Cox-2 Therapy Guidelines

Blue Cross of Idaho has established therapy guidelines for Cox-2 drugs due to the risks involved in their use. Celebrex will be approved for use in the following situations:

1. Patients with documented rheumatoid arthritis including patients who are on DMARDs (gold, MTX, azathioprine, cyclophosphamide, cyclosporine, sulfasalazine, hydroxychloroquine, Enbrel or Arava).
2. Patients who have any ONE of the following risk factors:
   • patient is 60 years old or older
   • patient is taking anticoagulant (Celebrex has the potential to increase INR's in patients on warfarin.  Close monitoring of INR's is recommended in patients started on this combination.)
   • patient has documented history of complicated GI event (i.e., bleed, perforation, symptomatic ulcer)
   • patient has chronic major organ impairment (i.e., CAD, unstable angina, severe COPD, anemia, congestive heart failure, hepatic insufficiency or diabetes.)
   • patient is on chronic, systemic corticosteroid therapy
   • patient has had treatment failure on two different NSAIDs within the last 90 days
3. Patients with familial adenomatous polyposis (FAP) - only Celebrex. 
4. As a short-term (not more than two weeks) transitional therapy for patients undergoing a surgical procedure who are on chronic NSAIDs and fail or do not tolerate alternate analgesic therapy which also does not affect platelet function (narcotics, acetaminophen, generic Trilisate).  Typical plan would be to convert from NSAID before the procedure, then continue on the COX-2 drug after surgery to avoid bleeding complications.    
5. Prescriptions written by rheumatologists.    

NOTE: NSAID associated dyspepsia or heartburn is not a reliable risk factor or a predictor for future clinically significant NSAID associated GI events. GERD is not a risk factor for NSAID associated complications.

References:

Singh G and Ramey DR. NSAID Induced Gastrointestinal Complications: The ARAMIS Perspective- 1997. J Rheumatol 1998;Vol 25 S 51:8-16.

Special Article: Recommendation for the Medical Management of Osteoarthritis of the Hip and Knee. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis and Rheumatism. September 2000. Vol 43(9): 1905-1915.

Quantity Limit per Prescription: COX-2 Inhibitors

If a member does not meet the above criteria, they will be able to receive a maximum of 15 units per prescription for one copay. After the initial prescription, they will be subject to the prior authorization.

  COX-2 Prior Authorization Form