6.1.2.3 Incretin mimetics

It should be remembered that control of modifiable cardiovascular risk factors such as lipids and blood pressure are the most important interventions to be made in patients with type II diabetes.

Specialist use	Liraglutide (Victoza^®)	Prefilled pen 6mg/ml
xx	Exenatide SR (Bydureon^®)	2mg single dose pens
xx	Exenatide (Byetta^®)	Prefilled pen 5mcg/dose, 10mcg/dose
	Dulaglutide (Trulicity^®)	Prefilled pen 1.5mg/ml, 3mg/ml
	Lixisenatide (Lyxumia^®)	Prefilled pen 10mcg, 20mcg

National/local guidance

NICE guidance

NG28: Type 2 diabetes in adults - management, December 2015

TA248 Diabetes type 2 - exenatide prolonged release, February 2012.

Spontaneous reports of acute pancreatitis have been received in association with exenatide. If pancreatitis is suspected, exenatide and other potentially suspect medicines should be discontinued. Patients should be informed of the characteristic symptom of acute pancreatitis: persistent, severe abdominal pain; back pain may also be present.
See Drug Safety Update May 2008

GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued. Drug Safety Update June 2019

Prescribing notes

Exenatide, liraglutide and lixisenatide are incretin mimetics. They increase insulin secretion, suppresses glucagon secretion and slow gastric emptying. They are given by subcutaneous injection for treatment of type 2 diabetes.

Exenatide should be considered as part of a triple therapy regimen in carefully selected patients. It may be used in combination with metformin and a sulfonylurea in patients who have not achieved adequate control with these drugs in combination. It is used twice daily and may be given at any time within the 60 minutes period before the two main meals of the day, with doses at least 6 hours apart. It must not be given after meals. Exenatide is also licensed for use with basal insulin, co-prescribing with insulin is not covered in NICE guidance as this was not licensed at the time of publication.

Liraglutide/lixisenatide should be considered as part of a triple therapy regimen in carefully selected patients, also they may occasionally be used in dual therapy regimens if the person is intolerant of either metformin or a sulfonylurea, or treatment with metformin or a sulfonylurea is contraindicated and the person is intolerant of pioglitazone and gliptins, or treatment with pioglitazone and gliptins is contraindicated.

Exenatide prolonged release is a once weekly formulation and is used in carefully selected patients in triple therapy regimes.

Liraglutide should be considered for those patients unable to tolerate exenatide, who only have one main meal a day or with significant needle phobia. It is given once daily irrespective of meal times. Doses above 1.2mg daily should not be used.

Lixisenatide is licensed for use in both dual and triple therapy regimens. It can also be used together with basal insulin. It is not currently included in NICE guidance - it should be prescribed using the same criteria as per NICE guidance for exenatide and liraglutide. Please note: co-prescribing with insulin is not covered in NICE guidance as this was not licensed at the time of publication. It should not be combined with both basal insulin and a sulphonylurea due to increased risk of hypoglycaemia.

Treatment with an incretin mimetic should only be continued if a beneficial metabolic response has been shown (defined as a reduction of at leat 1 percentage point in HbA1c and a weight loss of at least 3% of initial body weight at 6 months).

Hospital Choice