Dr Ian Neeland on Oral Semaglutide as a Backup Amid Injection Shortage

In cases where lowering the semaglutide dose is not feasible to address a drug shortage in a higher dose, an alternative for diabetes management is transitioning to oral semaglutide, which is more accessible, explains Ian Neeland, MD. Neeland serves as director of cardiovascular prevention and co-director of the Center for Integrated and Novel Approaches in Vascular-Metabolic Disease at the University Hospitals Harrington Heart & Vascular Institute, as well as associate professor of medicine at Case Western Reserve University School of Medicine.

Transcript

In cases where you can’t lower the semaglutide dose, are there alternative treatments you recommend?

For diabetes management, someone who can't access injectable semaglutide will probably have no problem accessing oral semaglutide. Although it's difficult to understand how to transition from a high dose, let's say, to the next dose of oral, so that requires a little bit of creativity, but certainly oral semaglutide we've not seen a shortage in. So, if there's a concern over breakage in therapy [or] long-term issues with accessing medications, I'll usually use oral semaglutide for diabetes management.

[Oral semaglutide is] not labeled for obesity management, so that is an off-label method to assist with that. But usually, in regard to weight loss management, breakage in therapies are probably not as urgent in terms of that, because when patients have diabetes we want to make sure that their glycemia is controlled, whereas for weight loss, maintaining the same dose or smaller dose can still have a lot of the efficacy that you can see for weight loss. Especially people who have reached higher doses, let's say at the 2 milligram dose of semaglutide going down to the 1 milligram dose, I've found at least in my experience it's not so difficult for the patient to maintain the weight loss they have been doing, so it's not as big of an issue.

What I don't like to do, especially for weight loss or diabetes, is to switch drug types. Switching from semaglutide, for example, to tirzepatide when there's a shortage in one and not the other, I don't like that approach very much, because there's not a lot of guidance or data around the transition, the switch, at what dose to go to. So, often you have to start the lower dose even for individuals who are at much higher doses of semaglutide, and that, again, delays therapy, prolongs therapeutic escalation, and makes it more difficult. And then often there'll be a shortage in one of those medications and they'll want to switch back, so it becomes very disruptive. I try my best to maintain a certain medication—the best that's covered for them, the best they can tolerate—and just kind of go up and down on the dosages a little bit to weather that storm of drug shortage. And if I really can't get injectable in for semaglutide, I'll use the oral Rybelsus version.

This transcript has been lightly edited for clarity.