VICTOZA (liraglutide)
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
- Initial dosage:
Approval:
- 1 year
Last review date: July 15, 2020