Can Ozempic (semaglutide) be combined with insulin and repaglinide?

From the Guidelines

I strongly advise against combining ozympic with insulin and repaglinide due to the increased risk of hypoglycemia. This three-drug combination creates significant overlap in blood glucose-lowering effects. Ozympic is a GLP-1 receptor agonist that stimulates insulin release and suppresses glucagon, while repaglinide is a meglitinide that also stimulates insulin release. Adding external insulin to these medications creates a triple mechanism for lowering blood glucose, which substantially increases hypoglycemia risk.

Key Considerations

• The most recent study 1 emphasizes the importance of careful dose adjustments and monitoring for patients with chronic kidney disease, highlighting the need for cautious management of glucose-lowering therapies.
• The use of GLP-1 receptor agonists, such as semaglutide, is recommended with caution, and dose adjustments may be necessary based on individual patient needs and kidney function 1.
• The combination of insulin and other glucose-lowering agents requires careful consideration of the potential risks and benefits, including the risk of hypoglycemia 1.

Recommendations

• If combination therapy is needed for diabetes management, it would be safer to use either ozympic with insulin OR ozympic with repaglinide, but not all three simultaneously.
• Blood glucose monitoring would need to be more frequent with any combination therapy.
• If you're currently taking these medications together, consult your healthcare provider immediately about adjusting your regimen to reduce hypoglycemia risk.
• Your provider might consider reducing insulin doses or eliminating one medication based on your specific clinical needs and glucose control targets.

From the FDA Drug Label

1. 1 Concomitant Use with an Insulin Secretagogue (e.g., Sulfonylurea) or with Insulin OZEMPIC stimulates insulin release in the presence of elevated blood glucose concentrations. Patients receiving OZEMPIC in combination with an insulin secretagogue (e.g., sulfonylurea) or insulin may have an increased risk of hypoglycemia, including severe hypoglycemia.

The combination of ozympic with insulin and repiglinide (a sulfonylurea-like medication, also known as a meglitinide) may increase the risk of hypoglycemia.

• When initiating ozympic, consider reducing the dose of concomitantly administered insulin secretagogue (such as sulfonylureas) or insulin to reduce the risk of hypoglycemia.
• Key points to consider when combining these medications include:
  • Monitoring blood glucose levels closely
  • Adjusting the dose of insulin or repiglinide as needed to minimize the risk of hypoglycemia
  • Being aware of the signs and symptoms of hypoglycemia, such as dizziness, blurred vision, and sweating 2

From the Research

Combination Therapy with Repaglinide and Insulin

• The provided studies do not directly address the combination of ozympic (presumably a misspelling of "ozempic," which is a brand name for semaglutide, a glucagon-like peptide-1 receptor agonist) with insulin and repaglinide. However, they do discuss combination therapies involving repaglinide, metformin, rosiglitazone, and insulin in the context of type 2 diabetes management 3, 4, 5, 6.
• Repaglinide has been shown to be effective in combination with other oral antidiabetic agents and intermediate-acting insulin (NPH) given at bedtime, indicating its potential for use in combination therapies 4.
• The combination of repaglinide with metformin has been found to be well-tolerated and effective in reducing HbA1c and fasting plasma glucose values compared to monotherapy with either agent 5.
• A study combining repaglinide with rosiglitazone demonstrated greater reductions in HbA1c and fasting plasma glucose values compared to monotherapy with either repaglinide or rosiglitazone 6.
• While there is evidence supporting the use of combination therapies in type 2 diabetes management, including combinations involving insulin and GLP-1 agonists like exenatide, the specific combination of ozympic (semaglutide), insulin, and repaglinide is not directly addressed in the provided studies 7.

Safety and Efficacy Considerations

• Combination therapies, including those with insulin and oral antidiabetic agents, require careful consideration of potential interactions, efficacy, and safety, including the risk of hypoglycemia 4, 6, 7.
• The choice of combination therapy should be individualized based on patient factors, including response to previous therapies, presence of comorbidities, and specific treatment goals 7.