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From access to assessment—here are tools to help

Downloads for Healthcare Professionals

Service Request Form (SRF)
  • Download and complete the fillable SRF here and fax it to APSS at 1-888-883-3053.
  • Or you can submit the SRF online via the iAssist ePrescribing portal.
60-Day Free* Trial SRF
  • Specifically for starting your patient on the 60-Day Free* Trial. Download it here and fax completed form to APSS.
  • Or fill it out and submit online here via the iAssist ePrescribing portal.

Downloads for Your Patients

Patient Brochure
  • An educational booklet with information about MS-related walking difficulty and AMPYRA that you can distribute to your patients.
60-Day Free Trial Brochure
  • A quick reference for eligible patients explaining the details of the AMPYRA 60-Day Free* Trial.

Provide your eligible patients with a 60-Day Free* Trial of AMPYRA

*Limitations and restrictions apply.
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, multiple sclerosis 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 and well-controlled studies of AMPYRA in pregnant women. AMPYRA should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
  • It is not known if AMPYRA passes into breast milk. Discontinue AMPYRA or nursing, taking into consideration the importance of AMPYRA to the mother.
  • 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.