Albiglutide (Tanzeum®), Dulaglutide (Trulicity®), Exenatide (Byetta®), exenatide extended release (Bydureon®), and liraglutide (Victoza®)
Approved for: self administration
Indications for Prior Authorization
- adjunctive therapy to improve glycemic control in type 2 diabetic patients who are compliant with metformin and 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.
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
All of the following must be met:
- 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. Unless contraindicated, member must currently adhere to maximal tolerated dose of metformin.
- An A1c level must be taken after a minimum of 3 months since last metformin dose change with confirmation in the pharmacy claims adjudication history of patient compliance with the treatment regimen.
- Concurrent administration with any dipeptidyl peptidase-4 inhibitor is not approvable
- Albiglutide (Tanzeum) is the preferred agent.
- Usual dosing: 30 mg SubQ once weekly.
- May increase to 50 mg SubQ once weekly for inadequate glycemic response.
- Initial Dosing: 0.75 mg SubQ once weekly
- May increase to 1.5 mg once weekly if inadequate glycemic response
- Maximum dose: 1.5 mg once weekly
Initiate at 5 mcg SubQ twice a day 60 minutes prior to morning and evening meals. If an inadequate response, then dose may be increased to 10 mcg twice a day after one month.
exenatide extended release (Bydureon®)
Inject 2 mg SubQ every week
Type 2 diabetes mellitus:
- 0.6 mg subcutaneously per day for 1 week.1
- After 1 week at 0.6 mg/day subcutaneously, the dose should be increased to 1.2 mg. If the 1.2 mg dose does not result in acceptable glycemic control, the dose can be increased to 1.8 mg.
Western Health Advantage Pharmacy and Therapeutics Committee
Approved: March 2012 | Revised: July 2016
Last review date: July 21, 2016