January/February Blog: Semaglutide Options for Type 2 Diabetes

Contributors: Shatiya Grant and Pegah Tavana, PharmD Candidates Class of 2022, PCOM Georgia School of Pharmacy

VG, a 62-year-old female, has lived with type 2 diabetes for the past fifteen years.  She has tried numerous medications for treatment of her diabetes. VG has been frustrated that many of the medications will lower her glucose; however, they also increase her risk of having low glucose and leaves her feeling hungry.  She has struggled with achieving and maintaining a healthy weight for years, and just simply wants to find a medication that will lower her glucose and help her lose weight.  Today, she has a six month visit with her primary care provider (PCP) to check her hemoglobin A1c (A1c).  Her A1c is 9%.  Her PCP mentions a medication, semaglutide, as a possible treatment option for her diabetes, and VG is excited it comes in either a pill or injection formulations.  VG’s PCP encourages her to research this medication before committing to taking it for her diabetes.

Rybelsus® and Ozempic® are both brand names for a drug called semaglutide, both are FDA approved to control blood sugar levels in persons with type 2 diabetes; however they each have a unique form of delivery. Semaglutide is a glucagon-like peptide-1 (GLP-1) analogue which acts by activating a GLP-1 receptor that is found in the pancreas and this leads to improved insulin release. It also works on the liver by blocking release of excessive amounts of glucose and delays gastric emptying so one feels full longer, and lastly works in the hunger center in the brain to suppresses appetite. This leads to weight loss and can be seen as a favorable side effect from the drug. Additionally, semaglutide provides cardiovascular risk reduction benefits, which decreases risk of having a heart attack, stroke, and death.

Rybelsus® is a once daily pill, whereas Ozempic® is a once weekly injection, which is a longer-acting dosage form. Rybelsus® is available in 3mg, 7mg and 14mg. It is recommended to start Rybelsus® with a 3mg tablet taken once daily in the morning on an empty stomach with 4oz of water for the first 30 days and then the dose may be increased to 7mg and then again to 14mg.  Ozempic® is a prefilled single injection pen, which is administered subcutaneously into the abdomen, upper arm, or thigh. The usual starting dose is a 0.25 mg injection once a week (on the same day each week) and may need to be increased to 0.5mg after 30 days then 1mg after another 30 days depending on shared decision making of the person with diabetes and their healthcare provider. It is strongly recommended that you rotate the injection site each time and to not inject in the same spot due to fatty deposits which may not allow the drug to be absorbed as well and cause it to be less effective. If a dose is missed within 5 days, take it as soon as possible. However, if it has been longer than 5 days, skip the dose and continue the next dose as scheduled. Unused Ozempic® pens are stored in the refrigerator, but once used it can be stored at room temperature or refrigerated.

Both Rybelsus® and Ozempic® have similar side effects. Gastrointestinal symptoms such as nausea, vomiting, diarrhea, and abdominal pain are the most common side effects. These adverse effects appear to be dose-related which is why it is advisable to start at a lower dose so that your body can get accustomed to the drug before increasing the dose. Ozempic® is an injection so it is important to note that some people may also experience injection site reactions that include redness, swelling, itching, and stinging. This is generally no cause for concern and goes away in a few days. It is also important to be aware that these medications have been associated with acute pancreatitis and may also mask the initial signs of pancreatitis including nausea, vomiting, and abdominal pain. People who have been diagnosed with or have had a family member diagnosed with medullary thyroid carcinoma or multiple endocrine neoplasia type 2 should not use any form of semaglutide. This medication has not been studied in persons with gastroparesis. Since semaglutide delays gastric emptying, it is not recommended for persons with gastroparesis.

Semaglutide is a wonderful drug in the world of diabetes and offers many benefits to people including cardiovascular benefits, weight loss, and of course reducing blood sugar levels. Ozempic® offers the benefit of once-weekly dosing which may be a benefit for some patients. While others may lean towards Rybelsus® since they can get the same great health benefits without the need for an injection. To conclude, selection of the most appropriate formulation can be made on an individual basis to best suit their preferences and needs.

Back to VG, after she completes her thorough research, she agrees with her PCP that semaglutide would be a good option.  While talking with her PCP a couple of weeks after her office visit, VG and her PCP choose the once daily, Rybelsus®. They both feel this treatment is most ideal since VG has a needle phobia and prefers oral over injectable formulation.  VG shares her excitement with her best friend, who also has type 2 diabetes, about the oral semaglutide she is now taking  and how it has improved both her glucose values and her weight loss.  VG’s best friend decides to talk with her PCP about the possibility of semaglutide for treatment of her diabetes because she really likes the idea of a once weekly injectable formulation.

References:

Meier JJ. GLP-1 receptor agonists for individualized treatment of type 2 diabetes mellitus. Nat Rev Endocrinol (2012) 8:728–42.  10.1038/nrendo.2012.140

European Medicines Agency. Ozempic® Summary of Product Characteristics. Available at: https://www.ema.europa.eu/en/documents/product-information/ozempic-epar-product-information_en.pdf (Accessed February 2, 2022)

Food and Drug Administration . Rybelsus® Prescribing Information. Available at: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/213051s000lbl.pdf (Accessed February 3, 2022).