From the Guidelines
When starting GLP-1 medications like Ozempic or GLP-1/GIP medications like Mounjaro, it is recommended to initiate metformin concurrently, if not already on it, due to its high glucose-lowering efficacy, neutral effect on weight, and potential benefit on major adverse cardiovascular events (MACE) as stated in the 2025 standards of care in diabetes 1. To minimize potential gastrointestinal side effects associated with GLP-1 and GLP-1/GIP medications, consider adding anti-nausea medications like ondansetron 4mg as needed up to three times daily. For constipation, starting a stool softener such as docusate sodium 100mg once or twice daily or an osmotic laxative like MiraLAX 17g daily can be beneficial. Key considerations for these medications include:
- Monitoring for potential vitamin B12 deficiency with metformin use, as it may cause deficiency over time 1.
- Being aware of the risk of diabetic ketoacidosis (DKA) with SGLT2 inhibitors, although this is rare in type 2 diabetes, and taking steps to mitigate this risk such as sick-day planning and discontinuing the medication before scheduled surgery or during critical illness 1.
- Understanding the potential benefits of GLP-1 RAs on cardiovascular outcomes and renal endpoints, which can guide the decision to use these medications in appropriate patients 1. Adequate hydration, aiming for at least 2-3 liters of water daily, and a daily multivitamin are also recommended to minimize side effects and ensure adequate nutrient intake. Starting these supportive treatments proactively can improve medication adherence and overall treatment success. It's crucial to follow the dosing considerations for each medication, especially in patients with kidney impairment, and to be mindful of the potential for drug interactions and the need for dose adjustments based on kidney function 1.
From the Research
Medications to Start with GLP or GLP/GIP Medications
When starting a GLP medication like Ozempic or a GLP/GIP medication like Mounjaro, the following medications should be considered:
- Metformin: often prescribed as a first-line treatment for type 2 diabetes, it can be used in conjunction with GLP or GLP/GIP medications 2, 3
- Statins: to manage cholesterol levels and reduce the risk of cardiovascular disease, which is often a comorbidity with type 2 diabetes 4
- Antihypertensives: to manage blood pressure and reduce the risk of cardiovascular disease 4
- Aspirin: to reduce the risk of cardiovascular disease, although this should be individualized based on patient risk factors 4
Considerations for Medication Selection
When selecting medications to start with GLP or GLP/GIP medications, the following factors should be considered:
- Patient's medical history and comorbidities
- Current medications and potential interactions
- Patient's kidney function and potential need for dose adjustments
- Patient's liver function and potential need for monitoring
Potential Benefits of Combination Therapy
Combination therapy with GLP or GLP/GIP medications and other medications may have several benefits, including: