Reglutide1.34 mg/ml

Reglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist available as a once-weekly subcutaneous injection and as a once-daily oral tablet, marketed at different dose ranges for glycemic control and for chronic weight management. Indications are classified below by strength of evidence.

Established / FDA-approved uses

• Glycemic control in type 2 diabetes: Reglutide (lower-dose weekly injectable or daily oral formulation) is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
• Cardiovascular risk reduction in type 2 diabetes: Reglutide (weekly injectable or daily oral formulation) is indicated to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke) in adults with type 2 diabetes mellitus and established cardiovascular disease.
• Diabetic kidney disease: Reglutide (weekly injectable, higher titrated dose) is indicated to reduce the risk of sustained estimated glomerular filtration rate (eGFR) decline, end-stage kidney disease, and cardiovascular death in adults with type 2 diabetes mellitus and chronic kidney disease.
• Chronic weight management: Reglutide (higher-dose weekly injectable formulation) is indicated, as an adjunct to a reduced-calorie diet and increased physical activity, for chronic weight management in adults with obesity (BMI ≥ 30 kg/m²) or overweight (BMI ≥ 27 kg/m²) with at least one weight-related comorbidity, and in pediatric patients 12 years of age and older with obesity.
• Cardiovascular risk reduction with obesity/overweight: Reglutide (higher-dose weekly injectable weight-management formulation) is indicated to reduce the risk of major adverse cardiovascular events in adults with established cardiovascular disease and obesity or overweight.
• Metabolic dysfunction-associated steatohepatitis (MASH): Reglutide (higher-dose weekly injectable formulation) is indicated, together with diet and exercise, for the treatment of adults with MASH with moderate to advanced liver fibrosis (approved under accelerated approval, based on improvement in liver histology).

Off-label use

• Use for weight loss outside the approved BMI/comorbidity criteria, and use as adjunct therapy in type 1 diabetes, occur in clinical practice but are not FDA-approved indications; such use should only be considered under direct physician supervision.

Semaglutide is available in more than one formulation and strength. The injectable form is supplied as a clear, colorless to slightly yellow solution in prefilled, multi-dose subcutaneous injection pens, with dose strengths that vary by brand/indication (for example, doses ranging from about 0.25 mg up to 2.4 mg per injection for weekly use), together with standard pharmaceutical excipients. The oral form is supplied as film-coated tablets (commonly 3 mg, 7 mg, and 14 mg strengths) in which Semaglutide is combined with an absorption-enhancing excipient that allows this peptide molecule to be absorbed after oral dosing.

Reglutide is a human glucagon-like peptide-1 (GLP-1) analog with approximately 94% sequence homology to native human GLP-1. Structural modifications, including a fatty di-acid side chain that promotes reversible albumin binding, protect Reglutide from rapid enzymatic degradation and give it a long elimination half-life of about one week, allowing once-weekly injectable dosing; a specially formulated oral tablet form also allows once-daily oral dosing.

Reglutide is used clinically both to improve blood glucose control in type 2 diabetes and, at higher doses, to promote sustained weight loss in patients with obesity or overweight with weight-related health problems. It works together with, not instead of, lifestyle measures such as a reduced-calorie diet and increased physical activity, and treatment is intended to be individualized and monitored by a physician.

Reglutide belongs to the glucagon-like peptide-1 (GLP-1) receptor agonist class of medicines, also called incretin mimetics. Depending on formulation and dose, it is used as an antidiabetic agent for glycemic control in type 2 diabetes, or as an anti-obesity agent for chronic weight management.

Mechanism of action

Semaglutide binds to and activates the GLP-1 receptor, the same receptor targeted by the naturally occurring incretin hormone GLP-1. Receptor activation stimulates glucose-dependent insulin secretion and reduces inappropriately elevated glucagon secretion from pancreatic islet cells, both in a glucose-dependent manner, which lowers blood glucose while limiting the risk of drug-induced hypoglycemia when used alone. Semaglutide also slows gastric emptying and acts on appetite-regulating centers in the hypothalamus and brainstem to reduce hunger and food intake, which underlies its weight-lowering effect at higher doses.

Pharmacokinetics

After subcutaneous injection, absolute bioavailability of Semaglutide is approximately 89%, with peak plasma concentrations reached 1 to 3 days after a weekly dose; steady state is reached after 4 to 5 weeks of once-weekly dosing. The oral tablet formulation, which co-formulates Semaglutide with an absorption enhancer (SNAC) to permit uptake of this peptide across the stomach lining, has much lower absolute bioavailability (roughly 0.4-1%), which is why the oral tablet must be taken on a strictly empty stomach with only a small amount of plain water. Semaglutide is extensively bound to plasma albumin (>99%), which contributes to its long elimination half-life of approximately one week for both formulations. It is metabolized by proteolytic cleavage of the peptide backbone and beta-oxidation of the fatty acid side chain, with no single organ responsible for elimination; metabolites are excreted mainly in urine and feces.

Injectable Reglutide: Administer once weekly, on the same day each week, at any time of day, with or without meals. Inject subcutaneously into the abdomen, thigh, or upper arm, rotating the injection site with each dose. The day of weekly administration can be changed if needed, as long as at least 2 days (48 hours) have passed since the last dose. Each injection pen is for single-patient use only and must never be shared between patients, even if the needle is changed. Follow the specific pen instructions provided with the product for priming and dose selection.

Oral Reglutide: Take one tablet by mouth once daily, first thing in the morning, on an empty stomach, with no more than about 120 mL (4 ounces) of plain water only - not with any other liquid. Swallow the tablet whole; do not split, crush, chew, or dissolve it. Wait at least 30 minutes after taking the tablet before eating food, drinking any other beverage, or taking other oral medications, since food, drink, and other pills taken sooner can significantly reduce absorption of the tablet.

• Insulin and insulin secretagogues (e.g., sulfonylureas): combined use with Reglutide increases the risk of hypoglycemia, including severe hypoglycemia; a physician may reduce the dose of insulin or the secretagogue when starting Reglutide.
• Oral medications in general: Reglutide slows gastric emptying, which can transiently affect the rate of absorption of co-administered oral drugs; this has not been shown to be clinically significant for most tested medications (including metformin, oral contraceptives, atorvastatin, digoxin, and warfarin) at the injectable formulation's usual doses, but caution and monitoring (e.g., of anticoagulation with warfarin) are still reasonable when starting or escalating Reglutide.
• Other oral drugs taken with oral Reglutide tablets specifically: because the oral tablet must be taken on an empty stomach and other oral medicines must be spaced at least 30 minutes after it (see Administration), incorrect spacing can reduce the absorption of either the tablet or the other oral drug; follow the administration instructions closely.

Common (dose-related, usually during dose escalation)

• Nausea, vomiting, diarrhea, constipation, and abdominal pain - the most frequently reported adverse effects, generally mild-to-moderate and more common at higher doses and during dose titration
• Decreased appetite, dyspepsia, belching, bloating, gastroesophageal reflux
• Headache, fatigue, dizziness
• Injection site reactions (injectable formulation)

Serious (require prompt medical attention)

• Acute pancreatitis: persistent, severe abdominal pain, sometimes radiating to the back, with or without vomiting - discontinue Reglutide and seek medical care immediately if suspected.
• Gallbladder disease (cholelithiasis, cholecystitis).
• Hypoglycemia, particularly when combined with insulin or a sulfonylurea (see Interactions).
• Acute kidney injury, often related to dehydration from severe nausea, vomiting, or diarrhea.
• Worsening of diabetic retinopathy in patients with pre-existing retinopathy, related to rapid improvement in blood glucose control.
• Serious hypersensitivity reactions, including anaphylaxis and angioedema.
• Rare postmarketing reports of ileus/intestinal obstruction and severe constipation.
• Possible risk of thyroid C-cell tumors, based on rodent data (human relevance unknown) - see boxed-warning information in Precautions and Warnings.

Pregnancy

Data on Reglutide use in human pregnancy are limited. Animal reproduction studies have shown adverse fetal effects (including structural abnormalities and fetal/ embryonic loss) at maternal exposures relevant to clinical use. Because of Reglutide's long half-life, it should be discontinued at least 2 months before a planned pregnancy. Reglutide should be used during pregnancy only if clearly needed and only when a physician determines that the potential benefit justifies the potential risk to the fetus; it is not recommended for weight management during pregnancy.

Lactation

There are no data on the presence of Reglutide in human breast milk or its effects on the breastfed infant or on milk production; Reglutide has been detected in the milk of lactating animals. A physician should be consulted to weigh the developmental and health benefits of breastfeeding against the mother's clinical need for Reglutide and any potential risk to the infant.

Boxed warning: risk of thyroid C-cell tumors

In rodent studies, Reglutide caused dose-dependent and treatment-duration-dependent thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), at clinically relevant exposures. Whether Reglutide causes MTC or other thyroid C-cell tumors in humans is unknown, as human relevance of these rodent findings has not been determined. Reglutide is contraindicated in patients with a personal/family history of MTC or MEN 2 (see Contraindications). Patients should be counseled on the symptoms of thyroid tumors (e.g., a lump or swelling in the neck, hoarseness, difficulty swallowing, shortness of breath) and told to report them promptly.

Other warnings and precautions

• Acute pancreatitis: observed in clinical trials; monitor for persistent severe abdominal pain and discontinue promptly if suspected (see Side Effects).
• Diabetic retinopathy complications: rapid improvement in glucose control can be associated with temporary worsening of diabetic retinopathy; use with caution and monitor patients with a history of diabetic retinopathy.
• Hypoglycemia with concomitant insulin secretagogues or insulin: risk of hypoglycemia is increased when Reglutide is combined with insulin or a sulfonylurea (see Interactions); dose adjustment of the other agent may be needed.
• Acute kidney injury: gastrointestinal adverse reactions with resulting dehydration/volume depletion may worsen renal function; monitor renal function in at-risk patients and manage GI symptoms promptly.
• Severe gastrointestinal disease: Reglutide has not been studied in patients with severe gastroparesis and is not recommended in this setting.
• Hypersensitivity reactions: discontinue Reglutide immediately if a serious hypersensitivity reaction is suspected and seek prompt medical care.
• Acute gallbladder disease: if cholelithiasis is suspected, gallbladder studies and appropriate clinical follow-up are indicated.
• Pulmonary aspiration during anesthesia/sedation: because Reglutide delays gastric emptying, inform the anesthesia/surgical team about Reglutide use before any procedure requiring general anesthesia or deep sedation.
• Pen sharing (injectable form): never share an injection pen between patients, even with a new needle, because of the risk of transmitting blood-borne pathogens.

Overdose of Reglutide may cause more pronounced gastrointestinal effects (severe nausea, vomiting, diarrhea) and an increased risk of hypoglycemia, particularly if taken together with insulin or a sulfonylurea. Because of Reglutide's long elimination half-life of about one week, effects of an overdose - including hypoglycemia and gastrointestinal symptoms - may be prolonged and require extended monitoring.

If overdose is suspected, seek immediate medical attention or contact emergency services / a poison control center right away. There is no specific antidote; management is general and supportive, based on the patient's clinical signs and symptoms (including monitoring and treatment of hypoglycemia and correction of fluid losses), and should only be carried out under medical supervision. Do not attempt to manage a suspected overdose at home.

Injectable pens: Store unopened/unused Reglutide pens in a refrigerator (2°C to 8°C). Do not freeze, and discard the pen if it has been frozen. Once in use, a pen may generally be stored either in the refrigerator or at room temperature (below 30°C) for a limited period specified in the product's patient information (commonly several weeks) - always check the specific product leaflet for the exact in-use storage duration. Keep the pen cap on when not in use and protect from direct light and excessive heat.

Oral tablets: Store at room temperature (below 30°C) in the original container, away from light and moisture; do not remove the desiccant.

Keep all forms of Reglutide out of reach of children.

• Renal impairment: no dose adjustment of Reglutide is required based on renal function alone; however, patients with renal impairment who develop severe gastrointestinal adverse reactions should be monitored closely for worsening renal function/acute kidney injury (see Precautions and Warnings).
• Hepatic impairment: no dose adjustment is required in mild, moderate, or severe hepatic impairment based on available pharmacokinetic data, though clinical experience in severe hepatic impairment is limited.
• Elderly: no overall differences in safety or effectiveness have been observed in patients 65 years and older compared with younger adults, though greater sensitivity in some older individuals cannot be ruled out.
• Pediatric use: the higher-dose weight-management injectable formulation is approved for chronic weight management in patients 12 years and older with obesity; the diabetes-indicated formulations have not established safety and efficacy in patients under 18 years (see Pediatric Uses).
• Pregnancy and lactation: see Pregnancy and Lactation.

Reglutide is generally used as a long-term, ongoing treatment for both type 2 diabetes and chronic weight management, for as long as a physician determines it is effective and appropriate, with periodic reassessment of glycemic control, weight, and tolerability. It is not a short-course medicine. For weight management specifically, most weight regain occurs after Reglutide is discontinued, so the decision to stop treatment should be made together with a physician, who will weigh the ongoing benefits against any side effects or other individual factors. Duration and the appropriateness of continuing therapy should not be decided by the patient alone.

Glucagon-like peptide-1 (GLP-1) receptor agonists; Incretin mimetics; Antidiabetic agents; Anti-obesity / weight-management agents (higher-dose formulation)

Semaglutide is a selective agonist at the glucagon-like peptide-1 (GLP-1) receptor. By activating this receptor on pancreatic beta cells, it stimulates insulin secretion in a glucose-dependent manner (i.e., mainly when blood glucose is elevated), and it suppresses glucagon secretion from alpha cells when glucose levels are high, together lowering blood glucose while limiting the risk of hypoglycemia when used without insulin or sulfonylureas. Semaglutide additionally slows gastric emptying and acts on GLP-1 receptors in appetite-regulating areas of the brain (hypothalamus and brainstem) to reduce hunger and caloric intake, which produces clinically significant weight loss at the higher doses used for chronic weight management.

Use of Reglutide in children differs by formulation and indication. The higher-dose weekly injectable formulation used for chronic weight management is approved for pediatric patients 12 years of age and older with obesity, as an adjunct to a reduced-calorie diet and increased physical activity, using a weight-management dosing and titration schedule similar to that used in adults, under physician supervision.

For the formulations and doses of Reglutide indicated for type 2 diabetes glycemic control and cardiovascular risk reduction, safety and effectiveness in pediatric patients (under 18 years) have not been established, and these should not be used in children outside of the approved pediatric weight-management indication described above.