Can a patient with end‑stage renal disease on chronic hemodialysis safely use Ozempic (semaglutide)?

Can Hemodialysis Patients Use Ozempic (Semaglutide)?

Yes, hemodialysis patients can safely use Ozempic (semaglutide) without dose adjustment, as the drug is eliminated primarily through proteolytic degradation rather than renal excretion, and pharmacokinetic studies demonstrate no clinically relevant changes in drug exposure across all stages of renal impairment including end-stage renal disease (ESRD). 1, 2

FDA-Approved Dosing in ESRD

• No dose adjustment is required for patients with renal impairment including ESRD on hemodialysis 1
• Semaglutide pharmacokinetics remain unchanged in ESRD patients, with no clinically relevant alterations in drug exposure 1, 2
• The standard dosing regimen (starting at 0.25 mg weekly, escalating to 0.5 mg, then 1 mg weekly as tolerated) applies to dialysis patients 1

Pharmacokinetic Rationale

• Semaglutide undergoes proteolytic cleavage and beta-oxidation rather than renal elimination, making it inherently safe in kidney failure 3, 1
• The primary mechanism of protraction is albumin binding, which results in decreased renal clearance and protection from metabolic degradation 1
• Hemodialysis does not remove semaglutide from circulation, as demonstrated in pharmacokinetic studies where dialysis had no effect on drug levels 2, 4
• Semaglutide was not detected in urine except in one ESRD subject, confirming minimal renal excretion 4

Clinical Evidence in Dialysis Patients

Real-World Efficacy Data

• A retrospective study of 76 patients with CKD stage 4 or greater (including dialysis patients) showed mean HbA1c reduction from 8.0% to 7.1% (P < 0.001) and mean weight loss of 4.9 kg (P < 0.001) 5
• In maintenance incremental hemodialysis patients (1 session weekly), semaglutide demonstrated favorable effects on glycemic control, albuminuria reduction, weight loss, and preservation of residual kidney function over 6 months 6
• 16% of patients with type 2 diabetes discontinued insulin after starting semaglutide in the advanced CKD cohort 5

Safety Profile

• 63.1% of patients reported no adverse effects in the advanced CKD/dialysis cohort 5
• Gastrointestinal side effects (nausea, vomiting, abdominal pain) were the most common complaints, similar to those in patients with normal kidney function 5
• Only 5.7% discontinued semaglutide due to digestive intolerance 7
• One patient with severe renal impairment experienced two major hypoglycemic events in pharmacokinetic trials, but no serious adverse events were noted overall 2

Monitoring Recommendations

• Monitor eGFR when initiating or escalating doses or in patients with adverse gastrointestinal reactions, as severe GI effects can potentially worsen kidney function through volume depletion 3
• Standard glycemic monitoring applies; no therapeutic drug monitoring is required 3
• Watch for hypoglycemia risk if used with insulin or sulfonylureas, particularly given the potential for insulin discontinuation 5
• Assess for volume depletion from GI side effects, which could theoretically impact dialysis adequacy 3

Comparison to Other GLP-1 Receptor Agonists in ESRD

• Exenatide is contraindicated in ESRD (eGFR <30 mL/min/1.73 m²) due to renal excretion 3
• Lixisenatide should be avoided if eGFR <15 mL/min/1.73 m² 3
• Liraglutide, dulaglutide, and semaglutide require no dose adjustment in ESRD, as they undergo proteolytic degradation 3
• Semaglutide has the advantage of once-weekly dosing compared to daily liraglutide, potentially improving adherence in dialysis patients 1

Practical Clinical Approach

• Start with 0.25 mg subcutaneous weekly for 4 weeks, then escalate to 0.5 mg weekly 1
• Consider escalation to 1 mg weekly after at least 4 weeks on 0.5 mg if additional glycemic control is needed 1
• Oral semaglutide (3 mg daily escalating to 7 mg or 14 mg) is also safe in ESRD without dose adjustment, though absorption may be more variable 4
• Administer at any time relative to dialysis sessions, as hemodialysis does not affect semaglutide pharmacokinetics 2
• Consider reducing or discontinuing insulin as glycemic control improves to minimize hypoglycemia risk 5

Common Pitfalls to Avoid

• Do not withhold semaglutide based on concerns about renal elimination—this is not the primary clearance mechanism 1, 2
• Do not confuse with SGLT2 inhibitors, which are contraindicated or ineffective in advanced CKD (eGFR <30-45 mL/min/1.73 m²) 3
• Do not assume all GLP-1 agonists are equivalent—exenatide and lixisenatide have renal clearance concerns that semaglutide does not share 3
• Do not overlook volume status—severe GI side effects can lead to dehydration, which may complicate dialysis management 3