Mark Warren, MD: Combinations of GLP-1 and insulin are very convenient for our patients. Usually, we get to this situation where they require 1 of 2 routes. They’re starting a GLP-1 receptor agonist earlier on, and eventually they fail that and need some basal insulin. Then you will add a basal insulin, and you can do that with a second injection or as a combination with 1 shot of these newer products. The combination offers a lot of convenience and less financial constraints for the patient with one copay. Anything that brings more convenience to the patient is good. The other way that we’ll sometimes get to a combination of insulin and GLP-1 receptor agonists is if they’re on a basal insulin and they’re not on a GLP-1 receptor agonist, we know we need to add one if they’re under 50 to 60 units of a basal insulin. That’s where I would like to go ahead and add a GLP-1 receptor agonist. And now, with the new combinations of a GLP-1 receptor agonist and basal insulin, this option is offered in just 1 convenient shot for our patients.

With the introduction of the combination GLP-1 receptor agonists and basal insulin, we do have an option to make it more convenient. So, my experience is that—when I want to add a GLP-1 receptor agonist to a basal insulin—this is really what I would prefer to go with, the combination. It makes things so much easier for the patient, so much easier for us to titrate just 1 drug. They don’t have to check their blood sugar, except for fasting and titrating to the fasting blood sugar. For us, it’s been very helpful to have these newer agents in combination.

The combination GLP-1 receptor agonist and long-acting insulin allows us to titrate more easily, and we start with a low dose and work our way up. That seems to be helpful in patients in mitigating the side effect profile of the GLP-1 receptor agonist, specifically the nausea. So, our nausea rates are much less than we’d expect with just adding a GLP-1 receptor agonist. The combination allows us to have more tolerability for the agents.

Formulary access for the combination GLP-1 receptor agonist and basal insulin is very important for us, because I think that this combination gives a lot of opportunities for simplifying one’s regimen, having better compliance of the patient, and gaining better glycemic control. When I choose to start them on that, it’s very frustrating for me to have started the sample and find that it’s not covered under their formulary. It constrains my ability to use these products when I know that I can get better results by simplifying the regimen and getting better compliance. I see that when I make these changes. Instead of taking multiple shots of maybe a basal and bolus insulin, taking 1 shot of a combination allows patients to get better compliance with just 1 shot. That’s very important for the patient, but it’s very frustrating as practitioners not to have that formulary access when we already had that whole discussion with the patient about what we think is best for them.

With not having access to the combination once we have started someone on a sample and having to go off the combination, we do see a deterioration in their glycemic control, because then they’re confused about what to do with the different dosing. So, we have to go back and discuss with them that these are the 2 separate agents. We have to have another office visit, more calls to the patient, and more inconvenience. In the meantime, there is a deterioration in their glycemic control. That is a big problem for us when we don’t have access in the formulary.

Access to Therapeutic Combinations in Type 2 Diabetes

Mark Warren, MD, explains some of the benefits associated with the GLP-1 receptor agonist/insulin combinations and the importance of formulary access to these newer agents.
Published Online: September 12, 2017


Mark Warren, MD: Combinations of GLP-1 and insulin are very convenient for our patients. Usually, we get to this situation where they require 1 of 2 routes. They’re starting a GLP-1 receptor agonist earlier on, and eventually they fail that and need some basal insulin. Then you will add a basal insulin, and you can do that with a second injection or as a combination with 1 shot of these newer products. The combination offers a lot of convenience and less financial constraints for the patient with one copay. Anything that brings more convenience to the patient is good. The other way that we’ll sometimes get to a combination of insulin and GLP-1 receptor agonists is if they’re on a basal insulin and they’re not on a GLP-1 receptor agonist, we know we need to add one if they’re under 50 to 60 units of a basal insulin. That’s where I would like to go ahead and add a GLP-1 receptor agonist. And now, with the new combinations of a GLP-1 receptor agonist and basal insulin, this option is offered in just 1 convenient shot for our patients.

With the introduction of the combination GLP-1 receptor agonists and basal insulin, we do have an option to make it more convenient. So, my experience is that—when I want to add a GLP-1 receptor agonist to a basal insulin—this is really what I would prefer to go with, the combination. It makes things so much easier for the patient, so much easier for us to titrate just 1 drug. They don’t have to check their blood sugar, except for fasting and titrating to the fasting blood sugar. For us, it’s been very helpful to have these newer agents in combination.

The combination GLP-1 receptor agonist and long-acting insulin allows us to titrate more easily, and we start with a low dose and work our way up. That seems to be helpful in patients in mitigating the side effect profile of the GLP-1 receptor agonist, specifically the nausea. So, our nausea rates are much less than we’d expect with just adding a GLP-1 receptor agonist. The combination allows us to have more tolerability for the agents.

Formulary access for the combination GLP-1 receptor agonist and basal insulin is very important for us, because I think that this combination gives a lot of opportunities for simplifying one’s regimen, having better compliance of the patient, and gaining better glycemic control. When I choose to start them on that, it’s very frustrating for me to have started the sample and find that it’s not covered under their formulary. It constrains my ability to use these products when I know that I can get better results by simplifying the regimen and getting better compliance. I see that when I make these changes. Instead of taking multiple shots of maybe a basal and bolus insulin, taking 1 shot of a combination allows patients to get better compliance with just 1 shot. That’s very important for the patient, but it’s very frustrating as practitioners not to have that formulary access when we already had that whole discussion with the patient about what we think is best for them.

With not having access to the combination once we have started someone on a sample and having to go off the combination, we do see a deterioration in their glycemic control, because then they’re confused about what to do with the different dosing. So, we have to go back and discuss with them that these are the 2 separate agents. We have to have another office visit, more calls to the patient, and more inconvenience. In the meantime, there is a deterioration in their glycemic control. That is a big problem for us when we don’t have access in the formulary.
View More From This Discussion
Episode 1 Selecting Therapy to Meet Individual Needs
Episode 2 When to Start Insulin? Lack of Consensus on Targets
Episode 3 Comparing New Insulins to Older Formulations
Episode 4 Understanding Factors Behind Insulin Costs
Episode 5 Formulary Decisions and Clinical Practice
Episode 6 Glycemic Control Is the Bottom Line
Episode 7 The Advantages of Insulin, GLP-1 Combinations
Episode 8 Adherence Matters When Weighing a Single Injection
Episode 9 Juggling Multiple Factors When Selecting Therapy
Episode 10 Formulary Management: Antidiabetes Medications
Episode 11 Barriers to Traditional Insulin Therapy
Episode 12 Evidence With Ultra–Long Acting Insulins
Episode 13 Appropriate Access: Payer Perspective on Newer Insulins
Episode 14 Cardiovascular Considerations in Antidiabetic Therapies
Episode 15 Formulary Decisions and GLP-1/Insulin Combinations
Episode 16 Role of GLP-1/Insulin Combinations
Episode 17 Barriers to Insulin Therapy in Type 2 Diabetes
Episode 18 Practical Decisions in Type 2 Diabetes
Episode 19 Deciding Among Insulin Therapies for Type 2 Diabetes
Episode 20 Formulary Access to Insulins in Type 2 Diabetes
Episode 21 Clinical Evidence of Insulin Degludec in Type 2 Diabetes
Episode 22 Hypoglycemia: An Unrecognized Complication in Diabetes
Episode 23 Access to Therapeutic Combinations in Type 2 Diabetes
Episode 24 Impact of Cardiovascular Data in Type 2 Diabetes
$AD300x250BB$
$vacMongoViewPlus$