How the New Oral GLP-1 Weight Loss Medications Work

These medications also “enhance insulin secretion,” which can result in better blood sugar control and weight loss, says Sara Velayati, MD, an obesity medicine specialist at Montefiore Einstein’s Fleischer Institute Medical Weight Center in Bronx, New York. By acting on your brain, stomach, and blood sugar systems at the same time, GLP-1 medications can support meaningful weight loss and improve metabolic health over time, she says.

The peptide nature of this hormone is why developing effective oral versions of GLP-1 medications has been so challenging, says Dr. Velayati.

Because the gut is a challenging environment for absorption, oral semaglutide doses are much higher — 25 milligrams (mg) daily — than standard 2.4-mg weekly injections.

Even though the oral dose is higher, only a tiny fraction actually enters the bloodstream. Velayati says your body absorbs only about 0.4 to 1 percent of semaglutide taken by mouth. “So if you take 100 units, less than one actually reaches the bloodstream. But that tiny amount is still enough to have a meaningful clinical effect,” she says. The higher oral dose of semaglutide ensures enough medication survives the stomach acid.

Dosage Timing

If you’re thinking about trying the new weight loss pill instead of the weekly injection, you may need to rethink your morning routine. Unlike the injection, which can be given at any time, the pill requires a strict fasting window. You need to take it on an empty stomach with no more than 4 ounces (oz) of plain water, and wait at least 30 minutes before eating breakfast or drinking a cup of coffee.

“The SNAC matrix changes the pH locally where it hits the stomach lining, and this allows absorption,” says W. Timothy Garvey, MD, professor of medicine and director of The University of Alabama at Birmingham’s Diabetes Research Center. “Food prevents this interaction.”

If you eat too soon after taking the pill, food surrounds it in your stomach. That keeps the medication from touching your stomach lining the way it needs to in order to work, says Velayati. Similarly, drinking too much water can dilute the SNAC buffer, and the medication will simply be digested and wasted.

Peptide medications have a large molecular weight and mimic your body’s delicate regulatory signals. “Small molecules are chemically synthesized and designed to interact with receptors and enzymes,” says Dr. Garvey. “They’re smaller in molecular weight than peptide medications that mimic or interfere with endogenous bioregulatory peptides.”

Think of it this way: While a peptide is like a fragile piece of paper that dissolves in the rain, a small molecule is like a tiny pebble, sturdy enough to survive the digestive storm.

Velayati says these newer drugs are “even more exciting,” because their natural stability allows them to survive stomach acid without a special chemical enhancer (like SNAC). Since your body doesn’t try to “digest” these molecules, these drugs likely won’t require strict fasting or perfect timing. In other words, you may eventually be able to take these medications alongside your morning protein latte.

• Oral GLP-1 medications work by mimicking a natural hormone that regulates appetite, slows digestion, and increases insulin secretion to support weight loss and metabolic health.
• The first FDA-approved pill, oral semaglutide, uses a chemical enhancer called SNAC to protect the medication from stomach acid. It requires significantly higher doses than injections to be effective.
• To ensure proper absorption, people taking oral semaglutide must follow a strict fasting routine. ?You take the pill with minimal water and wait 30 minutes before eating or drinking.
• Future “small-molecule” drugs currently in development are chemically sturdier than peptides like semaglutide. This may eventually get rid of the need for strict fasting requirements and special chemical enhancers in these drugs.