From the Guidelines
For a patient who cannot tolerate metformin and finds Ozempic (semaglutide) too expensive, the next best option would typically be a sulfonylurea such as glipizide (starting at 5mg daily) or glimepiride (starting at 1-2mg daily). These medications stimulate insulin release from the pancreas and are generally inexpensive, costing as little as $4-10 per month at many pharmacies.
Key Considerations
- Another cost-effective alternative is pioglitazone (starting at 15-30mg daily), which improves insulin sensitivity but may cause fluid retention and weight gain.
- DPP-4 inhibitors like sitagliptin (100mg daily) are better tolerated with minimal hypoglycemia risk but are more expensive than sulfonylureas.
- SGLT-2 inhibitors such as empagliflozin (10-25mg daily) offer cardiovascular benefits and weight loss but are also costly.
Patient Factors to Consider
- When selecting an alternative, consider the patient's:
- Cardiovascular risk
- Weight concerns
- Kidney function
- Risk of hypoglycemia
Additional Options
- Generic versions of these medications, patient assistance programs, or lower-cost GLP-1 agonists like dulaglutide might also be worth exploring to manage costs while effectively controlling blood glucose, as recommended by the World Health Organization guidelines 1.
- The American Diabetes Association also suggests considering the patient's disease characteristics, drug characteristics, and patient preferences when choosing a treatment option 1.
From the FDA Drug Label
The management of antidiabetic therapy should be individualized. ACTOS monotherapy in patients not adequately controlled with diet and exercise may be initiated at 15 mg or 30 mg once daily.
The next option for a patient not tolerating metformin and unable to afford Ozempic could be pioglitazone (ACTOS) monotherapy, starting at a dose of 15 mg or 30 mg once daily 2.
From the Research
Alternative Treatment Options
If a patient is not tolerating metformin and Ozempic is too expensive, the next option can be considered based on the following alternatives:
- Sulfonylureas: They are potent glucose-lowering drugs and are inexpensive and readily available everywhere 3. However, they may increase the risk of hypoglycemia and all-cause mortality compared to other oral hypoglycemic agents 4.
- Glucagon-like peptide-1 receptor agonists (GLP-1RAs): They have been shown to have an integrated beneficial effect on all outcomes, including reducing HbA1c, BMI, and blood pressure, and increasing HDL-C 5.
- Dipeptidyl peptidase-4 inhibitors (DPP-4is): They have been compared to metformin and sulphonylurea combination therapy, with results showing no significant difference in cardiovascular events, but an increased risk of serious adverse events with the combination therapy 6.
- Thiazolidinediones (TZDs): They have been compared to metformin and sulphonylurea combination therapy, with results showing no significant difference in cardiovascular events, but an increased risk of serious adverse events with the combination therapy 6.
Considerations for Treatment Selection
When selecting an alternative treatment, the following factors should be considered:
- Efficacy: The ability of the treatment to reduce HbA1c and improve glycemic control.
- Safety: The risk of hypoglycemia, serious adverse events, and other potential side effects.
- Cost: The expense of the treatment, including any potential cost savings or increased costs compared to metformin or Ozempic.
- Patient characteristics: The individual patient's medical history, comorbidities, and preferences should be taken into account when selecting a treatment.