Endocrinology: GLP-1 Affordability

PCP submission

75 yo Male PMHx DMII who was started on ozempic and jardiance. Unfortunately, insurance considers the medicines tier 3 and the cost is prohibitive for patient. Hoping to get some guidance on medicines.

Could you please provide medication recommendations to optimize this patient’s care?

Specialist response

Thank you for this consult. If a patient like this walked into my office, I would have the following general thoughts: Current medication regimen is evidenced based, using evidenced based medicines to reduce mortality and morbidity. I do not see any specific areas for medication optimization at this time. Deprescribing: Fish Oil 1000mg OTC lacks compelling data that it improves outcomes for mortality/morbidity and it may worsen GERD. I recommend discontinuing the over the counter Fish Oil supplement Continue to avoid oral NSAIDs If the pt continues to have episodes of orthostatic hypotension, I recommend having him hold his amlodipine for a 2-4weeks and monitoring his blood pressure and symptoms at home. If symptoms improve and BP still at goal, then go ahead and discontinue amlodipine altogether. If BP is still slightly above goal, then consider adding back a lower dose of amlodipine 2.5mg once daily DM mgmt: Evidence based regimen that is targeting improving microvascular and macrovascular outcomes with the use of SGLT2 and GLP1 along with insulin therapy to control glucoses Given advanced age and morbidities, I recommend a low threshold for backing off his insulin if he has any episodes of hypoglycemia. Consider a glucagon kit on hand for severe hypoglycemia Well this is not ideal, I do have some patients who are having to use their weekly GLP1 (Ozempic or Zepbound) every other week due to financial constraints. Anecdotally, they are doing well but this is not evidenced based use of the medication The pt could also try splitting his Farxiga dose in half and taking 5mg daily and assess any changes in his glucoses/blood pressure. (While insurance solutions are trying to be addressed) Though longterm, if the pt is unable to access Ozempic and Farxiga, then going back to adjusting his insulins would be my recommendation for managing his DM Financial considerations for Ozempic and Farxiga: Tier exemptions for these medications with Medicare/commercial insurance plans are difficult to acquire. I have not been successful in getting a tier exemption on a GLP1 or SGLT2, to help bring down the cost The best option depending on the pt’s income would be to seek assistance through the medication manufacturer. Ozempic has fairly high income eligibility limits, so pts are often surprised when they qualify. Application can be found here: https://www.novocare.com/diabetes/help-with-costs/pap.html Farxiga patient assistance program: https://www.astrazeneca-us.com/medicines/Affordability.html#! Thank you for the consult. Please let me know if I may be of additional assistance.