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Diabetes Treatment Suggested Treatment for Type II Diabetes

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Diabetes Treatment Suggested Treatment for Type II Diabetes Diabetes Treatment Suggested Treatment for Type II Diabetes MONOTHERAPY METFORMIN (if no contraindications) EFFICACY: High HYPOGLYCEMIA RISK: Low WEIGHT: Neutral/Weight Loss CV EFFECT: Beneficial SIDE EFFECTS: GI/Lactic Acidosis COST: $ Check A1c in three months. If the patient is not at program target of < 8 percent, consider two-drug combination (choice dependent on the individual patient and disease-specific factors). IF PATIENT CAN'T TOLERATE/CONTRAINDICATION TO METFORMIN: GLP-1 or SGLT-2 Inhibitor (SGLT2i) + basal insulin Intolerance: Use extended release formulation. Take with food. Titrate dose slowly. Go back to prior tolerated dose if excessive side effects, GI side effects will generally lessen with time. Contraindication: Updated safety labeling says safe to use in patients with eGFR > 30 mL/min/1.73m^2 DRUG ORDER KEY: GREEN YELLOW RED = progression of most to least preferred DUAL THERAPY METFORMIN+ GLP-1 SGLT2i Basal Insulin DPP-IV Inhibitor Glitazone (TZD) EFFICACY: High Intermediate High Intermediate High HYPOGLYCEMIA RISK: Low Low High Low Low WEIGHT: Loss Loss Gain Neutral Gain CV EFFECT: Beneficial Beneficial Neutral May increase HF hospitalizations Potential HF worsening SIDE EFFECTS: GI Dehydration, Fracture, Genitouri- Hypoglycemia Rare Edema, Fracture nary Infections COST: $$$$ $$$ $$$ $$$ $ Check A1c in three months. If the patient is not at program target of < 8 percent, consider combinations below (choice dependent on the individual patient and disease-specific factors). PATIENT SCENARIO PREFERRED DRUG(S) NOTES Refuses to administer Avoid using insulin as a threat or sign of failure. Patient education is key. Discuss with patient injections that diabetes is a progressive disease and injection therapies are important for glycemic control, teach patient about proper injection techniques, self-monitoring of glucose, recognizing signs and symptoms of hypoglycemia and how to treat it. High CV risk or metformin+SGLT2i or GLP-1 Metformin, SGLT2i (Farxiga®, Invokana®, Jardiance®) and GLP-1 established CV disease (Ozempic®, Rybelsus®, Trulicity®, Victoza®) have evidence for decreasing CVD events. Farxiga®, Invokana® and Jardiance® have evidence for reducing HF and/or CKD If further intensification needed, consider adding the other class (SGLT2i or GLP-1). Uncontrolled on oral therapy GLP-1 + metformin +/- basal insulin Metformin should be continued as long as not contraindicated. 01MK6624 R06/20 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association. PAGE 1/2 Key: Brand medications are listed in UPPER CASE and generics in lower case. BLUE CROSS AND BLUE SHIELD OF LOUISIANA FORMULARY AGENTS FOR DIABETES Metformin ($) metformin*, metformin ER* (generic GLUCOPHAGE® XR) GLP-1 Agonists OZEMPIC® (semaglutide) ($$$$) RYBELSUS® (semaglutide) TRULICITY® (dulaglutide) VICTOZA® (liraglutide) (All GLP-1 receptor agonists require PA; criterion to be met is diagnosis of diabetes) SGLT-2 Inhibitors/ FARXIGA® (dapagliflozin) SGLT-2 Inhibitor GLYXAMBI® (empagliflozin plus linagliptin) Combinations ($$$) JARDIANCE® (empagliflozin) SEGLUROMET™ (ertugliflozin plus metformin) STEGLATRO™ (ertugliflozin) SYNJARDY®/XR (empagliflozin plus metformin) XIGDUO® XR (dapagliflozin plus metformin) Basal Insulins BASAGLAR® (insulin glargine) (higher copay tier than other preferred agents) ($$$) LANTUS®/TOUJEO® (insulin glargine) LEVEMIR® (insulin detemir) TRESIBA® (insulin degludec) DPP-4 Inhibitors JANUMET®/XR (sitagliptin plus metformin) ($$$) JANUVIA® (sitagliptin) JENTADUETO® (linagliptin plus metformin) TRADJENTA® (linagliptin) TZDs ($) pioglitazone* Other Insulins FIASP® (human insulin aspart) ($$$) HUMULIN® R U-500 (human insulin regular) ($$$) NOVOLIN® N (human insulin NPH) ($$) NOVOLIN® R (human insulin regular) ($$) NOVOLIN® 70/30 (humulin insulin 70% NPH/30% Regular) ($$) NOVOLOG® (insulin aspart) ($$$) NOVOLOG® Mix (70% insulin aspart protamine suspension/30% insulin aspart) ($$$) RELION® N, R, and 70/30 ($)* (if patient cannot afford high cost of basal insulins, recommend Wal-Mart ReliOn® brand insulin) Sulfonylureas and TZDs should only be used with caution. Both agents are associated with clinically significant weight gain, and sulfonylureas also have a significant risk of causing hypoglycemia. However, it is recognized that these agents may be considered for use in selected patients when a lower-cost alternative is absolutely necessary. *For qualifying patients, these drugs are on our $0 generic program list. Disclaimer: This protocol is informational only. It is not intended or designed to substitute for the reasonable exercise of independent clinical judgment by healthcare providers who are evaluating each patient’s individual needs. This is intended to be a general guideline for a population of patients, not a treatment plan for specific patients. 01MK6624 R06/20 Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross and Blue Shield Association and incorporated as Louisiana Health Service & Indemnity Company. PAGE 2/2.
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