What is Rybelsus (semaglutide), benefits, risks and side effects?
Rybelsus is an oral semaglutide. Same molecule used in Ozempic. Patients take Rybelsus( semaglutide) orally daily. It is a GLP-1 hormone analog. GLP-1 is a gastrointestinal hormone we make after eating to make insulin. Rybelsus( oral semaglutide) needs to be taken empty stomach. After you take Rybelsus you should wait 30 minutes before eating or drinking.
Finally, Rybelsus (semaglutide) is here. You may have heard about Rybelsus from the TV, your doctor or from a friend. This article will tell you all about Rybelsus. Here is a diabetes specialist perspective about Rybelsus.
For a long time, there was a big competition between the different injectables in this class. But, there was no oral medication within the class. The biggest competition was between Ozempic and Trulicity. Both drugs had their merits. Now, Rybelsus (semaglutide) is here which is the oral form of the Ozempic injection. Ozempic is a once a week injection whereas Rybelsus (semaglutide) is a once a day oral medication.
Rybelsus (semaglutide) is the semaglutide molecule in the pill form( oral form). Semaglutide is a mimicker of a natural intestinal hormone. We call these hormones GLP-1 (glucagon-like peptide). Doctors recommend this medicine besides diet and exercise after metformin. So, it is not recommended as a first-line agent in diabetes treatment. It works by letting your pancreas know that there is food in the stomach. It alerts the pancreas to make insulin only when needed.
Limitations of Rybelsus (semaglutide)
Rybelsus ( oral semaglutide) of course has some limitations. Do not use Rybelsus if you have a history of pancreatitis, a family history of medullary thyroid cancer, or pancreatic cancer. Studies on rats showed some of the signs of medullary thyroid cancer and pancreatic cancer. There is not enough data to prove any harm to humans. This is possible because the genetics of human beings are different. The dosing and exposure are very different as well.
Pros of Rybelsus (semaglutide)
Rybelsus is the strongest oral diabetes treatment agent today. They compared it to Jardiance or Januvia. And, Rybelsus ( oral semaglutide) was much more effective. It was also as effective as an injectable treatment such as Victoza in the studies.
Rybelsus does not cause low blood sugar unless you are on sulfonylureas or insulin. Sulfonylurea are glipizide, glimepiride, glyburide. Your endocrinologist/diabetes specialist should adjust your meds to prevent low blood sugar. Depending on your blood sugar levels or A1c levels, they may tell you to reduce your basal insulin. They may also cut back on the dose of Glipizide or glimepiride. Sometimes, patients are able to stop the insulin and/or sulfonylureas on Rybelsus.
Since it is a pill you can keep Rybelsus in the room temperature and take it with you when traveling.
Good news for patients with kidney and liver problems
Patients with kidney and liver problems can use this medication. But, patients with kidney problems need to remember to stay hydrated.
Weight loss associated with Rybelsus
Rybelsus causes significant weight loss almost as much as or more than Victoza. This medication reduces appetite. It also slows down the stomach emptying and makes you feel full for a long time.
Drug interactions are not common. But, rybelsus can delay the absorption of certain medications. This slowed absorption may affect the efficacy of some medications. Examples of affected meds include antibiotics or birth control pills.
Important note for patients taking thyroid medications. Levothyroxine (Synthroid) exposure is 33% more when taken with Rybelsus (oral semaglutide).
Your endocrinologist/diabetes doctor will or should know all the drug interactions with Rybelsus. We can give you a diabetes consultation as well.
Cons or Side effects of Rybelsus (oral semaglutide)
There is a major disadvantage of this medication. You must take it at least 30 minutes before any food or beverage. Also, you can take it only with only 4 ounces of water but nothing else. Also, you should wait another 30 minutes before you eat or drink anything else.
You cannot crash or disintegrated tablets. So, if you have a problem with swallowing that may be a little difficult.
Stomach and intestinal issues
It can cause significant gastrointestinal distress such as nausea, vomiting, diarrhea, and constipation. The good news is that most of the side effects dissipate in weeks if patients can stand the side effects. Other side effects may include back pain, headaches, and fatigue. If you have any gastrointestinal diseases do not use Rybelsus. Rybelsus can be hard on ulcerative colitis, Crohn’s disease, gastroesophageal reflux, or gastroparesis. This also applies to any other medication in the same class (GLP-1).
Rybelsus (semaglutide) is expensive.
Most insurances do not cover Rybelsus yet in 2020. Although the company that created Rybelsus is promoting it via vouchers/coupons. It allows bypassing the insurance coverage issues. See if your physician is aware of that. Your pharmacist should also be willing to help you to get Rybelsus with a very marginal cost. The promotion may not last too long. Once the insurance companies start to cover the drug, promotions will be less. Our endocrinologists and pharmacist will be able to get you Rybelsus at a very low price.
Rybelsus itself may not be enough
If you have uncontrolled blood sugars you may need more than rybelsus. Sometimes you need a drug that works immediately. Rybelsus may not start working until 4 weeks. For example, if your blood sugars are running more than 200 you may need extra meds. Your physician may want to use medications that are effective faster than Rybelsus. Sometimes you may go on a combination regimen that includes Rybelsus. But, taking Rybelsus on its own may not completely bring you to the goal. That is because the titration schedule takes a few months to reach the desired dosage.
Some studies reported an increased risk of diabetic eye disease with Rybelsus (semaglutide). This was more common in patients with cardiovascular disease. The long duration of diabetes and known baseline retinopathy were also a problem.
Acute kidney injury is possible if patients become dehydrated. When patients start eating less due to appetite suppression dehydration may occur. If the patient already has a baseline chronic kidney disease, the risk is higher. So, maintaining fluid intake is essential. Your diabetes specialist should keep an eye on your kidneys while treating you with semaglutide.
The starting dose is 3 mg every day in the morning. After a month the dose can be increased to 7 mg. After another month if needed the dose can be increased to 14 mg daily. Not every patient will need or be able to tolerate a 14 mg dose.
In case of overdose, patients may have severe prolonged vomiting. Other neurological side effects such as confusion and severe headache may occur. Dehydration may happen. Doctors should observe hospitalized patients and give appropriate care for dehydrated patients. Physicians should remember that the half-life of Rybelsus is 1 week.
Caution: Rybelsus is not recommended for pregnant and breastfeeding women.
Room temperature between 68°F and 77°F (20°C to 25°C). Keep in a dry place away from moisture. Store tablet in the original pack. Keep the tablet in the pack until you are ready to take it
If you need further information please ask our endocrinologist/diabetes specialist about Rybelsus storage.
What happens if I miss a rybelsus dose
Skip the missed dose and continue taking your medication the next day.
Finally, never try to crash the rybelsus tablets.
My experience as an Endocrinologist with Rybelsus (semaglutide)
In our diabetes care center, I see a lot of patients with uncontrolled diabetes. I have started prescribing Rybelsus (oral semaglutide) around mid-October 2019. We always ask my patients how they feel, the side effects, perceived benefits. Our team finds out how blood sugar control is on a day to day basis. Although a lot of studies are done and the drug has proven itself, personal experience is invaluable.
So far, my experience has been positive if they can obtain the medication. I sometimes make personal phone calls to the pharmacist for them to understand the voucher. This helps patients to obtain the medication at a very minimal cost. I hate when patients pay too much out of pocket costs. Nevertheless, patients did not report excessive side effects. Thankfully, the starting dose is small, and gradually increasing dose allows the body to adapt.
Appetite Reduction with Rybelsus
Patients also report a significant reduction in their appetite. Even with the low-dose, blood sugar control improves which was surprising for me. I was expecting blood sugar to improve not until 7 to 14 mg. The truth of the fact that everybody will have different sensitivity and responses to Rybelsus. Somebody may respond to 3 mg greatly. On the other hand, another patient may not respond to even 14 mg if they are totally resistant to these agents.
The Role of an Endocrinologist and/or Diabetes Specialist
As an endocrinologist, my job is to determine which patient will respond best to any medication for diabetes. Treating diabetes is a combination of art and science. Just like one dress may not fit all, Rybelsus treatment may help one patient but not help another. That is why asking the opinion of an endocrinologist or diabetes specialist will make a great difference. With a few small changes in the diabetes treatment regimen, a lot can change.
An endocrinologist who has a special interest in diabetes care management will be able to understand your problems and challenges. He or she will be able to give you the best medications. They will choose the necessary meds that can fit you. Most importantly, a diabetes doctor along with the help of personal diabetes coaches helps you with your lifestyle changes in order to avoid medications.
How to go to an endocrinologist with not leaving your home
www.SugarMDs.com offers an online telemedicine concierge service for patients struggling with diabetes on a daily basis. Our job at www.sugarmds.com is to assess, diagnose, and manage patients with diabetes remotely. We do that without asking them to leave their job, family, and their whole life. Everything is electronic via an app. Devices have Bluetooth connection to the app for remote monitoring. Every bit of data that is transferred to the app is also transferred to the doctor’s monitoring center. This allows doctors to catch problems early and intervene on time.
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Author: Ahmet Ergin, MD, FACE, CDCES, ECNU
About the author: Dr. Ergin operates a large diabetes practice mostly in West Palm Beach, FL and yet can see diabetic patients across the entire state of Florida via a unique telehealth platform which also allows him and his team to track patient progress and be available at all times.