- ACRONYMS AND DEFINITIONS
- CrCl - Creatinine clearance
- GLP-1 - Glucagon-Like Peptide-1
- P = Drugs with pediatric dosing
- GLP-1 ANALOGS
Dulaglutide (Trulicity®)
Dosage forms
Single-dose pen
- 0.75 mg
- 1.5 mg
- 3 mg
- 4.5 mg
- Comes in carton with 4 pens
Dosing
Type 2 diabetes
- Starting: 0.75 mg once weekly
- Maintenance: 0.75 - 4.5 mg once weekly
- Max: 4.5 mg once weekly
- Increase to next higher dose if needed at intervals of 4 weeks
- May administer without regard to food
- If a dose is missed, administer ASAP if there are at least 3 days until the next scheduled dose
- If less than 3 days remain before the next scheduled dose, skip the missed dose and administer the next dose on the regularly scheduled day
- In each case, patients can then resume their regular once weekly dosing schedule
- The day of weekly administration can be changed if necessary as long as the last dose was administered 3 or more days before
Other
- Inject subcutaneously in thigh, abdomen, or upper arm
- If adding to insulin or sulfonylurea, consider lowering dose of these drugs when initiating to prevent hypoglycemia
Generic / Price
- NO/$$$$Storage
Refrigerated pens/syringes
- Good until expiration date
Room temp pens/syringes
- Good for 14 days
Exenatide (Byetta®)
Dosage forms
Multi-dose pen
- 5 mcg dose - 1.2 ml pen with 60 doses
- 10 mcg dose - 2.4 ml pen with 60 doses
Dosing
Type 2 diabetes (adults)
- Starting: 5 mcg twice a day
- Maintenance: 5 - 10 mcg twice a day
- Max: 10 mcg twice a day
- Increase dose at intervals of ≥ 4 weeks
- Give within the 60-minute time period before the morning and evening meal
Other
- Inject subcutaneously in thigh, abdomen, or upper arm
- To limit GI side effects, the recommended starting dose is 5 mcg twice a day
Generic / Price
- NO/$$$$Storage
Unpunctured pens
- Keep refrigerated
- Good until expiration date on product
Punctured pens
- Keep at temperature below 77° F (25°C)
- Good for 30 days
- Do not freeze
Exenatide | Bydureon® | Bydureon BCise®
Dosage forms
Single-dose pen, Bydureon®
- Each pen contains 2 mg
- Comes in carton of 4 pens
Dosing tray, Bydureon®
- Each dosing tray comes with a syringe, needle, and vial
- Each vial has a 2 mg dose
- Comes in carton of 4 trays
Autoinjector, Bydureon BCise®
- Each pen contains 2 mg
- Comes in carton of 4 pens
Dosing
Type 2 diabetes in adults and pediatric patients ≥ 10 years old
- Dosing: 2 mg once weekly
- Max: 2 mg once weekly
- May administer at any time of day without regard to food
- Inject subcutaneously in abdomen, thigh, or upper arm
- Missed doses: administer missed dose ASAP, provided the next regularly scheduled dose is due at least 3 days later. Thereafter, patients can resume their usual dosing schedule of once weekly. If a dose is missed and the next regularly scheduled dose is due 1 or 2 days later, the patient should not administer the missed dose and instead resume Bydureon with the next regularly scheduled dose. Do not take 2 doses within 3 days of each other.
Other
- The exenatide in Bydureon BCise comes suspended in medium chain triglycerides, and the exenatide in Bydureon comes as a powder that must be reconstituted. Bydureon BCise requires less mixing before administration.
- Bydureon BCise must be stored flat
Generic / Price
- NO/$$$$Storage
Refrigerated (pens/trays)
- Good until expiration date
- Bydureon BCise must be stored flat
Room temp (pens/trays)
- Good for 4 weeks
- Bydureon BCise must be stored flat
Reconstituted doses of Bydureon
- Use immediately
Liraglutide (Victoza®)
Dosage forms
Multi-dose pen
- Pen can be dialed to all 3 doses
- For 1.8 mg dose has 10 doses
- For 1.2 mg dose has 15 doses
- For 0.6 mg dose has 30 doses
- Comes in packages of 2 or 3 pens
Dosing
Type 2 diabetes (adults)
- Starting: 0.6 mg once daily for 1 week
- Maintenance: 1.2 - 1.8 mg once daily
- Max: 1.8 mg once daily
- To limit GI side effects, the recommended starting dose is 0.6 mg once daily
- 0.6 mg dose is not effective for blood sugar control
- May be administered without regard to food
Type 2 diabetes (Children ≥ 10 years old)
- Starting: 0.6 mg once daily
- Maintenance: 0.6 - 1.8 mg once daily
- Max: 1.8 mg once daily
- The dose may be increased by 0.6 mg every 7 days if necessary
- Pediatric approval based on PMID 31034184
- May be administered without regard to food
Other
- If adding to insulin or sulfonylurea, consider lowering dose of these drugs when initiating to prevent hypoglycemia
- It is acceptable to inject Victoza and insulin in the same body region but the injections should not be adjacent to each other
- If > 3 days have elapsed since last dose, reinitiate at 0.6 mg dose
Generic / Price
- NO/$$$$Storage
Unpunctured pens
- Keep refrigerated
- Good until expiration date if refrigerated
- Do not freeze
Punctured pens
- Keep at room temperature or refrigerate
- Good for 30 days
- Do not freeze
Lixisenatide (Adlyxin®)
Dosage forms
Multi-dose pen
- Starter pen - delivers 14 doses of 10 mcg
- Maintenance pen - delivers 14 doses of 20 mcg
- Starter pen comes in package with one pen
- Maintenance pen comes in package of 2 pens
Dosing
Type 2 diabetes
- Starting: 10 mcg once daily for 14 days
- Maintenance: 20 mcg once daily
- Max: 20 mcg once daily
- Administer within one hour before the first meal of the day preferably the same meal each day. If a dose is missed, administer within one hour prior to the next meal
Other
- Inject subcutaneously in thigh, abdomen, or upper arm
- Rotate injection sites with each dose. Do not use the same site for each injection.
Generic / Price
- NO/$$$$Storage
Unused pens
- Keep refrigerated
- Good until expiration date
- Do not freeze
After first dose
- Store below 86°F (30°C)
- Discard pen 14 days after first use
Semaglutide (Ozempic®)
Dosage forms
Multi-dose pen
- 2 mg pen - delivers 0.25 or 0.5 mg per injection. Can deliver four 0.25 mg doses or four 0.5 mg doses.
- 4 mg pen - delivers four 1 mg doses
- 8 mg pen - delivers four 2 mg doses
Dosing
Type 2 diabetes
- Starting: 0.25 mg SQ once weekly for 4 weeks. After 4 weeks of 0.25 mg, increase dose to 0.5 mg once weekly. The 0.25 mg dose is for titration only and is not effective for glycemic control.
- Maintenance: 0.5 - 2 mg SQ once weekly
- Max: 2 mg SQ once weekly
- Dose may be increased to 1 mg and then 2 mg if necessary. Each dose should be given for at least 4 weeks before increasing.
- The day of weekly administration can be changed if necessary as long as the time between two doses is at least 2 days (> 48 hours)
- If a dose is missed, administer it as soon as possible, within 5 days after the missed dose. If > 5 days have passed, skip the missed dose and administer the next dose on the regularly scheduled day.
- Inject subcutaneously in the thigh, abdomen, or upper arm. Rotate injection sites with each dose. Do not use the same site for each injection.
- May administer without regard to food
Generic / Price
- NO/$$$$Storage
Unused pens
- Keep refrigerated
- Good until expiration date
- Do not freeze
After first dose
- Store at room temperature or refrigerated
- Good for 56 days
Semaglutide (Rybelsus®)
Dosage forms
Tablet
- 3 mg
- 7 mg
- 14 mg
- Comes in blister pack of 30 tablets
Dosing
Type 2 diabetes
- Starting: 3 mg once daily for 30 days
- Maintenance: 7 mg once daily. 7 mg dose may be increased to 14 mg after at least 30 days.
- Max: 14 mg once daily
- The 3 mg dose is for titration only and is not effective for glycemic control
- Taking two 7 mg tablets to achieve 14 mg dose is not recommended
- If a dose is missed, the missed dose should be skipped, and the next dose should be taken the following day
- Take at least 30 minutes before the first food, beverage, or other oral medications of the day with no more than 4 ounces of plain water only. Waiting less than 30 minutes, or taking with food, beverages (other than plain water) or other oral medications will lessen the effect of Rybelsus by decreasing its absorption. Waiting more than 30 minutes to eat may increase the absorption of Rybelsus.
Switching between Ozempic and Rybelsus
- Patients taking Rybelsus 14 mg daily can be switched to Ozempic 0.5 mg SQ once weekly. Ozempic may be started the day after the last dose of Rybelsus.
- Patients taking Ozempic 0.5 mg SQ once weekly can be switched to either Rybelsus 7 mg or 14 mg. Patients can start Rybelsus up to 7 days after their last injection of Ozempic. There is no equivalent dose of Rybelsus for Ozempic 1 mg.
Other
- Do not split, crush, or chew tablets
- Leave tablets in blister pack until ready for use
Generic / Price
- NO/$$$$- GLP-1 ANALOG + INSULIN
Soliqua® (insulin glargine + lixisenatide)
Dosage forms
Pen (100/33)
- 100 units/ml insulin glargine and 33 mcg/ml lixisenatide
- Pens contain 3 ml
- Comes in package of 5 pens
- Pen window shows units of insulin glargine
Pharmacokinetics
NOTE: Parameters are for insulin glargine only
Onset of action
- 1 - 3 hours
Duration of action
- 24+ hours
Peak effect
- No peak
Mixing
- DO NOT MIX with other insulinsDosing
- Insulin glargine is a long-acting insulin
- Lixisenatide is a GLP-1 analog
- Pen is dialed to units of insulin glargine. Minimum dose pen can deliver is 15 units and max is 60 units.
- If inadequate control on < 30 units of basal insulin or lixisenatide, starting dose is 15 units once daily
- If inadequate control on 30 - 60 units of basal insulin, starting dose is 30 units once daily
- Titrate dose up or down by 2 - 4 units every week based on blood sugar goals
- Max dose is 60 units
- Administer once a day within the hour prior to the first meal of the day
- See insulin dosing for more
Other
- Soliqua should be clear and colorless to almost colorless
Storage
Unopened / Unused pens
- Store in refrigerator
- Good until expiration date on product
After first use
- Store at room temperature
- Good for 28 days
Xultophy® (insulin degludec + liraglutide)
Dosage forms
Pen (100/3.6)
- 100 units/ml insulin degludec and 3.6 mg/ml liraglutide
- Pens contain 3 ml
- Comes in package of 5 pens
- Pen window shows units of insulin degludec
Needles
- Recommended use with NovoFine®, Novofine® Plus or NovoTwist®
Pharmacokinetics
NOTE: Parameters are for insulin degludec only
Onset of action
- 1 - 3 hours
Duration of action
- 24+ hours
Peak effect
- No peak
Mixing
- DO NOT MIX with other insulinsDosing
- Insulin degludec is a long-acting insulin
- Liraglutide is a GLP-1 analog
- Pen is dialed to units of insulin degludec. Minimum dose pen can deliver is 10 units and max is 50 units.
- Recommended starting dose is 16 units once daily
- Titrate dose up or down by 2 units every 3 - 4 days based on blood sugar goals
- Max dose is 50 units
- Administer at the same time each day with or without food
- Patients who persistently require less than 16 units should discontinue Xultophy and use another product
- See insulin dosing for more
Other
- Xultophy should be clear and colorless
Storage
Unopened / Unused pens
- Store in refrigerator
- Good until expiration date on product
After first use
- Store at room temperature or in a refrigerator
- Good for 21 days
- Kidney disease dosing
- Dulaglutide (Trulicity®)
- No dose adjustment is recommended in patients with renal impairment including end-stage renal disease
- Gastrointestinal side effects may be worse in patients with kidney disease [16]
- Exenatide (Byetta®)
- CrCl > 50 ml/min: No dosage adjustment necessary
- CrCl 30 - 50 ml/min: Starting dose 5 mcg twice a day. Caution should be used if increasing to 10 mcg.
- CrCl < 30 ml/min: DO NOT USE [1]
- Exenatide (Bydureon®)
- CrCl > 50 ml/min: No dosage adjustment necessary
- CrCl 30 - 50 ml/min: Use caution
- CrCl < 30 ml/min: DO NOT USE [15]
- Liraglutide (Victoza®)
- No dose adjustment is recommended in patients with renal impairment
- Use caution in patients with dehydration [2]
- Lixisenatide (Adlyxin®)
- CrCl ≥ 60 ml/min: No dosage adjustment necessary
- CrCl 30 - 60 ml/min: No dose adjustment recommended. Monitor for increased GI and renal side effects.
- CrCl 15 - 30 ml/min: Very limited data. No dose adjustment recommended. Monitor for increased GI and renal side effects.
- CrCl < 15 ml/min: DO NOT USE
- Semaglutide (Ozempic®)
- No dose adjustment is necessary for any degree of renal impairment [22]
- Semaglutide (Rybelsus®)
- No dose adjustment is necessary for any degree of renal impairment [24]
- Liver disease dosing
- Dulaglutide (Trulicity®)
- In a study of patients with varying degrees of liver disease, no clinically relevant change in dulaglutide pharmacokinetics was observed. However, there is limited clinical experience with dulaglutide in liver disease so caution should be used.
- Exenatide (Byetta®)
- The manufacturer states that no studies have been performed on patients with significant liver disease
- Because exenatide is cleared primarily by the kidneys, liver disease is not expected to affect its clearance [1]
- Exenatide (Bydureon®)
- The manufacturer states that no studies have been performed on patients with significant liver disease
- Because exenatide is cleared primarily by the kidneys, liver disease is not expected to affect its clearance [15]
- Liraglutide (Victoza®)
- The prescribing information states that liraglutide should be used with caution in patients with liver disease
- The manufacturer does not recommend adjusting the dose in liver disease [2]
- Lixisenatide (Adlyxin®)
- Has not been studied
- Hepatic dysfunction is not expected to affect the pharmacokinetics of lixisenatide [21]
- Semaglutide (Ozempic®)
- No dose adjustment is necessary for any degree of hepatic impairment [22]
- Semaglutide (Rybelsus®)
- No dose adjustment is necessary for any degree of hepatic impairment [24]
- DRUG INTERACTIONS
- NOTE: Drug interactions presented here are NOT all-inclusive. Other interactions may exist. The interactions presented here are meant to encompass commonly prescribed medications and/or interactions that are well-documented. Always consult your physician or pharmacist before taking medications concurrently. CLICK HERE for more information on drug interactions.
- All GLP-1 analogs
- Insulin and insulin secretagogues - When GLP-1 analogs are used with insulin and insulin secretagogues (e.g. sulfonylureas, meglitinides), the risk for hypoglycemia is increased. Monitor blood sugars closely when combining and adjust medications as needed.
- Drugs affected by decreased gastric emptying - see gastric emptying below
- Drugs that alter gastrointestinal motility - Drugs that slow gastrointestinal motility may potentiate the gastric-slowing effects of GLP-1 analogs
- Exenatide (Byetta®)
- Oral contraceptives - Exenatide can affect the absorption of oral contraceptive pills (see gastric emptying below). Oral contraceptives should be taken at least one hour before exenatide is injected. [1]
- Lixisenatide (Adlyxin®)
- Oral contraceptives - Lixisenatide can affect the absorption of oral contraceptives. Oral contraceptives should be taken at least 1 hour before lixisenatide administration or at least 11 hours after the last dose of lixisenatide. [21]
- Drugs affected by gastric emptying
- When a person consumes food or medications, they are partially digested in the stomach
- The stomach then "empties" food and medications into the small intestine
- GLP-1 analogs slow the process of stomach emptying
- Since most medications are absorbed in the small intestine, slowing of stomach emptying by GLP-1 analogs may affect the absorption of some medications
- In many cases, the overall effect on the drug's therapeutic effect is not significant
- The large number of possible interaction has not been studied extensively
- The effect of the medications listed below may be altered by decreased gastric emptying caused by GLP-1 analogs
- Antibiotics
- Antibiotics require rapid absorption to achieve their desired therapeutic effect
- GLP-1 analogs may alter their absorption
- Antibiotics should be taken at least 1 hour before GLP-1 analogs
- Drugs with a narrow therapeutic index
- Drugs with narrow therapeutic index may be affected by GLP-1 analogs
- Taking these drugs at least 1 hour before GLP-1 analogs may help prevent an interaction
- Examples of drugs with a narrow therapeutic index:
- Carbamazepine (Tegretol®)
- Cyclosporine (Neoral®)
- Digoxin
- Levothyroxine (Synthroid®)
- Lithium
- Phenytoin (Dilantin®)
- Tacrolimus (Prograf®)
- Theophylline (Theo-24®)
- Warfarin (Coumadin®) [9]
- Metabolism and clearance
- GLP-1 analogs do not undergo significant liver metabolism
- PRICE ($) INFO
Pricing legend
- $ = 0 - $50
- $$ = $51 - $100
- $$$ = $101 - $150
- $$$$ = > $150
- Pricing based on one month of therapy at standard dosing in an adult
- Pricing based on information from GoodRX.com®
- Pricing may vary by region and availability
Patient Assistance Programs for GLP-1 Analogs | ||||
---|---|---|---|---|
Drug | Manufacturer | Ships to | PAP info | Application |
Dulaglutide (Trulicity™) | Lilly | Patient or doctor | Link | Link |
Exenatide (Bydureon®, Byetta®) | AstraZeneca | Patient or doctor | Link | Link |
Liraglutide (Victoza®) | Novo Nordisk | Doctor | Link | Link |
Liraglutide (Saxenda®) | Novo Nordisk | Doctor | Link | Link |
Lixisenatide (Adlyxin®) | Sanofi | Doctor | Link | Link |
Semaglutide (Ozempic®) | Novo Nordisk | Doctor | Link | Link |
Semaglutide (Rybelsus®) | Novo Nordisk | Doctor | Link | Link |
- BIBLIOGRAPHY
- Manufacturer's package insert
- 2 - North Carolina Pharmacy Practice Act. Article 4A. 90-85.28(b1).