Zeenat Parween, Correspondent, India Pharma Outlook
Inject subcutaneously once a week — abdomen, front thigh, or upper arm — rotating sites each time. Escalation: 0.25 mg (weeks 1–4) → 0.5 mg → 1 mg → 1.7 mg → 2.4 mg maintenance, four weeks at each step. Store pens refrigerated (2–8°C); once opened, they are stable at room temperature below 30°C for 28 days. Missed a dose? Inject within five days of the scheduled day. Beyond five days, skip it and resume the regular weekly schedule.
Rybelsus (3 mg, 7 mg, 14 mg tablets) is approved for type 2 diabetes — not obesity — and its weight-loss effect at 14 mg is meaningfully less than injectable 2.4 mg. The reason: oral bioavailability is only 0.4–1 percent, versus ~89 percent for the injection. It must be taken on an empty stomach with ≤120 mL of plain water, 30 minutes before any food or other medication. Non-adherence cuts absorption by up to 50 percent. An investigational oral 50 mg formulation (OASIS programme) is closing the efficacy gap and may expand options as global approvals progress.
SURMOUNT-5 (NEJM, May 2025) delivered the verdict: tirzepatide (a dual GLP-1/GIP agonist) produced −20.2 percent weight loss versus semaglutide's −13.7 percent at 72 weeks — a clear win on scale. One in three tirzepatide participants lost ≥25 percent of starting body weight. However, semaglutide's cardiovascular trial (SELECT, 17,500 patients, 20 percent reduction in major events) remains the more mature evidence base. For patients whose primary driver is metabolic risk rather than weight alone, semaglutide's cardiovascular data still matter.
Yes — roughly 15–25 percent of weight lost is lean mass, similar to dietary restriction alone but significant at 15–20 percent total weight loss. Lower lean mass reduces resting metabolic rate, accelerating regain after stopping. The three-part counter-strategy: progressive resistance training (not just walking), dietary protein at 1.2–1.6 g/kg/day, and a conservative escalation schedule to avoid rapid early loss that disproportionately draws on muscle.
The IDF's 2025 Diabetes Atlas estimates 89.8 million Indian adults were living with diabetes — second only to China. GLP-1 drug sales in India grew 178 percent year-on-year in February 2026 (Pharmarack), before generic competition had fully launched. Dr. Rajiv Kovil, a Mumbai diabetologist, estimated that 50 percent of his patients could clinically benefit from GLP-1 therapy — but only 5 percent were accessing it before generics arrived.
"Our goal is to democratise access to GLP-1 drugs worldwide. We are targeting annual sales of 12 million semaglutide pens in the first year of launch across all markets, including India," said Deepak Sapra, CEO of Pharmaceutical Services and API, Dr. Reddy's Laboratories
"These drugs are not magic bullets. They work best combined with sustained lifestyle changes and regular monitoring. The challenge is not starting patients on semaglutide — it is ensuring they stay on treatment safely over the long term," said Dr. Rajiv Kovil, Diabetologist, Mumbai
With patent expiry, the landscape has changed. CDSCO-approved generics from Dr. Reddy's, Sun Pharma (Noveltrast/Sematrinity), Natco, Zydus, and Alkem are now legally available on prescription. Monthly costs range from Rs 900–Rs 2,000 — a fraction of pre-generic branded pricing. The rule is simple: get it prescribed by a qualified physician, dispensed by a licensed pharmacy, and sourced from a manufacturer with CDSCO approval. Anything sold through unverified online channels without a prescription remains both legally and clinically risky.
Semaglutide is not a miracle. It is a well-engineered molecule that extends a hormone the gut already makes, works on hunger, reward circuitry, gastric emptying, and glucose simultaneously — and produces weight loss that is clinically meaningful, well-documented, and sustained for as long as the drug is taken. The weight returns when it stops. Some muscle is lost alongside fat. The side effects during escalation are real but manageable. And for the tens of millions of Indians living with metabolic disease, the patent expiry means this therapy is no longer a luxury. Whether it becomes a genuine public health tool depends on the prescribing infrastructure that surrounds it — not the molecule itself.
Q1. If semaglutide works so well, why does all the weight come back after stopping it?
Because semaglutide doesn't fix the underlying biology of obesity — it overrides it, temporarily. While you're on it, the body behaves as though its weight set-point has been lowered. Stop the drug, and ghrelin (the hunger hormone) rises, resting metabolic rate drops, and the body pushes back toward its original defended weight — the same way blood pressure returns when you stop antihypertensives. The STEP 1 withdrawal data put a number on it: patients who lost 17.3% regained 11.6 percentage points within 52 weeks of stopping. This is not a drug failure; it's the nature of obesity as a chronic condition. Semaglutide, for most patients, needs to be thought of as long-term therapy — not a course you complete and walk away from.
Q2. Is the nausea unavoidable, or is there a way to start without feeling sick every day?
Nausea is common but not inevitable at its worst — and severity is almost entirely within the patient's control. The drug is designed to start at 0.25 mg weekly for four weeks before any dose increase, precisely because the stomach needs time to adjust. Rushing this schedule is the single most reliable way to guarantee severe nausea and early dropout. Beyond the schedule, three adjustments make a significant difference: eating smaller portions, avoiding high-fat or spicy food during initial weeks, and not lying down for at least an hour after eating. For most patients who follow these steps, nausea peaks in weeks two to four of each dose step and then diminishes substantially.
Q3. Now that generic semaglutide is available in India, how do I know if what I'm buying is safe?
The distinction that matters most is regulatory status, not price. Following patent expiry, Dr. Reddy's, Sun Pharma (Noveltrast/Sematrinity), Natco, Zydus, and Alkem received CDSCO approval — these are manufactured to full pharmaceutical standards, carry pharmacovigilance obligations, and are dispensed on prescription through licensed pharmacies. What's unsafe is the parallel category of unlicensed products sold through unverified online platforms, often without requiring a prescription. These may carry incorrect doses, the wrong salt form, or contamination. The checklist: get a prescription from a qualified physician, fill it at a licensed pharmacy, verify the manufacturer's name against CDSCO-approved brands, and check for batch number, manufacturing date, and cold-chain instructions on the label. If any of those are missing — don't use it.
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