What assessment and education are needed for a patient interested in Glucagon-like peptide-1 (GLP1) receptor agonist therapy, such as liraglutide (Victoza) or semaglutide (Ozempic), for diabetes management?

Assessment Questions and Education for Patients Interested in GLP-1 Receptor Agonist Therapy

GLP-1 receptor agonists should be offered to patients with type 2 diabetes who have inadequate glycemic control, particularly those with established cardiovascular disease, high cardiovascular risk, or obesity, as these medications provide significant benefits for glycemic control, weight loss, and cardiovascular outcomes. 1

Initial Assessment Questions

Medical History Assessment

• Current diabetes control: HbA1c level and blood glucose patterns
• Duration of diabetes
• Current medications (especially metformin, insulin, or sulfonylureas)
• Presence of cardiovascular disease or risk factors
• Kidney function (eGFR)
• History of pancreatitis, gallbladder disease, or thyroid cancer
• Family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (MEN2)
• Gastrointestinal disorders (gastroparesis, inflammatory bowel disease)
• History of diabetic retinopathy
• Weight history and previous weight loss attempts

Lifestyle Assessment

• Current diet patterns and meal timing
• Physical activity level
• Alcohol consumption
• Smoking status
• Work schedule and daily routine (to assess medication administration feasibility)

Patient Goals and Preferences

• Primary goals for diabetes treatment (glycemic control, weight loss, reducing injection frequency)
• Preference for administration route (oral vs. injectable)
• Comfort level with self-injection
• Frequency preference (daily vs. weekly administration)
• Insurance coverage and affordability concerns

Patient Education Topics

Mechanism of Action

• Explain that GLP-1 receptor agonists mimic a natural hormone that:
  • Increases insulin release when blood sugar is high
  • Decreases glucagon (a hormone that raises blood sugar)
  • Slows stomach emptying
  • Increases feeling of fullness
  • Reduces appetite through brain signaling

Medication Options and Administration

• Available formulations:
  • Once-weekly injectable options: semaglutide (Ozempic), dulaglutide
  • Once-daily injectable options: liraglutide (Victoza)
  • Oral option: oral semaglutide
• Proper injection technique for injectable formulations
• Importance of proper storage (refrigeration before first use, room temperature after opening)
• Never sharing pens between patients, even with needle changes 2

Expected Benefits

• HbA1c reduction (typically 0.7-1.5%)
• Weight loss (typically 3-6 kg)
• Low risk of hypoglycemia when used alone
• Cardiovascular benefits (reduced risk of heart attack, stroke, and cardiovascular death) 2
• Potential kidney protection benefits 1, 3

Common Side Effects and Management

• Gastrointestinal effects:
  • Nausea, vomiting, diarrhea (usually transient and diminish over time)
  • Management strategies: starting with lowest dose, gradual titration, smaller meal portions
  • Typically improve within 4-8 weeks as the body adjusts
• Injection site reactions (for injectable formulations)
• Potential for mild dehydration due to GI effects

Serious Side Effects Requiring Medical Attention

• Symptoms of pancreatitis: persistent severe abdominal pain that may radiate to the back (with or without vomiting) 2
• Signs of thyroid tumors: lump in neck, hoarseness, trouble swallowing, shortness of breath 2
• Signs of allergic reactions: rash, swelling, difficulty breathing
• Symptoms of gallbladder disease
• Worsening of diabetic retinopathy in some patients

Dosing and Titration

• Explain the typical titration schedule:
  • For liraglutide: Start at 0.6 mg daily for one week, then increase to 1.2 mg, with potential increase to 1.8 mg 3
  • For semaglutide: Start at 0.25 mg weekly for 4 weeks, then 0.5 mg, with potential increase to 1.0 mg 3
• Importance of following the prescribed titration schedule to minimize side effects

Monitoring Requirements

• Regular blood glucose monitoring
• HbA1c testing every 3-6 months
• Kidney function monitoring every 3-6 months 3
• Weight monitoring
• Eye examinations for patients with existing retinopathy

Medication Interactions

• Potential need to reduce doses of insulin or sulfonylureas when adding GLP-1 RAs to minimize hypoglycemia risk 3
• Do not use with DPP-4 inhibitors 3
• Caution with medications that slow gastric emptying

Special Situations

• Missed dose instructions:
  • For daily medications: Take next dose as scheduled (don't double up)
  • For weekly medications: Take as soon as remembered if within 3-4 days, otherwise wait for next scheduled dose 2
• Surgery or procedures: Inform healthcare providers about GLP-1 RA use prior to procedures due to effects on gastric emptying 2
• Illness management: Maintaining hydration during illness is crucial due to risk of dehydration from GI effects

Follow-up Plan

• Schedule follow-up within 4 weeks of initiation to assess tolerability
• Regular monitoring of weight, blood glucose, and side effects
• HbA1c testing at 3 months to assess efficacy
• Discuss dose adjustments based on response and tolerability

Realistic Expectations

• Weight loss typically occurs gradually over 3-6 months
• Maximum glycemic effect usually seen within 3 months
• Some side effects are common initially but typically improve
• Importance of continuing healthy diet and exercise for optimal results

By thoroughly assessing patients and providing comprehensive education about GLP-1 receptor agonist therapy, healthcare providers can help ensure appropriate patient selection, set realistic expectations, and optimize treatment outcomes.