MOZOBIL (plerixafor)
OFFICE ADMINISTRATION OR SELF ADMINISTRATION - Subcutaneous injection
Indication for Prior Authorization:
- Indicated in combination with granulocyte-colony stimulating factor (G-CSF) to mobilize hematopoietic stem cells (HSCs) to the peripheral blood for collection and subsequent autologous transplantation in patients with non-Hodgkin's lymphoma (NHL) and multiple myeloma (MM).
Patients must meet the following criteria for the indication(s) above:
- Patient is 18 years of age or older, AND
- Chart note documentation is provided documenting one of the following:
- Patient with non-Hodgkin's lymphoma (NHL) who will be undergoing autologous hematopoietic stem cell (HSC) transplantation, OR
- Patient with multiple myeloma (MM) who will be undergoing autologous HSC transplantation, AND
- Prescribed by or in consultation with a hematologist/oncologist, AND
- Used in combination with granulocyte-colony stimulating factor (G-CSF) [e.g., Granix®, Neupogen®, Zarxio®, Nivestym™]
Dosing:
- Begin treatment with Mozobil® after the patient has received G-CSF once daily for 4 days.
- Administer Mozobil® approximately 11 hours prior to initiation of each apheresis for up to 4 consecutive days.
- Dosing is based on body weight:
- Weight less than or equal to 83 kg: 20 mg fixed dose or 0.24 mg/kg once daily
- Weight greater than 83 kg: 0.24 mg/kg once daily
- Maximum dose: 40 mg/day
- Each vial delivers 1.2 mL of 20 mg/mL solution, volume to be administered to patients should be calculated from the following equation: 0.012 x patient's actual body weight (in kg) = volume to be administered (in mL)
- Mozobil® dosing is modified for creatinine clearance 50 mL/min or less:
- Weight less than or equal to 83 kg: 13 mg fixed dose or 0.16 mg/kg once daily
- Weight greater than 83 kg and less than 160 kg: 0.16 mg/kg once daily
- Maximum dose: 27 mg/day
- Mozobil® dose and treatment of patients weighing more than 175% of ideal body weight have not been investigated.
- See package insert for full dosing information
- Administer daily morning doses of G-CSF 10 mcg/kg for 4 days prior to the first evening dose of Mozobil® and on each day prior to apheresis.
Approval:
- 1 treatment course (up to 4 days)
Review History:
- 8/18/2020 - Original review
- 10/12/2020 - Update to administration location