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Medications listed are available on OH EPIC Formulary, unless otherwise noted.
Not all formulary medications are available at each facility. Please refer to your local pharmacy for available inventory.
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lutetium Lu 177 vipivotide tetraxetan

lutetium Lu 177 vipivotide tetraxetan
Drug Name Form Strength Infusion Center Available Restricted Non-formulary Ambulatory Available Interchange REMS
Pluvicto SOLUTION, INTRAVENOUS 1000 MBq/mL        
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CLASS
780000
Additional Information and Links

Restricted to:

  • Service Line: Radiology/Nuclear Medicine
  • Formulary Location: Outpatient
  • Service location: Outpatient (e.g., Nuclear Medicine, Benson Center Cancer Center PET, potentially BCC Infusion, potentially OMC-Kenner Nuclear Medicine Infusion suites)
  • Patient population: Adult
  • Prior Authorization: Yes
  • Criteria of Use:
    • 18 years of age or older
    • ECOG Performance Status of 0-2
    • Documented progressive metastatic castration-resistant prostate cancer (mCRPC)
    • PSMA positron emission tomography (PET) scan positive
    • Castrate level of serum/plasma testosterone (< 50 ng/dL or < 1.7 nmol/L)
    • Must have received at least one androgen receptor (AR) pathway inhibitor (e.g., enzalutamide (Xtandi) and/or abiraterone (Zytiga))
    • Must have been previously treated with at least one but no more than two taxane regimens
    • Pluvicto will not be used with concurrent cytotoxic    
Last updated: Jan. 26, 2023

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