Azacitidine (Vidaza)

OFFICE ADMINISTRATION

Indications for Prior Authorization:

  • Myelodysplastic syndrome (MDS)
    • refractory anemia
    • chronic myelomonocytic leukemia
  • Acute myeloid leukemia (AML)

All of the following must be met:

  • Refractory anemia
    • failure or significant side effects to treatment with epoetin alpha
  • Acute myeloid leukemia
    • Diagnosis of untreated acute myelogenous leukemia (AML) in elderly patients (>60 years old) who are not considered eligible to receive conventional induction therapy.

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

  • Beta-thalassemia
  • Chronic myelogenous leukemia (CML)
  • Solid tumors
  • Any other diagnosis not listed in the approved indications

Dosing:

Initial

  • Up to 75 mg/m2 SubQ or IV for 7 days q 4 weeks for two treatment cycles

Maintenance

  • Up to 100 mg/m2 SubQ or IV for 7 days, repeat q 4 weeks

Approval:

6 months.


 

Last review date: July 20, 2016

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