Filgrastim (G-CSF) (Neupogen) , TBO-Filgrastim (Granix)
JCODE: J1440 (300 mcg)
J1441 (480 mcg)
Office/Home Health 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
- Chronic Infections
- ANC > 1000/mm
- 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