Rybelsus

Rybelsus is the tablet version of semaglutide, a GLP-1 receptor agonist developed by Novo Nordisk. GLP-1 is a hormone released by the gut after eating; semaglutide acts on the same receptors, so insulin output increases and glucagon output falls, but only while blood glucose is elevated. It also modestly delays gastric emptying early after a meal. The UK licence covers adults with type 2 diabetes that is not well enough controlled, used in addition to diet and physical activity – as a single treatment where metformin cannot be used, or added to other diabetes medicines. It is not intended for type 1 diabetes and is not a form of insulin.

This listing covers 3 mg, 7 mg and 14 mg tablets, each in boxes of 10, 20, 30, 60 or 90, supplied as an imported product. They are the first-generation Rybelsus tablets. On the UK medicines compendium those three strengths are now shown as discontinued, and the version currently marketed in the UK comes in 1.5 mg, 4 mg and 9 mg. The SmPC pairs them as equivalent – 1.5 mg with 3 mg, 4 mg with 7 mg, 9 mg with 14 mg – which means a figure printed on one formulation should never be read as the same dose of the other. Whichever version is used, Rybelsus is classed as a POM in the UK.

The first month is spent on 3 mg once daily. From the second month the usual maintenance dose is 7 mg once daily, and after a minimum of one further month the prescriber may move up to 14 mg once daily if glucose targets are not being met. Fourteen milligrams is the stated ceiling for this formulation, and the SmPC advises one tablet a day only – doubling up on a lower strength is not a way of reaching a higher dose. A forgotten tablet is not made up; the routine simply resumes with the next day’s tablet. No adjustment is required in older people or in mild to severe kidney disease, though experience in end-stage kidney disease is limited. Doses of a sulfonylurea or insulin taken at the same time may be reduced to lower the chance of a hypo.

Absorption from the stomach is limited and varies from person to person, so the SmPC sets out a strict routine. The tablet goes down whole, after a fast of eight hours or more, with no more than 120 ml of water. Breaking, crushing or chewing it is not advised. Food, other drinks and any other medicines taken by mouth should wait for at least half an hour, because anything taken sooner cuts the amount of semaglutide absorbed. People who take several tablets in the morning may need to plan their routine around this gap. Keep the tablets in their blister until use, as they are sensitive to light and moisture.

Allergy to semaglutide or to an ingredient of the tablet is the sole contraindication. Persistent, severe stomach pain may signal pancreatitis and means stopping the medicine. Existing diabetic eye disease should be monitored, since rapid improvement in glucose can temporarily worsen retinopathy, and sudden loss of sight needs urgent assessment. Use is not recommended in severe gastroparesis or class IV heart failure, and there is no experience after bariatric surgery. Fluid loss from sickness or diarrhoea can strain the kidneys. Before an operation under anaesthesia or deep sedation, the clinical team should know about Rybelsus. Levothyroxine exposure rises with semaglutide, so thyroid function may be checked, and blood clotting tests are watched closely when starting alongside a coumarin anticoagulant. Effective contraception is needed in women who could become pregnant; the medicine is not taken in pregnancy or while breastfeeding and is stopped at least two months before trying to conceive.

Feeling sick and loose stools are the effects people notice most often, especially while the dose is being stepped up; vomiting, stomach ache, bloating, constipation, heartburn, poor appetite, headache, dizziness and fatigue are also common. With insulin or a sulfonylurea, low blood sugar becomes very common. Less often, the heart rate rises slightly or gallstones form, and severe allergic reactions and pancreatitis are rare. The prescriber decides whether Rybelsus is the right option and which strength to use.