Can I use Ozempic (semaglutide) in a patient with an HbA1c of 11% who is already on insulin 20 units and Novolog (insulin aspart)?

Adding Ozempic to a Regimen with Insulin and Novolog for High HbA1c

Yes, Ozempic (semaglutide) can be added to your current regimen of insulin 20 units and Novolog (insulin aspart) to help improve your very high HbA1c of 11%. 1

Rationale for Adding Ozempic

When HbA1c remains significantly elevated (≥9.0%) despite insulin therapy, treatment intensification is strongly recommended to achieve better glycemic control and reduce the risk of diabetes complications. 1

The combination of GLP-1 receptor agonists (like Ozempic) with insulin therapy offers several advantages:

• More effective glycemic control than insulin alone
• Weight reduction benefits (versus weight gain with insulin)
• Lower risk of hypoglycemia compared to increasing insulin doses
• Cardiovascular benefits 2, 3

Implementation Plan

1. Starting Ozempic:

   • Begin with 0.25 mg subcutaneously once weekly for 4 weeks (initiation dose)
   • After 4 weeks, increase to 0.5 mg once weekly
   • If additional glycemic control is needed after at least 4 weeks on 0.5 mg, may increase to 1 mg once weekly
   • Maximum recommended dose is 1 mg once weekly 4

2. Insulin Adjustment:

   • Continue current insulin regimen initially
   • Monitor blood glucose closely after starting Ozempic
   • Be prepared to reduce insulin doses by 10-20% if hypoglycemia occurs 2
   • Administer Ozempic and insulin as separate injections (never mix them) 4

3. Administration Guidelines:

   • Administer Ozempic once weekly, on the same day each week
   • Can be given at any time of day, with or without meals
   • Inject subcutaneously in abdomen, thigh, or upper arm
   • Use a different injection site each week 4

Monitoring and Follow-up

• Check blood glucose levels more frequently after starting Ozempic
• Schedule follow-up in 2 weeks for initial adjustment, then monthly until stable
• Monitor for gastrointestinal side effects (nausea, vomiting, diarrhea) 1, 5
• Watch for signs of hypoglycemia, especially if taking sulfonylureas along with insulin 3

Potential Side Effects and Management

1. Gastrointestinal Effects:

   • Most common side effects are nausea (21-22%), vomiting, and diarrhea
   • Usually mild-to-moderate and transient (improving over time)
   • Starting with the lower dose and gradually increasing helps minimize these effects 5

2. Hypoglycemia Risk:

   • Lower risk of hypoglycemia compared to increasing insulin doses alone
   • Still requires monitoring, especially during initiation phase 3

3. Other Considerations:

   • May increase risk of gallbladder disease (cholelithiasis)
   • Monitor for any signs of pancreatitis (rare but serious)
   • If diabetic retinopathy is present, careful monitoring is recommended 5

Important Cautions

• If a dose is missed, administer Ozempic as soon as possible within 5 days after the missed dose
• If more than 5 days have passed, skip the missed dose and administer the next dose on the regularly scheduled day 4
• Ozempic should not be used in patients with personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2

Adding Ozempic to your current insulin regimen is an evidence-based approach that can significantly improve your glycemic control while potentially reducing insulin requirements and offering additional benefits like weight loss and cardiovascular protection.