Fostamatinib disodium hexahydrate (Tavalisse™)


Indications for Prior Authorization:
  • Indicated for the treatment of thrombocytopenia in adult patients with chronic immune thrombocytopenia (ITP) who have had an insufficient response to a previous treatment.
Patients must meet the following criteria for the indication(s) above:
  • Patient is at least 18 years of age, AND
  • Tavalisse is prescribed by or after consultation with a hematologist, AND
  • The patient meets one of the following criteria:
    • The patient has tried one other therapy (e.g., corticosteroids, intravenous immunoglobulin, anti-D immunoglobulin, Promacta®, Nplate®, or Rituxan®), OR
    • The patient has undergone splenectomy
  • Initiate at a dose of 100 mg taken orally twice daily.  After a month, if platelet count has not increased to at least 50 x 109/L, increase Tavaliise dose to 150 mg twice daily.
  • 1 year

Last review date: April 30, 2019

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