Cost Savings
Cost savings were evaluated using the MEDVAMC outpatient pharmacy procurement service. The total cost savings per patient per month was $82.49. For the 411 preclinician education patients converted to semaglutide, this resulted in a prospective annual cost savings of $406,840.68. An additional $13,858.32 was saved due to the intervention/clinician education for 14 patients converted to semaglutide. The total annual cost savings was $420,699.00.
Discussion
Overall, glycemic control significantly improved with veterans’ conversion from liraglutide to semaglutide. Not only were significant changes noted with HbA1c levels and weight, but consistencies were noted with mean HbA1c decrease and weight loss expected of GLP-1 RAs noted in clinical trials. The typical range for HbA1c changes expected is -1% to -2% and weight loss of 1 to 6 kg.4,7 Data from the LEAD-5 and SUSTAIN-4 trials, evaluating glycemic control in liraglutide and semaglutide, respectively, have noted comparable yet slightly more potent HbA1c decreases (-1.33% for liraglutide 1.8 mg daily vs -1.2% and -1.6% for semaglutide 0.5 mg and 1 mg weekly, respectively).8,9 However, more robust weight loss has been noted with semaglutide vs liraglutide (-4.62 kg for semaglutide 0.5 mg weekly and -6.33 kg for semaglutide 1 mg weekly vs -3.43 kg for liraglutide 1.8 mg daily).8,9 Results from the SUSTAIN-10 trial also noted mean changes in HbA1c of -1.7% for semaglutide 1 mg weekly vs -1.0% for liraglutide 1.2 mg daily; mean body weight differences were -5.8 kg for semaglutide and -1.9 kg for liraglutide at their respective doses.5 The mean weight loss noted with this QI project is consistent with prior trials of semaglutide.
Of note, 44 patients (14.5%) required the dosage increase of either one or multiple additional glucose-lowering agents at any time point within the 3- to 12-month period. Of those patients, 38 (86.4%) underwent further semaglutide dose titration to 1 mg weekly. Common reasons for a further dose increase to 1 mg weekly were an indication for more robust HbA1c lowering, a desire to decrease patients’ either basal or bolus insulin requirements, or a treatment goal of completely titrating patients off insulin.
It is uncertain why 30.3% of patients experienced an increase in HbA1c and 4.3% experienced no change. However, possibilities for the divergence in HbA1c outcomes in these subsets of patients may include suboptimal adherence to semaglutide or other antihyperglycemic agents as indicated by clinicians or nonadherence to dietary and lifestyle modifications.
Most patients (65.5%) experienced a decrease in HbA1c because of conversion to semaglutide, and AEs appeared as follows: 27.3% experienced hypoglycemia, and 8.2% experienced GI intolerance. The semaglutide discontinuation rate neared 10%, a majority due to intolerable AEs as previously described. Overall, patients seemed to tolerate the medication well as their glycemic control and weight loss improved. Adherence was not objectively assessed for this QI project but could be an area of improvement for future studies.
At the MEDVAMC, liraglutide is a nonformulary agent and semaglutide is now the formulary-preferred option. For patients with uncontrolled T2DM, if a GLP-1 RA is desired for therapy, clinicians are to place a prior authorization drug request (PADR) consultation for semaglutide for further evaluation and review of VA Criteria for Use (CFU) by clinical pharmacist practitioners. Liraglutide is the alternative option if patients do not meet the CFU for semaglutide (ie, have a diagnosis of DR among other exclusions). However, the semaglutide CFU was updated in April 2022 to exclude those specifically diagnosed with PDR, severe NPDR, and macular edema unless an ophthalmologist deems semaglutide acceptable. This indicates that patients with mild-to-moderate NPDR (who were originally excluded from this QI project) are now eligible to receive semaglutide. The incidence of new DR diagnoses (2%) observed in this study could indicate an unclear relationship between semaglutide and increased rates of DR; however, no definitive correlation can be established due to the retrospective nature of this project. The implications of the results of this QI project in relation to the updated CFU remain undetermined.
Due to the comparable improvements in HbA1c and more robust weight loss noted with semaglutide vs liraglutide, we deem it appropriate to select semaglutide as the more cost-efficient GLP-1 RA and formulary preferred option. The data of this QI project supports the overall safety and treatment utility of this option. Although significant cost savings were achieved (> $400,000), the long-term benefit of the liraglutide to semaglutide conversion remains unknown.