WHAT IS RYBELSUS?
Rybelsus (semaglutide) is a medication used to improve glycemic control in conjunction with an adequate diet for adults with type 2 diabetes mellitus (T2DM). It is not known if Rybelsus is safe and effective in those under the age of 18. Rybelsus is provided as 3, 7, or 14 milligram (mg) tablets. There are various restrictions to use with Rybelsus, including:
- Rybelsus should not be used as first-line agent due to potential C-cell tumor effects in rodents
- Rybelsus has not been researched in patients with pancreatitis
- Rybelsus should not be used in those with type 1 diabetes mellitus
HOW DOES RYBELSUS WORK?
GLP-1 is a naturally derived hormone that plays a role in glucose regulation through mediation of GLP-1 receptors. Rybelsus, or semaglutide, is a GLP-1 analogue and exerts its action as a GLP-1 receptor agonist. Semaglutide attaches to the GLP-1 receptor and activates it.
Semaglutide has a long half-life because of its extensive albumin binding. This leads to reduced renal clearance and prevents metabolic breakdown. Semaglutide activates the secretion of insulin and decreases the release of glucagon, thus reducing blood glucose. Therefore, when blood glucose levels are high, insulin release is increased, and secretion of glucagon is blocked. This phenomenon can consequently cause a gastric emptying delay during the early postprandial phase.
The most frequent and/or mild adverse effects from Rybelsus include:
- Stomach (abdominal) pain
- Decreased appetite
- Weight loss
- Gastroesophageal reflux disease (GERD)
- Gas and bloating
WARNINGS AND PRECAUTIONS
Thyroid C-Cell Tumors
In animal models, semaglutide induced dose- and treatment-duration-dependent elevations in thyroid C-cell tumor rates. No human data is available for the incidence of thyroid C-cell tumors. Medullary thyroid carcinoma (MTC) has been reported in other GLP-1 receptor agonists, though a causal relationship cannot be determined. Therefore, Rybelsus is not recommended in patients that have an individual or family history of MTC or for those that have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Patients should be made aware of the signs and symptoms of thyroid tumors, including neck masses, dyspnea, dysphagia, hoarseness.
In studies with Rybelsus, 6 patients on Rybelsus experienced pancreatitis compared to 1 patient on placebo. Patients should be monitored closely for pancreatitis symptoms such as serious abdominal pain. If pancreatitis is suspected, stop Rybelsus right away and initiate proper management. If pancreatitis is the case, do not initiate Rybelsus again.
Diabetic Retinopathy Complications
Patients treated with Rybelsus have been reported to develop diabetic retinopathy. Specifically, with quick glucose control improvements, transient worsening of diabetic retinopathy has occurred. Patients who have a diabetic retinopathy history should be observed for potential worsening.
Hypoglycemia with Simultaneous Use of Insulin Product
Patients on an insulin product concomitantly with Rybelsus have an elevated risk of developing hypoglycemia. Patients should be counseled on hypoglycemia symptoms such as shakiness, dizziness, sweating, increased heartbeat, or hunger. Lowering the dose of a sulfonylurea may decrease the risk of hypoglycemia.
Acute Kidney Injury
Patients on GLP-1 receptor agonists have reported acute kidney injury (AKI) and worsening chronic renal failure. Patients should be monitored for worsening renal function when starting or increasing doses of Rybelsus in those who experience GI symptoms.
Rybelsus has caused serious hypersensitivity reactions, including anaphylaxis and angioedema. If a patient experiences hypersensitivity, they should stop Rybelsus immediately and receive appropriate supportive care. Use Rybelsus with caution in those who have a history of anaphylaxis or angioedema with other GLP-1 receptor agonists should use caution.
Simultaneous Use with Insulin Products
Other insulin products, such as sulfonylureas, can increase hypoglycemia risk when used concomitantly with Rybelsus. Consider decreasing the dose of insulin products if given together with Rybelsus.
Rybelsus can cause gastric emptying delays which can affect how other medications are absorbed. For example, levothyroxine exposure increased by 33% while being taken with Rybelsus. If taking other oral medications, ensure compliance with proper Rybelsus administration instructions. For drugs with narrow therapeutic windows, consider more frequent monitoring.
USE IN SPECIFIC POPULATIONS
Animal models show the possible risk of Rybelsus to fetuses during pregnancy. Providers and patients should weigh the risks and benefits of Rybelsus including the potential birth defect, miscarriage, or maternal/fetal outcome risk and the benefits of controlled diabetes.
No data exists on the concentration of Rybelsus in human milk, exposure to a breastfed infant, or influence on milk production. Because little data is available, breastfeeding is not recommended when taking Rybelsus. There are other semaglutide formulations that may be more suitable for lactating patients.
Rybelsus has an extensive washout period after discontinuation. Therefore, Rybelsus should be stopped a minimum of 2 months before an expected pregnancy.
Rybelsus has not been studied in patients younger than 18 years of age. Therefore, safety and efficacy has not been determined in this patient population.
Rybelsus has been studied in older adults, and no major differences in efficacy and safety were seen. However, there is still the chance that geriatric patients are more sensitive to drugs such as Rybelsus.
Rybelsus doses should not be adjusted for those with renal impairment.
Rybelsus doses should not be adjusted for those with hepatic impairment.
3mg – 30 tabs, 7mg – 30 tabs, 14mg – 30 tabs