Januvia (sitagliptin) for diabetes treatment: A $450,000 annual cost opportunity.
Dipeptidyl peptidase-4 (DPP-4) inhibitors, e.g., sitagliptin, saxagliptin, linagliptin and alogliptin, are commonly prescribed medications for the treatment of type 2 diabetes, with the most common being Januvia (sitagliptin). Unfortunately, Januvia provides limited A1c lowering of 0.5% to 0.7%, costs approximately $5,000 annually, and does not have evidence supporting positive cardiovascular (CV) and renal outcomes. Considering its limited A1c lowering, high cost and lack of additional clinical benefits, the DPP-4 inhibitors have lower value (i.e., benefit/cost) relative to other diabetes treatments, such as SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin) and GLP-1 agonists (liraglutide, exenatide, dulaglutide, semaglutide, lixisenatide). In the Anthem Cooperative Care program, there are at least 90 patients prescribed Januvia, which represents an annual cost of $450,000 for this treatment.
As can be seen in Table 1, Januvia and other DPP-4 inhibitors lack the CV and renoprotective benefits found with SGLT2 inhibitors and GLP-1 receptor agonists. As an example, treatment with Victoza (liraglutide) is known to reduce the risk of major adverse cardiac events (MACE). For every 44 patients treated with Victoza over a period of three years, one hospitalization for MACE can be prevented.1 This data is not available for Januvia or other DPP-4 inhibitors, representing a preference for GLP-1 agonists and SGLT2 inhibitors in diabetes treatment.
Optimizing the use of Januvia.
Januvia should be reserved for patients without established ASCVD or CKD who are 0.5–1.0% above their individualized A1c goal, and who cannot tolerate other oral options such as pioglitazone or sulfonylureas. Preference should be given to GLP-1 agonists and SGLT2 inhibitors which lower A1c more and have been shown to provide CV and renal benefits.
Consideration should be given to stopping Januvia in patients with A1c 0.5% or more below their individualized goal, particularly in older adults. Many older adults are treated well below their HgbA1c goal and are at risk for hypoglycemia. Data shows that around 25,000 emergency department visits and 11,000 hospitalizations annually are attributed to treatment-associated hypoglycemia among patients over 65 years of age.3 In fact, hospitalization rates for hypoglycemia surpass those for hyperglycemia in older patients.4
Brief case examples:
- 81-year-old patient with A1c 6.1% on metformin, Januvia and pioglitazone. Her individualized A1c goal is <8% with no hypoglycemia events.
- Consider deprescribing Januvia as A1c is far below goal. Recheck A1c in 3 months to ensure patient remains at goal.
- 68-year-old patient with A1c 7.6% on maximum doses of metformin, pioglitazone, and Jardiance (empagliflozin). In the past, he has tried glipizide (caused severe hypoglycemia) and two GLP-1 receptor agonists (caused severe nausea/vomiting). He has no CV history.
- Start Januvia as he is 0.5–1.0% above his A1c goal, has no CV disease and no compelling indication to try another GLP-1 agonist, and minimizing risk of hypoglycemia is especially important.
- 59-year-old obese patient with A1c 8.6% on maximum doses of metformin and glipizide. She adamantly refuses injections. She also has CHF and CKD (eGFR 40). She asks you if Januvia would be the next best option for her.
- An SGLT2 inhibitor (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin) would be better than Januvia due to their renoprotective effects, benefit in CHF, better A1c reduction and weight-loss effects.
- Considering its limited A1c reduction, high cost and lack of demonstrated CV and renal benefits, Januvia (sitagliptin) has low value relative to other non-insulin diabetes medications.
- Overtreatment of patients with diabetes can increase patient and health system costs from hospitalizations for hypoglycemia.
- Changing from Januvia to an alternative agent, or deprescribing Januvia for select patients, can have long-term financial benefit for patients and health systems.
Please contact Joseph Vande Griend with any questions.
Vivian Cheng, PharmD, BCPS, PGY2 Ambulatory Care Pharmacy Resident, authored this article.
- Verma S, et al. Effects of Liraglutide on Cardiovascular Outcomes in Patients with Type 2 Diabetes Mellitus With or Without History of Myocardial Infarction or Stroke-Post Hoc Analysis from the LEADER Trial. Circulation 2018;138:2884-94.
- American Diabetes Association. Standards of Medical Care in Diabetes 2019. Diabetes Care 2019;42: S1-S147.
- Budnitz DS, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med2011;365: 2002-12.
- Lipska KJ, et al. National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Intern Med2014;1116-24.
- American Heart Association News. “Uninsured patients faced devastating hospital bills for heart attack, stroke.” November 13, 2017. https://newsarchive.heart.org/uninsured-patients-faced-devastating-hospital-bills-heart-attack-stroke/