TAVALISSE (fostamatinib disodium hexahydrate)

TAVALISSE (fostamatinib disodium hexahydrate)

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

Dosing:

• 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.

Approval:

• 1 year