Fostamatinib disodium hexahydrate (Tavalisse™)
SELF ADMINISTRATION - ORAL
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