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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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mitoMYcin

mitoMYcin
Drug Name Form Strength Infusion Center Available Restricted Non-formulary Ambulatory Available Interchange REMS
Jelmyto KIT, URETERAL 40 mg      
Mutamycin POWDER FOR INJECTION, INTRAVENOUS 5 mg        
MitoMYcin POWDER FOR INJECTION, INTRAVENOUS 20 mg; 40 mg        
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CLASS
100000
High Alert Drug : Policy
Additional Information and Links

OHS.PHARM.OS.052 Management of Medication Extravasation and Antidotes

Jelmyto:

  • Indication: Treatment of adult patients with low-grade upper tract urothelial cancer (LG-UTUC)
  • Service Line: Urology, Oncology
  • Formulary Location: Outpatient
  • Service location: Outpatient procedural area, Clinic
  • Patient Population: Adults
  • Prior Authorization Required: yes
  • Restriction/Criteria of Use: (all will apply, unless specify)
    • Residual low-grade, low volume (e.g., 5-15 mm) UTUC tumor.
    • Not a candidate for or are not seeking nephroureterectomy as a definitive treatment.
    • Verify pregnancy status in females of reproductive potential prior to initiating Jelmyto
Last updated: Feb. 15, 2024

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