Infliximab (Remicade)

Office administration

Indications for Prior Authorization

Moderate to Severe Rheumatoid Arthritis

  • Diagnosis by Rheumatologist (the prescribing MD does not have to be a rheumatologist); AND
  • Inadequate response to one or more Disease Modifying Anti-Rheumatic Drugs (DMARDs): Auranofin (Ridaura), Azathioprine (Imuran), Gold sodium thiomalate (Aurolate), Hydroxychloroquine (Plaquenil, Methotrexate (Rheumatrex), D-penicillamine (Cuprimine), Sulfasalazine (Azulfidine); AND
  • The patient is not currently taking another anti-TNF drug or interleukin-1 receptor antagonist

Crohn's Disease: Adult and Pediatric (six years old or more)

  • Diagnosis is Moderate to Severe Active Crohn's Disease; AND
  • Patient has failed or has a documented intolerance or contraindication to one agent from either of the following classes: oral corticosteroids or immunosuppressants; AND
  • The patient is not currently taking another anti-TNF drug or interleukin-1 receptor antagonist

Psoriatic Arthritis

  • Diagnosis by Rheumatologist (the prescribing MD does not have to be a rheumatologist); AND
  • Inadequate response to one or more Disease Modifying Anti-Rheumatic Drugs (DMARDs): Auranofin (Ridaura), Azathioprine (Imuran), Gold sodium thiomalate (Aurolate), Hydroxychloroquine (Plaquenil, Methotrexate (Rheumatrex), D-penicillamine (Cuprimine), Sulfasalazine (Azulfidine); AND
  • The patient is not currently taking another anti-TNF drug or interleukin-1 receptor antagonist Western Health Advantage Pharmacy and Therapeutics Committee Approved: December, 2008 Reviewed: July 2011

Ankylosing Spondylitis

  • Diagnosis by Rheumatologist (the prescribing MD does not have to be a rheumatologist); AND
  • Patients must have an inadequate response to two agents in the following list: NSAIDs (including COX-2 inhibitors) at maximum tolerated doses for at least three months, sulfasalazine, methotrexate, or intra-articular steroid injection

Ulcerative Colitis (UC)

  • Diagnosis of Moderate to Severe Ulcerative Colitis; AND
  • Patients have had an inadequate response or intolerance with three agents to treat UC. Treatment must include at least one agent from three different accepted medication classes in the following list: oral corticosteroids, oral aminosalicylates, immunomodulatory medications, peri-rectal therapy (such as mesalamine), and IV corticosteroids or IV cyclosporine; AND
  • The patient is not currently taking another anti-TNF drug or interleukin-1 receptor antagonist

Plaque Psoriasis

Patients must meet the following criteria

  • Diagnosis of Moderate to severe plaque psoriasis for at least one year by Rheumatologist (the prescribing MD does not have to be a rheumatologist)
  • Must be 18 years of age or older
  • Baseline PASI score of 10 or more
  • Must have failed PUVA or UVB or is intolerant to treatment
  • Must have failed treatment with at least one of the following three therapies: methotrexate or cyclosporine, or acitretin

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee.

  • Multiple Sclerosis
  • Hairy cell leukemia
  • Infertility
  • Use in pediatric patients, except Crohn's disease
  • Adult Still's Disease

Dosing

Recommended dose for Rheumatoid arthritis

  • 3 mg/Kg IV followed with additional doses at two and six weeks.
  • Then every eight weeks thereafter.

Recommended dose for Crohn's Disease

  • 5 mg/Kg initially, then again at weeks two and six.
  • Then every eight weeks thereafter.
  • Maximum 14 infusions per year adults, seven infusions per year children

Recommended dose for Ulcerative Colitis

  • 5 mg/Kg initially, then again at weeks two and six.
  • Then every eight weeks thereafter.
  • Maximum seven infusions per year.

Recommended dose for Ankylosing Spondylitis

  • 5 mg/Kg initially, then again at weeks two and six.
  • Then every six weeks thereafter.
  • Maximum nine infusions per year.

Recommended dose for Psoriatic Arthritis

  • 5 mg/Kg initially, then again at weeks two and six.
  • Then every eight weeks thereafter.
  • Maximum seven infusions per year.

Recommended dose for Plaque Psoriasis

  • 5 mg/Kg initially, then again at weeks two and six.
  • Then every eight weeks thereafter.
  • Maximum seven  infusions per year.

Western Health Advantage Pharmacy and Therapeutics Committee

Approved: December, 2008 Reviewed: December 2013