ADCETRIS (brentuximab)
OFFICE ADMINISTERED
Indication(s) for Prior Authorization:
- Hodgkin Lymphoma, refractory/relapsed
- Systemic anaplastic large cell lymphoma (sALCL), refractory
Patients must meet all the following criteria for the indication above:
Hodgkin Lymphoma, refractory/relapsed
- Diagnosis is relapsed or refractory Hodgkin Lymphoma AND
- Being used as monotherapy AND
- Either of the following
- Failure or inadequate response to High Dose Therapy/Autologous Stem Cell Rescue (HDT/ASCR) OR
- Failed at least two prior multi-agent chemotherapy regimens, if patient is not a candidate for HDT/ASCR
Systemic anaplastic large cell lymphoma (sALCL), refractory
- Diagnosis of refractory systemic anaplastic large cell lymphoma AND
- Being used as monotherapy AND
- Failure or inadequate response to at least one multi-agent chemotherapy regimen
The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee:
- Disease states not listed above
- Relapsed/refractory cutaneous ALCL
Dosing:
- Up to 1.8mg/kg IV infusion every 3 weeks*
*for patients >100 kg, dose should be calculated using a weight of 100kg
Last review date: December 1, 2014