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TREATMENT OF DIABETES MELLITUS DIABETES is a condition that affects how the body makes energy from food. Food is broken down into sugar (glucose) in the body and released into the blood. When the blood sugar level rises after a meal, insulin responds to let the sugar into the cells to be used as energy. In diabetes, the body either does not make enough insulin or it stops responding to insulin as well as it should. This results in sugar staying in the blood and leads to serious health problems over time. DIAGNOSIS OF DIABETES1 • A1C Test: Lab test measuring average blood sugar over past two to three months • Fasting Blood Sugar Test: Lab test measuring blood sugar after eight hours of no food or drink • Oral Glucose Tolerance Test (OGTT): Measures blood sugar before and two hours after drinking a specific sugary liquid • Random Blood Sugar Test: Measures blood sugar at a moment in time, without any kind of preparation (like fasting) FASTING BLOOD ORAL GLUCOSE TOLERANCE RANDOM BLOOD RESULT A1C TEST SUGAR TEST TEST SUGAR TEST Diabetes ≥ 6.5% ≥126 mg/dL ≥ 200 mg/dL ≥ 200 mg/dL Prediabetes 5.7 – 6.4% 100 – 125 mg/dL 140 – 199 mg/dL N/A Normal < 5.7% ≤99 mg/dL < 140 mg/dL N/A NON-DRUG TREATMENTS2 THERAPY COST WHAT TO EXPECT Diet (Mediterranean diet) and exercise (30 minutes a day, five days a week of moderate- Weight loss $-$$ intensity exercise); 7% weight loss decreases risk of diabetes3 Psychological intervention $$-$$$ Psychotherapy may reduce diabetic distress and improve glycemic control4,5 nationalcooperativerx.com PRESCRIPTION TREATMENTS THERAPY SUB-CATEGORY NOTES FORMULARY TIER Insulins – increase uptake of sugar into cells; in general, vials are less expensive than pens for those who pay a percentage of prescription costs; exceptions are noted below Insulin Aspart (NOVOLOG©, Used just before meals (“bolus”) or in insulin FIASP©) Rapid-acting pumps; effect lasts about three to five hours Tier 2 ($$$$) Vials and Pens Used 30 minutes before meals; less convenient Insulin Regular (NOVOLIN R©) Short-acting but a lower-cost option Tier 2 ($$) Vials and Pens Insulin Regular (HUMULIN RU- Concentrated version of insulin regular; used 30 500) Short-acting minutes before meals Tier 2 ($$) Vials and Pens Doesn’t last as long as long-acting insulins; peak Insulin NPH (NOVOLIN N©) Intermediate-acting effect in four to 10 hours Tier 2 ($$) Vials and Pens Insulin Glargine (BASAGLAR©) Lasts about 24 hours with steady action Long-acting Pens throughout the day Tier 2 ($$) Doesn’t always last 24 hours (may need twice Insulin Detemir (LEVEMIR©) Long-acting daily dosing); vials and pens are same price per Tier 2 ($$$) Vials and Pens mL Insulin Degludec (TRESIBA©) Longest-acting (once daily dosing); vials and Ultra long-acting Vials, U100 Pens, U200 Pens pens same price per unit of insulin Tier 2 ($$$) Insulin Aspart Protamine and Insulin Aspart (NOVOLOG MIX Given 15 minutes before a meal, two to three Tier 2 ($$$) Combination 70/30©) times per day; can last up to 24 hours Vials and Pens Insulin NPH and Insulin Regular Given 30 minutes before a meal, two to three (NOVOLIN 70/30©) Combination times per day; can last up to 24 hours Tier 2 ($$$) Vials and Pens Amylin Analogs – slow stomach emptying, reduce appetite, lessens blood sugar spikes from meals Taken with meals; lowers appetite, slows stomach emptying, lessens mealtime sugar spikes; must take fast-acting oral medicines one Pramlintide (SYMLINPEN©) Tier 2 ($$$$) hour before or two hours after Symlin; not widely used because of side effects in the GI tract and low blood sugars when used with insulin GLP-1 Receptor Agonists – slow digestion and lower blood sugar; low risk of hypoglycemia; common side effects are nausea and diarrhea; rare occurrence of pancreatitis Shown to lower risk of cardiovascular Dulaglutide (TRULICITY©) Weekly injections events in people with and without Tier 2 ($$$) history of previous event Shown to lower risk of cardiovascular Liraglutide (VICTOZA©) Daily injections events in those with heart disease; Tier 2 ($$$$) may have risk of gallbladder disease TREATMENT OF DIABETES MELLITUS Shown to lower risk of cardiovascular Semaglutide (OZEMPIC©) Daily injections events in those with heart disease; Tier 2 ($$$) may have risk of retinopathy Only oral GLP-1 product; must be Semaglutide (Rybelsus®) Daily tablet Tier 2 ($$$) taken on empty stomach Sulfonylureas – helps body secrete more insulin; tends to lose effectiveness after a while Causes more hypoglycemia and weight gain than second generation Chlorpropamide First generation Tier 1 ($$) sulfonylureas; should not be used in the elderly or those with poor kidney function Once daily dosing; very little benefit Glimepiride Second generation Tier 1 ($) above 4mg daily Twice daily dosing; very little benefit Glipizide Second generation Tier 1 ($) above 10mg daily Causes more hypoglycemia and weight Glyburide Once or twice daily with food Tier 1 ($) gain than glipizide or glimepiride Cause more hypoglycemia and weight Tolazamide First generation gain than second generation Tier 1 ($$) sulfonylureas Cause more hypoglycemia and weight gain than second generation Tolbutamide First generation Tier 1 ($$) sulfonylureas; increased risk of death from cardiovascular events Biguanides – lowers the body’s sugar production and improves the body’s use of insulin First-line treatment for most people with diabetes type II; does not cause weight gain; can cause diarrhea, but usually goes away within a couple Metformin Tier 1 ($) weeks; start at low dose and slowly increase to minimize this; can cause vitamin B12 deficiency, so need to monitor Meglitinide Analogs – works like sulfonylureas, faster-acting; can cause hypoglycemia and weight gain; less hypoglycemia than sulfonylureas and more dosing flexibility Nateglinide Very little data on cardiovascular risk, but seems to be neutral Tier 1 ($$) Repaglinide No data on cardiovascular benefit or risk Tier 1 ($$) Alpha-Glucosidase Inhibitors – prevent digestion of sugars; may cause gas and diarrhea; low risk of hypoglycemia; do not cause weight gain nationalcooperativerx.com Acarbose Neutral effect on cardiovascular risk Tier 1 ($) Miglitol No data on cardiovascular risk Tier 1 ($$) Dipeptidyl Peptidase-4 (DPP-4) Inhibitors – help body secrete more insulin, slow digestion of food Sitagliptin (JANUVIA®) Seems to have neutral cardiovascular risk Tier 2 ($$$) Thiazolidinediones - improve body’s use of insulin; cause weight gain and risk of fracture; low risk of hypoglycemia May reduce risk of heart attack or stroke; may improve cholesterol; may Pioglitazone (Actos®) Tier 1 ($) increase risk of heart failure and bladder cancer Rosiglitazone (Avandia®) May increase LDL (bad cholesterol) and risk of heart failure Tier 3 ($$) Sodium Glucose Co-Transporter 2 (SGLT2) Inhibitors – prevent body from taking sugar into blood; may help with weight loss; may cause urinary tract and yeast infections, low blood pressure, increased LDL (bad cholesterol), increased potassium, increased risk of fractures and amputations Dapagliflozin (FARXIGA®) May increase risk of bladder cancer and kidney injury Tier 2 ($$$) Empagliflozin (JARDIANCE®) Lowers risk of cardiovascular events Tier 2 ($$$) Combinations - see notes about effectiveness and safety above for each drug Insulin Degludec and Liraglutide Combination of Tresiba® and Victoza®; more cost-effective than taking both Tier 2 ($$$) (XULTOPHY©) drugs separately Insulin Glargine and Lixisenatide Combination of Lantus/Basaglar® and Adlyxin®; more cost-effective than Tier 2 ($$$) (SOLIQUA©) taking both drugs separately Sitagliptin and Metformin Combination of Januvia® and metformin; combination tablet cost-neutral to Tier 2 ($$$) (JANUMET©) the separate products Dapagliflozin and Metformin Combination of Farxiga® and metformin; combination tablet cost-neutral to Tier 2 ($$$) (XIGDUO©) the separate products Empagliflozin and Metformin Combination of Jardiance® and metformin; combination tablet cost-neutral to Tier 2 ($$$) (SYNJARDY©) the separate products Empagliflozin and Linagliptin Combination of Jardiance® and Tradjenta®; combination tablet cost-neutral to Tier 2 ($$$) (GLYXAMBI©) the separate products Glipizide and Metformin Combination tablet more expensive than separate products Tier 1 ($$) Glyburide and Metformin Combination tablet more cost-effective than taking both drugs separately Tier 1 ($) Pioglitazone and Glimepiride Combination tablet more expensive than taking both drugs separately Tier 1 ($$$) Pioglitazone and Metformin Combination tablet more expensive than taking both drugs separately Tier 1 ($$) TREATMENT OF DIABETES MELLITUS 1. American Diabetes Association. Diagnosis. https://www.diabetes.org/a1c/diagnosis. Accessed March 10, 2020. 2. Wexler DJ. Initial management of blood glucose in adults with type 2 diabetes mellitus. In: UpToDate, Mulder JE, UpToDate, Waltham, MA, 2019. 3. Knowler WC, Barret-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403. 4. Ismail K, Winkley K, Rabe-Hesketh S. Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes. Lancet. 2004;363(9421):1589-97. 5. Safren SA, Gonzalez JS, Wexler DJ, et al. A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes. Diabetes Care. 2014;37(3):625-33. 6. Dispel Concerns About CV Safety With Sulfonylureas. Pharmacist’s Letter, December 2019. 7. Diabetes Medications and Cardiovascular Impact. Pharmacist’s Letter/Prescriber’s Letter. January 2019 nationalcooperativerx.com .
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  • Qtern (Dapagliflozin/Saxagliptin) – New Drug Approval

    Qtern (Dapagliflozin/Saxagliptin) – New Drug Approval

    Qtern® (dapagliflozin/saxagliptin) – New drug approval • On February 28, 2017, AstraZeneca announced the FDA approval of Qtern (dapagliflozin/saxagliptin) as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (T2DM) who have inadequate control with Farxiga® (dapagliflozin) or who are already treated with dapagliflozin and Onglyza® (saxagliptin). • Qtern is not indicated for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis, and it should only be used in patients who tolerate 10 mg of dapagliflozin. • Qtern combines two anti-hyperglycemic agents, dapagliflozin, a sodium-glucose co-transporter 2 (SGLT-2) inhibitor, and saxagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor. • The efficacy of Qtern was evaluated in a study of 315 T2DM patients. Patients were randomized to saxagliptin or placebo, in combination with dapagliflozin and metformin. — Patients treated with add-on saxagliptin therapy had significantly greater reductions in HbA1c from baseline vs. the placebo group (-0.5% vs. -0.2%, respectively; difference between groups in HbA1c: -0.4%, p < 0.0001). — The proportion of patients achieving HbA1c < 7% at week 24 was 35.3% in the saxagliptin group vs. 23.1% in the placebo group. • Qtern is contraindicated in patients with a history of a serious hypersensitivity reaction to dapagliflozin or to saxagliptin (eg, anaphylaxis, angioedema or exfoliative skin conditions), and in patients with moderate to severe renal impairment (eGFR < 45 mL/min/1.73 m2), end-stage renal disease, or on dialysis. • Warnings and precautions of Qtern include pancreatitis, heart failure, hypotension, ketoacidosis, acute kidney injury and impairment in renal function, urosepsis and pyelonephritis, hypoglycemia with concomitant use of insulin or insulin secretagogues, genital mycotic infections, increases in low- density lipoprotein cholesterol, bladder cancer, severe and disabling arthralgia, and bullous pemphigoid.