What are the recommendations for monitoring patients initiating Glucagon-like peptide-1 (GLP-1) receptor agonist therapy?

From the Guidelines

Patients initiating GLP-1 receptor agonist therapy should be closely monitored for efficacy and potential adverse effects, with a focus on mitigating nausea, hypoglycemia, and diabetic retinopathy complications, as recommended by the 2020 expert consensus decision pathway 1.

Key Monitoring Recommendations

• Initially, patients should have baseline measurements of weight, blood pressure, and glycemic parameters (HbA1c and fasting glucose) before starting GLP-1 receptor agonist therapy.
• Instruct patients to more closely monitor glucose at home for the first 4 weeks of therapy, and consider discontinuing any sulfonylurea or glinide, as well as reducing total daily insulin dose by up to 20% if applicable 1.
• Advise patients to undergo appropriate, guideline-recommended eye examinations before starting therapy if not done within the last 12 months, especially for those with a history of diabetic retinopathy 1.
• Monitor gastrointestinal side effects like nausea, vomiting, and diarrhea, especially during the first few weeks of treatment or dose escalation, and consider starting at the lowest dose and up-titrating slowly to mitigate nausea 1.
• Patients with risk factors for pancreatitis should be monitored for abdominal pain, and renal function should be assessed periodically, particularly in patients with pre-existing kidney disease or those taking medications that affect kidney function.

Additional Considerations

• Discontinue DPP-4 inhibitor before starting GLP-1 receptor agonist therapy, as they both work through GLP-1 signaling and have not been approved for use together 1.
• Avoid using GLP-1 receptor agonists in patients with diabetic gastroparesis or active gallbladder disease, and use with caution in patients who have had problems with clinically significant gastroparesis 1.
• Educate patients about hypoglycemia symptoms if they're taking GLP-1 agonists with insulin or sulfonylureas, and consider reducing the dose of sulfonylurea or basal insulin by 20% when starting therapy if HbA1c is well-controlled at baseline or there is a known history of frequent hypoglycemic events 1.

From the FDA Drug Label

After initiation of OZEMPIC, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting) If pancreatitis is suspected, OZEMPIC should be discontinued and appropriate management initiated; if confirmed, OZEMPIC should not be restarted. Monitor renal function when initiating or escalating doses of OZEMPIC in patients reporting severe adverse gastrointestinal reactions. Patients with a history of diabetic retinopathy should be monitored for progression of diabetic retinopathy. The risk of hypoglycemia is increased when OZEMPIC is used in combination with insulin secretagogues (e.g., sulfonylureas) or insulin. Use caution when initiating or escalating doses of liraglutide injection in patients with renal impairment Inform patients using these concomitant medications and pediatric patients of the risk of hypoglycemia and educate them on the signs and symptoms of hypoglycemia. Monitor renal function in patients with renal impairment reporting severe adverse gastrointestinal reactions. Use TRULICITY with caution in patients with ESRD

The recommendations for monitoring patients initiating Glucagon-like peptide-1 (GLP-1) receptor agonist therapy include:

• Monitoring for signs and symptoms of pancreatitis
• Monitoring renal function when initiating or escalating doses in patients with severe adverse gastrointestinal reactions
• Monitoring for progression of diabetic retinopathy in patients with a history of diabetic retinopathy
• Monitoring for hypoglycemia when used in combination with insulin secretagogues or insulin
• Using caution when initiating or escalating doses in patients with renal impairment
• Educating patients on the signs and symptoms of hypoglycemia
• Using caution in patients with end-stage renal disease (ESRD) 2, 3, 4

From the Research

Monitoring Patients Initiating GLP-1 Receptor Agonist Therapy

When initiating GLP-1 receptor agonist therapy, several factors should be considered to ensure safe and effective treatment. The following are key recommendations for monitoring patients:

• Glycemic Control: Regular monitoring of HbA1c levels is essential to assess the efficacy of GLP-1 receptor agonist therapy 5, 6, 7, 8, 9.
• Body Weight: Monitoring body weight is crucial, as GLP-1 receptor agonists can cause weight loss 5, 6, 7, 8, 9.
• Gastrointestinal Adverse Events: Patients should be monitored for gastrointestinal adverse events, such as nausea, vomiting, and diarrhea, which are common with GLP-1 receptor agonist therapy 5, 6, 7, 8.
• Hypoglycemia: Patients should be monitored for hypoglycemia, especially when GLP-1 receptor agonists are used in combination with other glucose-lowering agents 6, 7, 8, 9.
• Cardiovascular Risk: Patients with pre-existing atherosclerotic vascular disease should be monitored for cardiovascular events, as GLP-1 receptor agonists have been shown to reduce cardiovascular risk 5.
• Renal Function: Patients with renal impairment should be monitored for changes in renal function, as GLP-1 receptor agonists may affect renal function 5.

Practical Considerations for Clinical Practice

When initiating GLP-1 receptor agonist therapy, the following practical considerations should be taken into account:

• Dose Titration: The dose of GLP-1 receptor agonist should be titrated slowly to minimize gastrointestinal adverse events 6, 7, 8.
• Combination Therapy: GLP-1 receptor agonists can be used in combination with other glucose-lowering agents, such as metformin, sulfonylureas, and basal insulin 5, 6, 7, 8.
• Patient Education: Patients should be educated on the proper use of GLP-1 receptor agonist therapy, including injection techniques and potential adverse events 7, 8.