What checklist should I use to assess a patient before initiating a GLP‑1 receptor agonist therapy?

Pre-GLP-1 Initiation Checklist

Before prescribing a GLP-1 receptor agonist, systematically screen for contraindications, assess baseline risk factors, and document specific clinical parameters that will guide safe initiation and monitoring.

Essential Patient History & Documentation

Indication & Treatment Goals

• Primary indication: Type 2 diabetes, obesity/weight loss, or cardiovascular/renal risk reduction 1, 2
• Specific treatment goals: Target A1C (if diabetic), weight loss goals, cardiovascular risk reduction
• Baseline A1C (if diabetic) and baseline weight/BMI 1

Contraindications & High-Risk Conditions

• Personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2 (absolute contraindication) 2, 3
• History of pancreatitis (relative contraindication; discontinue if suspected) 2, 4
• Active gallbladder disease (avoid initiation) 4
• Diabetic gastroparesis (avoid initiation) 4
• Severe gastrointestinal disease or history of gastro-oesophageal surgery 5

Cardiovascular & Renal Assessment

• Established cardiovascular disease (prioritize agents with proven CV benefit: liraglutide, semaglutide, dulaglutide) 2, 6
• Chronic kidney disease status: Document eGFR and albuminuria 3
  • GLP-1 RAs can be used down to eGFR 15 mL/min/1.73 m² 3
  • No dose adjustment needed for renal impairment (except lixisenatide requires caution <60 mL/min) 2
• Heart failure history 6

Diabetic Complications (if applicable)

• Diabetic retinopathy status: Ensure eye exam within past 12 months if not documented 4
  • Rapid glucose lowering can transiently worsen retinopathy; closer monitoring needed if A1C >10% with pre-existing retinopathy 7
• Diabetic neuropathy (document for foot care counseling) 4

Medication Reconciliation

Current Diabetes Medications (if applicable)

• Sulfonylureas or meglitinides: Plan to reduce dose or discontinue to prevent hypoglycemia 4, 7
• Insulin: Consider reducing total daily dose by 10-20% at initiation 4
• DPP-4 inhibitors: Must discontinue (redundant mechanism) 7
• SGLT2 inhibitors: Document use (can be continued; combination provides additive benefit) 6, 7

Medications Affecting Gastric Emptying

• Opioids, proton pump inhibitors, tricyclic antidepressants 5
• Recreational substances: Alcohol, cannabis 5

Gastrointestinal Symptom Screening

Current Symptoms

• Nausea, vomiting, or abdominal distention 5
• Chronic constipation or diarrhea
• Early satiety or postprandial fullness

Baseline Clinical Measurements

Physical Examination

• Weight and BMI 1
• Blood pressure and heart rate (GLP-1 RAs increase heart rate by ~5 bpm) 3
• Muscle strength and functional assessment (to monitor for sarcopenia during weight loss) 8
• Body composition assessment if available 8

Laboratory Tests

• A1C (if diabetic) 1
• Fasting glucose 1
• eGFR and urinary albumin-to-creatinine ratio 3
• Lipid panel 2
• Baseline nutritional status: Consider vitamin D, B12, iron studies (to monitor during treatment) 8

Social & Behavioral Assessment

Social Determinants of Health

• Food insecurity 8
• Medication cost concerns and insurance coverage 2, 4
• Access to pharmacy and injection supplies

Dietary & Lifestyle Factors

• Usual dietary habits and patterns 8
• Emotional eating triggers 8
• Disordered eating behaviors or eating disorder history 8
• Current physical activity level: Aerobic and resistance training 8
• Sleep quality and duration 8

Surgical Planning

• Any planned surgeries or procedures in next 3-6 months 5
  • If surgery planned, document timing and coordinate perioperative management
  • For weight loss indication: hold for 3 half-lives before procedure 5
  • For diabetes: consult endocrinology regarding holding vs. continuing 5

Patient Education & Shared Decision-Making

Pre-Initiation Counseling

• Gastrointestinal side effects: Nausea (15-20%), vomiting, diarrhea; usually improve over weeks 3, 7
  • Mitigation: Start lowest dose, slow titration, small frequent meals 4, 7
• Injection technique and frequency (daily vs. weekly formulations) 2, 7
• Hypoglycemia risk (low unless combined with insulin/sulfonylureas) 3, 4
• Weight loss expectations: 5-18% in trials, may be lower in real-world practice 8
• Diabetic ketoacidosis symptoms (if on SGLT2 inhibitor combination): Nausea, vomiting, abdominal pain even with glucose 150-250 mg/dL 4, 7
• Pancreatitis warning signs: Severe persistent abdominal pain 2, 4
• Need for ongoing lifestyle interventions: Diet, exercise, behavioral support 1, 8

Monitoring Plan

• Glucose monitoring frequency (if diabetic): Increase for first 4 weeks 4
• Follow-up schedule: Reassess every 3-6 months 1
• Prescription of glucagon for emergent hypoglycemia (if on insulin) 1

Agent Selection

Choose Based on:

• Cardiovascular disease present: Liraglutide, semaglutide, or dulaglutide (proven CV benefit) 2, 6
• CKD present: Any GLP-1 RA with CV benefit; dulaglutide showed slower GFR decline 3
• Weight loss priority: Semaglutide or dual GIP/GLP-1 RA (tirzepatide) for maximal weight reduction 1, 6
• Injection frequency preference: Daily (liraglutide) vs. weekly (semaglutide, dulaglutide) vs. oral (semaglutide) 2, 7
• Cost and insurance coverage 2, 4

Starting Doses (Titrate Slowly)

• Liraglutide: 0.6 mg daily × 1 week → 1.2 mg × 1 week → 1.8 mg 2, 7
• Semaglutide injectable: 0.25 mg weekly × 4 weeks → 0.5 mg × 4 weeks → 1 mg 2, 7
• Semaglutide oral: 3 mg daily × 30 days → 7 mg × 30 days → 14 mg 7
• Dulaglutide: 0.75 mg or 1.5 mg weekly 2, 7

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This checklist ensures comprehensive pre-treatment assessment, identifies patients requiring special precautions, and establishes the foundation for safe, effective GLP-1 RA therapy tailored to individual cardiovascular, renal, and metabolic needs.