Clinical Policy: Pitavastatin (Livalo), Ezetimibe/Simvastatin (Vytorin 10/10 mg) Reference Number: CP.CPA.62 Effective Date:

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1 Clinical Policy: Pitavastatin (Livalo), Ezetimibe/Simvastatin (Vytorin 10/10 mg) Reference Number: CP.CPA.62 Effective Date: Last Review Date: Line of Business: Commercial Revision Log See Important Reminder at the end of this policy for important regulatory and legal information. Description Pitavastatin (Livalo ) is an inhibitor of HMG-CoA reductase (statin) that lowers cholesterol in the blood for prevention of cardiovascular events and for the management of dyslipidemias. Ezetimibe/simvastatin (Vytorin ) is a combination cholesterol absorption inhibitor and HMG- CoA reductase inhibitor (statin). FDA approved indication Livalo: Primary Hyperlipidemia or Mixed Dyslipidemia: As an adjunctive therapy to diet to reduce elevated total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), apolipoprotein B (Apo B), triglycerides (TG), and to increase high density lipoprotein cholesterol (HDL-C) in adult patients with primary or mixed dyslipidemia. Vytorin: Primary Hyperlipidemia: As an adjunctive therapy to diet to reduce elevated total-c, LDL- C, apo B, TG, and non-hdl-c, and to increase HDL-C in patients with primary (heterozygous familial and non-familial) hyperlipidemia or mixed hyperlipidemia. Homozygous Familial Hypercholesterolemia (HoFH): As an adjunctive therapy to diet to reduce elevated total-c and LDL-C in patients with homozygous familial hypercholesterolemia (HoFH), as an adjunct to other lipid-lowering treatments. Limitations of use: Doses of Livalo greater than 4 mg once daily were associated with an increased risk for severe myopathy in premarketing clinical studies. Do not exceed 4 mg once daily dosing of Livalo. The effect of Livalo on cardiovascular morbidity and mortality has not been determined. Livalo has not been studied in Fredrickson Type I, III, and V dyslipidemias. No incremental benefit of Vytorin on cardiovascular morbidity and mortality over and above that demonstrated for simvastatin has been established. Vytorin has not been studied in Fredrickson Type I, III, IV, and V dyslipidemias. Page 1 of 6

2 Policy/Criteria Provider must submit documentation (which may include office chart notes and lab results) supporting that member has met all approval criteria It is the policy of health plans affiliated with Centene Corporation that Livalo and Vytorin are medically necessary when the following criteria are met: I. Initial Approval Criteria A. Hyperlipidemia (must meet all): 1. Diagnosis of one of the following: a. Primary Hyperlipidemia; b. Mixed Dyslipidemia; c. Homozygous Familial Hypercholesterolemia (HoFH); 2. One of the following (a or b): a. Failure to achieve National Cholesterol Education Program (NCEP) goals; b. Failure of one generic formulary statin (e.g., atorvastatin, lovastatin, pravastatin, simvastatin) unless contraindicated or clinically significant adverse effects are experienced; 3. Dose does not exceed: Livalo 4 mg/day; Vytorin 10/40 mg/day. Approval duration: Length of Benefit B. Other diagnoses/indications 1. Refer to CP.CPA.09 if diagnosis is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized). II. Continued Therapy A. Hyperlipidemia (must meet all): 1. Currently receiving medication via Centene benefit or member has previously met initial approval criteria; 2. Member is responding positively to therapy; 3. If request is for a dose increase, new dose does not exceed: Livalo 4 mg/day; Vytorin 10/40 mg/day. Approval duration: Length of Benefit B. Other diagnoses/indications (must meet 1 or 2): 1. Currently receiving medication via Centene benefit and documentation supports positive response to therapy. Approval duration: Duration of request or 12 months (whichever is less); or 2. Refer to CP.CPA.09 if diagnosis is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized). III. Diagnoses/Indications for which coverage is NOT authorized: A. Non-FDA approved indications, which are not addressed in this policy, unless there is sufficient documentation of efficacy and safety according to the off label use policy CP.CPA.09 or evidence of coverage documents. Page 2 of 6

3 IV. Appendices/General Information Appendix A: Abbreviation/Acronym Key Apo B: apolipoprotein B HDL-C: high-density lipoprotein-cholesterol HMG-CoA: 3-hydroxy-3-methyl-glutaryl-CoA HoFH: heterozygous familial and nonfamilial hypercholesterolemia LDL-C: low-density lipoprotein-cholesterol Mg: milligram(s) TG: triglyceride Total-C: total cholesterol Appendix B: General Information Vytorin is contraindicated with concomitant administration of: o Strong CYP3A3 inhibitors (e.g., itraconazole, ketoconazole, posaconazole, voriconazole, o HIV protease inhibitors, boceprevir, telaprevir, erythromycin, clarithromycin, telithromycin, nefazodone, and cobicistat-containing products) o Gemfibrozil, cyclosporine, or danazol. Simvastatin is metabolized by the cytochrome P450 isoform 3A4. Certain drugs that inhibit this metabolic pathway can raise the plasma levels of the simvastatin component of Vytorin and may increase the risk of myopathy. Due to the increased risk of myopathy, including rhabdomyolysis, associated with the 10/80 mg dose of Vytorin, patients unable to achieve their LDL-C goal utilizing the 10/40-mg dose of Vytorin should not be titrated to the 10/80-mg dose, but should be placed on alternative LDL-C-Iowering treatment(s) that provide greater LDL-C lowering. Livalo is contraindicated with co-administration of cyclosporine. Doses of Livalo greater than 4 mg once daily were associated with an increased risk for severe myopathy in pre-marketing clinical studies. Do not exceed 4 mg once daily dosing of Livalo. Liver function tests are recommended before initiating therapy with Vytorin or Livalo, and as clinically indicated thereafter. Relative LDL-lowering Efficacy of Statin and Statin-based Therapies: Pravastatin is FDA approved for pediatric patients 8 to 13 years up to 20 mg per day and 14 to 18 years up to 40 mg per day; simvastatin is FDA approved for pediatric patients 10 to 17 years of age up to 40 mg per day; lovastatin is FDA approved for pediatric patients 10 to 17 years of age up to 40 mg per day; atorvastatin is FDA approved for pediatric patients 10 to 17 years of age up to 20 mg per day. Appendix C: Therapeutic Alternatives Drug Dosing Regimen Dose Limit/ atorvastatin (Lipitor ) Maximum Dose mg PO QD 80 mg/day (20mg/day for pediatrics 10 to 17 years) Page 3 of 6

4 Drug Dosing Regimen Dose Limit/ Maximum Dose simvastatin (Zocor ) 5 80 mg PO QD 80 mg/day (40 mg/day for pediatrics 10 to 17 years) lovastatin (Mevacor ) mg PO QD 80 mg/day (40mg/day for pediatrics 10 to 17 years) pravastatin (Pravachol ) mg PO QD 80 mg/day Pediatrics: mg PO QD Pediatrics: 20 mg/day for 8 to 13 years 40 mg/day for 14 to 18 years Therapeutic alternatives are listed as Brand name (generic) when the drug is available by brand name only and generic (Brand name ) when the drug is available by both brand and generic. V. Dosage and Administration Drug Name Indication Dosing Regimen Maximum Dose Pitavastatin (Livalo) Primary Hyperlipidemia; 1-4 mg PO QD 4 mg PO QD Ezetimibe/ simvastatin (Vytorin) Mixed Dyslipidemia Primary Hyperlipidemia; Homozygous Familial Hypercholesterolemi a (HoFH) 10/10 mg - 10/40 mg PO QD Use of the 10/80 mg dose of Vytorin should be restricted to patients who have been taking Vytorin 10/80 mg for 12 months or more without evidence of muscle toxicity 10/80 mg PO QD VI. Product Availability Drug Livalo Vytorin Availability Tablets: 1 mg, 2 mg, 4 mg Tablets: 10/10 mg, 10/20 mg, 10/40 mg, 10/80 mg VII. References 1. Vytorin Prescribing Information. Whitehouse Station, NJ: Merck & Co., Inc. February Accessed January Page 4 of 6

5 2. Livalo Prescribing Information. Tokyo, Japan: Kowa Pharmaceuticals. October Accessed January Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. May 16, 2001; 285(19): Micromedex Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed January 23, Clinical Pharmacology Web site. Available at: Accessed January 23, Clinical Pharmacology Web site. Available at: Accessed January 17, Ezetimibe. American Hospital Formulary Service Drug Information. Available at: Accessed January 18, Simvastatin. American Hospital Formulary Service Drug Information. Available at: Accessed January 18, Livalo. American Hospital Formulary Service Drug Information. Available at: Accessed January 23, Reviews, Revisions, and Approvals Date P&T Approval Date Converted to new template. Minor changes to verbiage and grammar. References updated Important Reminder This clinical policy has been developed by appropriately experienced and licensed health care professionals based on a review and consideration of currently available generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by this clinical policy; and other available clinical information. The Health Plan makes no representations and accepts no liability with respect to the content of any external information used or relied upon in developing this clinical policy. This clinical policy is consistent with standards of medical practice current at the time that this clinical policy was approved. Health Plan means a health plan that has adopted this clinical policy and that is operated or administered, in whole or in part, by Centene Management Company, LLC, or any of such health plan s affiliates, as applicable. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures. Page 5 of 6

6 This clinical policy is effective as of the date determined by the Health Plan. The date of posting may not be the effective date of this clinical policy. This clinical policy may be subject to applicable legal and regulatory requirements relating to provider notification. If there is a discrepancy between the effective date of this clinical policy and any applicable legal or regulatory requirement, the requirements of law and regulation shall govern. The Health Plan retains the right to change, amend or withdraw this clinical policy, and additional clinical policies may be developed and adopted as needed, at any time. This clinical policy does not constitute medical advice, medical treatment or medical care. It is not intended to dictate to providers how to practice medicine. Providers are expected to exercise professional medical judgment in providing the most appropriate care, and are solely responsible for the medical advice and treatment of members. This clinical policy is not intended to recommend treatment for members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. Providers referred to in this clinical policy are independent contractors who exercise independent judgment and over whom the Health Plan has no control or right of control. Providers are not agents or employees of the Health Plan. This clinical policy is the property of the Health Plan. Unauthorized copying, use, and distribution of this clinical policy or any information contained herein are strictly prohibited. Providers, members and their representatives are bound to the terms and conditions expressed herein through the terms of their contracts. Where no such contract exists, providers, members and their representatives agree to be bound by such terms and conditions by providing services to members and/or submitting claims for payment for such services Centene Corporation. All rights reserved. All materials are exclusively owned by Centene Corporation and are protected by United States copyright law and international copyright law. No part of this publication may be reproduced, copied, modified, distributed, displayed, stored in a retrieval system, transmitted in any form or by any means, or otherwise published without the prior written permission of Centene Corporation. You may not alter or remove any trademark, copyright or other notice contained herein. Centene and Centene Corporation are registered trademarks exclusively owned by Centene Corporation. Page 6 of 6