What are the management options for bradycardia as a side effect of Ozempic (semaglutide)?

Management of Bradycardia as a Side Effect of Ozempic (Semaglutide)

First-line treatment for symptomatic bradycardia associated with Ozempic is atropine 0.5 to 1 mg IV, which can be repeated every 3-5 minutes as needed up to a total dose of 1.5-3 mg.

Assessment and Initial Management

• Evaluate the severity of bradycardia and determine if it is causing symptoms (altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or other signs of shock) 1
• Monitor vital signs including heart rate, blood pressure, and oxygen saturation 1
• Obtain a 12-lead ECG to better define the rhythm 1
• Ensure adequate oxygenation if the patient shows signs of increased work of breathing 1
• Establish IV access for potential medication administration 1

Treatment Algorithm for Ozempic-Induced Bradycardia

For Asymptomatic Bradycardia:

• Most patients with bradycardia are asymptomatic and do not require acute therapy 1
• Consider temporary discontinuation of Ozempic if clinically appropriate 1
• Monitor the patient closely if Ozempic therapy needs to be continued 1

For Symptomatic Bradycardia:

1. First-line treatment:

   • Atropine 0.5-1 mg IV, may be repeated every 3-5 minutes to a maximum total dose of 3 mg 1
   • Atropine facilitates sinoatrial conduction and increases sinus node automaticity 1

2. If bradycardia is unresponsive to atropine:

   • Consider IV infusion of β-adrenergic agonists with rate-accelerating effects 1:
     • Dopamine: 2-10 μg/kg/min IV 1
     • Epinephrine: 2-10 μg/min IV or 0.1-0.5 μg/kg/min IV titrated to desired effect 1
     • Isoproterenol: 20-60 μg IV bolus followed by doses of 10-20 μg, or infusion of 1-20 μg/min based on heart rate response 1

3. For persistent symptomatic bradycardia:

   • Transcutaneous pacing (TCP) is reasonable in unstable patients who do not respond to atropine 1
   • If the patient does not respond to drugs or TCP, transvenous pacing may be indicated 1

Special Considerations

• Patients with heart transplantation should not receive atropine for bradycardia as it may cause paradoxical AV block 1

• Use caution when combining Ozempic with other medications that can cause bradycardia, such as:

  • Beta-blockers 2
  • Calcium channel blockers (verapamil, diltiazem) 1, 2
  • Anti-arrhythmic drugs (amiodarone, sotalol) 1

• Monitor for other potential drug interactions, particularly with medications that may affect heart rate 1

Prevention and Long-term Management

• Regular monitoring of heart rate and blood pressure in patients on Ozempic therapy 1
• Consider dose reduction of Ozempic if bradycardia persists but is not severe enough to warrant discontinuation 1
• For recurrent symptomatic bradycardia despite medical management, consultation with a cardiologist is recommended to evaluate the need for permanent pacing 1
• Weigh the benefits of continuing Ozempic therapy against the risks of bradycardia, especially in patients with pre-existing cardiovascular disease 1

Pitfalls and Caveats

• Do not use atropine in patients with heart transplantation without evidence of autonomic reinnervation 1
• Avoid medications that may worsen bradycardia (beta-blockers, digitalis, verapamil, or amiodarone) in patients with Ozempic-induced bradycardia 1
• Be aware that bradycardia may be a sign of other underlying conditions and not solely due to Ozempic 1
• Remember that treatment should be based on symptoms and hemodynamic stability rather than an arbitrary heart rate threshold 3