bendamustine (Treanda®) 

OFFICE ADMINISTERED

Indication(s) for Prior Authorization:

  • Chronic lymphocytic leukemia (CLL)
  • (Classical) Hodgkin Lymphoma, refractory/relapsed
  • Multiple Myeloma, refractory/relapsed
  • Non-Hodgkin’s lymphoma
  • Waldenstrom’s macroglobulinemia/lymphoplasmacytic lymphoma

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

Chronic lymphocytic leukemia (CLL)

  • First line therapy with or without rituximab for stage II-IV disease OR
  • With or without rituximab for relapsed or refractory disease

Hodgkin Lymphoma, refractory/relapsed

  • Diagnosis of refractory or relapsed Hodgkin Lymphoma
  • Third line therapy, failure of two prior chemotherapeutic regimens

Multiple Myeloma, refractory/relapsed

  • Diagnosis of refractory or relapsed Multiple Myeloma

Non-Hodgkin’s lymphoma, subtypes as listed

  • Aids-related B-cell lymphoma
  • Diffuse large B-cell lymphoma
  • Follicular lymphoma
  • Gastric MALT lymphoma
  • Mantle Cell Lymphoma
  • Non-Gastric MALT lymphoma
  • Primary cutaneous B-Cell Lymphoma
  • Splenic marginal zone lymphoma
  • Indolent B-cell lymphoma

Indolent B-cell lymphoma

  • That has progressed during or within six months of treatment with rituximab or a rituximab containing regimen

Waldenstrom’s macroglobulinarmia/lyphoplasmacytic lymphoma

  • Diagnosis of Waldenstrom’s macroglobulinarmia/lyphoplasmacytic lymphoma

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:

Chronic lymphocytic leukemia (CLL)

  • Up to 100 mg/m2 IV infusion on days 1 and 2 of each 28 day cycle.

Hodgkin Lymphoma, refractory/relapsed

  • Up to 120mg/m2 IV infusion on days 1 and 2 of each 28 day cycle.

Multiple Myeloma, refractory/relapsed

  • Up to 100 mg/m2 IV infusion on days 1 and 2 of each 28 day cycle.

Non-Hodgkin’s lymphoma, any subtype listed above

  • Up to 120mg/m2 IV infusion on days 1 and 2 of each 21 day cycle.

Waldenstrom’s macroglobulinarmia/lyphoplasmacytic lymphoma

  • Up to 90 mg/m2 IV infusion on days 1 and 2 (or days 2 and 3) of each 28 day cycle, total dose/cycle = 180mg/m2 OR
  • Up to 90 mg/m2 IV infusion on days 8 and 9, 36 and 37, 64 and 65, 92 and 93, total dose = 720mg/m2

 

Last review date: December 1, 2014