albiglutide (Tanzeum®)

SELF ADMINISTRATION

Indications for Prior Authorization:

  • Adjunctive therapy to improve glycemic control in type 2 diabetic patients who are compliant with metformin yet have not achieved adequate glycemic control
  • Current A1c greater than 7 but less than 10 while compliant on oral therapy must be submitted for approval

Patients must meet all of the following criteria for the indications above:

  • Diagnosis of Type 2 diabetes
  • Failure, as defined as an HbA1c > 7%, intolerance or contraindication to metformin at maximum effective therapeutic dose of 1,500 mg/day or maximum tolerated does unless contraindicated
  • An A1c level must be taken after a minimum of 3 months since last metformin dose change with confirmation in Express Scripts of patient compliance with the treatment regimen
  • Concurrent administration with any dipeptidyl peptidase-4 inhibitor is not approvable

The following indications do not meet the criteria for use established by the Western Health Advantage Pharmacy and Therapeutics Committee:

  • Treatment of Type 1 diabetes
  • Treatment of ketoacidosis
  • Appetite suppression or treatment of obesity

Dosing:

  • Recommended dose: 30mg SC once weekly

 

 

Last review date: November 29, 2016