Product Details

Revolade

Eltrombopag Olamine
25 mg
Tablet


DIN/PIN/NPN

02361825

Manufacturer

GlaxoSmithKline Inc., GlaxoSmithKline Consumer Health Care

Formulary Listing Date

2023-07-31  

Unit Price

65.0000

Amount MOH Pays

55.2500

Coverage Status

Off-Formulary Interchangeable Exceptional Access Program Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

B02BX05

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02506742 Apo-Eltrombopag 55.2500 55.2500
02361825 Revolade 65.0000 55.2500
 

LU Clinical Criteria

NO  

EAP Criteria

Therapeutic Class Reimbursement Criteria
Blood Modifiers

Eltrombopag

  • Brand(s): Revolade
  • Dosage Form/Strength: 25 mg, 50 mg tablet

For the treatment of refractory chronic idiopathic thrombocytopenic purpura (ITP) with bleeding complications in patients who meet the following criteria: 

  • Patient has undergone a splenectomy1; AND 

  • Patient has tried and is unresponsive to other treatment modalities2. 

1Requests for Revolade where the requesting physician has stated that the patient is not a candidate for splenectomy will be assessed on a case-by-case basis. The requesting physician must provide rationale for why a splenectomy cannot be considered, and where possible, to include a preoperative/surgical evaluation on the patient’s surgical risks to splenectomy, to include consideration of risks of laparoscopic and open surgical interventions if these are available. This evaluation must come from a physician who is not the requesting physician. 

2Appropriate first-line treatment modalities may include: 

  • Corticosteroids 

  • IV anti-D 

  • Intravenous immune globulin (IVIG) 

2Appropriate second-line treatment modalities include: 

  • Azathioprine 

  • Cyclosporine 

  • Cyclophosphamide 

  • Mycophenolate 

  • Rituximab 

  • Danazol 

  • Dapsone

Note: Patients need to have failed at least two of the second-line therapies listed above prior to requesting Revolade. Dosage: 50 mg once daily to a maximum of 75 mg once daily. 

Duration of Approval: 1 year 

Renewal of requests for Revolade will be assessed on a case-by-case basis 

Note: Revolade therapy beyond 1 year of continuous treatment has not been studied. After 1 year of continuous treatment, therapeutic options should be reassessed. 

Duration of Approval: 1 year

EAP Drug Request Form:

Standard Form for EAP Drug Requests

Product Monograph

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