Treatment Form

Getting your patient started with NORTHERA® (droxidopa)

NORTHERA can be prescribed directly to a Specialty Pharmacy or through the Northera Support Center (NSC) using the following NORTHERA Treatment Form.

STOP HERE if you choose to prescribe directly to a Specialty Pharmacy through your electronic health record system. NO TREATMENT FORM IS REQUIRED.

IF PRESCRIBING THROUGH THE NSC, COMPLETE THE NORTHERA TREATMENT FORM IN ITS ENTIRETY AND FAX ALL PAGES TO 844-601-0102
Please ensure the following:
  • All required fields (indicated by red asterisk) are complete
  • The patient (or authorized representative) has signed the HIPAA release and the release is faxed over with the rest of the documents
  • The Initial NORTHERA Prescription Information section is completed and signed by the prescriber
  • Patient clinical notes from up to the last three visits are faxed along with the rest of the paperwork

There are 2 ways to proceed

START THE ONLINE TREATMENT FORM

This form will time out after 20 minutes. Please ensure you have uninterrupted time to complete this form. After completion, fax all pages to the NSC.

or
DOWNLOAD TREATMENT FORM PDF

This PDF is an alternative to the interactive form above and may be filled out, printed, and faxed at a later time for your convenience. See an example of a completed form here.

Use

NORTHERA (droxidopa) is a prescription medication used to reduce dizziness, lightheadedness, or the “feeling that you are about to black out” in adults who experience a significant drop in blood pressure when changing positions or standing (called symptomatic neurogenic orthostatic hypotension (nOH)) and who have one of the following:

  • Parkinson’s disease (PD), a neurodegenerative disease that causes slowness in muscle movement as well as shaking in the hands
  • Multiple system atrophy (MSA), a Parkinson’s-like disorder with more widespread effects on the brain and body
  • Pure autonomic failure (PAF), a neurodegenerative disease that results in frequent drops in blood pressure upon standing
  • Dopamine beta-hydroxylase deficiency, a condition where the body cannot make enough of the hormones that help regulate blood pressure
  • Non-diabetic autonomic neuropathy, an inability to maintain blood pressure upon standing that can be caused by a number of rare diseases

Effectiveness beyond 2 weeks of treatment has not been established, and your doctor will decide if you should continue taking NORTHERA.

IMPORTANT SAFETY INFORMATION

WARNING: SUPINE HYPERTENSION (this is high blood pressure while lying down)

When lying down, elevating the head and upper body lowers the risk of high blood pressure. Check your blood pressure in this position prior to starting and during NORTHERA treatment. If you experience high blood pressure, talk to your doctor about your NORTHERA treatment.

  • Do not take NORTHERA if you have a known allergy to NORTHERA or its ingredients.
  • NORTHERA may cause high blood pressure when lying down, which could lead to strokes, heart attacks, and death. To reduce this risk of supine hypertension, take your late afternoon dose of NORTHERA at least 3 hours before going to bed.
  • Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening side effect reported with NORTHERA. Call your doctor right away and go to the nearest emergency room if you develop these signs and symptoms: high fever, stiff muscles, movements that you cannot control, confusion or problems thinking, very fast or uneven heartbeats, or increased sweating. NORTHERA should be stopped immediately if NMS is diagnosed.
  • If you have coronary artery disease, irregular heartbeat, or heart failure, NORTHERA may worsen the symptoms of these disorders. Call your doctor if your symptoms become worse.
  • NORTHERA may cause allergic reactions. Stop taking NORTHERA and contact your doctor right away, or go to the nearest emergency room if you experience any signs or symptoms of an allergic reaction such as: fast heartbeat, nausea, vomiting, swelling, trouble breathing, hives, or rash. NORTHERA contains tartrazine (FD&C Yellow No. 5), which may also cause an allergic reaction, especially if you have had a reaction to aspirin.
  • The most common side effects with NORTHERA are headache, dizziness, nausea, and high blood pressure.
  • Taking NORTHERA with other medications may cause side effects. Tell your doctor if you take prescription or over-the-counter medicines, vitamins, or herbal supplements.
  • You should not breastfeed during treatment with NORTHERA.
  • If you plan to become or are currently pregnant, talk to your doctor as it is not known if NORTHERA could harm your unborn baby.
  • Take NORTHERA the same way each time, either with or without food.
  • If you miss a dose of NORTHERA, take your next dose at the regularly scheduled time. Do not double the dose.

For more information, please see the full Prescribing Information, including Boxed Warning for supine hypertension.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

Use

NORTHERA (droxidopa) is a prescription medication used to reduce dizziness, lightheadedness, or the “feeling that you are about to black out” in adults who experience a significant drop in blood pressure when changing positions or standing (called symptomatic neurogenic orthostatic hypotension (nOH)) and who have one of the following:

  • Parkinson’s disease (PD), a neurodegenerative disease that causes slowness in muscle movement as well as shaking in the hands
  • Multiple system atrophy (MSA), a Parkinson’s-like disorder with more widespread effects on the brain and body
  • Pure autonomic failure (PAF), a neurodegenerative disease that results in frequent drops in blood pressure upon standing
  • Dopamine beta-hydroxylase deficiency, a condition where the body cannot make enough of the hormones that help regulate blood pressure
  • Non-diabetic autonomic neuropathy, an inability to maintain blood pressure upon standing that can be caused by a number of rare diseases

Effectiveness beyond 2 weeks of treatment has not been established, and your doctor will decide if you should continue taking NORTHERA.

IMPORTANT SAFETY INFORMATION

WARNING: SUPINE HYPERTENSION (this is high blood pressure while lying down)

When lying down, elevating the head and upper body lowers the risk of high blood pressure. Check your blood pressure in this position prior to starting and during NORTHERA treatment. If you experience high blood pressure, talk to your doctor about your NORTHERA treatment.

  • Do not take NORTHERA if you have a known allergy to NORTHERA or its ingredients.
  • NORTHERA may cause high blood pressure when lying down, which could lead to strokes, heart attacks, and death. To reduce this risk of supine hypertension, take your late afternoon dose of NORTHERA at least 3 hours before going to bed.
  • Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening side effect reported with NORTHERA. Call your doctor right away and go to the nearest emergency room if you develop these signs and symptoms: high fever, stiff muscles, movements that you cannot control, confusion or problems thinking, very fast or uneven heartbeats, or increased sweating. NORTHERA should be stopped immediately if NMS is diagnosed.
  • If you have coronary artery disease, irregular heartbeat, or heart failure, NORTHERA may worsen the symptoms of these disorders. Call your doctor if your symptoms become worse.
  • NORTHERA may cause allergic reactions. Stop taking NORTHERA and contact your doctor right away, or go to the nearest emergency room if you experience any signs or symptoms of an allergic reaction such as: fast heartbeat, nausea, vomiting, swelling, trouble breathing, hives, or rash. NORTHERA contains tartrazine (FD&C Yellow No. 5), which may also cause an allergic reaction, especially if you have had a reaction to aspirin.
  • The most common side effects with NORTHERA are headache, dizziness, nausea, and high blood pressure.
  • Taking NORTHERA with other medications may cause side effects. Tell your doctor if you take prescription or over-the-counter medicines, vitamins, or herbal supplements.
  • You should not breastfeed during treatment with NORTHERA.
  • If you plan to become or are currently pregnant, talk to your doctor as it is not known if NORTHERA could harm your unborn baby.
  • Take NORTHERA the same way each time, either with or without food.
  • If you miss a dose of NORTHERA, take your next dose at the regularly scheduled time. Do not double the dose.

For more information, please see the full Prescribing Information, including Boxed Warning for supine hypertension.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.