Alnylam Assist™ Online Start Form

Help your patients get started on AMVUTTRA® (vutrisiran) by filling out the electronic Start Form together.
The purpose of this form is to permit Alnylam Assist™ participants to receive additional information and support (“Patient Support”) from Alnylam Pharmaceuticals, Inc., its affiliates, representatives, agents, and contractors (“Alnylam”). Alnylam Assist™ provides Patient Support to eligible patients who have been prescribed an Alnylam medicine. This includes: (1) providing reimbursement and financial support to eligible patients (such as investigating your insurance coverage, confirming out-of-pocket costs, and reviewing eligibility for financial assistance); (2) working with you and your provider to fill your prescription; and (3) providing you with disease and medication-related educational resources and communications. Your authorization in this form will relate to information and support with respect to any Alnylam medicine you have been prescribed or may be prescribed in the future.
PLEASE NOTE: Patients and healthcare providers should be together when filling out the Start Form. Consent via electronic signature is mandatory for submission of the form. Forms must be submitted once started, as progress will not be saved. If you are unable to complete the electronic Start Form with your patient, you can begin filling out the form and email it to your patient via DocuSign.
This form is best viewed using the latest version of Chrome, Safari, or Firefox.
  • Patient Information
  • Insurance Information
  • Patient Authorization
  • Prescriber Information
  • AMVUTTRA® (vutrisiran) Prescription
  • Confirm & Submit
Patient Information
* Indicates required field
Caregiver Information (Optional)
Additional Patient Information
* Language Translation?
HCP Triangles transparent

IMPORTANT SAFETY INFORMATION

Reduced Serum Vitamin A Levels and Recommended Supplementation
AMVUTTRA® (vutrisiran) treatment leads to a decrease in serum vitamin A levels.

Supplementation at the recommended daily allowance (RDA) of vitamin A is advised for patients taking AMVUTTRA. Higher doses than the RDA should not be given to try to achieve normal serum vitamin A levels during treatment with AMVUTTRA, as serum vitamin A levels do not reflect the total vitamin A in the body.

Patients should be referred to an ophthalmologist if they develop ocular symptoms suggestive of vitamin A deficiency (e.g., night blindness).

Adverse Reactions
The most common adverse reactions that occurred in patients treated with AMVUTTRA were pain in extremity (15%), arthralgia (11%), dyspnea (7%), and vitamin A decreased (7%).

INDICATION

AMVUTTRA® (vutrisiran) is indicated for the treatment of the polyneuropathy of hereditary transthyretin-mediated amyloidosis in adults.

For additional information about AMVUTTRA, please see the full Prescribing Information.