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

JCODE: J1440 (300 mcg)

    J1441 (480 mcg)

Office/Home Health Administration

or

Self Administration

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.

Western Health Advantage Pharmacy and Therapeutics Committee

Approved/Revised: November 2004 Reviewed: December 2013 Reviewed by: NorthBay

Last review date: July 24, 2016