The Cost of Medication Management in the Diabetic Patient By Paula Straub, RPh

Objectives Review factors for best therapeutic approach for appropriate pharmacologic choices for diabetes management Review cost implications for oral medications and non- insulin treatment options Discuss cost impact for insulin therapies

Diabetes Facts Nearly 86 million Americans have pre-diabetes and another 30 million have diabetes Overall cost to treat pre-diabetes and diabetes has escalated to $322 Billion As the number of cases increases, the cost of diabetes treatment and medications is rising Diabetes patients incur medical expenses 2.3 times higher than those without diabetes Significant increase in vital diabetes medications has occurred over the past few years, especially insulin therapy Managed Healthcare Executive-4/17. Advancements in Diabetes.

Treatment Goals Management of both hyperglycemia and risk factors Individualized Approach

Important Factors for Best Therapeutic Pharmacologic Approach Assessment of patient’s health and comorbid conditions Extent of A1C elevation Patient motivation Adherence-approach should be simple Cost Risk of Hypoglycemia Patient’s weight Patient’s age AACE/ACE Comprehensive Diabetes Mgmt Algorithm, 2017.

Factors Continued Ease of use Safety impact of kidney, liver and liver disease Individual circumstances Formulary Restrictions Combination therapy usually required and should involve agents with complementary actions Monitoring requirements Other Adverse Effects AACE/ACE Comprehensive Diabetes Mgmt Algorithm, 2017.

Effectiveness of Therapy Evaluation Evaluated frequently until stable using multiple criteria A1C SMBG records-fasting and post-prandial Documented and suspected hypoglycemia Potential adverse effects..i.e. weight gain, fluid retention, hepatic, renal or cardiac disease Comorbidities and concomitant drug administration American Diabetes Association-Diabetes Basics.

Oral Medications with Cost Analysis Biguanides Metformin Metformin HCL(500mg, 850mg, 1000mg)-$4.00 list $4.00/60/30 days $10.00/180/90 days Metformin HCL ER 500mg-$4.00/60/30 days, $10.00/180/90days 750mg-$71.82, 1000mg-$124.95(Fortamet) Fortamet/Glumetza (generic)-Costly! 500mg ER-$421.69 500mg ER-$2549.59, 750mg ER- $3875.59,1000mg ER-$5487.69 Walmart List, 1/2017. WAC. First Data. 2017

Sulfonylureas 1st Generation Chlorpropamide-Approximate cost/month-$20 Tolazamide-Approximate cost/month-$48 Tolbutamide-Approximate cost/month-$70 WAC. First Data. 2017

Sulfonylureas 2nd Generation Glimepiride Drug Name Cost Glimepiride Walmart list $4.00/ 30 days, $10.00/ 90 days Glipizide $4.00/ 30 days, $10.00/ 90 days Glyburide Walmart list. 1/2017

Meglitinides Nateglinide (Starlix)- Approximate cost/month-$85 Repaglinide (Prandin)- Approximate cost/month- $50/Prandimet-$55 Repaglinide/Metformin (Prandimet)-Approximate cost/month- $65 WAC. First Data. 2017

TZDs Pioglitazone (Actos)-Approximate cost/month-$25; Alogliptin/Pioglitazone (Oseni)-$195 Avandia-Approximate cost/month-$115 WAC. First Data. 2017

DPP-4 Inhibitors Drug Name Cost Januvia/Janumet $381/$381 Onglyza/Kombiglyze XR $385/$485 Tradjenta/Jentadueto Nesina/Kazano $374/$399 WAC. First Data. 2017

SGLT2 Inhibitors (Canagliflozin)-Invokana-Approximate cost/month- $426.60. With Metformin/Invokamet, XR-$426.60. (Dapagliflozin)-Farxiga-Approximate cost/month- $430.50. With Metformin/Xigduo XR-$430.50. (Empagliflozin)-Jardiance-Approximate cost/month- $430.50. With Linagliptin/Glyxambi-$523.50. With Metformin-Synjardy, XR-$430.20. WAC. First Data. 2017

Alpha-Glucosidase Inhibitors Acarbose (Precose)-Approximate cost/month-$45 Miglitol (Glyset)-Approximate cost/month-$145 WAC. First Data, 2017.

Bile Acid Sequestrants Colesevelam (Welchol)- Approximate cost/month-$470 WAC. First Data, 2017.

Cost Analysis for GLP1 Agonists Drug Name Cost/Month Tanzeum $426.36 Trulicity $585 Byetta $574.01 Bydureon $570.32

Cost Analysis for GLP1 Agonists-Continued Drug Name Cost/Month Victoza $612.78 Xultophy $850-$950 Adlyxin $600 Soliqua $740-$760 WAC. First Data. 2017

Cost Analysis for Rapid Acting Insulins Humalog-100 units/ml: $254.80/10 ml vial; $414/5 of 3ml cartridge, $430.25/5 of 3ml Kwikpen 200units/ml: $393.60/2 of 3ml Kwikpen Novolog-$275.58/10 ml vial; $393.60/5 of 3ml Penfill, $532.20/5 of 3 ml Flexpen Apidra-$255.11/10 ml vial; $492.83/5 of 3ml Solostar Pen WAC. First Data. 2017.

Short Acting Insulins Humulin R-$137.90/10 ml vial; $1379/20ml vial (U500); $514.56/2 of 3 ml Kwikpen (U-500) Novolin R-$137.70/ 10 ml vial WAC.First Data. 2017

Intermediate-Acting Insulins Humulin N-$137.90/ 10 ml vial; $437.25/5 of 3ml Kwikpen Novolin N-$137.70/ 10 ml vial WAC. First Data. 2017

Approximate cost/month Long Acting Insulins Drug Name Approximate cost/month Basaglar Kwikpen $316.80/pkg/5 of 3ml Lantus, Solostar (~$222.08 vial) , (~$372.50/pkg/5 of 3ml) Levemir, Flextouch (~$269 vial) , (~$403.50/pkg/5 of 3ml) Toujeo Solostar (~$335.48/pkg/3 of 1.5ml) WAC. First Data. 2017.

Ultra Long-Acting Insulins Tresiba-$443.85/5 of 3ml Flextouch (100 unit/ml), $532.62/3 of 3ml Flextouch (200 unit/ml) WAC. First Data. 2017

Insulin Mixtures Novolog Mix 70/30-$285.83/10ml vial, $532.20/5 of 3ml FlexPen Humalog Mix 75/25-$264.10/10ml vial, $430.20/5 of 3ml KwikPen, $591.90/3 ml KwikPen-200u/ml Humalog Mix 50/50-$264.10/10ml vial, $430.20/5 of 3ml KwikPen, $591.90/3ml KwikPen-200u/ml Humulin 70/30-$137.90/10 ml vial, $437.25/5 of 3ml KwikPen Novolin 70/30-$137.70/10 ml vial WAC. First Data. 2017

Cost Analysis of Amylin Analog Symlin-Pramlintide- Initial dosing (60 mcg SC prior to major meals)- $546.54/month. Maintenance dosing- $973/month WAC. First Data, 2017.

Reduced RX Program Savings Program between CVS Health and Novo Nordisk Assist patients who are facing high out-of-pocket costs Provides a lower option for diabetes patients to obtain insulin Offers Novolin R, Novolin N and Novolin 70/30 at cost of $25 per vial Patients present card at any of the more than 67,000 participating pharmacies nationwide in the CVS Caremark Network Program starts 5/10/2017 Phone Number for patients 1-844-379-1668 www.reducedrx.com

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