Filgrastim (G-CSF) (Neupogen) , TBO-Filgrastim (Granix)

OFFICE / HOME HEALTH / SELF ADMINISTRATION

JCODE: J1440 (300 mcg); J1441 (480 mcg)

Approved for the following indications (TBO-Filgrastim preferred unless noted below):

  • Prophylaxis in pts with non-myeloid leukemia, lymphoma, solid tumor, or recurrent myeloid malignancy who are receiving myelosuppressive chemotherapeutic agents

  • Bone marrow transplantation (Neupogen preferred)

  • Treatment of patients receiving myelosuppressive anticancer drug with neutropenia

  • Following Radiotherapy

  • Dose Dense Chemotherapy for Breast Cancer

Indications that require prior authorization:

  • Congenital agranulocytosis

  • Cyclic neutropenia

  • Myelodysplastic syndromes

  • AIDS pts. on myelosuppressive therapy

  • Active infection with febrile neutropenia

  • Drug-induced neutropenia in an HIV-infected patient (Septra, ganciclovir) when therapy cannot be stopped or modified

When the above conditions (3-6) are met, approve if:

  • Initial absolute neutrophil count (ANC) <800/mm or ANC < 1000/mm with expected neutropenia of > 5 days

  • For cyclic neutropenia and congenital granulocytosis, must have at least 3 clinically significant infections requiring antibiotic therapy, or at least one life threatening infection within the past year

  • Peg-Interferon induced neutropenia, only when decreasing Peginterferon dose by 50% does not result in ANC > 750

The following do not meet criteria for coverage:

  • Auto Immune Disorders

  • Burn Patients

  • CML

  • Chronic Infections

  • ANC > 1000/mm

Dosing:

  • 5 mcg/kg/day; if no increase in ANC is seen after 5 days, the dose of filgrastim may be increased to 10mcg/kg/day. If ANC does not increase after additional 5 days, discontinue treatment

  • Dosing is titrated to maintain ANC between 800/mm – 1400/mm

  • Dosing continued beyond 10 days only if response is documented

  • Initial: 10 days, then re-evaluate. If response is seen, may allow up to two months, then must re-review

  • Dosage for chemotherapy: 5 mcg/Kg/day beginning day after chemotherapy and continuing past the expected nadir and discontinued when ANC > 3000

  • Neulasta (pegfilgrastim) has no therapeutic advantage over filgrastim. Neulasta requires a prior authorization for intolerance to filgrastim


 

Last review date: July 24, 2016