Emicizumab-kxwh (Hemlibra®)

OFFICE OR HOME HEALTH ADMINISTRATION

Indications for Prior Authorization:

  • Indicated for the routine prophylaxis to prevent or reduce the frequency of bleeding episodes in adult and pediatric patients with hemophilia A (congenital factor VIII deficiency) with or without factor VIII inhibitors

Patients must meet the following criteria for the indication above:

  • Diagnosis of hemophilia A (congenital factor VIII deficiency), AND
  • Prescribed by or in consultation with a hemophilia specialist, AND
  • The patient has factor VIII inhibitors

Dosing:

  • Loading dose: 3 mg/kg by subcutaneous injection once weekly for the first 4 weeks
  • Maintenance dose:
    • 1.5 mg/kg once every week, OR
    • 3 mg/kg once every two weeks, OR
    • 6 mg/kg once every four weeks
  • Discontinue the prophylactic use of bypassing agents the day before starting Hemlibra prophylaxis
  • The prophylactic use of factor VIII (FVIII) products may be continued during the first week of Hemlibra prophylaxis

Approval:

  • 1 year

Last review date: December 17, 2018