What is the indication and dosage of Liraglutide (GLP-1 receptor agonist) for an adult patient with type 2 diabetes or obesity, considering their renal and hepatic function, and cardiovascular history?

Liraglutide: Indications and Dosage

FDA-Approved Indications

Liraglutide is FDA-approved for two distinct indications with different dosing regimens: type 2 diabetes management (Victoza) and chronic weight management (Saxenda). 1

Type 2 Diabetes (Victoza)

• Indicated as an adjunct to diet and exercise to improve glycemic control in adults and pediatric patients aged 10 years and older with type 2 diabetes mellitus 1
• Indicated to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with type 2 diabetes mellitus and established cardiovascular disease 1

Obesity Management (Saxenda)

• Indicated for chronic weight management in adults with BMI ≥30 kg/m² or BMI ≥27 kg/m² with at least one weight-related comorbidity (hypertension, dyslipidemia, type 2 diabetes) 2, 3
• Must be used as an adjunct to a reduced-calorie diet and increased physical activity 2

Dosing Regimens

For Type 2 Diabetes (Victoza)

Adult Dosing:

• Starting dose: 0.6 mg subcutaneously once daily for one week (this dose is intended only to reduce gastrointestinal symptoms and is not effective for glycemic control) 1
• After week 1: Increase to 1.2 mg once daily 1
• Maximum dose: 1.8 mg once daily (increase after at least one week at 1.2 mg if additional glycemic control is needed) 1

Pediatric Dosing (≥10 years):

• Starting dose: 0.6 mg subcutaneously once daily 1
• Titration: Increase in 0.6 mg increments after at least one week on current dose if additional glycemic control is required 1
• Maximum dose: 1.8 mg once daily 1

For Obesity Management (Saxenda)

The titration schedule for liraglutide 3.0 mg is more gradual to minimize gastrointestinal adverse effects: 2

• Week 1: 0.6 mg daily 2
• Week 2: 1.2 mg daily 2
• Week 3: 1.8 mg daily 2
• Week 4: 2.4 mg daily 2
• Week 5 onward: 3.0 mg daily (maintenance dose) 2

Administration Guidelines

• Inject subcutaneously once daily at any time of day, independently of meals 1
• Injection sites: abdomen, thigh, or upper arm 1
• Rotate injection sites within the same region to reduce risk of cutaneous amyloidosis 1
• When using with insulin, administer as separate injections—never mix 1

Special Considerations by Patient Population

Renal Function

• No dose adjustment required for any degree of renal impairment, including end-stage renal disease 4
• Liraglutide reduces albuminuria and slows eGFR decline in patients with chronic kidney disease 4

Hepatic Function

• No specific dose adjustments are provided in the FDA label for hepatic impairment 1
• May provide therapeutic benefits for metabolic dysfunction-associated steatotic liver disease (MASLD) 4

Cardiovascular Disease

• Prioritize liraglutide in patients with established cardiovascular disease and type 2 diabetes, as it reduces major adverse cardiovascular events by 26% (HR 0.74,95% CI 0.58-0.95) 4
• Provides cardioprotective effects through improved myocardial substrate utilization, anti-inflammatory effects, and improved lipid profiles 4

Missed Dose Protocol

• If <3 days since last dose: Resume once-daily regimen with next scheduled dose—do not double up 1
• If ≥3 days since last dose: Reinitiate at 0.6 mg once daily and retitrate to mitigate gastrointestinal symptoms 1

Absolute Contraindications

• Personal or family history of medullary thyroid carcinoma (MTC) 1
• Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) 1
• Serious hypersensitivity reaction to liraglutide or any excipients 1

Concomitant Medication Adjustments

• When initiating with insulin: Reduce basal insulin by 20% to prevent hypoglycemia 4
• When using with sulfonylureas: Consider discontinuing or reducing sulfonylurea dose by 50% due to increased hypoglycemia risk 4
• Do not combine with other GLP-1 receptor agonists or DPP-4 inhibitors 4

Expected Efficacy

Type 2 Diabetes

• HbA1c reductions of approximately 1.1% from baseline with liraglutide 1.2-1.8 mg 5
• Fasting plasma glucose decreases by 1.6 mmol/L by week 26 5
• Weight-neutral to modest weight loss (+0.3 kg to -0.2 kg) at diabetes doses 5

Obesity Management

• Mean weight loss of 5.24-6.1% with liraglutide 3.0 mg daily 4, 6
• Approximately 40% of patients achieve ≥5% total body weight loss 2
• Significantly less effective than semaglutide 2.4 mg (14.9% weight loss) or tirzepatide 15 mg (20.9% weight loss) 6

Common Adverse Effects and Management

• Gastrointestinal effects are most common: nausea (40%), vomiting (16%), diarrhea 2
• These effects are typically mild-to-moderate, dose-dependent, and decrease over time 4
• Slow titration is essential to improve tolerability 2, 4
• Rare but serious risks include pancreatitis (<0.1%) and symptomatic gallstones (<0.05%) requiring hospitalization 2

Treatment Duration and Discontinuation

• Lifelong treatment is typically necessary to maintain weight loss benefits 4
• Discontinuation results in significant weight regain (approximately 50-67% of lost weight within 1 year) 4
• Evaluate treatment response at 12-16 weeks: If <5% weight loss achieved, consider discontinuation and alternative approaches 4

Cost Considerations

• Average cost approximately $1,600 per 30-day supply 2, 3
• Insurance authorization may be challenging, particularly for obesity management without diabetes 4