What is the recommended starting dose and treatment plan for GLP-1 (Glucagon-like peptide-1) agonist therapy, such as liraglutide (Victoza) or semaglutide (Ozempic)?

GLP-1 Agonist Starting Dose and Treatment Plan

For GLP-1 agonist therapy, start with the lowest dose and gradually titrate up to minimize gastrointestinal side effects, following specific dose escalation schedules for each medication.

Recommended Starting Doses and Titration

Liraglutide (Victoza/Saxenda):

• Starting dose: 0.6 mg subcutaneously once daily for 7 days 1, 2
• Titration schedule:
  • Week 2: Increase to 1.2 mg daily
  • Week 3: Increase to 1.8 mg daily
  • Week 4: Increase to 2.4 mg daily
  • Week 5: Increase to maintenance dose of 3.0 mg daily 2

Semaglutide (Ozempic/Wegovy):

• Starting dose: 0.25 mg subcutaneously once weekly for 4 weeks 3, 2
• Titration schedule:
  • Weeks 5-8: Increase to 0.5 mg weekly
  • Weeks 9-12: Increase to 1.0 mg weekly
  • Weeks 13-16: Increase to 1.7 mg weekly
  • Week 17 onwards: Maintenance dose of 2.4 mg weekly 2, 3

Administration Guidelines

• Inject subcutaneously in abdomen, thigh, or upper arm
• Can be administered at any time of day, with or without meals
• Maintain consistent weekly schedule (same day each week) for once-weekly formulations 3, 1
• No dose adjustment required for mild-to-moderate renal impairment 2

Monitoring and Adjustments

Before Starting:

• Assess for contraindications:
  • Personal/family history of medullary thyroid carcinoma or MEN2
  • History of pancreatitis
  • Severe gastroparesis 2, 3, 1

During Treatment:

• If patient has type 2 diabetes:

  • Monitor blood glucose more closely during first 4 weeks of therapy
  • If well-controlled A1C at baseline, reduce sulfonylurea dose by 50% or basal insulin by 20% 2
  • Discontinue DPP-4 inhibitors before starting GLP-1 agonists 2

• Monitor for adverse effects:

  • Nausea, vomiting, diarrhea (most common, usually transient)
  • If persistent GI side effects, consider slowing titration schedule 2

Special Considerations

Renal Function:

• Dulaglutide, liraglutide, and semaglutide: No dose adjustment required for any level of renal function
• Exenatide: Not recommended with eGFR <30 ml/min/1.73 m²
• Lixisenatide: Not recommended with eGFR <15 ml/min/1.73 m² 2

Missed Doses:

• If 1-2 consecutive doses missed: Resume at same dose if well-tolerated
• If 3+ consecutive doses missed: Consider restarting titration schedule 2

Common Pitfalls to Avoid

1. Rapid dose escalation: Titrating too quickly increases risk of GI side effects; follow recommended schedule 2, 4

2. Combining with DPP-4 inhibitors: Do not use GLP-1 agonists concurrently with DPP-4 inhibitors 2

3. Ignoring hypoglycemia risk: While GLP-1 agonists have low intrinsic hypoglycemia risk, combination with insulin or sulfonylureas increases this risk 2

4. Overlooking eye examinations: For patients starting semaglutide, ensure appropriate eye examination if not done within past 12 months due to potential risk of diabetic retinopathy complications 2

5. Inadequate patient education: Patients should be informed about:

   • Expected GI side effects (typically improving over time)
   • Proper injection technique
   • Need to report severe abdominal pain (potential pancreatitis)
   • Potential weight loss effects 2, 5

By following these specific dosing recommendations and monitoring guidelines, you can optimize the safety and efficacy of GLP-1 agonist therapy while minimizing adverse effects.