Liraglutide (Victoza®)

SELF ADMINISTRATION

Indications for Prior Authorization:
  • Adjunctive therapy to diet and exercise to improve glycemic control in patients 10 years of age and older with type 2 diabetes mellitus
  • To reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with type 2 diabetes mellitus and established cardiovascular disease
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 as a condition(s) for coverage:
  • Diagnosis of Type 2 diabetes confirmed by chart note documentation, AND
  • Trial and failure of metformin
  • DPP4 (dipeptidyl peptidase-4) inhibitors are not approvable with concurrent administration of GLP-1 (glucagon-like peptide-1) agonists
  • Exenatide (Byetta®), Exenatide Extended-Release (Bydureon®, Bydureon BCise®), Liraglutide (Victoza®), Semaglutide (Ozempic®, Rybelsus®), Dulaglutide (Trulicity®) are the preferred agents
Dosing:
  • Type 2 diabetes mellitus:
    • Initial dosage:
      • 0.6 mg subcutaneously per day for 1 week.
    • Dosage titration:
      • 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
Approval: 
  • 1 year

Last review date: July 15, 2020

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