Helen Pervanas, PharmD

Patients with multiple sclerosis (MS) are prone to polypharmacy (PP) and are at risk for at least 1 potential drug-drug interaction (pDDI), according to the results of a study published in the 

MS is a progressive and debilitating medical condition. Because of its complexity, patients require many medications to treat the symptoms, in addition to disease-modifying medications, to slow the progression of MS. Simultaneous use of multiple medications or PP can, in turn, lead to drug interactions.

The study authors assessed the medications of 627 patients with MS using 2 databases to determine the number of medications and pDDIs. The researchers defined total PP as 5 or more prescription or OTC medications and prescription PP (RxPP) as 5 or more prescription medications. More than half of the patients (53%) had PP and 63% of patients had at least 1 pDDIs.

Of the 627 patients, researchers detected 2887 pDDIs, most of which were mild (65%) or mildly moderate (17%). The study cited 7 (0.2%) severe DDIs that included the prescription medication citalopram used in combination with 1 of the following medications: ciprofloxacin, doxepin, flecainide, levofloxacin, ondansetron, and quetiapine. The most frequent interactions were between magnesium and cholecalciferol and acetylsalicylic acid and methylprednisolone.

In this study, researchers assessed the extent of PP and the prevalence and severity of pDDIs in patients with MS. Minimizing the potential of DDIs and reducing PP rates is crucial. Deprescribing unnecessary medications is the simplest approach to reduce PP rates and pDDIs.

Pharmacists should review the patient’s medications regularly to assess the potential for DDIs. When assessing medications, it’s important to include prescription drugs, OTC medications, and herbals/supplements. The researchers noted that 22% of pDDIs included OTC medications. Pharmacists must be proactive and always ask patients about OTC medication use.

Another approach includes the pharmacist performing a medication therapy management (MTM) service with the patient.

 MTM is effective in reducing health care costs, improving adherence, and enhancing clinical outcomes.

Last, pharmacists should always assess medication adherence. If patients are not taking their medications as prescribed, nonadherence could lead to treatment failure or adverse events. Prescribers could inadvertently start a cascade by prescribing more—and unnecessary—medications.

Safe medication use among patients is of utmost importance. Reducing polypharmacy can reduce the potential of DDIs, especially in those with severe chronic medical conditions.

Bachmann P, Frahm N, Debus JL, et al. U.K. Prevalence and Severity of Potential Drug–Drug Interactions in Patients with Multiple Sclerosis with and without Polypharmacy. 

 2022, 14, 592. https:// doi.org/10.3390/

American Pharmacists Association. National Association of Chain Drug Stores Foundation Medication therapy management in pharmacy practice: Core elements of an MTM service model (version 2.0). 

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Pharmacists should review the medications of patients with multiple sclerosis regularly to assess drug-drug interactions.

Polypharmacy and Potential Drug-Drug Interactions: Monitor Patients With Multiple Sclerosis

 (Wegovy) is a glucagon-like peptide-1 (GLP-1) receptor agonist for chronic weight management in adult patients, when combined with a reduced calorie diet and exercise.

Patients with a body mass index (BMI) of or exceeding 30 kg/m

and have a least 1 weight-related comorbid condition, such as hypertension, diabetes, or dyslipidemia, can take semaglutide. 

Semaglutide is also indicated with diet and exercise to improve blood sugar control in adults with type 2 diabetes mellitus. Semaglutide 1 mg injection (Ozempic) was initially approved as a treatment for type 2 diabetes in 2017.

Researchers conducted a double-blind trial with 1961 adult patients with a BMI of at least 30 or BMI at or exceeding 27 with comorbid conditions without diabetes. The 68-week trial randomized patients 2:1 to once weekly subcutaneous semaglutide 2.4 mg (n=1306) or placebo (n=655) and lifestyle interventions.

Primary endpoints were percentage change of weight at 68 weeks from baseline and percentage of patients achieving weight loss of at least 5% at week 68. Observed weight change at week 68 was 14.9% with semaglutide compared to placebo at 2.4%; 95% CI, −13.4 to −11.5; P<0.001.

A total of 86.4% of patients on semaglutide achieved a 5% weight loss at week 68 compared to 31.5% in the placebo group. Additionally, 69% of patients on semaglutide achieved a 10% weight loss compared to 12% in the placebo group. Gastrointestinal adverse events (AEs) were most common among patients receiving semaglutide than those receiving placebo; 74.2% versus 47.9%.

Semaglutide increases insulin secretion and reduces glucagon secretion. As a GLP-1 receptor agonist, it acts in areas of the brain that regulate appetite and caloric intake.

Semaglutide is a subcutaneous weekly injection with a dose escalation every 4 weeks until reaching the maintenance dose of 2.4 mg. Consider delaying the dose increase for an additional four weeks in patients who cannot tolerate the medication. Discontinue the medication if the patient cannot tolerate the maintenance dose of 2.4 mg. See 

If the patient misses a dose, administer as soon as possible within 5 days and then continue with the scheduled dose.If patients miss a dose and it is greater than 5 days, they should skip the missed dose and then continue with the next scheduled weekly dose. If the patient misses more than 2 consecutive doses, continue scheduled dosing.

Solution auto-injector, subcutaneous; Wegovy: 0.25 mg/0.5 mL (0.5 mL); 0.5 mg/0.5 mL (0.5 mL); 1 mg/0.5 mL (0.5 mL); 1.7 mg/0.75 mL (0.75 mL); 2.4 mg/0.75 mL (0.75 mL).

Semaglutide does not require dosing adjustments in patients with renal or hepatic impairment.

Patients should administer the subcutaneous injection into the thigh, abdomen, or upper arm, weekly on the same day, rotating the sites. Health care providers should counsel patients to remove the pen cap and firmly press the device against the skin to release the medication when administering the dose. Patients must continue to press the device against the skin until the yellow bar stops moving before removing it. This may take 5 to 10 seconds.

Semaglutide’s most common AEs are gastrointestinal in nature, resulting in nausea, diarrhea, vomiting, constipation, abdominal pain, dyspepsia, gastroenteritis, gastroesophageal reflux disease, and flatulence. Other AEs include dizziness, hypoglycemia in patients with type 2 diabetes, headache, and fatigue.

The following are disease-related AEs that may occur in patients taking semaglutide.

Hypersensitivity reactions-anaphylaxis, angioedema

Diabetic neuropathy in patients with type 2 diabetes

Semaglutide increases the risk of hypoglycemia when combined with other agents that cause hypoglycemia, such as sulfonylureas and insulin. A dose reduction of the concomitant agents may be necessary. Semaglutide can delay gastric emptying and can affect the absorption of oral medications. Avoid combining with other GLP-1 receptor agonists.

Patients with a history or family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2 should not take semaglutide. Patients with a prior serious hypersensitivity reaction to semaglutide, such as anaphylaxis and angioedema, should also avoid semaglutide.

Semaglutide may cause fetal harm, therefore patients should discontinue use if they become pregnant. Females and males planning pregnancy should discontinue semaglutide 2 months before becoming pregnant because of semaglutide’s long half-life.

Pregnant women taking semaglutide and health care providers should contact Novo Nordisk at 800-727-6500 as part of the pregnancy exposure registry to monitor outcomes.

There are no data about semaglutide and risk in breastfeeding. Semaglutide was present in lactating rats. Consider semaglutide’s benefits and risks for the mother and the child.

HbA1c: Every 6 months if stable or quarterly if goals not met

Signs/symptoms of adverse reactions relevant to warnings/precautions

Store the Wegovy pen in the refrigerator, between 2°C to 8° (36°F to 46°F). Do not freeze and keep in the original packaging to avoid exposure to light.

, is a professor of Pharmacy Practice at MCPHS University.

Semaglutide (Wegovy™). Prescribing information. Novo Nordisk; 2021 Accessed March 3, 2022. 

Wilding JPH, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight or obesity. 

 2021;384:989-1002. DOI: 10.1056/NEjMoa2032193.

FDA approval Wegovy™ Accessed March 3, 2022. 

https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-treatment-chronic-weight-management-first-2014

Semaglutide. Lexi-Drugs. Lexicomp Online. Wolters Kluwer Clinical Drug Information, Inc. Updated July 05, 2020. Accessed March 3, 2022. 

https://online-lexi-com.ezproxymcp.flo.org/

In a clinical trial, 86.4% of patients on semaglutide achieved a 5% weight loss at week 68 compared to 31.5% with placebo. 