Alefacept (Amevive)

APPROVED FOR: OFFICE ADMIN

USE JCODE: J3490

Alefacept should only be used under the guidance and supervision of a physician.

Indications for Prior Authorization

  • moderate to severe Plaque Psoriasis

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

  • Rheumatoid Arthritis
  • Psoriatic Arthritis
  • Patient has HIV infection or CD4+ count less then 250 cells/mcl

ALL OF THE FOLLOWING MUST BE MET:

  • Must be > 18 years old
  • Must be diagnosed and prescribed by a Dermatologist
  • Must have diagnosis of moderate to severe plaque psoriasis for at least one year
  • Must have psoriasis over greater then or equal to 10% body surface area involvement
  • Must have failed treatment with PUVA or UVB or is intolerant/contraindication to PUVA and UVB.
  • Must have failed treatment with at least 2 out of 3: with Methotrexate or Cyclosporine (Neoral) or Acitretin (Soriatane) or is intolerant/contraindication to Methotrexate, Cyclosporin, and Acitretin.

OBTAIN THE FOLLOWING:

  • Baseline CD4
  • Percent of body surface area involvement of psoriasis

OBTAIN IF POSSIBLE:

  • Baseline PASI

Dosing

Moderate to severe plaque psoriasis:

  • 7.5 mg IV bolus once weekly for 12 weeks, or 15 mg IM once weekly for 12 weeks.

Monitoring:

  • Must monitor CBC weekly during therapy
  • CD4+ counts must be normal (>250 cells/μL) Western Health Advantage Pharmacy and Therapeutics Committee Approved: July 2006 Reviewed: July 2011

Alefacept should only be used under the guidance and supervision of a physician.

  • Dosing should be withheld if CD4+ T lymphocyte counts < 250 cells/μL.
  • The drug should be discontinued if the counts remain < 250 cells/μL for one month.

Approval Period

Initial approval for 12 weeks (first course of treatment).

Approve for 2nd course of treatment for 12 weeks if:

  • Minimum of 12 weeks has passed since the end of the last treatment course,

AND

  • CD4 > 250,

AND

  • Patient has shown some response to first treatment (chart documentation, shows some reduction of psoriasis or PASI score from baseline)

Approve for subsequent courses of treatment for 12 weeks each if:

  • Patient has RELAPSED after the first course of treatment, (defined as loss of improvement seen in body surface area involvement of psoriasis after the end of the first course of treatment

OR

  • loss of > 50% of improvement seen in PASI score after the end of the first course of treatment,

AND

  • Minimum of 12 weeks has passed since the end of the last treatment course,

AND

  • CD4 > 250,

AND

  • Prior to relapse, patient had shown a response after the last course of treatment

Western Health Advantage Pharmacy and Therapeutics Committee

Approved: July 2006 Reviewed: December 2013