Practical guidance for use of oral semaglutide in primary care: a narrative review

Abstract

As the cornerstone of type 2 diabetes (T2D) management within the community, primary care providers are now faced with the challenge of not only managing diabetes itself, but also preventing hypoglycemia and weight gain associated with intensive disease management, and reducing cardiovascular risk. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are well established as efficacious treatments for T2D, and the safety/tolerability profile of this drug class is well defined. However, despite their beneficial effects, GLP-1RAs are under-utilized, highlighting the need for novel approaches to increase their use in primary care. Oral semaglutide is the first oral GLP-1RA approved for the treatment of T2D, offering glucose lowering and body weight loss, a low risk of hypoglycemia, and no increase in cardiovascular risk. Oral semaglutide represents an additional treatment option for patients not achieving their glycemic goal despite treatment with metformin, either alone or with other hypoglycemic agents. Oral semaglutide has the potential to increase usage of GLP-1RAs in the primary care setting by addressing clinician and patient concerns about injections, and may facilitate earlier initiation of GLP-1RA therapy in T2D. Due to the formulation of oral semaglutide, clinicians need to be aware of specific considerations in order to ensure optimal use. Such considerations include dosing conditions and use of concomitant medications. This article provides practical guidance on the use of oral semaglutide in the primary care setting, based on evidence from clinical studies, including the phase 3a PIONEER program, and the authors' clinical experience.

A new era for oral peptides: SNAC and the development of oral semaglutide for the treatment of type 2 diabetes

“…Many individuals with T2D are required to take multiple medications [70]. Given the mechanism of action of oral semaglutide [56], which includes delayed gastric emptying [24], a number of studies have assessed the impact of oral semaglutide/SNAC on exposure to other commonly administered oral drugs [71][72][73].…”

“…These are typically mild to moderate in intensity, most often occur during dose escalation [24,38,39,61,62,[76][77][78][79][80][81][82], and most likely reflect the mechanism of action of semaglutide in terms of delaying gastric emptying and increasing satiety via a central action [56]. To minimize potential GI side effects and support tolerability, oral semaglutide should be initiated at 3 mg once daily for 30 days; the dose is then increased to 7 mg once daily for glycemic control [24,70]. Following at least 30 days of 7 mg once daily, the dose may be increased to 14 mg once daily if additional glycemic control is required [24].…”

Semaglutide: A Strategic Weapon for Primary Care

“…20 This may be due to the challenges PCPs face in T2D management: they need to address concerns such as risk of hypoglycaemia, high body weight, and cardiovascular and renal issues, beyond the mere monitoring of HbA1c levels, but may not be sufficiently equipped to do so. 21 The role of PCPs is undeniably crucial, thus they should be well supported through the use of robust treatment options that can simplify clinical treatment and enhance patients' adherence to anti-diabetic treatment. A strong candidate for consideration would definitely be semaglutide.…”

Instituting a Successful Discharge Plan for Patients With Type 2 Diabetes: Challenges and Solutions

“…However, for the multidose pens, if a patient develops significant GI side effects even at the lowest dose, providers may instruct patients to dial a "microdose" by counting clicks (e.g., 8-9 clicks is 0.125 mg, or half the typical starting dose of injectable semaglutide) (61). This "microdosing" of GLP-1 receptor agonists is not approved by the FDA but offers the potential for slower titration and reduced risk of GI side effects (62,63).…”