Abatacept (Orencia)

JCODE: J0129

OFFICE ADMINISRATION OR SELF INJECTION

Indications for Prior Authorization:

  • Moderate to Severe active Rheumatoid Arthritis
  • Juvenile Idiopathic Arthritis (ages: six-17)

Patients must meet the following criteria for the indications above:

Rheumatoid Arthritis

  • Diagnosis of moderate to severe active rheumatoid arthritis by Rheumatologist (the prescribing MD does not have to be a rheumatologist) AND
  • Inadequate response to one or more Disease Modifying Anti-Rheumatic Drugs (DMARDs): Auranofin (Ridaura), Azathioprine (Imuran), Gold sodium thiomalate (Aurolate), Hydroxychloroquine (Plaquenil, Methotrexate (Rheumatrex), D-penicillamine (Cuprimine), Sulfasalazine (Azulfidine). Inadequate response to at least one TNF antagonist: etanercept (Enbrel), infliximab (Remicade), or adalimumab (Humira), AND
  • Inadequate response to at least two preferred biologic agents: Humira, Enbrel, Actemra, Xeljanz

Juvenile Idiopathic Arthritis

  • Diagnosis of active Juvenile Idiopathic Arthritis in patients six-17 years old confirmed by a rheumatologist AND
  • Inadequate response to one or more Disease Modifying Anti-Rheumatic Drugs (DMARDs): Auranofin (Ridaura), Azathioprine (Imuran), Gold sodium thiomalate (Aurolate), Hydroxychloroquine (Plaquenil, Methotrexate (Rheumatrex), D-penicillamine (Cuprimine), Sulfasalazine (Azulfidine). OR
  • Documented medical justification why methotrexate and sulfasalazine cannot be used. AND
  • Inadequate response to at least one TNF antagonist: etanercept (Enbrel), infliximab (Remicade), or adalimumab (Humira).

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee:

  • Crohn’s Disease
  • Ulcerative Colitis
  • Psoriasis
  • Psoriatic Arthritis
  • Irritable Bowel Disease

Abatacept should not be given concomitantly with a TNF antagonist or anakinra.

Dosing:

Rheumatoid Arthritis

  • Intravenous:  Dose is given at weeks 0, 2, and 4; then every 4 weeks thereafter according to body weight:
Body Weight Dose Number of Vials
< 60 kg 500 mg 2
60 - 100 kg 750 mg 3
> 100 kg 1000 mg 4
  • Subcutaneous:  125 mg SubQ injection given within one day of an intravenous loading dose (based on the above chart), then 125 mg SC injection once weekly thereafter*
    • Patients who are unable to receive an infusion may initiate weekly injections of subcutaneous abatacept without an intravenous loading dose OR
    • Patients transitioning from abatacept intravenous therapy to subcutaneous administration should administer the first subcutaneous dose instead of the next scheduled intravenous dose

Juvenile Idiopathic Arthritis

  • Intravenous only:  Dose is given at weeks 0, 2, and 4; then every 4 weeks therafter according to body weight:
Body Weight Dose
< 75 kg 10 mg/kg
> or = 75 kg Use adult dosing up to a maximum of 1000 mg

 

Coverage Period:

Cover yearly based upon patient's continued response to therapy


 

Last review date: July 20, 2016

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