DAURISMO (glasdegib)

SELF ADMINISRATION - ORAL

Indications for Prior Authorization:

  • Indicated, in combination with a low-dose cytarabine, for the treatment of newly diagnosed acute myeloid leukemia (AML) in adult patients who are ≥ 75 years of age or who have comorbidities that preclude use of intensive induction chemotherapy.

Patients must meet the following criteria for the indication(s) above:

  • Patient is ≥ 18 years of age, AND
  • Patient meets one of the following:
    • Age ≥ 75 years of age, OR
    • Inability to use  intensive induction chemotherapy supported by medical justification
  • Diagnosis of AML confirmed by chart note documentation, AND
  • Prescribed by or in consultation with an oncologist or hematologist, AND
  • Prescribed in combination with cytarabine

Dosing:

  • Oral: 100 mg once daily (in combination with subcutaneous low-dose cytarabine) for a minimum of 6 (28-day) cycles
  • Available in 25 mg and 100 mg tablets
  • Dose does not exceed 100 mg (1 tab) per day

Approval:

  • 1 year

 

Last review date: April 16, 2019

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