SEMAGLUTIDE FORMULATIONS — Ozempic has been available since 2018 in two multidose pens: one that delivers doses of 0.25 or 0.5 mg and one that delivers 1-mg doses (see Table 1). Up to 30% of patients treated with 1-mg doses of the drug do not achieve the desired A1C goal.1,2 An oral formulation of semaglutide (Rybelsus) has been available for treatment of type 2 diabetes since 2019.3 Injectable semaglutide is also available in a higher dose (2.4 mg) as Wegovy for chronic weight management in adults with or without type 2 diabetes who have a body mass index (BMI) ≥30 kg/m² or a BMI ≥27 kg/m² and at least one weight-related comorbidity.4

CLINICAL STUDIES — FDA approval of the new formulation was based on the results of a double-blind trial (SUSTAIN FORTE) in 961 patients with type 2 diabetes that was inadequately controlled on metformin with or without a sulfonylurea. Patients were randomized to receive semaglutide 1 or 2 mg SC once weekly. Patients in the 2-mg group had statistically significantly greater mean changes from baseline at 40 weeks in A1C (-2.2% vs -1.9%) and weight (-6.9 kg vs -6.0 kg) compared to those in the 1-mg group.5

ADVERSE EFFECTS — GI adverse effects (nausea, vomiting, diarrhea, constipation) are common with semaglutide. In SUSTAIN FORTE, GI adverse effects occurred in 34% of patients in the 2-mg group and in 31% of those in the 1-mg group. Acute pancreatitis and cholelithiasis have been reported with use of injectable and oral semaglutide. The labels of all semaglutide formulations include a boxed warning about a risk of thyroid C-cell tumors (based on animal data, no corroborating human data); the drug is contraindicated for use in patients with a personal or family history of medullary thyroid carcinoma and in those with multiple endocrine neoplasia syndrome type 2.

DOSAGE AND ADMINISTRATION — The starting dosage of Ozempic for treatment of type 2 diabetes is 0.25 mg injected SC once weekly in the abdomen, thigh, or upper arm. After 4 weeks, if tolerated, the dose should be increased to 0.5 mg. If additional glycemic control is needed, the dose can be doubled every 4 weeks to a maximum of 2 mg once weekly.

Unused pens should be stored in the refrigerator; after first use, they can be kept at room temperature for up to 56 days. A new needle should be attached for each injection and injection sites should be rotated each week. Ozempic does not need to be reconstituted before administration.

CONCLUSION — A 2-mg dose of the injectable GLP-1 receptor agonist semaglutide (Ozempic) has been approved by the FDA for use in patients with type 2 diabetes that requires additional glycemic control. In one clinical trial, addition of semaglutide 2 mg once weekly to standard treatment reduced A1C and weight more than addition of a 1-mg dose of the drug, but the effect was modest. GI adverse effects were common with both doses.