What is the equivalent dose of Rybelsus (semaglutide) for a patient switching from 1 mg/week of Ozempic (semaglutide) subcutaneously?

Switching from Ozempic 1 mg Weekly to Rybelsus

For a patient on Ozempic (subcutaneous semaglutide) 1 mg weekly, switch to Rybelsus (oral semaglutide) 14 mg once daily, as this is the maximum approved dose for oral semaglutide and provides the closest therapeutic equivalence. 1

Dosing Rationale

• Oral semaglutide (Rybelsus) has significantly lower bioavailability (0.8%) compared to subcutaneous semaglutide (89%), which necessitates much higher oral doses to achieve comparable therapeutic effects 1

• The approved oral semaglutide doses are 3 mg, 7 mg, and 14 mg once daily 1

• For patients requiring glycemic control equivalent to subcutaneous semaglutide 1 mg weekly, the 14 mg oral dose is recommended 1

Titration Schedule

Start with Rybelsus 3 mg once daily for 30 days, then increase to 7 mg once daily for 30 days, and finally escalate to the maintenance dose of 14 mg once daily 1

• This gradual titration minimizes gastrointestinal adverse effects (nausea, vomiting, diarrhea) that are common with GLP-1 receptor agonists 1

• The titration should ideally be completed 2-3 weeks before any significant events (such as Ramadan fasting) to ensure therapeutic efficacy and patient tolerance 1

Critical Administration Instructions

Rybelsus must be taken at least 30 minutes before the first food, beverage, or other oral medications of the day, with no more than 120 mL (4 ounces) of plain water only 1

• This strict administration requirement is essential due to the extremely low oral bioavailability 1

• Failure to follow these instructions will significantly reduce drug absorption and therapeutic efficacy 1

• Patients should wait at least 30 minutes after taking Rybelsus before consuming anything else 1

Expected Outcomes

• Oral semaglutide 14 mg daily achieves HbA1c reductions of approximately 1.5-1.9% and weight loss of 5-10% from baseline 2, 1

• These outcomes are generally comparable to subcutaneous semaglutide 1 mg weekly, though individual responses may vary 3, 2

Important Monitoring Considerations

• Monitor for gastrointestinal adverse effects during dose escalation, as nausea (up to 44%) and diarrhea (up to 32%) are common but typically transient 1

• If the patient is taking insulin or sulfonylureas concurrently, monitor closely for hypoglycemia and adjust doses accordingly 1

• Ensure adequate hydration, particularly during the titration phase 1

Contraindications and Precautions

• Contraindicated in patients with personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia type 2 1

• Use caution and monitor renal function when initiating or escalating doses in patients with kidney disease (eGFR <45 mL/min) 1, 4

• Discontinue if pancreatitis is suspected, though causality with GLP-1 RAs has not been definitively established 1

• May cause cholelithiasis and gallstone-related complications 1

Drug Interaction Considerations

Oral semaglutide delays gastric emptying and may impact absorption of other oral medications, particularly those requiring rapid onset of action 1, 2

• For oral contraceptives, advise patients to use or add a non-oral contraceptive method for 4 weeks after initiation and dose escalation 1

• Monitor medications with narrow therapeutic indices (such as warfarin) more closely 1

• Do not use with other GLP-1 receptor agonists or DPP-4 inhibitors 1