Deferasirox (Exjade®)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

  • Treatment of chronic iron overload due to blood transfusions
  • Treatment of chronic iron overload with non-transfusion dependent thalassemia

Patients must meet the following criteria for the indication(s) above:

Transfusional iron overload

  • Patients age 2 years and older
  • Chelation therapy has proven inadequate
  • Serum ferritin > or = 1000 mcg/L AND CrCl > or = 40 mL/min

Chronic iron overload

  • Patients age 10 and older
  • Serum ferritin > or = 300 mcg/L AND creatinine clearance > or = 40 mL/min
  • Non-transfusion dependent thalassemia syndromes
  • LIC > or = 5 mg Fe per gram of dry weight

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:

  • All non-FDA approved uses not listed in the approved indications

Dosing:

  • Transfusional iron overload: 20-40 mg/Kg orally daily
  • Iron overload (non-transfusion): 10-20 mg/Kg orally daily

Approval:

One year


 

Last review date: July 20, 2016

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