Article By: Rachel Ignomirello, MS, RDN, CSOWM, LDN
Rachel Ignomirello is a Bariatric Dietitian and Board-Certified Specialist in Obesity and Weight Management.
Thanks to social media influencers, tech moguls, and Hollywood superstars, semaglutide (pronounced “sem-a-gloo-tide") has been quite the talking point this year. It has gained attention because people are losing weight on it. However, semaglutide is so much more than that. In today’s blog, we will cover everything you need to know.
1) What is semaglutide? Semaglutide belongs to a medication class known as glucagon-like peptide-1 (GLP-1) receptor agonists. These medications mimic the naturally occurring GLP-1 hormone. After eating, blood sugar levels start to rise in the body. This is when GLP-1 is released by the gastrointestinal tract. It will prompt the body to make more insulin, a hormone that lowers blood sugar, while inhibiting glucagon, a hormone that raises blood sugar. GLP-1 also reduces appetite in the brain and reduces gastric (stomach) emptying. All this combined leads to increased feelings of fullness. With the disease of obesity, postprandial (after meals) GLP-1 levels are reduced. This can lead to poor fullness, which is why many patients with obesity report higher food intake.
2) Which medications contain semaglutide? The Food and Drug Administration (FDA) has currently approved three semaglutide products: Ozempic, Rybelsus, and Wegovy. Ozempic is a once-weekly injection that was approved in 2017 by the FDA for use in adults with type 2 diabetes. Ozempic has the most buzz. Rybelsus is a daily tablet that was approved in 2019 by the FDA for use in adults with type 2 diabetes. They are both used to lower blood sugar levels, along with diet and exercise. Wegovy is a once-weekly injection that was approved in 2021 by the FDA to help adults and children aged 12 years and older with obesity or being overweight. It is used for weight management, along with diet and exercise. All three medications are only available with a prescription, and there are no approved generic versions.
3) What are the common side effects & possible risks? The most common side effects of semaglutide include nausea, diarrhea, vomiting, indigestion, decreased appetite, abdominal pain, and constipation. Nausea does reduce overtime. The risk of low blood sugar increases if taking another medication that lowers blood sugar. Common examples include insulin and sulfonylureas (glipizide and glimepiride).
Semaglutide is contraindicated in those with personal or family history of medullary thyroid cancers. That risk was observed in laboratory animals but not humans. Semaglutide is not recommended in patients with a history of gastroparesis (slow gastric emptying) or pancreatitis. There has been some concern from patients that the medication will cause gastroparesis, but there is a very low incidence of this occurring.
For patients that have severe GI side effects, kidney function should be monitored due to dehydration risk. There is limited data use in pregnancy, so people of reproductive potential should use non-oral contraceptives and barrier method of contraception for 4 weeks after initiation and for 4 weeks after each dose escalation. Because semaglutide delays stomach emptying, oral contraceptives are less effective. It should also be noted that weight regain is likely if semaglutide is stopped.
4) Are there any tips or barriers for getting started?
- If using Ozempic or Wegovy, talk to your prescriber about the pen mechanism. They may have a demonstration device to practice.
- Set realistic expectations about the potential GI side effects. To help reduce nausea, eat smaller meals, stop eating when full, and avoid greasy/oily foods.
- Cost may be a barrier. Out-of-pocket costs vary depending on insurance or prescription savings cards. A one-month supply can be over $1,000. Using the GoodRx website, the most affordable out-of-pocket cost was $1,300 Wegovy.
- Availability may be another barrier. As of May 2023, Ozempic and Wegovy are listed on the FDA’s Drug Shortage list. During shortages, some companies will compound the drug, which is a process of mixing ingredients to create a medication. However, compounded drugs are not FDA-approved. The FDA issued a warning this year, encouraging patients to only obtain semaglutide with a prescription from a licensed health care provider.
5) Can semaglutide be used in bariatric patients? Remember, bariatric surgeries like the sleeve and bypass are considered metabolic because they affect metabolism and support weight loss. Bariatric surgery naturally increases postprandial GLP-1 levels, and these levels will remain elevated for at least 12 months. This is one of the metabolic changes that supports postoperative weight loss and blood sugar improvements.
Before surgery, many of our pre-op patients may use semaglutide or other GLP-1 receptor agonist medications to support weight loss and blood sugar improvements. It can be difficult to get insurance approval, but it’s easier if you have type 2 diabetes. These types of medications must be stopped before surgery to reduce the risk of post-op GI side effects and dehydration. Your bariatric center will provide guidance on medication adjustments.
Research is very limited in use after bariatric surgery because these medications were not studied in bariatric populations. In my experience, I have seen semaglutide or other GLP-1 receptor agonist medications occasionally used. In my bariatric center, providers prefer to hold off on restarting or trialing these medications until patients are over 1-year post-op. If there are no active GI issues (nausea/vomiting) or food intake issues (undereating), then patients may be able to restart. It can be difficult to tell if the patient was non-compliant or non-responder to surgery, but I have seen some patients benefit from restarting semaglutide for better fullness. Keep in mind that patients with a malabsorptive procedure (bypass or duodenal switch) should avoid using Rybelsus due to poor absorption.
BariMelts provides general recommendations, not to be construed as medical advice. Please consult your doctor.