What are the implications of starting Ozempic (semaglutide) on a patient with a blood pressure of 120/80 mmHg being considered normal, this patient has 100/70 mmHg?

Blood Pressure Management for Patient Starting Ozempic with BP 100/70 mmHg

Patients with a blood pressure of 100/70 mmHg should be monitored closely when starting Ozempic (semaglutide) due to potential hypotension risk, and may require adjustment or discontinuation of existing antihypertensive medications if symptomatic hypotension develops.

Assessment of Current Blood Pressure Status

According to the 2024 ESC Guidelines for the Management of Elevated Blood Pressure and Hypertension, a blood pressure of 100/70 mmHg is classified as "non-elevated BP" (<120/70 mmHg) 1. This BP is already at the lower end of the normal range, which warrants careful consideration when starting medications that may further lower blood pressure.

Semaglutide (Ozempic) and Blood Pressure Effects

Semaglutide has been shown to have blood pressure-lowering effects:

• GLP-1 receptor agonists like semaglutide can reduce systolic blood pressure by approximately 2-6 mmHg 2
• This effect is generally beneficial for patients with hypertension but may pose risks for those with already low or normal blood pressure
• The blood pressure reduction is thought to be related to weight loss and direct vascular effects of the medication

Management Approach

Immediate Considerations

1. Baseline Assessment:

   • Document current blood pressure (100/70 mmHg)
   • Check for symptoms of hypotension (dizziness, lightheadedness, fatigue)
   • Review current antihypertensive medications if any

2. Patient Education:

   • Inform patient about potential BP-lowering effects of Ozempic
   • Teach patient to recognize symptoms of hypotension
   • Instruct on home BP monitoring, particularly during the first few weeks of treatment

Monitoring Protocol

1. Blood Pressure Monitoring:

   • Measure BP in both sitting and standing positions to assess for orthostatic hypotension 3
   • Schedule follow-up within 1-2 weeks of starting Ozempic
   • Recommend home BP monitoring with documentation

2. Symptom Assessment:

   • Evaluate for symptoms of hypotension at each visit
   • Pay particular attention if BP drops below 90/60 mmHg

Management of Antihypertensive Medications (if applicable)

1. If patient is currently on antihypertensive medications:

   • Consider reducing or temporarily discontinuing antihypertensive medications, especially if:
     • BP drops below 90/60 mmHg
     • Patient develops symptomatic hypotension
     • Orthostatic hypotension occurs (drop >20 mmHg systolic upon standing)

2. Prioritization for medication adjustment (if needed):

   • First: Reduce diuretics (most likely to cause symptomatic hypotension)
   • Second: Adjust calcium channel blockers or beta-blockers
   • Third: Consider reducing ACE inhibitors or ARBs (particularly if used for hypertension rather than for kidney protection in diabetes)

Special Considerations

For Diabetic Patients

• While ACE inhibitors or ARBs are recommended for diabetic patients 1, the priority should be maintaining adequate BP without symptomatic hypotension
• If BP remains consistently below 100/70 mmHg with Ozempic, consider reducing antihypertensive medications while maintaining ACE inhibitor/ARB at lowest effective dose

For Elderly Patients

• Elderly patients (≥65 years) are at higher risk for orthostatic hypotension
• More gradual dose titration of Ozempic may be warranted
• Consider a more conservative approach to BP management (avoiding BP <110/70 mmHg) 1

For Patients with History of Cardiovascular Disease

• While BP reduction may be beneficial for cardiovascular outcomes, symptomatic hypotension can increase fall risk and reduce organ perfusion
• Balance cardiovascular benefits against risks of hypotension

Pitfalls and Caveats

1. Dehydration Risk:

   • Gastrointestinal side effects of semaglutide (nausea, vomiting, diarrhea) may lead to dehydration and worsen hypotension 4
   • Ensure adequate fluid intake, especially during initial weeks of therapy

2. Medication Timing:

   • Consider administering antihypertensive medications (if any) at a different time of day from Ozempic to minimize additive hypotensive effects

3. Avoid Overtreatment:

   • Remember that a BP of 100/70 mmHg is already at the lower end of normal range
   • The goal is not to lower BP further but to prevent significant hypotension while achieving metabolic benefits of semaglutide

4. Drug Interactions:

   • Monitor for potential interactions between Ozempic and other medications that may affect BP

By following these guidelines, clinicians can safely initiate Ozempic therapy in patients with lower baseline blood pressure while minimizing the risk of symptomatic hypotension.