Managing T2D Patients on GLP-1 Therapy

APRIL 21, 2019


Recommendations for managing patients with type 2 diabetes through adverse events while on a GLP-1 agonist, including recommendations for dose titrations.


Troy Trygstad, PharmD, MBA, PhD: So let’s go back to our previous case. And again, I’m at 10.3%. I’m new to diabetes. You decide to pull the trigger on the GLP-1 [glucagon-like peptide-1]. What else would you like to give me?

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: She’s discharged you from the clinic?

Jessica L. Kerr, PharmD: Yes.

Troy Trygstad, PharmD, MBA, PhD: Remember, I’m coming as a new patient to your clinic, Jess, and I say, “I’m new to diabetes. I had no idea I could get diabetes, and I’m at 10.3% [glycated hemoglobin].” I’m given a GLP-1. Three months from now, for the average patient, I’m working with you closely. I’m expecting to be what?

Jessica L. Kerr, PharmD: Well, within the first 6 months, just with behavior modifications you could drop about 2 percentage points.

Troy Trygstad, PharmD, MBA, PhD: Let’s say that I’m OK. I’m not great, but I’m OK. That gives me 1 percentage point. What else do I get?

Jessica L. Kerr, PharmD: What I’m hoping is that you come back in as at least 8%. Not necessarily, because that GLP-1 gave you a 2-percentage-point reduction.

Troy Trygstad, PharmD, MBA, PhD: And I’m going to get that in 3 months or 6 months?

Jessica L. Kerr, PharmD: I see it in 3 months. It depends on the patient.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Yes.

Troy Trygstad, PharmD, MBA, PhD: So my goal is to get to 8%, and you’ve given me what? What do I need to do to get to 8% from 10.3%? I want to work with you.

Jessica L. Kerr, PharmD: You’re going to work with me.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: You mean you want to get down further?

Jessica L. Kerr, PharmD: You want to get down further? So you’re on the GLP-1 plus the metformin.

Troy Trygstad, PharmD, MBA, PhD: Right.

Jessica L. Kerr, PharmD: I’d go probably go straight to an SGLT2 [sodium-glucose cotransporter 2].

Troy Trygstad, PharmD, MBA, PhD: OK. A week later, you call me and you ask me what? “Did you pick them up?”

Jessica L. Kerr, PharmD: Did you pick them up, yes.

Troy Trygstad, PharmD, MBA, PhD: I said, “Yes, I picked them up.” What else?

Jessica L. Kerr, PharmD: Are your tolerating them?

Troy Trygstad, PharmD, MBA, PhD: I have slight nausea, but I figured out how to manage it. Now what else?

Jessica L. Kerr, PharmD: If we can walk through and get through that nausea and everything, now that I’ve put you on the SGLT2, I’m more worried about the adverse effects of the SGLT2. I’ve already medically managed you with your adverse-effect profile for the GLP-1. So I started you on it, and I’m assuming if it’s an agent that I started you on, based on the case that was presented, I titrated you up to the max tolerable dose of the GLP-1. So you’re at max. Metformin is tolerable, as well as the GLP-1. And then I’m seeing if you’re a candidate for an SGLT2.

Troy Trygstad, PharmD, MBA, PhD: So the likelihood that I’m changing doses however many times between now and 3 months post initial visit is what?

Jessica L. Kerr, PharmD: Depending on your product, 2 or 3 titrations. Two titrations. You have your starting dose and then a titration. Or if you use the exenatide extended release, it is that dose.

Troy Trygstad, PharmD, MBA, PhD: So here’s the curveball. I went back to the pharmacy and they said, “Refill too soon,” because you’ve titrated me. Now what do you do?

Susan Cornell, PharmD, CDE, FAPhA, FAADE: No, that shouldn’t happen because of how the dose titration is.

Troy Trygstad, PharmD, MBA, PhD: So you’re setting me correctly right up front with the titration?

Jessica L. Kerr, PharmD: Yes.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Correct.

Troy Trygstad, PharmD, MBA, PhD: And you’re basically giving me 6 months, or a year, or something. As I’m prescribing it, for folks who don’t work in an endocrinology clinic out there, I should be thinking ahead.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: You’re not going to get the supply part wrong, if that’s where you’re thinking.

Jessica L. Kerr, PharmD: Yeah.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Right.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Whereas with insulin, you’re not sure. You give 10 units, and by the time you come back again, you’re like, “I’m on a higher dose.” Here, they factor in. Let’s take liraglutide, for example.

If you maintain a patient on the 1.2-mg dose, they actually make it 2 packs. That’s all you need for that person. If they’re on the 1.8-mg dose, then you’re going to give them the 3 packs, and that covers you for that entire 30 days. So that patient-experience part is pretty smooth, and that’s being factored in. If it’s the auto-injector, then you throw it away. You have a new one every single week. And so that’s been well thought out with this new class.

Jessica L. Kerr, PharmD: The biggest problem you’re going to probably run into is if it is a device that requires a needle head and you didn’t write that prescription for the needle head.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: I’ve seen that.

Jessica L. Kerr, PharmD: That happens a lot and I think a lot of the prescribing providers—I mean, there are some GLP-1s that come with their own needle heads that go on to the device—forget to actually prescribe the second, or the box of the needle heads. And so, it’s not uncommon for a patient to call me. They’re seeing their outside primary care doctor. They tell me what has been prescribed. Then I bring it up and they never got the needle heads.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: In our state, we need 2 separate prescriptions.

Jessica L. Kerr, PharmD: Yes, ours as well.

Troy Trygstad, PharmD, MBA, PhD: To run on insurance as well.  Don’t forget that.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Right, I think that’s an important factor for pharmacists to remember. So obviously all of us practice within a clinic setting, where we can prescribe those or the person we’re working with can actually do it. We can remind them, “You know, don’t forget the needles.” They’re pen needles. But I think from a community pharmacist’s standpoint, if they’re seeing 1 of these devices come in and there [are] no pen needles written, they should be calling back to get that prescription. Again, they shouldn’t be dispensing without investigating. “Well, what about the pen needles?” And maybe the patient was given samples. So at our clinic, maybe we gave some samples to the patient. That’s fine, but, again, the community pharmacist needs to be checking to make sure: “Do you have everything you need?” It’s kind of like with meters. You know you have meters, but, if you don’t have a test strip, you can’t use the meter. So it’s about making sure the survival supplies are there for what the patient needs.


View additional Peer Exchange videos in the 'Benefits of GLP-1 Agonists for Type 2 Diabetes' series on PharmacyTimes.com.


Recommendations for managing patients with type 2 diabetes through adverse events while on a GLP-1 agonist, including recommendations for dose titrations.


Troy Trygstad, PharmD, MBA, PhD: So let’s go back to our previous case. And again, I’m at 10.3%. I’m new to diabetes. You decide to pull the trigger on the GLP-1 [glucagon-like peptide-1]. What else would you like to give me?

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: She’s discharged you from the clinic?

Jessica L. Kerr, PharmD: Yes.

Troy Trygstad, PharmD, MBA, PhD: Remember, I’m coming as a new patient to your clinic, Jess, and I say, “I’m new to diabetes. I had no idea I could get diabetes, and I’m at 10.3% [glycated hemoglobin].” I’m given a GLP-1. Three months from now, for the average patient, I’m working with you closely. I’m expecting to be what?

Jessica L. Kerr, PharmD: Well, within the first 6 months, just with behavior modifications you could drop about 2 percentage points.

Troy Trygstad, PharmD, MBA, PhD: Let’s say that I’m OK. I’m not great, but I’m OK. That gives me 1 percentage point. What else do I get?

Jessica L. Kerr, PharmD: What I’m hoping is that you come back in as at least 8%. Not necessarily, because that GLP-1 gave you a 2-percentage-point reduction.

Troy Trygstad, PharmD, MBA, PhD: And I’m going to get that in 3 months or 6 months?

Jessica L. Kerr, PharmD: I see it in 3 months. It depends on the patient.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Yes.

Troy Trygstad, PharmD, MBA, PhD: So my goal is to get to 8%, and you’ve given me what? What do I need to do to get to 8% from 10.3%? I want to work with you.

Jessica L. Kerr, PharmD: You’re going to work with me.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: You mean you want to get down further?

Jessica L. Kerr, PharmD: You want to get down further? So you’re on the GLP-1 plus the metformin.

Troy Trygstad, PharmD, MBA, PhD: Right.

Jessica L. Kerr, PharmD: I’d go probably go straight to an SGLT2 [sodium-glucose cotransporter 2].

Troy Trygstad, PharmD, MBA, PhD: OK. A week later, you call me and you ask me what? “Did you pick them up?”

Jessica L. Kerr, PharmD: Did you pick them up, yes.

Troy Trygstad, PharmD, MBA, PhD: I said, “Yes, I picked them up.” What else?

Jessica L. Kerr, PharmD: Are your tolerating them?

Troy Trygstad, PharmD, MBA, PhD: I have slight nausea, but I figured out how to manage it. Now what else?

Jessica L. Kerr, PharmD: If we can walk through and get through that nausea and everything, now that I’ve put you on the SGLT2, I’m more worried about the adverse effects of the SGLT2. I’ve already medically managed you with your adverse-effect profile for the GLP-1. So I started you on it, and I’m assuming if it’s an agent that I started you on, based on the case that was presented, I titrated you up to the max tolerable dose of the GLP-1. So you’re at max. Metformin is tolerable, as well as the GLP-1. And then I’m seeing if you’re a candidate for an SGLT2.

Troy Trygstad, PharmD, MBA, PhD: So the likelihood that I’m changing doses however many times between now and 3 months post initial visit is what?

Jessica L. Kerr, PharmD: Depending on your product, 2 or 3 titrations. Two titrations. You have your starting dose and then a titration. Or if you use the exenatide extended release, it is that dose.

Troy Trygstad, PharmD, MBA, PhD: So here’s the curveball. I went back to the pharmacy and they said, “Refill too soon,” because you’ve titrated me. Now what do you do?

Susan Cornell, PharmD, CDE, FAPhA, FAADE: No, that shouldn’t happen because of how the dose titration is.

Troy Trygstad, PharmD, MBA, PhD: So you’re setting me correctly right up front with the titration?

Jessica L. Kerr, PharmD: Yes.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Correct.

Troy Trygstad, PharmD, MBA, PhD: And you’re basically giving me 6 months, or a year, or something. As I’m prescribing it, for folks who don’t work in an endocrinology clinic out there, I should be thinking ahead.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: You’re not going to get the supply part wrong, if that’s where you’re thinking.

Jessica L. Kerr, PharmD: Yeah.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Right.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Whereas with insulin, you’re not sure. You give 10 units, and by the time you come back again, you’re like, “I’m on a higher dose.” Here, they factor in. Let’s take liraglutide, for example.

If you maintain a patient on the 1.2-mg dose, they actually make it 2 packs. That’s all you need for that person. If they’re on the 1.8-mg dose, then you’re going to give them the 3 packs, and that covers you for that entire 30 days. So that patient-experience part is pretty smooth, and that’s being factored in. If it’s the auto-injector, then you throw it away. You have a new one every single week. And so that’s been well thought out with this new class.

Jessica L. Kerr, PharmD: The biggest problem you’re going to probably run into is if it is a device that requires a needle head and you didn’t write that prescription for the needle head.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: I’ve seen that.

Jessica L. Kerr, PharmD: That happens a lot and I think a lot of the prescribing providers—I mean, there are some GLP-1s that come with their own needle heads that go on to the device—forget to actually prescribe the second, or the box of the needle heads. And so, it’s not uncommon for a patient to call me. They’re seeing their outside primary care doctor. They tell me what has been prescribed. Then I bring it up and they never got the needle heads.

Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: In our state, we need 2 separate prescriptions.

Jessica L. Kerr, PharmD: Yes, ours as well.

Troy Trygstad, PharmD, MBA, PhD: To run on insurance as well.  Don’t forget that.

Susan Cornell, PharmD, CDE, FAPhA, FAADE: Right, I think that’s an important factor for pharmacists to remember. So obviously all of us practice within a clinic setting, where we can prescribe those or the person we’re working with can actually do it. We can remind them, “You know, don’t forget the needles.” They’re pen needles. But I think from a community pharmacist’s standpoint, if they’re seeing 1 of these devices come in and there [are] no pen needles written, they should be calling back to get that prescription. Again, they shouldn’t be dispensing without investigating. “Well, what about the pen needles?” And maybe the patient was given samples. So at our clinic, maybe we gave some samples to the patient. That’s fine, but, again, the community pharmacist needs to be checking to make sure: “Do you have everything you need?” It’s kind of like with meters. You know you have meters, but, if you don’t have a test strip, you can’t use the meter. So it’s about making sure the survival supplies are there for what the patient needs.


View additional Peer Exchange videos in the 'Benefits of GLP-1 Agonists for Type 2 Diabetes' series on PharmacyTimes.com.
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