Product Details

Arixtra

Fondaparinux Sodium
2.5 mg/0.5 mL
Solution for Injection
0.5-mL Prefilled Syringe Pack (Preservative Free)

DIN/PIN/NPN

02245531

Manufacturer

Aspen Pharma Trading Limited

Formulary Listing Date

2004-04-06  

Unit Price

12.2124

Amount MOH Pays

11.1944

Coverage Status

Limited Use Product

ODB Formulary Therapeutic Classification

Therapeutic Note

NO

ATC Code

B01AX05

Interchangeable Products

DIN/ PIN/ NPN Brand name Unit Price Amount MOH pays
02406853 Fondaparinux Sodium Injection 11.1944 11.1944
02245531 Arixtra 12.2124 11.1944
 

LU Clinical Criteria

LU Code Auth. Period Clinical Criteria
378 1 year

For the post-operative prophylaxis of venous thromboembolic events in patients undergoing orthopedic surgery of the lower limbs such as hip fracture, hip replacement or knee surgery.

Note: Limited to 9 days of reimbursement.

 

EAP Criteria

Therapeutic Class Reimbursement Criteria
Anticoagulants

Fondaparinux

  • Brand(s): Arixtra and generic
  • Dosage Form/Strength: 2.5 mg

For the post-operative prophylaxis of venous thromboembolism following abdominal or pelvic surgery for cancer.

Standard Approval Duration: Maximum of 30 days


Fondaparinux

  • Brand(s): Arixtra (2.5mg) and Generic (2.5mg and 7.5mg). Check formulary or e-formulary for funded products
  • Dosage Form/Strength: 2.5 mg and 7.5 mg

For the treatment of venous thromboembolism (VTE) [deep vein thrombosis (DVT), pulmonary embolism (PE)] in the setting of acute heparin induced thrombocytopenia (HIT)

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


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

Product Monograph

View Monograph