As a nutritional support pharmacist, you will hear about using Rybelsus (semaglutide) for weight loss, it is now available in Egypt. Rybelsus will be the first ORAL GLP-1 agonist for type 2 diabetes, it's a tablet version of injectable Ozempic.
Glucagon-like peptide-1 (GLP-1) is inactivated in the stomach. That's why other GLP-1 agonists, Bydureon (exenatide), Trulicity (dulaglutide), Victoza (liraglutide) are injected. Rybelsus is formulated to prevent breakdown and improve absorption. But it's hard to take correctly, similar to a bisphosphonate.
Emphasize that Rybelsus must be taken DAILY with a sip or no more than 4 ounces of water at least 30 minutes before the first food, other beverage, or oral medications of the day. Not doing so reduces efficacy. Keep in mind that Ozempic and Trulicity are injected WEEKLY at any time of day, with or without meals. Also weigh cardiovascular (CV) data. So far, evidence isn't strong enough to say that Rybelsus lowers CV risk in type 2 patients with CV disease or at high CV risk even though Ozempic does.
Don't recommend Rybelsus if a metformin add-on is needed for CV patients. Instead, think of GLP-1 agonists that reduce CV risk, Ozempic, Trulicity, or Victoza. Or suggest an oral SGLT2 inhibitor that lowers CV risk, Jardiance (empagliflozin) or Invokana (canagliflozin). Still, expect Rybelsus to sound appealing to some patients. For example, it lowers A1C by about 1% and leads to short-term weight loss of about 4 to 9 pounds (~ 4 Kg) in the same range as injectable GLP-1 agonists (Ozempic, Wegovy, etc). Rybelsus is NOT approved by the FDA to be prescribed for weight loss. These days, doctors may prescribe this drug for weight loss in cases of obesity due to the shortage of Ozempic and Saxenda in the market. But GI side effects may last longer when starting Rybelsus, likely because it's titrated monthly, slower than most injectables.
Advise saving Rybelsus for type 2 diabetes patients withOUT CV disease or high CV risk who want an oral medication, can manage its tricky administration and when lower-cost options aren't the best choice. For example, consider Rybelsus if a gliptin won't get the patient to A1C goal or hypoglycemia or weight gain are concerns with sulfonylureas.
REFERENCES
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Aroda VR, Rosenstock J, Terauchi Y, Altuntas Y, Lalic NM, Morales Villegas EC, Jeppesen OK, Christiansen E, Hertz CL, HaluzÃk M; PIONEER 1 Investigators. PIONEER 1: Randomized Clinical Trial of the Efficacy and Safety of Oral Semaglutide Monotherapy in Comparison With Placebo in Patients With Type 2 Diabetes. Diabetes Care. 2019 Sep;42(9):1724-1732. Available at: https://pubmed.ncbi.nlm.nih.gov/31186300
Bucheit JD, Pamulapati LG, Carter N, Malloy K, Dixon DL, Sisson EM. Oral Semaglutide: A Review of the First Oral Glucagon-Like Peptide 1 Receptor Agonist. Diabetes Technol Ther. 2020 Jan;22(1):10-18. Available at: https://pubmed.ncbi.nlm.nih.gov/31436480