Is Ozempic (semaglutide) safe for patients with achalasia?

Safety of Ozempic (Semaglutide) in Patients with Achalasia

Ozempic (semaglutide) should be used with caution in patients with achalasia due to its mechanism of action that delays gastric emptying, which could potentially worsen esophageal emptying problems in these patients.

Understanding Achalasia and GLP-1 RA Effects

Achalasia is a primary esophageal motility disorder characterized by:

• Impaired lower esophageal sphincter (LES) relaxation
• Aperistalsis of the esophageal body
• Functional loss of ganglion cells in the myenteric plexus 1
• Progressive dysphagia to both solids and liquids
• Regurgitation of undigested food

Ozempic (semaglutide) is a GLP-1 receptor agonist that:

• Slows gastric emptying
• Promotes satiety
• May potentially exacerbate symptoms in patients with pre-existing upper GI motility disorders

Potential Concerns for Achalasia Patients

Physiological Considerations

1. Worsening of esophageal emptying: Semaglutide's effect on delaying gastric emptying could potentially worsen the already compromised esophageal emptying in achalasia patients.

2. Increased risk of regurgitation: Patients with achalasia already experience regurgitation; adding a medication that further slows gastric emptying may increase this risk.

3. Aspiration risk: The combination of impaired esophageal emptying and delayed gastric emptying could potentially increase the risk of aspiration pneumonia.

Clinical Decision-Making Algorithm

1. Assess achalasia severity and control:

   • Well-controlled achalasia with minimal symptoms after successful treatment (POEM, LHM, or pneumatic dilation)
   • Poorly controlled with persistent symptoms
   • Presence of megaesophagus or sigmoid esophagus

2. Evaluate treatment options:

   • For well-controlled achalasia: Consider Ozempic with close monitoring
   • For poorly controlled achalasia: Consider alternative weight management options
   • For severe anatomical changes: Avoid Ozempic

3. Monitoring plan if Ozempic is used:

   • Regular assessment of dysphagia symptoms
   • Monitoring for increased regurgitation
   • Vigilance for signs of aspiration

Treatment Considerations for Achalasia Patients

The American Gastroenterological Association recommends several treatment options for achalasia that should be optimized before considering medications that could affect GI motility 1, 2:

• Peroral Endoscopic Myotomy (POEM): Highly effective with >90% success rate, particularly beneficial for type III achalasia 1, 2
• Laparoscopic Heller Myotomy (LHM): 84-94% success rate with lower post-procedure reflux 2
• Pneumatic Dilation: Effective non-surgical option with 90% first-year success 2

Special Considerations and Monitoring

If Ozempic is deemed necessary for a patient with well-controlled achalasia:

• Start with the lowest possible dose and titrate slowly
• Schedule more frequent follow-up visits during dose escalation
• Educate the patient about warning signs that would warrant discontinuation
• Consider pH monitoring and endoscopic evaluation before and during treatment
• Be vigilant for post-POEM reflux, which occurs in 41-65% of patients and could be exacerbated 1

Conclusion

While no absolute contraindication exists in current guidelines specifically addressing GLP-1 RAs in achalasia, the physiological effects of these medications warrant caution. For patients with well-controlled achalasia who have a strong indication for GLP-1 RA therapy, careful monitoring and dose adjustment may allow safe use. However, for those with poorly controlled symptoms or severe anatomical changes, alternative weight management strategies should be considered.