Should Ozempic (semaglutide) be discontinued in a 51-year-old male with prediabetes and a thyroid nodule with a Ti-RADS 4 classification, indicating a potential need for biopsy?

From the Guidelines

There is no need to discontinue Ozempic (semaglutide) at this point, as the presence of thyroid nodules, including those requiring biopsy, is not a contraindication for GLP-1 receptor agonists like Ozempic. The thyroid nodule identified as TI-RADS 4 should be biopsied as recommended, but this can be done while continuing your diabetes medication. Ozempic works primarily by affecting insulin secretion, glucose metabolism, and appetite regulation, and has no direct causative relationship with thyroid nodules. Thyroid nodules are common in the general population, affecting approximately 50% of people by age 60, and most are benign. While there were some concerns about GLP-1 agonists and medullary thyroid cancer in animal studies, this has not been demonstrated as a significant risk in humans, as stated in the 2025 standards of care in diabetes 1. You should proceed with the recommended thyroid biopsy while maintaining your current diabetes management with Ozempic, unless your endocrinologist specifically advises otherwise based on your complete medical history. Some key points to consider in the management of thyroid nodules and diabetes include:

• The use of GLP-1 receptor agonists like Ozempic for diabetes management, as recommended in the 2025 standards of care in diabetes 1
• The importance of regular monitoring and screening for thyroid nodules, as recommended in the ACR Appropriateness Criteria for thyroid disease 1
• The need for a comprehensive treatment plan that addresses both diabetes and thyroid health, as recommended in the NCCN Guidelines for Thyroid Carcinoma 1
• The potential benefits and risks of different treatment options, including pharmacologic agents like metformin and liraglutide, as discussed in the 2022 standards of medical care in diabetes 1.

From the FDA Drug Label

OZEMPIC may cause serious side effects, including: • Possible thyroid tumors, including cancer Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, OZEMPIC and medicines that work like OZEMPIC caused thyroid tumors, including thyroid cancer It is not known if OZEMPIC will cause thyroid tumors or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people.

The patient should inform their healthcare provider about the thyroid nodule findings, as Ozempic may cause possible thyroid tumors, including cancer. However, the label does not explicitly state that Ozempic should be discontinued in this situation. Therefore, the decision to continue or discontinue Ozempic should be made by the healthcare provider, taking into account the patient's individual circumstances and medical history 2.

From the Research

Thyroid Nodule Evaluation and Ozempic

• The patient has been diagnosed with a heterogeneous thyroid gland with multiple nodules, and the dominant 1.9 cm Ti-RADS 4 nodule in the right lobe meets size criteria to consider biopsy 3, 4, 5.
• The evaluation of thyroid nodules is based on risk assessment for thyroid cancer, as determined by clinical and ultrasound features to guide the need for biopsy 3.
• Fine-needle aspiration biopsy (FNAB) is the most efficient diagnostic tool for evaluating thyroid nodules, and the findings from FNAB allow avoidance of operative treatment for a large portion of patients with palpable thyroid nodules 4.
• There is no direct evidence to suggest that Ozempic should be discontinued in patients with thyroid nodules, but metformin, a medication related to Ozempic, has been shown to be safe and useful in shrinking benign thyroid nodules volume, improving thyroid function and insulin resistance 6.

Management of Thyroid Nodules

• The management of thyroid nodules depends on the diagnostic findings, and surgery is indicated for fine-needle aspiration biopsy (FNAB) findings of malignancy or indeterminate cytology when there is a high risk clinical context 5.
• Molecular analysis of indeterminate FNAB samples has potential to better discriminate benign from malignant nodules and thus guide management 5.
• Ultrasound is critical in detection, diagnosis, and management of thyroid nodules, and surveillance ultrasound in papillary microcarcinomas is being evaluated and compared with surgical management 7.

Ozempic and Thyroid Nodules

• There is limited evidence on the use of Ozempic in patients with thyroid nodules, but metformin, a medication related to Ozempic, has been shown to have a positive effect on benign thyroid nodules 6.
• Further studies are needed to determine the effect of Ozempic on thyroid nodules and to guide management decisions in patients with thyroid nodules taking Ozempic.