Ask the Pharmacist

Q: I was told by my pharmacy that I may not be able to refill my Ozempic prescription. What is the reason behind this and what are my options?

A: For those of you who already take this injectable form of semaglutide (Ozempic), it will not come as a surprise to learn that there is a supply problem and that pharmacies are faced with challenges each day to fill prescriptions for their patients.

Novo Nordisk, the manufacturer of Ozempic, states that it has faced with supply challenges in its production process. With that, and the increased demand we have seen over the last year or so, we are finding ourselves in this dire situation today.

Ozempic has been shown to effectively reduce blood sugar which has immensely helped many people living with diabetes. The side effect of slowing digestion and making people feel full sooner and longer, has also led to Ozempic being prescribed “off-label” (not officially indicated for this purpose) for weight loss. Many believe this added to the increased demand and, thus, the lack of availability we are seeing today.

As you can well imagine, this shortage is wreaking havoc on those individuals who rely on this medication to help manage their blood sugars. Novo Nordisk initially believed the supply issue would be resolved in October of 2023. Now that we are well into November, the company has informed Health Canada that this shortage is expected to continue well into the new year and the hope is that the company will be able to meet the demand by March 31, 2024.

What are people expected to do in the meantime? That all depends on your reason for taking this medication. If you are using this for weight loss, there are other medications that can be prescribed that may be of benefit alongside changes to your lifestyle which, hopefully, include proper food choices and exercise.

You might want to go back and find our previous “Ask the Pharmacist” article that discussed various options for weight loss which did include semaglutide (yes, semaglutide has been approved for weight loss under the name Wegovy but not under the name Ozempic), along with the combination medication, naltrexone/bupropion (Contrave), and orlistat (Xenical).

There are other medications that are used for diabetes that also have a side effect of weight loss but the danger with going down that road is we may find ourselves in the same position we see with Ozempic.

For those individuals who are using Ozempic to control blood sugar, there is not an obvious or automatic switch that can be done. We need to look at each person’s profile and history and observe what other medications the person is currently taking to control blood sugar, as well as ones that have been tried in the past.

Some alternatives that can be considered are as follows;

Oral semaglutide: The active ingredient in Ozempic is semaglutide and there is an oral form of the same drug called Rybelsus that is taken daily. Though it appears to be not as effective as its injectable version, Ozempic, it still does help to lower the A1C (a three-month average of the body blood sugar) to a more manageable level.

The downside to this option is two-fold. Because it is taken orally, it gets absorbed after going through the digestive system and has been known to have a higher prevalence of nausea, vomiting, abdominal pain and constipation/diarrhea. Secondly, it is not covered by the government’s Ontario Drug Benefit (ODB) plan. This does not preclude people from paying for their medication personally or perhaps you may have a private drug plan to help with the cost.

GLP-1 agonists: Since semaglutide is in the class of medications called glucagon-like peptide-1 (GLP-1) receptor agonists, another option may be to switch to another GLP-1 receptor agonist that is available, such as liraglutide (Victoza), dulaglutide (Trulicity) or lixisenatide (Adlyxine). These options are also administered by injection although both liraglutide and lixisenatide are given daily as opposed to once weekly.

Unfortunately, liraglutide and dulaglutide are also not covered by ODB but once again, people may opt to pay for it in the meantime or perhaps there is a private drug plan that can help offset the costs. Lixisenatide is covered by ODB but it is also on a long-term back-order so, unfortunately, not an option. Most recently, dulaglutide has now become unavailable from our wholesaler.

Gliptins: Before Ozempic, many people were taking a “gliptin” medication, such as sitagliptin (Januvia). Since the gliptin class of medications enhances the effect of GLP-1 in the body, it has been recommended to not be on both a GLP-1 agonist and a gliptin. If you were on a gliptin before starting Ozempic, you likely stopped taking it at that time. So, another option would be to introduce or re-introduce the gliptin into your diabetes medication mix. With the number of alternatives becoming unavailable, this might prove to be a great option.

GLP-1 agonist/insulin combination medications: There are numerous medications that consist of two active ingredients which helps to decrease the number of medications people need to take to manage their diabetes. An option to consider as a replacement to your Ozempic is to use one of the products that combine another GLP-1 agonist (also called incretin mimetics) with an insulin. Xultophy is the combination of liraglutide and insulin degludec (Tresiba), whereas Soliqua is the combination of lixisenatide and insulin glargine (Lantus). Of these options, Soliqua is covered by ODB; whereas, the Xultophy is not.

Different class: Depending on the medication(s) that you currently take to manage your diabetes, your health-care provider may opt for a different medication altogether. In most cases, a GLP-1 analog, such as Ozempic, is added to a current regime of medication(s) to control blood sugar. A review of your current medications will help your practitioners decide how to move forward with this dilemma.

Below, you will see the list of various types of medications typically used for lowering blood sugar, in alphabetical order, and their expected A1C reduction. For more detailed information on these various classes, refer to the earlier Ask the Pharmacist diabetes columns from a few months ago.
 

• Alpha-glucosidase inhibitors
  • acarbose (Prandase): 0.7-0.8 per cent when added to metformin
• Biguanide
  • metformin: one per cent as monotherapy
• Dipeptidyl peptidase-4 inhibitor “gliptins” or incretin enhancer
  • Sitagliptin (Januvia), linagliptin (Trajenta): 0.5-0.7 per cent
• Glucagon-like peptide-1 agonist (GLP-1) or incretin mimetic:
  • Dulaglutide (Trulicity): 1.8 per cent
  • Liraglutide (Victoza): 1.6 per cent
  • Oral semaglutide (Rybelsus): 1.2 per cent when given with metformin or SGLT2 inhibitor
  • Semaglutide (Ozempic): 2.3 per cent when given with metformin +/- sulfonylureas
• Glucagon-like peptide-1 (GLP-1) agonist and glucose-dependent insulinotropic polypeptide (GIP) agonist or “twincretin”
  • tirzepatide (Mounjaro): 2.3 per cent
• Insulin (various short-, intermediate- and long-acting insulins): 0.9-1.2 per cent
• Meglitinide
  • Repaglinide (GlucoNorm): 0.7-1.1 per cent
• Sodium-glucose co-transporter 2 (SGLT2) inhibitors: 0.5-0.7 per cent
  • canagliflozin (Invokana)
  • dapagliflozin (Forxiga)
  • empagliflozin (Jardiance)
• Sulfonylureas-second generation: 0.6-1.2 per cent
  • gliclazide (Diamicron)
  • glyburide (DiaBeta)
• Thiazolidinedione (TZD): 0.7-0.9 per cent
  • pioglitazone (Actos)

You may have noticed a new class of medications in the above list that is referred to as a “twincretin.” It is very new on the market and though it consists of one medication, it has a dual role with it being both a GLP-1 agonist and a GIP agonist; hence, the term twincretin.

The news so far with tirzepatide is very promising as it appears to have more A1C reduction than most GLP-1 agonists and more weight loss as well (11.2 kilograms compared to 6.4 kilograms with Ozempic). The downside is that it is not covered by ODB and it is unsure if any private insurance plans will pay for it. It is given as a weekly injection and appears to have a similar side effect profile as other GLP-1 agonists.

For more information about this or any other health-related questions, contact the pharmacists at Gordon Pharmasave, Your Health and Wellness Destination. Also check the website at www.gordon-pharmasave.com/ and the Facebook page at www.facebook.com/GordonPharmasave/