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Aetna Aetna
Clinical Policy Bulletin:
Androgens and Anabolic Steroids
Number: 0528


Policy

Note: Most policies specifically exclude coverage of steroids for performance enhancement.  For plans without this exclusion, androgens and anabolic steroids as well as other medical interventions for performance enhancement are not covered because performance enhancement of non-diseased individuals is not considered treatment of disease or injury.  Please check benefit plan descriptions for details.

Aetna considers anabolic steroids medically necessary for any of the following indications:

  • AIDS wasting syndrome; or
  • Anemia accompanying renal failure; or
  • Bone marrow failure anemias; or
  • Breast cancer; or
  • Conditions associated with decreased fibrinolytic activity due to anti-thrombin III deficiency or fibrinogen excess (including cutaneous vasculitis, scleroderma of Raynaud's disease, vasculitis of Behcet's disease, complications of deep vein thrombosis such as venous lipodermatosclerosis, other vascular disorders associated with these forms of reduced fibrinolytic activity, and prevention of recurrent venous thrombosis associated with anti-thrombin III deficiency); or
  • Constitutional delay in growth (androgenic anabolic steroids); or
  • Delayed male puberty (androgenic anabolic steroids); or
  • Endometriosis (danazol) (see CPB 0327 - Infertility); or
  • Female to male gender reassignment; or
  • Fibrocystic breast disease or mastalgia (danazol) (see CPB 0512 - Premenstrual Syndrome and Premenstrual Dysphoric Disorder); or
  • Growth failure in children with growth hormone deficiency (treatment adjunct); or
  • Hereditary angioedema; or
  • Hypospadias (testosterone injection as pre-surgical adjuvant hormonal therapy); or
  • Klinefelter's syndrome with hypogonadism (androgenic anabolic steroids) (see appendix); or
  • Microphallus (androgenic anabolic steroids); or
  • Refractory red cell production anemias (including aplastic anemia, myelofibrosis, myelosclerosis, agnogenic myeloid metaplasia, hypoplastic anemias caused by malignancy or myelotoxic drugs); or
  • Severe burn injury; or
  • Symptomatic androgen deficiency in men* (androgenic anabolic steroids) (androgen deficiency is indicated by either a low total testosterone level (below 200 ng/dL), or a low normal total testosterone levels (above 200 ng/dL but below 500 ng/dL) plus elevated sex hormone binding globulin (see appendix)); or
  • Weight loss from cancer chemotherapy.

* Two total testosterone levels are required to determine medical necessity of testosterone replacement.  Two morning samples drawn between 8:00 a.m. and 10:00 a.m. obtained on different days are required.

Injectable androgens are considered experimental and investigational for treatment of female menopause because of insufficient evidence in the peer-reviewed literature.

Aetna considers androgen therapy experimental and investigational to improve live birth outcome in poor responders undergoing in-vitro fertilization/intra-cytoplasmic sperm injection treatment because of insufficient evidence.

Aetna considers androgens and anabolic steroids experimental and investigational as a treatment for chronic obstructive pulmonary disease, chronic pressure ulcers and for other indications because of insufficient evidence in the peer-reviewed literature.

Aetna considers testosterone injections experimental and investigational for the treatment of amyotrophic lateral sclerosis, female sexual dysfunction/hypoactive sexual desire disorder, and heart failure because of insufficient evidence in the peer-reviewed literature.

See also CPB 345 - Implantable Hormone Pellets.



Background

Androgens and anabolic steroids include:

  • Danazol
  • Fluoxymesterone
  • Megesterol acetate
  • Methyltestosterone
  • Oxandrolone
  • Oxymetholone
  • Stanozolol
  • Testosterone. 

Depot forms of testosterone include testosterone cypionate and testosterone undecanoate.

Testosterone should be administered only to a man who is hypogonadal, as evidenced by clinical symptoms and signs consistent with androgen deficiency and a distinctly subnormal serum testosterone concentration (Snyder, 2013). In comparison, increasing the serum testosterone concentration in a man who has symptoms suggestive of hypogonadism but whose testosterone concentration is already normal will not relieve those symptoms. The principal goal of testosterone therapy is to restore the serum testosterone concentration to the normal range. The role of testosterone replacement to treat the decline in serum testosterone concentration that occurs with increasing frequency above age 60 in the absence of identifiable pituitary or hypothalamic disease is uncertain.

Measurement of the serum testosterone concentration is usually the most important single diagnostic test for male hypogonadism because a low value usually indicates hypogonadism. Measurement of the serum total (free plus protein-bound) testosterone concentration is usually an accurate reflection of testosterone secretion. Interpretation of serum testosterone measurements should take into consideration its diurnal fluctuation, which reaches a maximum at about 8 AM and a minimum, approximately 70 percent of the maximum, at about 8 PM. It is easier to distinguish subnormal from normal when normal is higher, so the measurements should always be made at 8 AM. If a single 8 AM value is well within the normal range, testosterone production can be assumed to be normal. If a single 8 AM value is low or borderline low or does not fit with the clinical findings, the measurement should be repeated once or twice before making the diagnosis of hypogonadism.

In a prospective, double-blind, placebo-controlled, 16-week study, Sharma et al (2008) examined the benefits of anabolic steroids in patients with severe chronic obstructive pulmonary disease (COPD) who did not participate in a structured rehabilitation program.  Biweekly intra-muscular injections of either the drug (nandrolone decanoate) or placebo were administered.  A total of 16 patients with severe COPD were randomized to either placebo or nandrolone decanoate.  The placebo group weighed 55.32 +/- 11.33 kg at baseline and 54.15 +/- 10.80 kg at 16 weeks; the treatment group weighed 68.80 +/- 6.58 kg at baseline and 67.92 +/- 6.73 kg at 16 weeks.  Lean body mass remained unchanged, 71 +/- 6 kg versus 71 +/- 7 kg in placebo group and 67 +/- 7 kg versus 67 +/- 7 kg in treatment group, at baseline and 16 weeks respectively.  The distance walked oin 6 mins was unchanged at baseline, 8 weeks, and 16 weeks in placebo (291.17 +/- 134.83 m, 282.42 +/- 115.39 m, 286.00 +/- 82.63 m) and treatment groups (336.13 +/- 127.59 m, 364.83 +/- 146.99 m, 327.00 +/- 173.73 m).  No improvement occurred in forced expiratory volume in 1 second, forced vital capacity, maximal inspiratory pressure, maximal expiratory pressure, VO(2) max or 6-min walk distance or health related quality of life.  The authors concluded that administration of anabolic steroids (nandrolone decanoate) outside a dedicated rehabilitation program did not lead to either weight gain, improvement in physiological function, or better quality of life in patients with severe COPD.

It is interesting to note that while testosterone treatment improved body composition and sexual function in men with COPD in a 6-month trial, no improvement in pulmonary function was found (Svartberg et al, 2004). 

Miller and Btaiche (2009) stated that severe thermal injury is associated with hyper-metabolism and hyper-catabolism, leading to skeletal muscle breakdown, lean body mass loss, weight loss, and negative nitrogen balance.  Muscle protein catabolism in patients with severe thermal injury is the result of stress-induced increased release of cytokines and counter-regulatory hormones.  Coupled with decreased serum anabolic hormone concentrations such as testosterone and growth hormone along with the presence of insulin resistance, anabolism in patients with severe thermal injury is inefficient or impossible during the acute post-burn period.  This causes difficulty in restoring lean body mass and regaining lost body weight, as well as poor healing of the burn wound and delayed patient recovery.  Oxandrolone, a synthetic derivative of testosterone, has been used in adult patients with severe thermal injury to enhance lean body mass accretion, restore body weight, and accelerate wound healing.  In clinical studies, oxandrolone 10 mg orally twice-daily improved wound healing, restored lean body mass, and accelerated body weight gain.  During the rehabilitation period, oxandrolone therapy with adequate nutrition and exercise improved lean body mass, increased muscle strength, and restored body weight.  However, most data on oxandrolone use in adult patients with severe thermal injury were derived from single-center studies, many of which enrolled a relatively small number of subjects and some of which had a poor design.  The authors stated that multi-center, prospective, randomized studies are needed to better define the optimal oxandrolone dosage and to confirm the safety and effectiveness of this drug in adult patients with severe thermal injury.

Woerdeman and de Ronde (2010) stated that a variety of clinical conditions/diseases are complicated by loss of weight and skeletal muscle, which may contribute to morbidity and mortality.  Anabolic androgenic steroids have been demonstrated to increase fat-free mass, muscle mass and strength in healthy men and women without major adverse events and therefore could be beneficial in these conditions.  The authors provided an overview of clinical trials with anabolic androgenic steroids in the treatment of chronic diseases including HIV-wasting, chronic renal failure, COPD, muscular disease, alcoholic liver disease, burn injuries and post-operative recovery.  Relevant studies were identified in PubMed (years 1950 to 2010), bibliographies of the identified studies and the Cochrane database.  Although the beneficial effects of anabolic androgenic steroids in chronic disorders are promising, clinically relevant endpoints such as quality of life, improved physical functioning and survival were mainly missing or not significant, except for burn injuries.  The authors concluded that more studies are needed to confirm their long-term safety and effectiveness.

Oxandrolone, an anabolic steroid used to treat muscle wasting in HIV patients, is associated with decreased loss of lean body mass, improved wound healing compared with placebo, and decreased hospital stay in severe burn injury (Wolf et al, 2006).  However, oxandrolone may prolong the need for mechanical ventilation in trauma patients and can elevate serum transaminase levels.

Sunkara and colleagues (2011) noted that many trials have evaluated the use of androgen supplements and androgen-modulating agents to improve outcome of poor responders undergoingin-vitro fertilization (IVF) treatment.  These investigators performed a systematic review and meta-analysis of controlled trials of androgen adjuvants (testosterone, dehydroepiandrostereone) and the androgen-modulating agent (letrozole) in poor responders undergoing IVF treatment.  Searches were conducted on MEDLINE, EMBASE, Cochrane Library, ISRCTN Register and ISI proceedings.  All randomized and non-randomized controlled trials were included.  Study selection, quality appraisal and data extraction were performed independently and in duplicate.  The main outcome measure was clinical pregnancy rate.  The secondary outcome measures were dose and duration of gonadotrophin use, cycles cancelled before oocyte retrieval, oocytes retrieved and ongoing pregnancy rates.  A total of 2,481 cycles in women considered as poor responders undergoing IVF/intra-cytoplasmic sperm injection (ICSI) treatment were included in 9 controlled trials.  Meta-analyses of these studies did not show any significant difference in the number of oocytes retrieved and ongoing pregnancy/live-birth rates with androgen supplementation or modulation compared with the control groups.  The authors concluded that there is currently insufficient evidence from the few randomized controlled trials to support the use of androgen supplementation or modulation to improve live birth outcome in poor responders undergoing IVF/ICSI treatment.

Makinen and Huhtaniemi (2011) stated that normal testicular function is essential for the maintenance of male physical strength and behavior irrespective of age.  A new term of late-onset hypogonadism (LOH) has been coined for the condition of decreased testosterone and hypogonadal symptoms in aging men.  The most important testicular hormone, testosterone, is responsible for the gender-specific androgenic-anabolic effects in men.  Testicular production of testosterone remains stable until around the age of 40 years after which it declines by 1 to 2 % annually.  Despite this age-related decline, serum testosterone levels in most older men remain within the reference range of younger men.  The decreasing androgen levels are paralleled by well-defined objective biological and non-specific subjective signs and symptoms of aging.  Because these symptoms are similar to those observed in young men with documented hypogonadism, androgen replacement therapy (ART) has been considered a logical way to treat them.  These researchers conducted a thorough review of the existing literature to evaluate the current concepts and controversies related to aging men and ART.  Although it is intuitively logical that the symptoms of LOH are due to the aging-related deficiency of testosterone, and that they can be reversed by ART, the evidence for this is still variable and often weak.  In particular, evidence-based information about long-term benefits and risks of ART in aging men is largely missing.  The authors concluded that despite widespread use, evidence-based proof for the objective benefits and side effects of ART of elderly men is still scanty, and such treatments should be considered experimental.

Shelton and Rajfer (2012) noted that androgen deficiency in aging men is common, and the potential sequelae are numerous.  In addition to low libido, erectile dysfunction, decreased bone density, depressed mood, and decline in cognition, studies suggest strong correlations between low testosterone, obesity, and the metabolic syndrome.  Because causation and its directionality remain uncertain, the functional and cardiovascular risks associated with androgen deficiency have led to intense investigation of testosterone replacement therapy in older men.  Although promising, evidence for definitive benefit or detriment is not conclusive, and treatment of LOH is complicated.

The British Committee for Standards in Haematology’s guideline on “The diagnosis and management of myelofibrosis” (Reilly et al, 2012) provided the following recommendations:

  • Danazol should be considered as a therapeutic option to improve the hemoglobin concentration of patients with myelofibrosis and transfusion-dependent anaemia (Evidence level 2, Grade B).
  • Recommended starting dose is 200 mg daily, with a gradual dose escalation, depending on tolerability and patient weight (to a maximum of 600 mg daily for patients less than80 kg and 800 mg for patients greater than 80 kg) (Evidence level 2, Grade B).
  • Patients should be treated for a minimum period of 6 months.  Responding patients should be maintained for a further 6 months on 400 mg daily before titrating down the dose to the minimum required in order to maintain a response (Evidence level 2, Grade B).

Toma et al (2012) stated that low testosterone is an independent predictor of reduced exercise capacity and poor clinical outcomes in patients with heart failure (HF).  These investigators examined if testosterone therapy improves exercise capacity in patients with stable chronic HF.  They searched Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials (1980 to 2010).  Eligible studies included randomized controlled trials (RCTs) reporting the effects of testosterone on exercise capacity in patients with HF.  Reviewers determined the methodological quality of studies and collected descriptive, quality, and outcome data.  A total of 4 trials (n = 198; men, 84 %; mean age of 67 years) were identified that reported the 6-minute walk test (2 RCTs), incremental shuttle walk test (2 RCTs), or peak oxygen consumption (2 RCTs) to assess exercise capacity after up to 52 weeks of treatment.  Testosterone therapy was associated with a significant improvement in exercise capacity compared with placebo.  The mean increase in the 6-minute walk test, incremental shuttle walk test, and peak oxygen consumption between the testosterone and placebo groups was 54.0 m (95 % confidence interval [CI]: 43.0 to 65.0 m), 46.7 m (95 % CI: 12.6 to 80.9 m), and 2.70 ml/kg per min (95 % CI: 2.68 to 2.72 mL/kg per min), respectively.  Testosterone therapy was associated with a significant increase in exercise capacity as measured by units of pooled SDs (net effect, 0.52 SD; 95 % CI: 0.10 to 0.94 SD).  No significant adverse cardiovascular events were noted.  The authors concluded that given the unmet clinical needs, testosterone appears to be a promising therapy to improve functional capacity in patients with HF.  They stated that adequately powered RCTs are required to assess the benefits of testosterone in this high-risk population with regard to quality of life, clinical events, and safety.

On March 6, 2014, the Food and Drug Administration (FDA) approved testosterone undecanoate injectable (Aveed, Endo Pharmaceuticals) for the treatment of men with hypogonadism.  Aveed is a long-acting depot formulation of testosterone in castor oil and benzyl benzoate.  It offers a novel dosing schedule, with a single 3-ml (750 mg) intra-muscular injection given once at initiation of therapy, at 4 weeks, and then every 10 weeks thereafter.  The approval follows 3 previous rejections of Aveed by the FDA for safety and risk/benefit concerns and comes just a month after the FDA announced that it is investigating cardiovascular safety data for all testosterone preparations.  The FDA is requiring that Aveed's label contain a boxed warning regarding the risks of serious pulmonary oil micro-embolism (POME) and anaphylaxis and is making the product available only through a restricted distribution scheme known as a risk evaluation and mitigation strategy (REMS) to ensure that it is used only in men for whom the benefits out-weigh the risks. 

According to the Prescribing Information, Aveed (testosterone undecanoate) injection is indicated for testosterone replacement therapy in adult males (18 years and older) for primary hypogonadism (congenital or acquired) and hypogonadotropic hypogonadism (congenital or acquired).  The most common side effects of Aveed include acne, difficulty sleeping, feeling tired, increased estradiol level, increased prostate specific antigen, increased red blood cell count, irritability, low testosterone level, mood swings, and pain at the injection. 

Reis and Abdo (2014) evaluated the use of androgens in the treatment of a lack of libido in women, comparing 2 periods, i.e., before and after the advent of the phosphodiesterase type 5 inhibitors.  These researchers also analyzed the risks and benefits of androgen administration.  They searched the Latin-American and Caribbean Health Sciences Literature, Cochrane Library, Excerpta Medica, Scientific Electronic Library Online, and Medline (PubMed) databases using the search terms disfunção sexual feminina/female sexual dysfunction, desejo sexual hipoativo/female hypoactive sexual desire disorder, testosterona/testosterone, terapia androgênica em mulheres/androgen therapy in women, and sexualidade/sexuality as well as combinations thereof.  They selected articles written in English, Portuguese, or Spanish.  After the advent of phosphodiesterase type 5 inhibitors, there was a significant increase in the number of studies aimed at evaluating the use of testosterone in women with hypoactive sexual desire disorder.  However, the risks and benefits of testosterone administration have yet to be clarified.

The European Federation of Neurological Societies’ guidelines on the clinical management of amyotrophic lateral sclerosis (Andersen et al, 2012) did not recommend testosterone for the treatment of amyotrophic lateral sclerosis because of insufficient evidence of its effectiveness.

In a parallel-group, placebo-controlled, randomized trial, Bauman et al (2013) examined if oxandrolone increases the percentage of target pressure ulcers (TPUs) that heal compared with placebo and whether healed ulcers remain closed 8 weeks after treatment.  A total of 1,900 patients were prescreened, 779 screened, and 212 randomly assigned inpatients with spinal cord injury (SCI) and stage III or IV TPUs.  Oxandrolone, 20 mg/d (n = 108), or placebo (n = 104) until the TPU healed or 24 weeks.  The primary outcome was healed TPUs.  The secondary outcome was the percentage of TPUs that remained healed at 8-week follow-up.  A total of 24.1 % (95 % CI: 16.0 % to 32.1 %) of TPUs in oxandrolone recipients and 29.8 % (CI: 21.0 % to 38.6 %) in placebo recipients healed (difference, -5.7 percentage points [CI: -17.5 to 6.8 percentage points]; p = 0.40).  At 8-week follow-up, 16.7 % (CI: 9.6 % to 23.7 %) of oxandrolone recipients and 15.4 % (CI: 8.5 % to 22.3 %) of placebo recipients retained a healed TPU (difference, 1.3 percentage points [CI: -8.8 to 11.2 percentage points]; p = 0.70).  No serious adverse events were related to oxandrolone.  Liver enzyme levels were elevated in 32.4 % (CI: 23.6 % to 41.2 %) of oxandrolone recipients and 2.9 % (CI: 0.0 % to 6.1 %) of placebo recipients (p < 0.001).  The authors concluded that oxandrolone showed no benefit over placebo for improving healing or the percentage of TPUs that remained closed after 8 weeks of treatment.

Appendix

Androgen deficiency is indicated by either a low total (free plus protein-bound) serum testosterone level (below 200 ng/dL), or a low normal total testosterone levels (above 200 ng/dL but below 500 ng/dL) plus elevated sex hormone binding globulin (above the normal reference range indicated in the table below or above the testing laboratory's normal reference range). Two total testosterone levels are required to determine medical necessity of testosterone replacement. Two morning samples drawn between 8:00 a.m. and 10:00 a.m. obtained on different days are required.

Note: The Endocrine Society's clinical practice guideline on "Testosterone therapy in adult men with androgen deficiency syndromes" (Bhasin et al, 2010) stated that reference laboratories ranges should be used for reporting testosterone levels.  Available at: http://www.endo-society.org/guidelines/final/upload/FINAL-Androgens-in-Men-Standalone.pdf.

Table: Reference Ranges for Sex Hormone Binding Globulin in Men

Age  nmol/L 
0-1 mo 11-71
1-12 mo  60-209
1-3 yr 42-156
4-6 yr 39-146
7-9 yr 38-114
10-12 yr 32-93
13-15 yr 13-93
16-18 yr 11-54
>18 yr 13-71

Reference: Hicks SJ, Bailey JM, Beatey J, et al. Pediatric reference ranges for sex hormone binding globulin. Clin Chem. 1997;43:S200.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
80414
84270
84402
84403
96372
99506
HCPCS codes covered if selection criteria are met:
J0900 Injection, testosterone enanthate and estradiol valerate, up to 1 cc
J1060 Injection, testosterone cypionate and estradiol cypionate, up to 1 ml
J1070 Injection, testosterone cypionate, up to 100 mg
J1080 Injection, testosterone cypionate, 1 cc, 200 mg
J2320 Injection, nandrolone decanoate, up to 50 mg
J3120 Injection, testosterone enanthate, up to 100 mg
J3130 Injection, testosterone enanthate, up to 200 mg
J3140 Injection, testosterone suspension, up to 50 mg
J3150 Injection, testosterone propionate, up to 100 mg
ICD-9 codes covered if selection criteria are met:
042 Human immunodeficiency virus [HIV] disease
136.1 Behcet's syndrome
174.0 - 175.9 Malignant neoplasm of breast
238.71 - 238.79 Neoplasm of uncertain behavior of other lymphatic and hematopoietic tissues (e.g., myelosclerosis with myeloid metaplasia)
253.3 Pituitary dwarfism
257.1 Post-ablative testicular hypofunction
257.2 Other testicular hypofunction
259.0 Delay in sexual development and puberty, not elsewhere classified
273.2 Other paraproteinemias
277.6 Other deficiencies of circulating enzymes
284.0 - 284.9 Aplastic anemia
285.21 Anemia in end-stage renal disease
285.22 Anemia in neoplastic disease
286.3 Congenital deficiency of other clotting factors
298.81 Primary hypercoagulable state [antithrombin III deficiency]
302.50 - 302.53 Trans-sexualism
302.85 Gender identity disorder in adolescents or adults
443.0 Raynaud's syndrome
447.6 Arteritis, unspecified
453.8 Other venous embolism and thrombosis
610.1 Diffuse cystic mastopathy
611.71 Mastodynia [mastalgia]
617.0 - 617.9 Endometriosis
701.0 Circumscribed scleroderma
752.61 Hypospadias
752.64 Micropenis
758.7 Klinefelter's syndrome
783.21 - 783.22 Abnormal loss of weight and underweight
783.40 - 783.43 Lack of expected normal physiological development in childhood
941.30 - 941.59
942.30 - 942.59
943.30 - 943.59
944.30 - 944.58
945.30 - 945.59
946.3 - 946.5
948.00 - 948.99
949.3 - 949.5
Third degree burns
996.85 Complications of transplanted organ, bone marrow (e.g., graft-versus-host disease (acute) (chronic))
ICD-9 codes not covered for indications listed in the CPB:
302.70 Psychosexual dysfunction, unspecified
302.71 Hypoactive sexual desire disorder
302.72 Psychosexual dysfunction with inhibited sexual excitement (impotence)
302.73 Female orgasmic disorder
302.76 Dyspareunia, psychogenic
302.79 Psychosexual dysfunction, with other specified psychosexual dysfunctions
335.20 Amyotrophic lateral sclerosis
398.91 Rheumatic heart failure (congestive)
402.01 Hypertensive heart disease, malignant, with heart failure
402.11 Hypertensive heart disease, benign, with heart failure
402.91 Hypertensive heart disease, unspecified, with heart failure
404.01 Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified
404.03 Hypertensive heart and chronic kidney disease, malignant, with heart failure and chronic kidney disease stage V or end stage renal disease
404.11 Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified
404.13 Hypertensive heart and chronic kidney disease, benign, with heart failure and chronic kidney disease stage V or end stage renal disease
404.93 Hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage V or end stage renal disease
428.0 - 428.9 Heart failure
490 - 496 Chronic obstructive pulmonary disease and allied conditions
606.0 - 606.9 Infertility, male
628.0 - 628.9 Infertility, female
627.0 - 627.9 Menopausal and postmenopausal disorders
707.00 - 707.9 Chronic ulcer of skin
V07.4 Hormone replacement therapy (postmenopausal)
V49.81 Asymptomatic postmenopausal status (age-related) (natural)
Other ICD-9 codes related to the CPB:
E933.1 Adverse effects of antineoplastic and immunosuppressive drugs


The above policy is based on the following references:
  1. United States Pharmacopeial Convention, Inc. USP Dispensing Information. Volume I -- Drug Information for the Health Care Professional. 19th ed. Englewood, CO: Micromedex, Inc.; 1999.
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