Lixisenatide (Adlyxin®)


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
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, AND
  • Trial and failure of at least two preferred 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]
  • DPP4 (dipeptidyl peptidase-4) inhibitors are not approvable with concurrent administration of GLP-1 agonists
  • Initial dosage:
    • 10 mcg once daily for 14 days
  • Dosage titration:
    • On day 15 increase to 20 mcg once daily.  Maintenace dose: 20mcg once daily
  • 1 year

Last review date: April 22, 2020

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