allergic reaction. Signs and symptoms included respiratory compromise, urticaria, and angioedema of the throat or tongue. If an anaphylactic or other serious allergic reaction occurs, permanently discontinue AMPYRA.
  • AMPYRA is cleared predominantly by the kidneys. The risk of seizures in patients with mild renal impairment (CrCl 51–80 mL/min) is unknown, but AMPYRA plasma levels in these patients may approach those seen at a dose of 15 mg twice daily, a dose that may be associated with an increased risk of seizures. Estimated CrCl should be known before initiating AMPYRA and monitored at least annually during treatment.
  • The most common adverse reactions (incidence ≥ 2% and at a rate greater than placebo) for AMPYRA in MS patients were urinary tract infection, insomnia, dizziness, headache, nausea, asthenia, back pain, balance disorder, MS relapse, paresthesia, nasopharyngitis, constipation, dyspepsia, and pharyngolaryngeal pain.
  • The risk of adverse reactions, including seizures, increases with increasing AMPYRA doses. There is no evidence of additional benefit at doses greater than 10 mg twice daily.
  • Concomitant use with OCT2 inhibitors (e.g., cimetidine) may cause increased exposure to AMPYRA and potential risk of seizures.
  • There are no adequate data on AMPYRA in pregnant women. Based on animal data, use of AMPYRA during pregnancy may cause fetal harm.
  • There are no data on presence of AMPYRA in breastmilk; benefits of breastfeeding should be considered along with benefit of AMPYRA to the mother and potential risks to the infant.
  • Safety and effectiveness of AMPYRA in patients younger than 18 years have not been established.
  • Clinical studies of AMPYRA did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Because elderly patients are more likely to have decreased renal function, it is important to know the estimated CrCl before initiating AMPYRA.

Please see the Full Prescribing Information.