What patient specific factors outside of health insurance coverage do you use to decide which GLP1 R agonist or dual agonist therapy to start in patients with diabetes?
What patient specific factors outside of health insurance coverage do you use to decide which GLP1 R agonist or dual agonist therapy to start in patients with diabetes?
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The class of drugs called GLP 1 RA continues to grow. Single agonist drugs include dulaglutide and semaglutide. There is now a “dual agonist” available for use, tirzepatide, which really is a GLP 1 RA and GIP RA. There are “triple agonists” which also bind the glucagon receptor that are close to FDA approval. And in the future at least 7 different receptors have been identified which may be targets for single compound/multiple receptor targets development.
Semaglutide seems more effective for weight and glucose than dulaglutide at highest available doses.
For weight and glucose control, the dual and triple agonists seem to have increasing efficacy over the single agonists. Tirzepatide appears to have cardiovascular and renal benefits comparable to single agonist outcomes studies. I am not aware of any patient specific factor where the single agonists have better outcomes than tirzepatide.
On a patient specific basis, some patients may have fewer side effects with one over another of these drugs, but in general, I haven’t tried a lot of switching between drugs for side effects except injection site specific problems (induration, etc).
Availability in the pharmacies may vary between the different drugs in this class and that may dictate which to use.
Given the above considerations, all things being equal in terms of cost and availability, I would go with tirzepatide for now for most patients, given its greater efficacy both for weight and glucose control.
Usually it has to do with the following factors
- Difficulty manipulating objects/eyesight issues. The Trulicity pen tends to be easier to function, as it doesn't need to have needles installed, and the ample base makes it easier for patients that may have hand/eye coordination issues.
- Need to titrate. Liraglutide pens are more flexible for patients that may have intermittent GI issues and may want to down titrate their doses. On the other hand, they are also easier to uptitrate, so they may reduce your patient's trips to the pharmacy.
- Cardiovascular benefit priority, and weight loss priority. The newer agents (Semaglutide) seem to have increased weight loss in comparison to the older ones. Same with cardiovascular benefit.
Overall, the high level of benefits that are obtained with GLP1 R-agonists make the insurance coverage the most important one. Any of the agents is better than none.
I generally favor semaglutide or tirzepatide when coverage is not an issue, particularly when greater weight loss and glycemic efficacy are priorities. However, I individualize therapy based on GI tolerance, comorbidities, cardiovascular risk, and prior experience with the class, if any. Some patients simply tolerate older agents such as dulaglutide better, and in those patients tolerability outweighs differences in efficacy.