agalsidase beta (Fabrazyme ®)

OFFICE ADMINISTRATION

Indication(s) for Prior Authorization:

  • Fabry disease

Patients must meet all the following criteria for the indication above:

Male with Fabry Disease

  • Diagnosed and followed by a geneticist or nephrologist
    • Low or undetectable levels of Alpha-Gal A (<1.5 nmol/hr/ml in plasma or <4 nmol/hrmg in leukocytes OR
    • DNA test showing a mutation

Female with Fabry Disease

  • Diagnosed and followed by a geneticist or nephrologist
  • DNA test showing mutation AND
  • Has clinical symptoms of the disease (renal dysfunction, cardiomyopathy, neuropathy, proteinuria, acroparesthesias, etc.)

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

Dosing:

  • Up to 1mg/kg infusion every 2 weeks

 

 

Last review date: December 1, 2014