CAM 172

Daratumumab (Darzalex®) Injection

Category:Prescription Drug   Last Reviewed:August 2019
Department(s):Medical Affairs   Next Review:August 2020
Original Date:August 2017    

Description
Daratumumab (Darzalex) is an immunoglobulin G1 kappa (IgG1k) human monoclonal antibody against CD38 antigen, produced in a mammalian cell line using recombinant DNA technology.

CD38 is a transmembrane glycoprotein (48 kDa) expressed on the surface of hematopoietic cells, including multiple myeloma and other cell types and tissues and has multiple functions, such as receptor mediated adhesion, signaling, and modulation of cyclase and hydrolase activity.

Daratumumab (Darzalex) is the first monoclonal antibody approved for treating multiple myeloma.

Multiple myeloma is a form of blood cancer that occurs in infection-fighting plasma cells (a type of white blood cell) found in the bone marrow. These cancerous cells multiply, produce an abnormal protein and push out other healthy blood cells from the bone marrow. The disease may result in a weakened immune system and cause other bone or kidney problems.

Policy
DARZALEX is a CD38-directed cytolytic antibody is considered MEDICALLY NECESSARY:

  • in combination with lenalidomide and dexamethasone, or bortezomib and dexamethasone, for the treatment of patients with multiple myeloma who have received at least one prior therapy
  • in combination with pomalidomide and dexamethason for the treatment of patients with multiple myeloma who have received at least two prior therapies including lenalidomide and proteasome inhibitor
  • as monotherapy, for the treatment of patients with multiple myeloma who have received at least three prior lines of therapy including a proteasome inhibitor (PI) and an immunomodulatory agent or who are double-refractory to a PI and an immunomodulatory agent.
  • In combination with bortezomib, melphalan and prednisone for the treatment of patients with newly diagnosed multiple myeloma who are ineligible for autolgous stem cell transplant

Darzalex is considered NOT MEDICALLY NECESSARY for any indication other than those listed above.

Policy Guidelines
Pre-medicate with corticosteroids, antipyretics and antihistamines.
Dilute and administer as an intravenous infusion
Recommended dose is 16 mg/kg actual body weight according to the following schedule.

Monotherapy and in combination with lenalidomide and low-dose dexamethasone:

Weeks 1 to 8                                                                             weekly (total of 8 doses)
Weeks 9 to 24                                                                           every two weeks (total of 8 doses)
Week 25 onward until disease progression                              every four weeks

In combination with bortezomib and dexamethasone:

Weeks 1 to 9                                                                            weekly (total of 9 doses)
Weeks 10 to 24                                                                        every three weeks (total of 5 doses)
Week 25 onward until disease progression                             every four weeks              

Administer post-infusion medications.

References 

  1. Darzalex (daratumumab) injection package insert. Horsham, PA: Janssen Biotech, Inc. November 2016.
  2. U.S. Food and Drug Administration (FDA). FDA approves Darzalex for patients with previously treated multiple myeloma. Press Announcements. Silver Spring, MD: FDA; November 16, 2015. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm472875.htm. Accessed December 14, 2016.
  3. Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc.; 2017. Available at: www.clinicalpharmacilogy-ip.com. Accessed 5/25/17.
  4. Dimopoulos MA, Oriol A, Nahi H, et al.; POLLUX Investigators. Daratumumab, Lenalidomide, and Dexamethasone for Multiple Myeloma. N Engl J Med. 2016 Oct 6;375(14):1319-1331.
  5. FDA Orphan Drug Designations and Approvals [Internet]. Washington, D.C. [cited 2017 May 30]. Available from: http://www.accessdata.fda.gov/scripts/opdlisting/oopd/.
  6. Lokhorst HM, Plesner T, and Laubach JP, et al. Targeting CD38 with daratumumab monotherapy in multiple myeloma. N Engl J Med 2015;373(13):1207-1219.
  7. Micromedex® Healthcare Series [Internet Database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed 05/25/17.
  8. National Comprehensive Cancer Network. Cancer Guidelines. Cancer Guidelines and Drugs and Biologics Compendium. Accessed 05/25/17.
  9. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Version 3.2017 Multiple Myeloma. Available at http://www.nccn.org/professionals/physician_gls/PDF/myeloma.pdf. Accessed 05/30/17.
  10. Palumbo A, Chanan-Khan A, Weisel K, et al. Daratumumab, Bortezomib, and Dexamethasone for Multiple Myeloma. N Engl J Med. 2016 Aug 25;375(8):754-66.

Coding Section 

Code Number Description
CPT C82.00-C82.99 Follicular lymphoma
  C83.10-C83.19

Mantle Cell lymphoma

  C83.30-C83.39 Diffuse large B-cell lymphoma
  C90.00 Multiple myeloma not having achieved remission
  C90.02 Multiple myeloma in relapse
  C90.10 Plasma cell leukemia not having achieved remission
  C90.12 Plasma cell leukemia in relapse
HCPCS J9145

Injection, daratumumab, 10 mg

  S0353

Treatment planning and care coordination management for cancer, initial treatment

  S0354

Treatment planning and care coordination management for cancer, established patient

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.

Definitions 

  1. Heavy chain – the larger component of an immunoglobulin. There are five types: IgG, IgA, IgM, IgD, and IgE.
  2. Immunoglobulins (a.k.a., antibodies) – proteins made by normal plasma cells that have an important role in fighting infection as part of the humoral immune response. Antibodies are composed of two heavy chains and two light chains that form a larger complex. Each plasma cell produces only one type of heavy chain and one type of light chain.
  3. Light chain – the smaller component of an immunoglobulin. There are two types: kappa and lambda.
  4. Minimal response (MR) (according to the Revised Uniform Response Criteria by the International Myeloma Working Group)ALL of the following:
    •  ≥25% but ≤49% reduction of serum M-protein
    • Reduction in 24-hour urine M-protein by 50% to 89%
    • In addition, if present at baseline, 25% to 49% reduction in size of soft tissue plasmacytomas is also required
    • No increase in size or number of lytic bone lesions (development of compression fractures dose not exclude response).
  5. Myeloma Protein (M-Protein) – a nonfunctional immunoglobulin protein or protein fragment produced by malignant plasma cells (or myeloma cells). Since myeloma cells are monoclonal, the M-proteins for a given patient are structurally identical. Both portions of an immunoglobulin (the heavy chain and light chain) can be found in the serum, while only light chains can be found in the urine.
  6. Plasma cell - a fully differentiated B lymphocyte (a type of white blood cell) that is specialized for immunoglobulin production and is found primarily in bone marrow.
  7. Primary refractory MM - patients who never achieve at least an MR to initial induction therapy and progress while on therapy.
  8. Progressive MM - at least a 25% increase from nadir in the serum M-protein (absolute increase must be ≥0.5 g/dL) or urine M-protein (absolute increase must be ≥200mg/24 hours), or in the difference between involved and uninvolved serum-free light-chain (FLC) levels (with an abnormal FLC ratio and FLC difference >100 mg/L).
  9. Relapsed and refractory MM - patients who never achieve at least an MR or who progress within 60 days of their last therapy.
  10. Serum free light chain assay (SFLCA) – a test that detects the amount of unbound or free light chains (i.e., not attached to a heavy chain) in the serum. Normal values - kappa: 3.3 to 19.4 mg/L, lambda: 5.71 to 26.3 mg/L, kappa/lambda ratio: 0.26–1.65 (0.37–3.1 if renal impairment).
  11. Serum Protein Electrophoresis (SPEP) – a test that detects and quantifies the amount of M-protein in the serum. An serum M-protein of greater than 30 g/L is consistent with a diagnosis of MM.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2017 Forward     

08/01/2019 

Annual review, adding medical necessity criteria for newly diagnosed patients who are ineligible for an autologous stem cell transplant. No other changes. 

08/07/2018 

Annual review, no change to policy intent. 

08/09/2017

New Policy


Go Back