Iron Chelating Agents - BMC HealthNet Plan

congestive heart failure, endocrinopathies, hepatic fibrosis and death. Iron chelatingtherapies are used to reduce iron levels or reverse the aforementioned toxicities of irondeposition in patients with conditions associated with iron overload. Such conditionsinclude sickle-cell anemia, thallassemia and myelodysplastic syndromes. There arecurrently three iron chelators available – deferoxamine (Desferal ® ), deferasirox(Exjade ® ), and deferiprone (Ferriprox ® ).Deferoxamine is indicated for the treatment of chronic iron overload secondary to bloodtransfusions. It is administered parenterally as a continuous intravenous or subcutaneousinfusion due to its poor oral absorption and short half-life. Use of deferoxamine is limitedby the burden and pain associated with infusions which adversely affect adherence. Sideeffectsinclude ocular and audiological toxicity as well as Yesinia & klebsiella spinfections.Exjade ® (deferasirox) is an oral iron chelating agent that is indicated for the treatment ofchronic iron overload due to blood transfusions (transfusional hemosiderosis) in patients2 years of age and older and to treat patients aged 10 years and older who have chroniciron overload resulting from a genetic blood disorder called non-transfusion-dependentthalassemia (NTDT). Exjade ® carries a black box warning related to the risk of causingrenal impairment and failure, hepatic impairment and failure, and GI hemorrhage. Thisrequires close monitoring of serum creatinine/creatinine clearance, serum transaminasesand bilirubin. To minimize adverse effects, the recommendation is to interruptdeferasirox therapy when serum ferritin is consistently below 500mcg/L.Ferriprox ® (deferiprone) is another oral iron chelating agent indicated for the treatment ofpatients with transfusional iron overload due to thalassemia syndromes when currentchelation therapy is inadequate. The safety and effectiveness have not been establishedfor the treatment of transfusional iron overload in patients with other chronic anemias.It carries a black box warning regarding the risk of agranulocytosis/neutropenia that canlead to serious infections and death. Therefore measurement of absolute neutrophil count(ANC) prior to initiating therapy and weekly thereafter is recommended. Therapy shouldbe interrupted if neutropenia or infections develops.Choice of chelating therapy should be individualized based on tolerability, safety profile,ease of use, adherence, and trends of organ-specific iron loading. There is clinicalevidence showing efficacy of a combination of deferiprone and deferoxamine inimproving cardiac function in patients with cardiac iron burden. Safety and efficacy ofother combination chelator therapy regimen have not been extensively studied.This guideline provides information on BMC HealthNet Plan clinical criteria and claims adjudication processing guidelines. Theuse of this guideline is not a guarantee of payment and will not determine how a specific claim(s) will be paid. Reimbursement isbased on member benefits and eligibility, medical necessity review, where applicable, coordination of benefits, adherence to Planpolicies, clinical coding criteria, and the BMC HealthNet Plan agreement with the rendering or dispensing provider.Reimbursement policies may be amended at BMC HealthNet Plan’s discretion. BMC HealthNet Plan will always use the mostrecent CPT and HCPCS coding guidelines. All Plan policies are developed in accordance with state, federal and accreditingorganization guidelines and requirements, including NCQA.This document is subject to further revision in response to additional terms and requirements imposed under the Integrated CareProgram, including the ICP contract.BMCHP refers to Boston Medical Center HealthNet Plan in Massachusetts and Well Sense Health Plan in New Hampshire.Boston Medical Center HealthNet Plan and Well Sense Health Plan are trade names used by Boston Medical Center Health Plan,Inc.BMC HealthNet Plan – Iron Chelating Agents2 of 6