ramucirumab (Cyramza®)

OFFICE ADMINISTRATION

Indications for Prior Authorization:

  • Patients with advanced/metastatic gastric adenocarcinoma with progression after prior fluoropyrimidine or platinum chemotherapy
  • Non-small cell lung cancer (NSCLC, metastatic)

Patients must meet the following criteria for the indications above:

Advanced/metastatic gastric adenocarcinoma

  • Documented diagnosis of advanced/metastatic gastric adenocarcinoma with progression after prior fluoropyrimidine or platinum chemotherapy

Non-small cell lung cancer (NSCLC, metastatic)

  • Diagnosis of metastatic NSCLC, AND
  • Disease progression on or after platinum-based chemotherapy, AND
  • Being used in combination with docetaxel, AND
  • One of the following:
    • Negative EGFR or ALK mutation, OR
    • Positive EGFR or ALK mutation AND prior treatment with FDA-approved therapy* for EGFR or ALK genomic tumor aberrations, OR
    • Unknown EGFR or ALK mutation status, AND
    • Patient has pure squamous cell histology
    • *Table of FDA-approved therapies for NSCLC tumors expressing EGFR or ALK genomic tumor abberations.
      • EGFR:  erlotinib (Tarceva), afatinib (Gilotrif)
      • ALK:  crizotinib (Xalkori), ceritinib (Zykadia)

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

  • Any other diagnosis not listed in the approved indications

Dosing:

Advanced/metastatic gastric adenocarcinoma

  • The dose of ranibizumab is 8 mg/kg by IV infusion over 60 minutes every 2 weeks

Non-small cell lung cancer (NSCLC, metastatic)

  • Up to 10mg/kg IV on day 1 of 21-day cycles

Monitoring:

  • Pre-medicate with intravenous histamine (H1) antagonist

 

Last review date: July 21, 2016

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