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Date Printed: August 18, 2017: 10:26 AM

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09-J1000-50

Original Effective Date: 01/01/12

Reviewed: 11/09/16

Revised: 12/15/16

Subject: Sorafenib (Nexavar®) Tablets

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Dosage/ Administration Billing/Coding Reimbursement Program Exceptions Definitions
           
Related Guidelines Other References Updates  
           

DESCRIPTION:

Sorafenib (Nexavar®) is an oral multikinase inhibitor that acts by inhibiting tumor growth and disrupting tumor microvasculature through antiproliferative, anti-angiogenic and proapoptotic effects. It exerts these effects via inhibition of multiple targets including Raf serine/threonine kinases, vascular endothelial growth factor receptor (VEGFR) tyrosine kinases; VEGFR-1, VEGRF-2, VEGRF-3 and platelet-derived growth factor receptor beta. Sorafenib as a single agent has shown promising activity in some cancers including renal cell carcinoma (RCC), hepatocellular carcinoma (HCC), and thyroid cancers. In 2005, the Food and Drug Administration approved sorafenib for the treatment of advanced renal cell carcinoma. Two years later in 2007, sorafenib was FDA-approved for the treatment of unresectable hepatocellular carcinoma.

POSITION STATEMENT:

Comparative Effectiveness

The Food and Drug Administration has deemed the drug(s) or biological product(s) in this coverage policy to be appropriate for self-administration or administration by a caregiver (i.e., not a healthcare professional). Therefore, coverage (i.e., administration) in a provider-administered setting such as an outpatient hospital, ambulatory surgical suite, physician office, or emergency facility is not considered medically necessary.

I. Initiation of sorafenib (Nexavar) meets the definition of medical necessity when the dose does not exceed 400 mg twice daily (800 mg/day), it is administered for treatment of an indication in Table I below, and all of the indication specific criteria are met:

Table 1

Indication

Specific Criteria

Acute Myeloid Leukemia (AML)

Member meets ALL of the following:

1. Sorafenib is used in combination with azacitidine (Vidaza) or decitabine (Dacogen)

2. Treatment is for relapsed or refractory disease

3. FLT3-ITD mutation positive disease

Chordoma

When used as a single agent for the treatment of recurrent chordoma

Hepatocellular carcinoma

When used as a single agent for members with Child-Pugh Class A or B disease and ONE of the following:

1. Unresectable disease and is not a candidate for transplant

2. Metastatic disease

3. Inoperable due to performance status or comorbidities and has local disease with or without minimal extrahepatic involvement

4. Extensive tumor burden

Kidney cancer

When used as a single agent in member’s with relapsed or surgically unresectable stage IV disease meeting ONE of the following:

1. Sorafenib is used as first line or subsequent therapy for disease with predominant clear cell histology

2. Sorafenib is used as treatment for disease with non-clear histology

Osteosarcoma

When used as second-line therapy and member has relapsed, refractory or metastatic disease and ONE of the following:

1. Sorafenib is used as a single agent

2. Sorafenib is used in combination with everolimus

Soft tissue sarcoma:

Angiosarcoma

Desmoid tumors

Gastrointestinal stromal tumors (GIST)

When used as a single agent and sorafenib is used for ONE of the following:

1. angiosarcoma

2. desmoid tumors (aggressive fibromatosis)

3. gastrointestinal stromal tumors after disease progressed on imatinib (Gleevec), sunitinib (Sutent), or regorafenib (Stivarga)

Thyroid cancer:

Follicular carcinoma

Hurthle cell carcinoma

Papillary carcinoma

Medullary carcinoma

When the member meets all criteria for ONE of the following:

1. Follicular carcinoma, Hurthle cell carcinoma, or Papillary carcinoma of the thyroid when used as a single agent for iodine-refractory symptomatic or progressive disease classified as ONE of the following:

a. Unresectable locoregional disease that is recurrent or persistent

b. Distant metastatic disease

2. Medullary carcinoma of the thyroid when used as a single agent for progressive or symptomatic distant metastatic disease and member meets ONE of the following:

a. Disease is refractory to vandetanib (Caprelsa) or cabozantinib (Cometriq)

b. Member is unable to tolerate or has a contraindication to vandetanib (Caprelsa) or cabozantinib (Cometriq)

Approval duration: 180 days (all indications)

II. Continuation of sorafenib (Nexavar®) meets the definition of medical necessity for the indications in Table 1 when the following criteria are met:

A. The member’s disease has not progressed while receiving treatment with sorafenib

B. The member has been previously approved by Florida Blue or another health plan in the past 2 years, OR the member has previously met all indication-specific criteria for coverage

C. The dose does not exceed 400 mg twice daily (800 mg/day)

Approval duration: 1 year

DOSAGE/ADMINISTRATION:

THIS INFORMATION IS PROVIDED FOR INFORMATIONAL PURPOSES ONLY AND SHOULD NOT BE USED AS A SOURCE FOR MAKING PRESCRIBING OR OTHER MEDICAL DETERMINATIONS. PROVIDERS SHOULD REFER TO THE MANUFACTURER’S FULL PRESCRIBING INFORMATION FOR DOSAGE GUIDELINES AND OTHER INFORMATION RELATED TO THIS MEDICATION BEFORE MAKING ANY CLINICAL DECISIONS REGARDING ITS USAGE.

FDA-approved: sorafenib is indicated for the treatment of unresectable hepatocellular carcinoma, advanced renal cell carcinoma, and locally recurrent or metastatic, progressive, differentiated thyroid carcinoma refractory to iodine treatment. The recommended dosage is 400 mg (2 tablets) orally twice daily without food (at least 1 hour before or 2 hour after a meal). Treatment should continue until the member is no longer clinically benefiting from therapy or until unacceptable toxicity occurs.

Dosage Adjustment

i. Renal Impairment: Dosage adjustments are not indicated for members with mild, moderate or severe renal impairment. Sorafenib has not been evaluated in individuals receiving dialysis.

ii. Hepatic Impairment: Dosage adjustments are not indicated for members with mild (Child-Pugh A) or moderate (Child-Pugh B) hepatic impairment. Sorafenib has not been evaluated in individuals with severe (Child-Pugh C) hepatic impairment.

iii. Adverse Reactions: management of suspected adverse drug reactions may require temporary interruption, permanent discontinuation, and/or dose reduction. For renal cell carcinoma or hepatobiliary carcinoma, the dose may be initially reduced to 400 mg once daily; if additional dose reduction is required, sorafenib may be reduced to a single 400 mg dose every other day. For differentiated thyroid carcinomas, the dose may initially be reduced to 600 mg divided twice daily, further reduced to 400 mg divided twice daily, with additional reduction to 200 mg once daily if necessary.

iv. Skin toxicity: suggested dose adjustments for skin toxicity for renal cell carcinoma and hepatobiliary carcinoma are described in Table 1. See prescribing information for dose adjustments for skin toxicity with differentiated thyroid carcinomas.

Table 1

Skin toxicity dose modifications (renal cell carcinoma or hepatobiliary carcinoma)

Skin Toxicity Grade

Occurrence

Dose Modification

Grade 1

Any occurrence

Continue treatment, consider topical therapy for symptomatic relief

Grade 2

1st occurrence

Continue treatment, consider topical therapy for symptomatic relief; if no relief within 7 days, see below

No relief within 7 days or 2nd/3rd occurrence

Interrupt treatment until toxicity resolves to Grade 0-1

When resuming treatment, reduce dose by one dose level (400 mg daily or 400 mg every other day)

4th occurrence

Discontinue treatment

Grade 3

1st or 2nd occurrence

Interrupt treatment until toxicity resolves to Grade 0-1

When resuming treatment, reduce dose by one dose level (400 mg daily or 400 mg every other day)

3rd occurrence

Discontinue treatment

Drug Availability: sorafenib is available as a 200 mg tablet.

PRECAUTIONS:

CONTRAINDICATIONS

Sorafenib is contraindicated in members with known severe hypersensitivity to sorafenib or any other component of the product. Additionally, sorafenib in combination with carboplatin and paclitaxel is contraindicated in members with squamous cell lung cancer.

WARNINGS

Bleeding: if bleeding necessitates medical intervention, discontinue therapy. Temporarily interrupt therapy in members undergoing major surgical procedures

Cardiovascular: cardiac ischemia and/or infarction may occur; consider temporary or permanent discontinuation.

Dermatologic: Interrupt and/or decrease dose. Discontinue for severe reactions or if Stevens-Johnson syndrome or toxic epidermal necrolysis is suspected.

Drug-induced hepatitis: Monitor liver function tests regularly; discontinue therapy if there is no alternative explanation for elevated transaminase levels.

Gastrointestinal: discontinue if perforation occurs.

Hypertension: Typically occurs early in the course of treatment and can be managed with antihypertensive therapy. Monitor blood pressure weekly during the first 6 weeks of therapy and periodically thereafter. Treat as required.

Impairment of TSH suppression: Monitor TSH monthly and adjust thyroid replacement in individuals with thyroid carcinoma.

Pregnancy and Lactation: Sorafenib is classified as pregnancy category D. Although there are no adequate and well-controlled studies in pregnant women, pre-clinical studies demonstrated fetal harm. It is unknown if sorafenib is excreted in human milk. A careful risk vs. benefit analysis should be considered prior to sorafenib administration in women who are breastfeeding.

QT Prolongation: Monitor for prolonged QT in members with congestive heart failure, bradyarrhythmias, drugs known to prolong the QT, and electrolyte abnormalities. Avoid in members with congenital prolonged QT syndrome.

BILLING/CODING INFORMATION:

HCPCS Coding

C9399

Unclassified drugs or biologicals

J8999

Prescription drug, oral, chemotherapeutic, NOS

ICD-10 Diagnoses Codes That Support Medical Necessity (Effective 10/01/15)

C22.0

Liver cell carcinoma

C22.2

Hepatoblastoma

C22.7

Other specified carcinomas of liver

C22.8

Malignant neoplasm of liver, primary, unspecified as to type

C22.9

Malignant neoplasm of liver, not specified as primary or secondary

C40.00 – C40.92

Malignant neoplasm of bone and articular cartilage of limbs

C41.0 – C41.9

Malignant neoplasm of bone and articular cartilage of other and unspecified sites

C47.8

Malignant neoplasm of overlapping sites of peripheral nerves and autonomic nervous system

C48.0 – C48.8

Malignant neoplasm of retroperitoneum and peritoneum

C49.0 – C49.9

Malignant neoplasm of connective and soft tissue

C64.0 – C65.9

Malignant neoplasm of kidney

C72.0

Malignant neoplasm of spinal cord

C72.1

Malignant neoplasm of cauda equina

C73

Malignant neoplasm of thyroid gland

C92.00 – C92.92

Myeloid leukemia

C93.00 – C93.02

Acute monoblastic/monocytic leukemia

C94.00 – C94.22

Other acute leukemias

D48.1

Neoplasm of uncertain behavior of connective and other soft tissue

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products: No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline revised date.

Medicare Advantage: BCBSF has delegated to Prime Therapeutics authority to make coverage determinations for the Medicare Part D services referenced in this guideline

DEFINITIONS:

FLT3-ITD mutation: a mutation of the FMS-like tyrosine kinase 3 (FLT3) gene that includes internal tandem duplication (ITDs). ITDs of the FLT3 gene are present in approximately 30% of individuals with acute myeloid leukemia and are associated with a poor prognosis.

RELATED GUIDELINES:

Adoptive Immunotherapy, 01-96400-01
Allogeneic Bone Marrow and Stem Cell Transplantation, 02-38240-01

Bevacizumab (Avastin®) Injection, 09-J0000-66

Carboplatin (Paraplatin®) IV, 09-J0000-93

Cryoablation of Liver Tumors, 02-40000-22

Cryosurgical Ablation of Solid Tumors Other Than Liver or Prostate Tumors, 02-99221-12

Erythropoiesis Stimulating Agents, 09-J0000-31

External Infusion Pumps (non-insulin), 09-E0000-10

Gemcitabine (Gemzar®), 09-J0000-96

Imatinib Mesylate (Gleevec) Tablets 09-J1000-46

Intensity-Modulated Radiation Therapy (IMRT), 04-77260-22

Kidney Transplantation, 02-50300-01

Liver Transplant, 02-40000-20

Positron Emission Tomography (PET Scans) Oncologic Applications, 04-78000-17

Proton Beam Therapy, 04-77260-18

Radiofrequency Ablation of Liver Tumors, 02-40000-23

Radiofrequency Ablation of Solid Tumors Other Than Liver Tumors, 02-99221-13

Selective Internal Radiation Therapy, 04-77260-21

Stereotactic Body Radiotherapy, 02-77371-02

Sunitinib Maleate (Sutent) Capsules 09-J1000-51

Zoledronic Acid IV (Reclast®; Zometa®), 09-J0000-72

OTHER:

TABLE 2: Stages of Renal Cell Cancer

Stage I

The tumor is 7 centimeters or smaller and is found only in the kidney.

Stage II

The tumor is larger than 7 centimeters and is found only in the kidney.

Stage III

The tumor is any size and cancer is found only in the kidney and in 1 or more nearby lymph nodes; or cancer is found in the main blood vessels of the kidney or in the layer of fatty tissue around the kidney. Cancer may be found in 1 or more nearby lymph nodes.

Stage IV

Cancer has spread beyond the layer of fatty tissue around the kidney and may be found in the adrenal gland above the kidney with cancer, or in nearby lymph nodes; or to other organs, such as the lungs, liver, bones, or brain, and may have spread to lymph nodes.

TABLE 3: Child-Pugh Score and Classification

 

1 point

2 points

3 points

Total bilirubin

< 2

2-3

> 3

Serum albumin

> 3.5

2.8-3.5

< 2.8

INR

> 1.7

1.71-2.20

< 2.20

Ascites

None

Mild

Severe

Hepatic encephalopathy

None

Grade I-II

Grade III-IV

Classification of Result:
Class A: 5-6 points
Class B: 7-9 points
Class C: 10-15 points

REFERENCES:

  1. Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.;2016. URL www.clinicalpharmacilogy-ip.com Accessed 10/20/16
  2. INGENIX HCPCS LEVEL II, EXPERT 2013.
  3. INGENIX ICD-9-CM FOR PHYSICIANS-VOLUMES 1 & 2, EXPERT 2013.
  4. Micromedex® Healthcare Series [Internet Database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed 10/20/16.
  5. National Comprehensive Cancer Network. Cancer Guidelines. Cancer Guidelines and Drugs and Biologics Compendium. Accessed 10/20/16.
  6. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Version2.2016. Acute Myeloid Leukemia. Available at http://www.nccn.org/professionals/physician_gls/PDF/aml.pdf Accessed 10/25/16.
  7. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Version 1.2017. Bone Cancer. Available at http://www.nccn.org/professionals/physician_gls/PDF/bone.pdf Accessed 10/25/16.
  8. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Version 2.2016. Hepatobiliary Cancer. Available at http://www.nccn.org/professionals/physician_gls/PDF/hepatobiliary.pdf Accessed 10/25/16.
  9. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Version 1.2017 Kidney Cancer. Available at http://www.nccn.org/professionals/physician_gls/PDF/kidney.pdf Accessed 10/20/16.
  10. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Version 2.2016. Soft Tissue Sarcoma. Available at http://www.nccn.org/professionals/physician_gls/PDF/sarcoma.pdf Accessed 10/24/16.
  11. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Version 1.2016. Thyroid Carcinoma. Available at http://www.nccn.org/professionals/physician_gls/PDF/thyroid.pdf Accessed 10/20/16.
  12. Nexavar (sorafenib) [package insert]. Bayer HealthCare Pharmaceuticals, Inc. South San Francisco (CA): July 2015.
  13. Sorafenib. In McEvoy GK, editor. AHFS drug information 2016 [monograph on the internet]. Bethesda (MD): American Society of Health-System Pharmacists; 2016 [cited 2016 October 20]. Available from http://online.statref.com Subscription required to review.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Pharmacy Policy Committee on 11/09/16.

GUIDELINE UPDATE INFORMATION:

01/01/12

New Medical Coverage Guideline.

12/15/12

Review and revision to guideline; consisting of reformatting and revising position statement; revising description, dosage/administration, precaution sections; updating references, coding and related guidelines.

12/15/13

Review and revision to guideline; consisting of updating the position statement to include treatment of osteosarcoma and adding approval duration, updating references and coding.

12/15/14

Review and revision to guideline; consisting of reformatting position statement, updating references and coding.

12/15/15

Review and revision to guideline; consisting of updating the position statement, description, dosage, precautions, references and coding.

12/15/16

Review and revision to guideline; consisting of updating the position statement, coding and references.

Date Printed: August 18, 2017: 10:26 AM