Ponatinib (Iclusig®)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

  • Treatment of adult patients with chronic, accelerated, or blast phase chronic myeloid leukemia (CML)
  • Treatment of adult patients with Philadelphia chromosome positive (Ph+) acute lymphoblastic leukemia (ALL)

Patients must meet the following criteria for the indication(s) above:

  • Patient is resistant or intolerant to prior tyrosine kinase inhibitor therapy
    • CML: Gleevec, Sprycel, Tasigna and Bosulif
    • Ph+ ALL: Gleevec and Sprycel
  • For ALL, patients must undergo genetic testing to confirm Ph+ status
  • Patient must not be pregnant or planning on becoming pregnant

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:

  • All non-FDA approved uses not listed in the approved indications

Dosing:

  • 45 mg orally once a day

Box warnings: 

  • For arterial/venous thrombosis, hepatotoxicity, congestive heart failure, pancreatitis, cardiac arrhythmias and myelosuppression

Approval:

One year or until disease progression or intolerable side effects


 

Last review date: December 2, 2013

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