What are the alternative treatments for a patient with insurance that won't cover Trulicity (dulaglutide)?

Alternative Treatments for Patients When Insurance Won't Cover Trulicity (Dulaglutide)

When insurance won't cover Trulicity (dulaglutide), several alternative GLP-1 receptor agonists and other medication classes can be considered based on efficacy, cost, and patient-specific factors.

Alternative GLP-1 Receptor Agonists

• Semaglutide (Ozempic/Wegovy) - Available in weekly subcutaneous injection or daily oral formulation with similar high to very high glucose-lowering efficacy and weight loss benefits as dulaglutide 1
• Liraglutide (Victoza) - Once-daily subcutaneous injection with demonstrated cardiovascular benefits similar to dulaglutide 1
• Exenatide (Byetta) - Available in twice-daily or once-weekly (extended release) formulations 1
• Tirzepatide (Mounjaro) - A dual GIP and GLP-1 receptor agonist with very high glucose-lowering efficacy and weight loss potential 1

Other Medication Classes to Consider

First-Line Option

• Metformin - Should be maintained as the foundation of therapy when tolerated due to its high glucose-lowering efficacy, neutral weight effect, potential cardiovascular benefit, and low cost (median NADAC $1-3 for a 30-day supply) 1

Additional Options

• SGLT2 inhibitors (canagliflozin, empagliflozin, dapagliflozin, ertugliflozin)

  • Provide intermediate to high glucose-lowering efficacy
  • Offer cardiovascular and renal benefits
  • Promote weight loss
  • Lower risk of hypoglycemia 1

• DPP-4 inhibitors (sitagliptin, saxagliptin, linagliptin, alogliptin)

  • Provide intermediate glucose-lowering efficacy
  • Weight neutral
  • Lower risk of hypoglycemia
  • May be better tolerated than GLP-1 RAs with fewer gastrointestinal side effects 1

• Sulfonylureas (glimepiride, glipizide, glyburide)

  • High glucose-lowering efficacy
  • Significantly lower cost than GLP-1 RAs (median NADAC $2-13 for a 30-day supply)
  • Higher risk of hypoglycemia and weight gain 1

Cost Considerations

The cost difference between Trulicity and alternatives is substantial:

• Dulaglutide (Trulicity): Median NADAC $941 for a 30-day supply 1
• Generic metformin: Median NADAC $1-3 for a 30-day supply 1
• Generic sulfonylureas: Median NADAC $2-13 for a 30-day supply 1
• SGLT2 inhibitors: Median NADAC $343-586 for a 30-day supply 1
• DPP-4 inhibitors: Median NADAC $145-550 for a 30-day supply 1

Clinical Decision Algorithm

1. Verify insurance coverage status:

   • Check if prior authorization might be possible
   • Investigate manufacturer patient assistance programs for Trulicity

2. If Trulicity remains unavailable, select alternative based on:

   • Primary concern is cardiovascular disease: Consider another GLP-1 RA with proven CV benefit (liraglutide, semaglutide) or SGLT2 inhibitor (empagliflozin, canagliflozin, dapagliflozin) 1
   • Primary concern is weight management: Consider semaglutide or tirzepatide which offer similar or greater weight loss benefits 1
   • Primary concern is cost: Consider metformin and/or sulfonylurea as significantly less expensive options 1
   • Primary concern is avoiding hypoglycemia: Avoid sulfonylureas; consider metformin, SGLT2 inhibitors, or DPP-4 inhibitors 1

Important Considerations and Caveats

• Medication transitions: When switching from dulaglutide to another GLP-1 RA, consider differences in dosing frequency and potential for gastrointestinal side effects during initiation 1, 2

• Perioperative management: If switching medications, be aware that GLP-1 RAs may delay gastric emptying, which could increase risk of pulmonary aspiration during anesthesia. Consider appropriate timing of medication discontinuation before scheduled procedures 1

• Monitoring for adverse effects: All GLP-1 RAs carry similar risks for gastrointestinal side effects, potential pancreatitis risk, and gallbladder disease 1, 3

• Combination therapy: Consider combination of lower-cost agents to achieve similar efficacy as Trulicity if cost is the primary barrier 1