Fondaparinux Sodium Injection

For the treatment of venous thromboembolism (VTE) [deep vein thrombosis (DVT), pulmonary embolism (PE)] in patients with previous HIT who cannot use rivaroxaban

Duration: 1 month if patient is able to transition to warfarin OR up to 1 year for patients who cannot be managed on warfarin*

*Patients may not be able to use warfarin as extended treatment or prophylaxis of VTE due to contraindication, previous clinical failure, inability to swallow/ take oral medications, immobility, inability to monitor INR, etc. The reasons why warfarin is not appropriate must be clearly described.

Renewal of funding for the above indications may be considered on a case-by-case basis with documented clinical rationale that includes details pertaining to patient’s risks for recurrent VTE, risks of bleeding, update on whether warfarin therapy may now be considered, and response to therapy.

For peri-operative bridging for patients with history of HIT who require long-term warfarin therapy and must temporarily discontinue it before and after surgery, and who are at moderate- to high-risk for an embolic event while off warfarin.

Duration: As requested up to a maximum of 10 days before the date of surgery plus up to 7 days after surgery

Renewal of funding will NOT be considered for this indication.

EAP Drug Request Form:

Standard Form for EAP Drug Requests