Pharmacy Prior Authorization Criteria

Daurismo (glasdegib)

Indications for Prior Authorization

Daurismo (glasdegib)

• For diagnosis of Acute Myeloid Leukemia (AML)
  Indicated for use in combination with low-dose cytarabine, for the treatment of newly-diagnosed acute myeloid leukemia (AML) in adult patients who are greater than or equal to 75 years old or who have comorbidities that preclude use of intensive induction chemotherapy.

Criteria

Daurismo

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of newly-diagnosed acute myeloid leukemia (AML)
AND
• Used in combination with low-dose cytarabine
AND
• One of the following:
• Patient is greater than or equal to 75 years old
OR
• Patient has comorbidities that preclude use of intensive induction chemotherapy [A]

Daurismo

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient does not show evidence of progressive disease while on therapy

P & T Revisions

2025-03-04, 2024-03-05, 2023-06-05, 2023-03-07, 2022-02-07, 2021-03-04, 2020-03-04

References

1. Daurismo Prescribing Information. Pfizer Inc. New York, NY. December 2024.
2. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology. Acute Myeloid Leukemia. v.2.2025. Available by subscription at: https://www.nccn.org/professionals/physician_gls/pdf/aml.pdf. Accessed February 17, 2025.

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End Notes

1. Examples of comorbid conditions are severe cardiac disease, ECOG performance status greater than or equal to 2, or baseline creatinine greater than 1.3 mg/dL. [2]

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Revision History

• 2025-03-04: 2025 Annual Review. No criteria changes. Updated references.
• 2024-03-05: 2024 Annual Review. No criteria changes. Background updates.
• 2023-06-05: Removed prescriber requirement.
• 2023-03-07: Annual Review
• 2022-02-07: Annual Review
• 2021-03-04: Annual review: Background updates.
• 2020-03-04: Annual review: updated reauthorization criteria and background.

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