What is the recommended Body Mass Index (BMI) for initiating Ozempic (semaglutide) or Wegovy (semaglutide) therapy?

BMI Requirements for Initiating Ozempic/Wegovy (Semaglutide)

For Wegovy (semaglutide 2.4mg), initiation is recommended for patients with a BMI ≥30 kg/m² or BMI ≥27 kg/m² with at least one weight-related comorbidity. 1

Eligibility Criteria by Medication Type

Wegovy (Semaglutide 2.4mg for Weight Management)

• BMI ≥30 kg/m² (obesity) OR
• BMI ≥27 kg/m² with at least one weight-related comorbidity such as:
  • Hypertension
  • Type 2 diabetes
  • Dyslipidemia
  • Sleep apnea
  • Cardiovascular disease

Ozempic (Semaglutide for Diabetes)

• Primary indication is for type 2 diabetes management
• When used off-label for weight loss, the same BMI criteria as Wegovy are typically applied
• For patients with type 2 diabetes, weight management with semaglutide should be prioritized regardless of BMI 2

Regional Considerations

In South and Southeast Asian populations, different BMI thresholds may apply:

• Overweight defined as BMI ≥23 kg/m² in most countries 2
• Waist circumference criteria: ≥80 cm for women or ≥90 cm for men 2
• In Brunei Darussalam, overweight is defined as BMI ≥25 kg/m² 2

Clinical Recommendations for Initiation

1. Assess BMI and comorbidities:

   • Calculate current BMI
   • Document weight-related comorbidities
   • Consider waist circumference measurements, especially in Asian populations

2. Evaluate for contraindications:

   • Personal or family history of medullary thyroid cancer
   • Multiple endocrine neoplasia syndrome type 2
   • Pregnancy or planning pregnancy
   • History of pancreatitis or gallbladder disease 3

3. Titration protocol:

   • For Wegovy (weight management): Start at 0.25 mg weekly for 4 weeks, then increase to 0.5 mg, 1.0 mg, 1.7 mg, and finally 2.4 mg weekly at 4-week intervals 3
   • For Ozempic (diabetes management): Lower maximum doses typically used (up to 1 mg or 2 mg weekly)

Monitoring and Continuation Criteria

• Evaluate treatment efficacy after 16 weeks on the maintenance dose
• Continue therapy if ≥5% weight reduction is achieved from baseline 3
• Discontinue if <5% weight reduction after 16 weeks on the maintenance dose

Efficacy Expectations

• Semaglutide 2.4 mg produces mean weight loss of 14.9-16.0% at 68 weeks 3, 4
• In Asian populations, semaglutide 2.4 mg demonstrated 13.2% mean weight reduction 5
• Weight loss is typically accompanied by improvements in cardiometabolic risk factors 4

Common Pitfalls and Considerations

1. Failure to recognize appropriate candidates:

   • Not all patients with BMI ≥30 kg/m² or BMI ≥27 kg/m² with comorbidities are offered appropriate weight management pharmacotherapy

2. Inadequate titration:

   • Rapid titration increases gastrointestinal side effects
   • Follow the recommended gradual titration schedule to minimize adverse effects 3

3. Premature discontinuation:

   • Maximum weight loss benefits may not be seen until after 6 months of therapy
   • Continue treatment beyond reaching weight loss goals to maintain health benefits 2

4. Overlooking Asian-specific BMI thresholds:

   • Lower BMI thresholds (≥23 kg/m²) should be considered for Asian populations 2

5. Not addressing insurance coverage:

   • Cost can be prohibitive ($1,300-1,600 for a 30-day supply)
   • Insurance coverage may be limited 3

The American Gastroenterological Association strongly recommends adding pharmacological agents to lifestyle interventions for adults with obesity or overweight with weight-related complications who have had an inadequate response to lifestyle interventions alone 2.

Remember that GLP-1 receptor agonists are generally needed chronically, and sudden discontinuation often results in weight regain and worsening of cardiometabolic risk factors 2.