GLP-1 RECEPTOR

AGONISTS
When and how to initiate
Objectives
• To develop awareness of the available GLP-1 RA and of
the available pen devices.

• To understand the process involved in the initiation of

GLP-1 RA therapy, including special considerations.

• To have an awareness of the considerations for ongoing

management.
GLP-1
When to consider initiation of a GLP-1 RA

• Type 2 diabetes and:

• a body mass index of 35 kg/m2 or higher OR
• a body mass index of less than 35 kg/m2 where:
1. Insulin treatment would be unacceptable for
significant occupational reasons
2. Where weight loss would benefit other
significant obesity related co-morbidities
• Sometimes used ‘off licence’ in Type 1 diabetes under
specialist initiation
Considerations Before Initiation
• Patient thoughts/preconceptions around injectable
therapy.
• Contraception for women of child-bearing age
• Cautions:
 Pancreatitis
 Renal function (U&E’s within last 3 months)
 Gastrointestinal problems
 History of Medullary Thyroid Cancer
• Current diabetes treatments- risk of hypoglycaemia with
sulphonyureas/insulin
Factors influencing choice
• What factors would you consider when choosing a GLP-1
RA?
• Ease of administration
• Adherence
• Current treatment regimen
• Ease of teaching people to use
• Timing of injections
• Needle ‘phobia’
• Patient preference
• Local formulary
PEN QUIZ
Lixisenatide (Lyxumia®)
• Daily injection
• Give 1hr before biggest meal
• Metered doses (14 doses per pen)
• Green pen 10 micrograms daily (titration for 2 weeks)
• Purple pen 20 micrograms daily
• Prime prior to first use of pen
• Renal impairment:
• eGFR 30–50 mL/minute/1.73 m2 - use with caution
• eGFR less than 30 mL/minute/1.73 m2 - avoid
Victoza ® (Liraglutide)
• Daily injection
• Prime prior to first use of pen
• Give at any time of the day regardless of meals
• Starting dose 0.6mg for a week (titration), increasing to
1.2mg (therapeutic)
• Can increase to 1.8mg
• Reduced CVD risk (LEADER study)
• Store pen in use at room temperature (30 days), spare
pens in fridge.
• Use down to eGFR of 15mL/min/1.73 m*2
Victoza ® (Liraglutide)
• Multi-dose, prefilled pen device
• Each pen contains 18 mg liraglutide in 3 ml.
• 30 doses of 0.6mg
• 15 doses of 1.2mg
• 10 dose of 1.8mg
• 2 or 3 prefilled pen packs (Need needles)
Trulicity® (dulaglutide)
• Once weekly
• Monotherapy 0.75mg
• Add on therapy 1.5mg
• Starts to work after first injection
• GI side effects are usually mild to moderate
(declining after second dose)
• 4 pens per pack
Trulicity® (dulaglutide)
• Single use prefilled pen device
• Hidden needle- Sharps waste
• Give at any time of the day
regardless of meals
• Missed dose:
• If there are at least 3 days before
the next dose is due, then give as
soon as possible and continue to
give as usual.
• If there are less then 3 days before
the next dose, skip the dose and
continue to give as usual.
Ozempic ® Semaglutide
• Once weekly, with or without food
• Prime the pen prior to first use
• Starting dose 0.25mg for 4 weeks (titration), then 0.5mg
(therapeutic)
• Can increase to 1mg weekly
• Each pen contains 2mg Ozempic
• Avoid in end-stage renal failure
• SUSTAIN trial- superior weight loss and gylcaemic control
compared to Trulicity, Bydureon, Glargine and Sitagliptin.
• Improved cardiovascular benefits for high risk patients.
Ozempic ® Semaglutide

• Store pen in use at room temperature (30 days) or in

fridge.
• Missed dose: Take as soon as possible within 5 days.
If more than 5 days have passed, skip the missed
dose and continue to give as usual.
Patient Education Pre-Initiation
• Expectations of treatment (patient and HCP)
• Mode of action and side effect profile
• Pharmacological expectations versus side effects (e.g.
satiety, weight loss)
• Dummy injection/demonstration of pen device
• Targets: reduction in HbA1c and weight
• Next steps if not effective
• Baseline data:
 Weight
 BMI
 HbA1c
 eGFR/renal function
Patient Education Initiation

• Dose and titrations

• Injection technique
• Injection sites and rotation
• Pen device
• Storage
• Safe disposal of Sharps
• Changes to current treatments/doses
Ongoing Assessment
Review at 3 and 6 months:

• Weight/BMI (3% loss at 6 months)

• HbA1c (11mmol/mol reduction at 6 months)
• Tolerance
• Adherence
• Other medications
Ongoing Assessment

• When would you discontinue GLP-1 RA use?

• Would you consider switching from one GLP-1 RA to

another? If so why?
Case Studies
• 60 year old.
• Type 2 diabetes for past 6 years
• HbA1c 79mmol/mol
• BMI 34
• eGFR 59
• Current medications: Meformin 1g twice daily, Sitagliptin 100mg
• Has ‘fear’ of injections but meets criteria for GLP-1 RA and has
‘reluctantly’ agreed to commence.

 Which GLP-1 RA would

you consider and why?

 Would you alter existing

medications?

 Any other considerations?

Case Studies
• 48 year old
• Type 2 diabetes for 3 years
• HbA1c 65mmol/mol
• BMI 45
• eGFR 90
• Current medications: Metformin 1g twice daily, Gliclazide 160mg
twice daily and Sitagliptin 100mg daily.

 Which GLP-1 RA would

you consider and why?

 Would you alter existing

medications?

 Any other considerations?

Case Studies
• 59 year old
• Type 2 diabetes for 10 years
• Active foot ulcer (under Podiatry)
• BMI 46
• HbA1c 97mmol/mol
• eGFR 72
• Previous MI
• Current medications: Metformin 1g twice daily, Canagliflozin 300mg
once daily, NovoMix 30 42 units (breakfast) 38 units (evening meal)
 Which GLP-1 RA would
you consider and why?

 Would you alter existing

medications?

 Any other considerations?

Case Studies
• 50 year old
• Type 2 diabetes for 16 years
• BMI 38
• HbA1c 88mmol/mol
• eGFR 92
• Current medications: Metformin SR 2g daily, NovoMix 30 90 units
TDS, Lixisenatide 20micrograms daily
• Tolerating Lixisenatide well but no significant reduction in HbA1c or
weight
 Which GLP-1 RA would
you consider and why?

 Would you alter existing

medications?

 Any other considerations?