Golimumab (Simponi®)

SELF  / OFFICE ADMINISTRATION

Indications for Prior Authorization:

  • Moderate to severe rheumatoid arthritis
  • Psoriatic arthritis
  • Ankylosing spondylitis
  • Ulcerative colitis

Patients must meet the following criteria for the indications above:

  • For approval for Rheumatoid Arthritis, patient must fail two of the four preferred:  adalimumab (Humira®) AND/OR etanercept (Enbrel®) AND/OR tocilizumab (Actemra®) AND/OR tofacitinib (Xeljanz®).  
  • For approval for Ankylosing Spondylitis, patient must fail two of the three preferred:  adalimumab (Humira®) AND/OR etanercept (Enbrel®) AND/OR secukinumab (Cosentyx®).
  • For approval for Psoriatic Arthritis, patient must fail two of the four preferred:  adalimumab (Humira®) AND/OR etanercept (Enbrel®) AND/OR ustekinumab (Stelara®) AND/OR secukinumab (Cosentyx®).
  •  For approval for Ulcerative Colitis, patient must have tried and failed adalimumab (Humira®).
  • Failure is defined as patient not in remission OR has clinically significant adverse reaction to the preferred medication(s).  

Dosing:

Rheumatoid Arthritis

  • Golimumab is patient administered by subcutaneous injection (SubQ) 50 mg, once monthly

Ulcerative Colitis

  • Self-inject 200mg SubQ initially, then 100mg SubQ at week two. Inject 100mg once a month for maintenance therapy

Ankylosing Spondylitis

  • Up to 50mg SubQ once a month

Psoriatic Arthritis

  • Up to 50mg SubQ once a month

Approval:

  • Initial approval 3 months to assess patient’s response
  • Renew for one year if patient has clinical response

Risk of Tuberculosis and Serious Infection:

Patients should be evaluated for latent tuberculosis infection with a TB skin test. Treatment of latent tuberculosis infection should be initiated prior to therapy with golimumab

Do not administer live vaccines or attenuated vaccines concurrently with golimumab


 

Last review date: July 21, 2016

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