GLP-1 ANALOG DOSING





Acronyms


Dulaglutide
Trulicity®

Dosage forms

Single-dose pen
  • 0.75 mg/0.5 ml
  • 1.5 mg/0.5 ml
  • 3 mg/0.5 ml
  • 4.5 mg/0.5 ml
  • Comes in carton with 4 pens

Dosing

Type 2 diabetes
  • Starting: 0.75 mg once weekly
  • Maintenance: 0.75 - 4.5 mg once weekly
  • Max: 4.5 mg once weekly
  • Increase to next higher dose if needed at intervals of 4 weeks
  • May administer without regard to food
  • If a dose is missed, administer ASAP if there are at least 3 days until the next scheduled dose
  • If less than 3 days remain before the next scheduled dose, skip the missed dose and administer the next dose on the regularly scheduled day
  • In each case, patients can then resume their regular once weekly dosing schedule
  • The day of weekly administration can be changed if necessary as long as the last dose was administered 3 or more days before
Kidney disease
  • No dose adjustment is recommended in patients with renal impairment including end-stage renal disease
  • Gastrointestinal side effects may be worse in patients with kidney disease
Liver disease
  • In a study of patients with varying degrees of liver disease, no clinically relevant change in dulaglutide pharmacokinetics was observed. However, there is limited clinical experience with dulaglutide in liver disease so caution should be used.

Other

  • Inject subcutaneously in thigh, abdomen, or upper arm
  • If adding to insulin or sulfonylurea, consider lowering dose of these drugs when initiating to prevent hypoglycemia

Generic / Price

  • NO/$$$$

Storage

Refrigerated pens/syringes
  • Good until expiration date
Room temp pens/syringes
  • Good for 14 days

Exenatide
Byetta®

Dosage forms

Multi-dose pen
  • 5 mcg dose - 1.2 ml pen with 60 doses
  • 10 mcg dose - 2.4 ml pen with 60 doses

Dosing

Type 2 diabetes (adults)
  • Starting: 5 mcg twice a day
  • Maintenance: 5 - 10 mcg twice a day
  • Max: 10 mcg twice a day
  • Increase dose at intervals of ≥ 4 weeks
  • Give within the 60-minute time period before the morning and evening meal
Kidney disease
  • CrCl > 50 ml/min: No dosage adjustment necessary
  • CrCl 30 - 50 ml/min: Starting dose 5 mcg twice a day. Caution should be used if increasing to 10 mcg.
  • CrCl < 30 ml/min: DO NOT USE
Liver disease
  • The manufacturer states that no studies have been performed on patients with significant liver disease
  • Because exenatide is cleared primarily by the kidneys, liver disease is not expected to affect its clearance

Other

  • Inject subcutaneously in thigh, abdomen, or upper arm
  • To limit GI side effects, the recommended starting dose is 5 mcg twice a day

Generic / Price

  • NO/$$$$

Storage

Unpunctured pens
  • Keep refrigerated
  • Good until expiration date on product
Punctured pens
  • Keep at temperature below 77° F (25°C)
  • Good for 30 days
  • Do not freeze

Exenatide
Bydureon BCise®

Dosage forms

Autoinjector
  • 2 mg/0.85 ml
  • Comes in carton of 4 autoinjectors

Dosing

Type 2 diabetes in adults and pediatric patients ≥ 10 years old
  • Dosing: 2 mg once weekly
  • Max: 2 mg once weekly
  • May administer at any time of day without regard to food
  • Inject subcutaneously in abdomen, thigh, or upper arm
  • Missed doses: administer missed dose ASAP, provided the next regularly scheduled dose is due at least 3 days later. Thereafter, patients can resume their usual dosing schedule of once weekly. If a dose is missed and the next regularly scheduled dose is due 1 or 2 days later, the patient should not administer the missed dose and instead resume Bydureon with the next regularly scheduled dose. Do not take 2 doses within 3 days of each other.
Kidney disease
  • CrCl 45 - 89 ml/min: exposure is increased. Monitor for adverse reactions and hypovolemia.
  • CrCl < 45 ml/min: DO NOT USE
Liver disease
  • The manufacturer states that no studies have been performed on patients with significant liver disease
  • Because exenatide is cleared primarily by the kidneys, liver disease is not expected to affect its clearance

Generic / Price

  • NO/$$$$

Storage

Refrigerated
  • Good until expiration date
  • Bydureon BCise must be stored flat
Room temp not to exceed 86°
  • Good for 4 weeks
  • Bydureon BCise must be stored flat

Liraglutide
Victoza®

Dosage forms

Multi-dose pen
  • Pen contains 18 mg/3 ml and can be dialed to all 3 doses
  • For 1.8 mg dose has 10 doses
  • For 1.2 mg dose has 15 doses
  • For 0.6 mg dose has 30 doses
  • Comes in packages of 2 or 3 pens

Dosing

Type 2 diabetes (adults)
  • Starting: 0.6 mg once daily for 1 week
  • Maintenance: 1.2 - 1.8 mg once daily
  • Max: 1.8 mg once daily
  • To limit GI side effects, the recommended starting dose is 0.6 mg once daily
  • 0.6 mg dose is not effective for blood sugar control
  • May be administered without regard to food
Type 2 diabetes (children ≥ 10 years old)
  • Starting: 0.6 mg once daily
  • Maintenance: 0.6 - 1.8 mg once daily
  • Max: 1.8 mg once daily
  • The dose may be increased by 0.6 mg every 7 days if necessary
  • Pediatric approval based on PMID 31034184
  • May be administered without regard to food
Kidney disease
  • No dose adjustment is recommended in patients with renal impairment
  • Use caution in patients with dehydration
Liver disease
  • The prescribing information states that liraglutide should be used with caution in patients with liver disease
  • The manufacturer does not recommend adjusting the dose in liver disease

Other

  • If adding to insulin or sulfonylurea, consider lowering dose of these drugs when initiating to prevent hypoglycemia
  • It is acceptable to inject Victoza and insulin in the same body region but the injections should not be adjacent to each other
  • If > 3 days have elapsed since last dose, reinitiate at 0.6 mg dose

Generic / Price

  • NO/$$$$

Storage

Unpunctured pens
  • Keep refrigerated
  • Good until expiration date if refrigerated
  • Do not freeze
Punctured pens
  • Keep at room temperature or refrigerate
  • Good for 30 days
  • Do not freeze

Semaglutide
Ozempic®

Dosage forms

Multi-dose pen
  • 2 mg/1.5 ml pen - discontinued
  • 2 mg/3 ml pen - delivers 4 doses of 0.25 mg and 2 doses of 0.5 mg OR 4 doses of 0.5 mg
  • 4 mg/3 ml pen - delivers four 1 mg doses
  • 8 mg/3 ml pen - delivers four 2 mg doses

Dosing

Type 2 diabetes
  • Starting: 0.25 mg SQ once weekly for 4 weeks. After 4 weeks of 0.25 mg, increase dose to 0.5 mg once weekly. The 0.25 mg dose is for titration only and is not effective for glycemic control.
  • Maintenance: 0.5 - 2 mg SQ once weekly
  • Max: 2 mg SQ once weekly
  • Dose may be increased to 1 mg and then 2 mg if necessary. Each dose should be given for at least 4 weeks before increasing.
  • The day of weekly administration can be changed if necessary as long as the time between two doses is at least 2 days (> 48 hours)
  • If a dose is missed, administer it as soon as possible, within 5 days after the missed dose. If > 5 days have passed, skip the missed dose and administer the next dose on the regularly scheduled day.
  • Inject subcutaneously in the thigh, abdomen, or upper arm. Rotate injection sites with each dose. Do not use the same site for each injection.
  • May administer without regard to food
Kidney disease
  • No dose adjustment is necessary for any degree of renal impairment
Liver disease
  • No dose adjustment is necessary for any degree of hepatic impairment

Generic / Price

  • NO/$$$$

Storage

Unused pens
  • Keep refrigerated
  • Good until expiration date
  • Do not freeze
After first dose
  • Store at room temperature or refrigerated
  • Good for 56 days

Semaglutide
Rybelsus®

Dosage forms

Tablet (formulation R1)
  • 3 mg
  • 7 mg
  • 14 mg
Tablet (formulation R2)
  • 1.5 mg
  • 4 mg
  • 9 mg

Dosing

Type 2 diabetes (formulation R1)
  • Starting (Day 1 to 30): 3 mg once daily for 30 days (this dosage is not effective for glycemic control)
  • Escalation and Maintenance Dosage:
    • Days 31 to 60: Increase the dosage to 7 mg orally once daily
    • Day 61 and on: If blood sugars are controlled, continue 7 mg once daily. If additional glycemic control is needed, increase to 14 mg once daily.
  • Missed doses: If a dose is missed, skip the missed dose, and take the next dose the following day
  • Take on an empty stomach in the morning with water (up to 4 ounces of water). Do not take with other liquids besides water. After taking Rybelsus, wait at least 30 minutes before eating food, drinking beverages, or taking other oral medications.
  • Swallow tablets whole. Do not split crush, or chew.
Type 2 diabetes (formulation R2)
  • Starting (Day 1 to 30): 1.5 mg once daily for 30 days (this dosage is not effective for glycemic control)
  • Escalation and Maintenance Dosage:
    • Days 31 to 60: Increase the dosage to 4 mg orally once daily
    • Day 61 and on: If blood sugars are controlled, continue 4 mg once daily. If additional glycemic control is needed, increase to 9 mg once daily.
  • Missed doses: If a dose is missed, skip the missed dose, and take the next dose the following day
  • Take on an empty stomach in the morning with water (up to 4 ounces of water). Do not take with other liquids besides water. After taking Rybelsus, wait at least 30 minutes before eating food, drinking beverages, or taking other oral medications.
  • Swallow tablets whole. Do not split crush, or chew.
Switching between Rybelsus formulations
  • Do not switch between Rybelsus formulations during the initiation phase (Days 1-30)
  • After 30 days, patients may switch between Rybelsus formulations using the following ratios:
    • Formulation R1 7 mg and Formulation R2 4 mg may be switched for each other
    • Formulation R1 14 mg and Formulation R2 9 mg may be switched for each other
  • When switching between the formulations, initiate the other Rybelsus formulation the day after discontinuing the previous one
Switching between Ozempic and Rybelsus
  • Ozempic to Rybelsus formulation R1
    • One week after discontinuing 0.5 mg of subcutaneous Ozempic, start 7 mg or 14 mg of Rybelsus (formulation R1) orally once daily
    • Switching recommendations for patients taking Ozempic 0.25 mg, 1 mg, or 2 mg subcutaneously once weekly to Rybelsus (formulation R1) are not available
  • Ozempic to Rybelsus formulation R2
    • One week after discontinuing 0.5 mg of subcutaneous Ozempic, start 4 mg or 9 mg of Rybelsus (formulation R2) orally once daily
    • Switching recommendations for patients taking Ozempic 0.25 mg, 1 mg, or 2 mg subcutaneously once weekly to Rybelsus (formulation R2) are not available
Kidney disease
  • No dose adjustment is necessary for any degree of renal impairment
Liver disease
  • No dose adjustment is necessary for any degree of hepatic impairment

Other

  • Do not split, crush, or chew tablets
  • Leave tablets in blister pack until ready for use

Generic / Price

  • NO/$$$$

Soliqua®
Insulin glargine + lixisenatide

Dosage forms

Pen (100/33)
  • 100 units/ml insulin glargine and 33 mcg/ml lixisenatide
  • Pens contain 3 ml
  • Comes in package of 5 pens
  • Pen window shows units of insulin glargine

Dosing

Type 2 diabetes
  • Insulin glargine is a long-acting insulin, and lixisenatide is a GLP-1 analog
  • Pen is dialed to units of insulin glargine. Minimum dose pen can deliver is 15 units and max is 60 units. See the Soliqua PI [sec 2.2] for the amount of lixisenatide with each dose of insulin.
  • Recommended starting dose:
    • Discontinue other basal insulin and/or GLP-1 agonist before initiating Soliqua
    • Patients naive to basal insulin or a GLP-1 agonist, currently on a GLP-1 agonist or less than 30 units of basal insulin daily: starting dose is 15 units once daily
    • Patients currently on 30 to 60 units of basal insulin daily, with or without a GLP-1 agonist: starting dose is 30 units once daily
  • Maintenance: titrate dose up or down by 2 - 4 units every week based on blood sugar goals
  • Missed doses: resume dosing at the next scheduled dose. Do not administer an extra dose or increase the dose to make up for the missed dose.
  • Administer once a day within the hour prior to the first meal of the day

Efficacy

Parkinson's disease

Generic / Price

  • NO/$$$$

Storage

Unopened / Unused pens
  • Store in refrigerator
  • Good until expiration date on product
After first use
  • Store at room temperature
  • Good for 28 days

Xultophy®
Insulin degludec + liraglutide

Dosage forms

Pen (100/3.6)
  • 100 units/ml insulin degludec and 3.6 mg/ml liraglutide
  • Pens contain 3 ml
  • Comes in package of 5 pens
  • Pen window shows units of insulin degludec
  • Compatible with NovoFine® and NovoTwist® needles

Dosing

Type 2 diabetes
  • Insulin degludec is a long-acting insulin, and liraglutide is a GLP-1 analog
  • Pen is dialed to units of insulin degludec. Minimum dose pen can deliver is 10 units and max is 50 units. See the Xultophy PI [sec 2.2] for the amount of liraglutide with each dose of insulin.
  • Recommended starting dose:
    • Discontinue other basal insulin and/or GLP-1 agonist before initiating Xultophy
    • Patients naïve to basal insulin or a GLP-1 agonist: starting dose is 10 units once daily
    • Patients currently on basal insulin or a GLP-1 agonist: starting dose is 16 units once daily
  • Maintenance: titrate dose up or down by 2 units once or twice weekly, depending on blood sugar goals
  • Missed doses: resume dosing at the next scheduled dose. Do not administer an extra dose or increase the dose to make up for the missed dose. If more than 3 days have passed since the last dose, reinitiate Xultophy at the recommended starting dose to mitigate GI side effects.
  • Administer at the same time each day with or without food

Generic / Price

  • NO/$$$$

Storage

Unopened / Unused pens
  • Store in refrigerator
  • Good until expiration date on product
After first use
  • Store at room temperature or in a refrigerator
  • Good for 21 days




DRUG INTERACTIONS




PRICE ($) INFO

  • $ = 0 - $50
  • $$ = $51 - $100
  • $$$ = $101 - $150
  • $$$$ = > $150
  • Pricing based on one month of therapy at standard dosing in an adult
  • Pricing based on information from GoodRX.com®
  • Pricing may vary by region and availability

Patient Assistance Programs for GLP-1 Analogs
Drug Manufacturer Ships to PAP info Application
Dulaglutide (Trulicity™) Lilly Patient or doctor Link Link
Exenatide (Bydureon®, Byetta®) AstraZeneca Patient or doctor Link Link
Liraglutide (Victoza®) Novo Nordisk Doctor Link Link
Liraglutide (Saxenda®) Novo Nordisk Doctor Link Link
Semaglutide (Ozempic®) Novo Nordisk Doctor Link Link
Semaglutide (Rybelsus®) Novo Nordisk Doctor Link Link

BIBLIOGRAPHY