How do I prescribe semaglutide injection?

How to Prescribe Semaglutide Injection

Start semaglutide at 0.25 mg subcutaneously once weekly, escalating every 4 weeks through 0.5 mg, 1 mg, 1.7 mg, to a maintenance dose of 2.4 mg weekly for weight management, or up to 1 mg weekly for type 2 diabetes. 1

Dosing Algorithm

For Type 2 Diabetes (Ozempic):

• Week 1-4: 0.25 mg once weekly
• Week 5-8: 0.5 mg once weekly
• Week 9+: 1 mg once weekly (maintenance)
• Maximum dose: 1 mg weekly 2

For Weight Management (Wegovy):

• Week 1-4: 0.25 mg once weekly
• Week 5-8: 0.5 mg once weekly
• Week 9-12: 1 mg once weekly
• Week 13-16: 1.7 mg once weekly
• Week 17+: 2.4 mg once weekly (maintenance) 1, 3

The 4-week escalation schedule is mandatory to minimize gastrointestinal adverse events, which are the most common side effects and primary reason for discontinuation. 2, 3

Practical Administration Instructions

Injection Technique (from FDA label):

1. Wash hands with soap and water
2. Check the pen - verify it says "OZEMPIC" or "Wegovy" and that the solution is clear and colorless (discard if cloudy or contains particles)
3. Attach a new needle - use NovoFine Plus or NovoFine needles up to 8mm length; push straight on and turn until tight
4. Prime the pen (new pens only) - turn dose selector to flow check symbol, hold needle up, press dose button until "0" appears and a drop forms at needle tip
5. Select your dose - turn dose selector to prescribed dose
6. Inject subcutaneously - abdomen, thigh, or upper arm; insert needle, press and hold dose button until "0" appears, keep holding for 6 seconds
7. Remove needle immediately after injection and dispose in sharps container 1

Critical Safety Points:

• Always use a new needle for each injection - never reuse or share needles (infection risk)
• Never share pens between patients even with needle changes
• Rotate injection sites to prevent lipodystrophy
• Any day of the week works - choose a consistent day the patient can remember; flexible scheduling is acceptable 4

Storage Requirements

• Unopened pens: Refrigerate 36-46°F (2-8°C) until expiration date
• In-use pens: Room temperature 59-86°F (15-30°C) or refrigerated for 56 days maximum
• Never freeze - discard if frozen
• Mark disposal date on calendar when first used 1

Patient Selection and Monitoring

Indications:

• Type 2 diabetes: Any patient requiring glucose lowering, particularly those with established cardiovascular disease, heart failure, or chronic kidney disease (prioritize GLP-1 RAs for cardiovascular/renal protection) 2
• Weight management: BMI ≥30 kg/m² OR BMI ≥27 kg/m² with at least one weight-related comorbidity 3, 5

Contraindications and High-Risk Situations:

• Personal/family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2
• Active pancreatitis or history of pancreatitis (relative contraindication - do not initiate if high risk)
• Gastroparesis - not recommended
• Severe renal impairment - no dose adjustment needed for semaglutide, but monitor closely 2

Pre-Treatment Evaluation:

• Screen for diabetic retinopathy in patients with diabetes ≥10 years duration - close monitoring required during rapid glucose lowering 2
• Assess gallbladder disease risk - avoid in patients with active cholelithiasis
• Review surgical schedule - discontinue before elective procedures due to delayed gastric emptying risk 2

Managing Adverse Events

Gastrointestinal Side Effects (Most Common):

• Nausea, vomiting, diarrhea occur in majority of patients initially
• Mitigation strategies:
  • Slower dose escalation if needed (extend 4-week intervals)
  • Reduce meal size and stop eating when full
  • Avoid high-fat and spicy foods
  • Take with food if tolerated 2

Serious Adverse Events to Monitor:

• Acute pancreatitis - discontinue immediately if suspected (severe abdominal pain)
• Gallbladder disease - evaluate if symptoms develop
• Diabetic ketoacidosis - rare in T2D but possible; educate on sick-day management
• Hypoglycemia - only when combined with insulin or sulfonylureas (reduce those doses proactively) 2

Clinical Outcomes

Weight loss expectations:

• At 1 mg: ~6% at 1-3 months, ~12% at 3-6 months 6
• At 2.4 mg: ~15-16% at 68 weeks 7
• Many patients achieve desired outcomes at 1 mg and may not require escalation to 2.4 mg 6

Cardiovascular benefits: Semaglutide reduces major adverse cardiovascular events (MACE) by 12%, cardiovascular death by 12%, and stroke by 16% in patients with established cardiovascular disease 8. This benefit should be considered independently of glucose control - prescribe for cardiovascular protection even if HbA1c is at goal 8.

Common Prescribing Pitfalls

1. Escalating too quickly - always follow 4-week intervals minimum
2. Not educating about GI side effects - patients discontinue unnecessarily when unprepared
3. Failing to reduce insulin/sulfonylurea doses - causes hypoglycemia
4. Not checking flow on new pens - leads to missed doses
5. Prescribing without needle supplies - specify NovoFine needles on prescription
6. Ignoring the 56-day disposal rule - patients waste medication or use expired pens 1

Renal Considerations

No dose adjustment required for any level of kidney function including dialysis. Continue for cardiovascular and renal benefits even when eGFR <45 mL/min/1.73 m² (though glucose-lowering effect diminishes at this threshold). 2