A pharmacist’s guide to oral GLP-1s

In this article:

• A pharmacist’s role in GLP-1 treatment
• Oral GLP-1 options
• Counseling points
• Safety updates
• Interactions
• Access and Cost
• What’s next
• Patient FAQs
• Referring patients to a healthcare provider

In this article

• A pharmacist’s role in GLP-1 treatment
• Oral GLP-1 options
• Counseling points
• Safety updates
• Interactions
• Access and Cost
• What’s next
• Patient FAQs
• Referring patients to a healthcare provider

GLP-1 agonists have become some of the most prescribed medications in the United States. Around 1 in 8 adults report currently taking a GLP-1, according to a KFF poll. That number could grow as prices go down and more uses are approved. For many patients who don’t do well with GLP-1 injections, oral GLP-1s are a common alternative. As a first point of contact for medications, pharmacists can make an impact by staying up to date on oral GLP-1s and guiding patients on how to use them.

Pharmacists’ skin in the game

It’s no secret that pharmacists help improve patient outcomes. A retrospective cohort in JACCP found greater A1C reductions in pharmacist-managed diabetes care than usual care. Additionally, a systematic review showed that pharmacist-led interventions greatly improved adherence in nearly 70% of 26 randomized trials. Those types of results can directly apply to managing patients on oral GLP-1s.

The current lineup of oral GLP-1 agonists

As of mid-2026, FDA-approved oral GLP-1 products include semaglutide and orforglipron in brand-name forms.

• Ozempic pill (oral semaglutide): Approved for managing Type 2 diabetes and reducing the risk of major cardiovascular events in high-risk adults with Type 2 diabetes. Novo Nordisk started discontinuing the Rybelsus brand in May 2026 and launched the Ozempic pill in new strengths, including 1.5 mg, 4 mg, and 9 mg.
• Wegovy (oral semaglutide): Approved as the first oral GLP-1 to treat overweight and obesity in adults, as well as for cardiovascular risk reduction in adults with heart disease and overweight or obesity.
• Foundayo (orforglipron): Approved in April 2026 for chronic weight management, with no strict fasting requirements. An FDA submission for Type 2 diabetes is currently underway.

Foundayo is the first non-peptide GLP-1 to hit the market. Unlike oral semaglutide, which is a peptide molecule that can easily break down in gastric acid, orforglipron is a small molecule that may have more predictable absorption from patient to patient.

The 2026 ADA Standards of Care lists GLP-1 agonists as a potential first-line therapy for Type 2 diabetes alongside ASCVD, heart failure, chronic kidney disease, or obesity, and a pill could be the dosage form a patient prefers to take

GLP-1 counseling points at the pharmacy

For many patients, picking up their GLP-1 at the pharmacy for the first time is often when they need advice the most. Taking a few minutes to go over some key counseling points could save a patient weeks of poor absorption.

Exact timing with oral semaglutide

The Ozempic pill contains an absorption enhancer called salcaprozate sodium (SNAC), but the timing of administration needs to be exact. It needs to be taken on an empty stomach with no more than 4 oz of plain water, ideally after waking up. Then, it’s important to wait at least 30 minutes before eating, drinking, or taking other oral medications, especially levothyroxine.

Foundayo is more forgiving

Foundayo is unique in that it can be taken at any time of the day, with or without food. There are also no special instructions for drinking water, unlike oral semaglutide. For many patients, this flexibility could mean the difference between sticking to treatment and giving up on it.

Missed doses are usually skipped

Patients on daily oral GLP-1 agonists will generally need to skip the missed dose entirely and take the next regularly scheduled dose. Patients should not double up on doses. In any case, it’s best to check the medication or product label to verify information for missed doses.

Titration schedules are not set in stone

All patients typically start at a lower dose that’s titrated up to prevent GI side effects. While GLP-1s have specific titration schedules, many patients benefit from going slower, especially if adverse effects are intolerable. That could mean pausing at the current dose for longer or going back to a lower one, although they should seek guidance from their healthcare provider if there are any doubts.

Safety updates in 2026

GLP-1 agents still hold a boxed warning for thyroid C-cell tumors, with all of them contraindicated in patients with a personal or family history of medullary thyroid carcinoma or MEN 2. Still, this warning is based on animal studies, and more recent studies are potentially uncovering detection bias

Suicidality warning has been removed

In January 2026, the FDA requested the removal of suicidal thoughts and behavior from the labeling for Saxenda, Wegovy, and Zepbound. They found no causal association after reviewing 91 trials. That doesn’t detract from the fact that mental health care is still important in patients with a history of depression or related conditions.

Lean mass is a greater percentage of total weight lost

Around 25% to 40% of the weight lost on semaglutide or tirzepatide comes from lean mass. Therefore, it’s even more crucial to counsel patients on eating enough protein and keeping up with resistance training to preserve muscle, especially in older adults. Nutrition also goes beyond just sufficient protein intake.

Acute pancreatitis, cholelithiasis, and cholecystitis continue to be seen as potential risks across all GLP-1s. Postmarketing reports include acute kidney injury in patients with severe GI symptoms, which means hydration is even more important while titrating doses.

Drug interactions to take note of

Since delayed gastric emptying is a core mechanism of action of GLP-1s, it makes sense to watch for potential drug interactions.

• Levothyroxine: Oral semaglutide has been shown to increase exposure to levothyroxine by about 33%. Reinforce waiting 30 minutes after taking oral semaglutide before taking other medications.
• Oral contraceptives: The Foundayo label recommends switching to a non-oral contraceptive or adding a barrier method for 30 days after starting and for 30 days after increasing the dose.
• CYP3A4 inhibitors and inducers: The maximum dose of Foundayo is 9 mg when taken with strong CYP3A4 inhibitors, and strong inducers should be avoided. The dosage of simvastatin should not exceed 20 mg daily while taking Foundayo.

The risk of hypoglycemia is another factor to counsel on if patients are on a sulfonylurea or insulin. If you see a patient on one of these, consider calling it out to their prescriber if the dose hasn’t changed.

Access, cost, and the end of compounded GLP-1s

Compounded GLP-1s continue to be a hot topic even though the FDA declared the semaglutide and tirzepatide shortages resolved. While compounded medications still have their place, it’s a good idea to let patients know about potential dosing errors and other risks with compounded products.

When it comes to costs, patients may be happy to know that manufacturer programs have relieved much of the burden for cash-paying patients with LillyDirect, and NovoCare Pharmacy offers discounts for cash-paying patients with commercial insurance.

Medicare Part D weight-management coverage is opening up, too. The CMS Medicare GLP-1 Bridge, running from 2026 through December 31, 2027, decreases the copay for Wegovy tablets and Foundayo (along with select injectables) to $50 a month for eligible Part D members who meet one of the following:

• BMI of 35 or higher
• BMI of 30 or higher with heart failure, uncontrolled hypertension, or CKD
• BMI of 27 or higher with pre-diabetes, prior MI or stroke, or symptomatic PAD

For patients who don’t qualify, SingleCare’s prescription discount card may help take the edge off GLP-1 pill costs.

What’s coming next

Oral GLP-1s have a lot to look forward to. Eli Lilly plans to submit orforglipron for FDA approval for Type 2 diabetes after strong data was found in comparison trials with oral semaglutide.

In addition, Novo Nordisk has filed a 25 mg semaglutide tablet for Type 2 diabetes, and their newest potential drug, oral amycretin, is a combination GLP-1 and amylin agonist that has entered Phase 3 trials for obesity. Other oral GLP-1s in the pipeline include Structure Therapeutics’ aleniglipron, Viking Therapeutics’ oral VK2735, and AstraZeneca’s elecoglipron.

Patient FAQs

Some patient questions may come up more often than others. It can be helpful to have an answer when they arise.

Is the pill as effective as the shot?

Although the benefits for blood sugar and heart health are similar to those with the injection, weight-loss results tend to be lower with oral semaglutide. However, Foundayo is bridging the gap with data that places it closer to the injectables.

Can I switch from the pen to a pill?

It’s entirely possible to switch from the pen to an oral version after getting input from a healthcare provider. However, the dosing is not equivalent, with an effective dose of 7 to 14 mg daily for the Ozempic pill versus 2.4 mg weekly for the injection.

Why is there a water restriction with the Ozempic pill?

The Ozempic pill contains SNAC to improve absorption in the stomach. However, drinking too much water can dilute the levels of SNAC, which can ultimately reduce absorption. Foundayo does not have this requirement.

Referring patients to their healthcare provider

A few situations may warrant a call to their prescriber, including severe GI issues with dehydration, suspected pancreatitis, gallbladder disease, severe hypoglycemia, and rapid vision changes in patients with a history of diabetic retinopathy.  Women with a planned or confirmed pregnancy should also consult their healthcare provider, as semaglutide should be stopped at least two months before conception. Foundayo should be discontinued as soon as a pregnancy is confirmed.

With the GLP-1 cat out of the bag and many more patients being on one, it’s now more important for pharmacists to stay current. Label changes are possible as more studies on oral GLP-1s come out. Other practical tips on administering GLP-1s and accessing them at a lower cost can also be helpful for patients who could benefit.