Semaglutide Starting Dose for Type 2 Diabetes
The recommended starting dose of subcutaneous semaglutide for type 2 diabetes is 0.25 mg once weekly for 4 weeks, followed by dose escalation to 0.5 mg weekly. 1, 2, 3
Initial Dosing Protocol
Start at 0.25 mg subcutaneously once weekly for the first 4 weeks to minimize gastrointestinal side effects, which are the most common adverse events (nausea occurs in 18% vs 7% with placebo). 1, 2, 3
After the initial 4-week period, increase to 0.5 mg once weekly, which serves as the standard maintenance dose for most patients. 1, 2, 3
Dose Escalation for Additional Glycemic Control
If glycemic targets are not achieved after at least 4 weeks on 0.5 mg, escalate to 1.0 mg once weekly. 1, 2, 3
For patients requiring further intensification, increase to 2.0 mg once weekly after at least 4 weeks on 1.0 mg. 2, 4, 5
The 2.0 mg dose provides superior HbA1c reduction compared to 1.0 mg (treatment difference of -0.23 percentage points; p=0.0003) and additional weight loss (-0.93 kg; p=0.015). 5
Administration Guidelines
Administer once weekly at any time of day, with or without meals. 1, 2, 4, 3
Inject subcutaneously in the abdomen, thigh, or upper arm. 1, 2, 4, 3
If a dose is missed, administer within 5 days of the missed dose. 3
Oral Semaglutide Alternative
For patients who prefer oral therapy:
Start at 3 mg once daily for 1 month, then increase to 7 mg daily for 1 month, with a final maintenance dose of 14 mg once daily. 6
Must be taken on an empty stomach with up to 4 oz of plain water, at least 30 minutes before any food, beverage, or other medications. 6
Special Populations
No dose adjustments are required for renal impairment of any degree, including end-stage renal disease. 2, 4
No dose adjustments are required for hepatic impairment. 1, 2
Critical Safety Considerations
Absolute contraindications include:
- Personal or family history of medullary thyroid carcinoma 2, 6, 4
- Multiple endocrine neoplasia syndrome type 2 (MEN2) 2, 6, 4
- Pregnancy or lactation 2, 4
- History of severe hypersensitivity reaction to semaglutide 2
Monitor closely for:
- Pancreatitis (discontinue if suspected and do not restart if confirmed) 1, 2, 4
- Gallbladder disease and acute kidney injury 2
- Hypoglycemia risk when combined with insulin or sulfonylureas (dose reduction of these agents may be required) 1, 6
- Diabetic retinopathy worsening with rapid glycemic improvement 6
Common Pitfalls to Avoid
Do not skip the 0.25 mg starting dose—this initial low dose for 4 weeks is essential to minimize gastrointestinal side effects, which cause treatment discontinuation in 8-10% of patients. 2
Do not escalate doses too rapidly—allow at least 4 weeks at each dose level before increasing. 1, 2, 3
Monitor for delayed gastric emptying effects on absorption of oral medications with narrow therapeutic index (e.g., warfarin). 2