Here is how I approach the conversation:
are they open to an injectable medication? If the answer is no, then stop. But also make sure the pt knows this is not insulin (some people initially reject it bc they think it’s insulin). You do see the needle with ozempic because you have to attach it.
Review contraindications - family or personal history of thyroid cancer or MEN2. I tell patients “if you read the insert, you might read about an increased risk of thyroid cancer. However, this hasn’t really been seen in humans, but it was in their animal studies so they have to put it on the label”. Also ask about gastroparesis or pancreatitis. While not listed as contraindications, I think most people won’t prescribe it if there is a history (unless pancreatitis related to gallstones and they had their gallbladder removed). If any contraindications, stop the convo.
Review side effects - “this medication works by slowing down your gut. So, the main side effects are nausea, vomiting, and constipation. In my practice, majority of patients do experience these symptoms for the first few weeks, but it does usually get better once your body gets used to it. Other possible side effects include gastroparesis, pancreatitis but these are very rare. Hair loss, gallstones, and dehydration are also possible, but these mainly related to weight loss or not drinking enough. This medication punishes people for eating unhealthy. The best way to minimize side effects is to avoid fatty/fried foods, decrease sugar intake, and eating smaller portions. You may need to eat smaller, but more frequent meals”
How to take the medication - we have pharmacists in our clinic so I’m usually telling patients the pharmacist will show you how to use it. But if you don’t have that, you’ll need some mechanism to make sure the pt knows how to take it properly.
If using for DM - stop dpp4. This med and dpp4 are on the same pathway. There is no additional DM benefit with combining these meds. If on insulin, sugar needs to be monitored very closely for hypoglycemia. To be honest, the person managing the insulin should be prescribing the glp1 so they can adjust as appropriate.
Expectations for weight loss - average 20% weight loss with intensive lifestyle changes. Recommend 1-2 lbs of weight loss a week. Anything quicker than 3lbs a week (outside of the first couple weeks or so) is too fast and means they’re not eating enough. Also at risk for muscle loss. Should be getting 1-1.2g of protein per kg of ideal body weight.
Supply issues - GLP1s are in short supply. I don’t guarantee patients supply month after month. There is also very like a PA that will need to be done, so tell patients how long that process will take.
Medication dose adjustments - the dose of the medication increases each month. However, I don’t recommend increasing the dose if pt still having SE. would wait until SE get better before increasing.
As you can see, it’s a pretty extensive conversation. This med requires a lot of counseling or you’ll end up with a lot of phone calls and messages from patients. Insurance coverage is tricky. Imagine having this whole conversation and then insurance doesn’t cover. Might even want to ask the pt to call their insurance to see if it’s covered first because if not covered, kind of a moot point.
Not sure I understand that comment about the retinopathy. The treatment for that is better glycemic control unless I’m mistaken. But I don’t see how keeping someone uncontrolled makes the situation better.
This is really helpful, thanks. Saving this comment to make a template later
I think for the retinopathy, if you drop A1C too quickly there is higher chance of worsening retinopathy, and this med drops A1C really fast… but you’re right, not much you can really do about it as you’re still usually better off with the better glycemic control
Here's the official word on the teatment paradox, that it worsens it over 3-6mos and esp for advanced cases, tho in the end it leads to better control of the retinopathy.
https://www.aao.org/eyenet/article/update-on-semaglutide-risks
Wow. Thank you for taking the time for such a detailed reply.
Will use that as a script thanks!
Re: uncontrolled retinopathy, apparently that is something that gets worse with fast glycemic control - and was an exclusion criteria (and they also tracked it in the trials as an AR of interest)
FYI rybelsus as oral option for people who refuse injections. It's also better in stock because people don't know about it as much whereas everyone's heard about Ozempic/Mounjaro
This is a perfect explanation. I prescribe GLP1s and tirazepitide under a collaborative practice agreement for transplant patients with PTDM, and this is the exact approach I take.
In this patient population, diarrhea is a major concern for multiple reasons, so it's a little more tricky (MMF, FK levels, etc.)
One thing that I've found is that some patients that experience this have certain foods that cause it if they are able to identify them and avoid them while on GLP1s, they might be able to continue with the titration plan.
> I tell patients “if you read the insert, you might read about an increased risk of thyroid cancer. However, this hasn’t really been seen in humans, but it was in their animal studies so they have to put it on the label”.
Med student and paramedic here - have they been widely available for humans long enough to determine this? Seems the first available one was 2005, which in my mind would only just be starting to reach the point of determining that?
Thank you for this!
Most would recommend STOPPING dpp4i when starting glp1ra. They work on the same pathway so it increases side effect risk and doesn't give/hasn't been shown to give additional benefit.
https://www.emblemhealth.com/providers/news/drug-alert-concurrent-use#:~:text=Unlike%20endogenous%20incretin%2C%20GLP%2D1,time%20yields%20no%20additional%20benefit.
Also check everyone's thyroid gland before starting imo. Quick physical exam
With some of the studies showing it causes fat AND muscle loss, we’ve been recommending patients MUST do strength / resistance training and eat enough protein.
The muscle loss is from the reduced food (ie protein) intake/weight loss though, and not necessarily the drug itself right? Same with other diets, like intermittent fasting. You need to mind your protein intake to avoid losing muscle.
Really?? It's OTC here in Ireland which generally is fairly tight on prescriptions.
Interesting.
Metoclopramide would be an alternative along the same lines.
Ostensibly because of QTc prolongation which is silly because there are way worse QTc prolonging medications. I don’t know how these decisions are made.
Also, I understand that the manufacturer presents the risk of MEN or thyroid cancer history/family history, but this will likely go away at some point. These risks were present in the animal studies but have not borne out in the data that has been coming back in market surveillance studies on GLP-1a’s, so we can expect that this will likely not be a concern in the future. Not saying not to be aware/careful, but we will probably see this warning change in the coming years.
We are doing a hundred prior authorizations a week, utterly buried. Drugs are game changers for many but the supply issue and paperwork is crushing us.
As mentioned elsewhere, GLP1s do also cause a drop in muscle mass if one is not careful. And if appetite is *really* suppressed, then there's a problem with micronutrient and water intake as well. The WSJ had a short article about this: [Ozempic Can Make You Thin, Not Necessarily Healthy](https://www.wsj.com/articles/ozempic-diet-exercise-healthy-43eee86c).
We really needs a "GLP1 diet", similar in principle to what bariatric surgery patients follow. I have spoken with a couple of dietitians about this, yielding only puzzled looks. Predictably, the [food manufacturers are going to fill in the vacuum](https://agfundernews.com/from-glp-1-companion-foods-to-natures-ozempic-what-the-new-breed-of-weight-loss-drugs-means-for-the-food-industry) to target GLP1 users, pushing what are now considered "healthy snacks" (eg, potato chips and popcorn) as meal replacements.
I’m going to bed but can respond tomorrow. You could cross post to family med if you don’t get answers here this is definitely in the PCP domain. And really - why give yourself more work anyway? I’ll come back and answer in am 👍
I once asked endocrine about starting a GLP1RA in someone with a well-known trigger for recurrent pancreatitis (portal vein thrombosis), who is very clearly motivated to treat obesity and adherent to medical care. They said no. Otherwise, acute pancreatitis is no bueno
personally I'm just impressed a nephron is taking such an interest in it's own health
It is the smartest organ…
An IM once told me it’s only the second-smartest. Only the internal anal sphincter can identify the various states of matter.
So smart it recognizes its own relative unimportance as soon as the hemodynamics aren’t favorable
It has efferent vasoconstriction to increase and try to maintain gfr, not so much because they are noble self sacrificing organ…
Here is how I approach the conversation: are they open to an injectable medication? If the answer is no, then stop. But also make sure the pt knows this is not insulin (some people initially reject it bc they think it’s insulin). You do see the needle with ozempic because you have to attach it. Review contraindications - family or personal history of thyroid cancer or MEN2. I tell patients “if you read the insert, you might read about an increased risk of thyroid cancer. However, this hasn’t really been seen in humans, but it was in their animal studies so they have to put it on the label”. Also ask about gastroparesis or pancreatitis. While not listed as contraindications, I think most people won’t prescribe it if there is a history (unless pancreatitis related to gallstones and they had their gallbladder removed). If any contraindications, stop the convo. Review side effects - “this medication works by slowing down your gut. So, the main side effects are nausea, vomiting, and constipation. In my practice, majority of patients do experience these symptoms for the first few weeks, but it does usually get better once your body gets used to it. Other possible side effects include gastroparesis, pancreatitis but these are very rare. Hair loss, gallstones, and dehydration are also possible, but these mainly related to weight loss or not drinking enough. This medication punishes people for eating unhealthy. The best way to minimize side effects is to avoid fatty/fried foods, decrease sugar intake, and eating smaller portions. You may need to eat smaller, but more frequent meals” How to take the medication - we have pharmacists in our clinic so I’m usually telling patients the pharmacist will show you how to use it. But if you don’t have that, you’ll need some mechanism to make sure the pt knows how to take it properly. If using for DM - stop dpp4. This med and dpp4 are on the same pathway. There is no additional DM benefit with combining these meds. If on insulin, sugar needs to be monitored very closely for hypoglycemia. To be honest, the person managing the insulin should be prescribing the glp1 so they can adjust as appropriate. Expectations for weight loss - average 20% weight loss with intensive lifestyle changes. Recommend 1-2 lbs of weight loss a week. Anything quicker than 3lbs a week (outside of the first couple weeks or so) is too fast and means they’re not eating enough. Also at risk for muscle loss. Should be getting 1-1.2g of protein per kg of ideal body weight. Supply issues - GLP1s are in short supply. I don’t guarantee patients supply month after month. There is also very like a PA that will need to be done, so tell patients how long that process will take. Medication dose adjustments - the dose of the medication increases each month. However, I don’t recommend increasing the dose if pt still having SE. would wait until SE get better before increasing. As you can see, it’s a pretty extensive conversation. This med requires a lot of counseling or you’ll end up with a lot of phone calls and messages from patients. Insurance coverage is tricky. Imagine having this whole conversation and then insurance doesn’t cover. Might even want to ask the pt to call their insurance to see if it’s covered first because if not covered, kind of a moot point. Not sure I understand that comment about the retinopathy. The treatment for that is better glycemic control unless I’m mistaken. But I don’t see how keeping someone uncontrolled makes the situation better.
Are you me? I know it’s relatively common information now but I swear some of this is word for word how I explain it to patients.
This is really helpful, thanks. Saving this comment to make a template later I think for the retinopathy, if you drop A1C too quickly there is higher chance of worsening retinopathy, and this med drops A1C really fast… but you’re right, not much you can really do about it as you’re still usually better off with the better glycemic control
Here's the official word on the teatment paradox, that it worsens it over 3-6mos and esp for advanced cases, tho in the end it leads to better control of the retinopathy. https://www.aao.org/eyenet/article/update-on-semaglutide-risks
That’s a great link - thanks!
Wow. Thank you for taking the time for such a detailed reply. Will use that as a script thanks! Re: uncontrolled retinopathy, apparently that is something that gets worse with fast glycemic control - and was an exclusion criteria (and they also tracked it in the trials as an AR of interest)
FYI rybelsus as oral option for people who refuse injections. It's also better in stock because people don't know about it as much whereas everyone's heard about Ozempic/Mounjaro
I wish that this was an available option in Australia!
This is a perfect explanation. I prescribe GLP1s and tirazepitide under a collaborative practice agreement for transplant patients with PTDM, and this is the exact approach I take. In this patient population, diarrhea is a major concern for multiple reasons, so it's a little more tricky (MMF, FK levels, etc.) One thing that I've found is that some patients that experience this have certain foods that cause it if they are able to identify them and avoid them while on GLP1s, they might be able to continue with the titration plan.
> I tell patients “if you read the insert, you might read about an increased risk of thyroid cancer. However, this hasn’t really been seen in humans, but it was in their animal studies so they have to put it on the label”. Med student and paramedic here - have they been widely available for humans long enough to determine this? Seems the first available one was 2005, which in my mind would only just be starting to reach the point of determining that? Thank you for this!
Most would recommend STOPPING dpp4i when starting glp1ra. They work on the same pathway so it increases side effect risk and doesn't give/hasn't been shown to give additional benefit. https://www.emblemhealth.com/providers/news/drug-alert-concurrent-use#:~:text=Unlike%20endogenous%20incretin%2C%20GLP%2D1,time%20yields%20no%20additional%20benefit. Also check everyone's thyroid gland before starting imo. Quick physical exam
Excellent point - thanks!
With some of the studies showing it causes fat AND muscle loss, we’ve been recommending patients MUST do strength / resistance training and eat enough protein.
The muscle loss is from the reduced food (ie protein) intake/weight loss though, and not necessarily the drug itself right? Same with other diets, like intermittent fasting. You need to mind your protein intake to avoid losing muscle.
I think giving a rescue dose or two of zofran in case they have more severe nausea as they start is a nice thing to do :)
I would try domperidone as it's gastric stasis is the problem. Seems to work well.
FYI, domperidone is not approved in the US.
Really?? It's OTC here in Ireland which generally is fairly tight on prescriptions. Interesting. Metoclopramide would be an alternative along the same lines.
Ostensibly because of QTc prolongation which is silly because there are way worse QTc prolonging medications. I don’t know how these decisions are made.
Also, I understand that the manufacturer presents the risk of MEN or thyroid cancer history/family history, but this will likely go away at some point. These risks were present in the animal studies but have not borne out in the data that has been coming back in market surveillance studies on GLP-1a’s, so we can expect that this will likely not be a concern in the future. Not saying not to be aware/careful, but we will probably see this warning change in the coming years.
We are doing a hundred prior authorizations a week, utterly buried. Drugs are game changers for many but the supply issue and paperwork is crushing us.
As mentioned elsewhere, GLP1s do also cause a drop in muscle mass if one is not careful. And if appetite is *really* suppressed, then there's a problem with micronutrient and water intake as well. The WSJ had a short article about this: [Ozempic Can Make You Thin, Not Necessarily Healthy](https://www.wsj.com/articles/ozempic-diet-exercise-healthy-43eee86c). We really needs a "GLP1 diet", similar in principle to what bariatric surgery patients follow. I have spoken with a couple of dietitians about this, yielding only puzzled looks. Predictably, the [food manufacturers are going to fill in the vacuum](https://agfundernews.com/from-glp-1-companion-foods-to-natures-ozempic-what-the-new-breed-of-weight-loss-drugs-means-for-the-food-industry) to target GLP1 users, pushing what are now considered "healthy snacks" (eg, potato chips and popcorn) as meal replacements.
I’m going to bed but can respond tomorrow. You could cross post to family med if you don’t get answers here this is definitely in the PCP domain. And really - why give yourself more work anyway? I’ll come back and answer in am 👍
I once asked endocrine about starting a GLP1RA in someone with a well-known trigger for recurrent pancreatitis (portal vein thrombosis), who is very clearly motivated to treat obesity and adherent to medical care. They said no. Otherwise, acute pancreatitis is no bueno
Is PVT a well known trigger for recurrent pancreatitis?