What is the recommended approach for counseling patients on Wegovy (semaglutide)?

Counseling Patients on Wegovy (Semaglutide 2.4 mg)

Patient Eligibility and Indication

Wegovy is indicated for chronic weight management in adults with BMI ≥30 kg/m² or BMI ≥27 kg/m² with at least one weight-related comorbidity (type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea, or cardiovascular disease), used as an adjunct to reduced-calorie diet and increased physical activity. 1

Mandatory Pre-Treatment Screening

Before initiating Wegovy, you must screen for and counsel patients about:

• Personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) - these are absolute contraindications 2, 1, 3
• Pregnancy status - Wegovy is contraindicated in pregnancy; reliable contraception is required during treatment 1, 3
• Baseline renal function (eGFR/creatinine) and hepatic function 1
• Lipid panel and hemoglobin A1c if the patient has dyslipidemia or diabetes 1
• Recent eye examination if the patient has diabetes, especially those with proliferative retinopathy or diabetes duration ≥10 years 2

Dosing Protocol and Titration Schedule

Start with 0.25 mg subcutaneously once weekly and gradually escalate to minimize gastrointestinal side effects, reaching the maintenance dose of 2.4 mg once weekly. 1 The slow titration schedule (increasing every 4 weeks) is critical to reduce nausea and vomiting 2.

• If a dose is missed, administer within 5 days; if >5 days have passed, skip and resume regular weekly schedule 3
• If treatment is suspended and restarted, begin again at the lowest dose with gradual up-titration 2

Expected Weight Loss Outcomes

Counsel patients on realistic expectations:

• Mean weight loss of 14.9-17.4% at 68 weeks in patients without diabetes 4
• 69-79% of patients achieve ≥10% weight loss (vs. 12-27% with placebo) 4
• 51-64% achieve ≥15% weight loss (vs. 5-13% with placebo) 4
• Weight loss continues through 24 months with sustained treatment 5
• Weight regain occurs after discontinuation - patients regained 11.6% of lost weight within 52 weeks of stopping 2

Gastrointestinal Side Effects Management

Transient nausea and vomiting are the most common side effects and can be minimized through slow dose titration, eating smaller portions, and dietary modifications. 2

Specific counseling points:

• Reduce meal size and practice mindful eating (stop when full) 2
• Decrease intake of high-fat or spicy foods 2
• GI side effects are usually self-limited and do not indicate pathology 2
• Consider slower dose titration if experiencing significant GI challenges 2

Critical Safety Warnings

Thyroid C-Cell Tumors

Counsel patients to report symptoms of thyroid tumors immediately: neck lump, hoarseness, difficulty swallowing, or shortness of breath. 3 Semaglutide causes thyroid C-cell tumors in rodents; human relevance is unknown 3.

Pancreatitis

Instruct patients to discontinue Wegovy immediately and contact you if they develop severe abdominal pain that may radiate to the back, with or without vomiting. 3 Do not restart if pancreatitis is confirmed 2.

Dehydration and Renal Impairment

Advise patients to monitor for signs of volume depletion (orthostatic lightheadedness) and maintain adequate hydration, especially during illness. 3 GI side effects can lead to dehydration and acute kidney injury 1. Monitor renal function closely in patients with pre-existing renal disease 1.

Diabetic Retinopathy Complications

Patients with diabetes should report any vision changes immediately. 3 Diabetic retinopathy complications were reported with semaglutide, particularly in patients with prior proliferative retinopathy, possibly due to rapid glucose improvement 2.

Hypoglycemia Risk

Reduce doses of insulin or insulin secretagogues (sulfonylureas, glinides) when initiating Wegovy to minimize hypoglycemia risk. 1, 2 The hypoglycemia risk increases when combined with these medications 2.

Contraindications and Cautions

Absolute contraindications 2, 1:

• Personal or family history of MTC or MEN 2
• Pregnancy or breastfeeding
• History of serious hypersensitivity to semaglutide

Use caution in 2:

• Gastroparesis - not recommended in clinically significant gastroparesis 2
• Prior gastric surgery including bariatric surgery 2
• Patients taking oral medications with narrow therapeutic index (e.g., warfarin) - monitor closely due to delayed gastric emptying 1

Monitoring Schedule

Assess efficacy monthly for the first 3 months, then at least quarterly thereafter. 1

• Consider discontinuation if <5% weight loss after 3-4 months at the maximally tolerated dose 1
• However, some patients may not show maximal benefit until after 6-12 months on the maximum dose 2
• Monitor blood pressure and heart rate in patients with cardiovascular disease 1
• Monitor renal function, especially in the first several weeks after initiation 2

Lifestyle Intervention Requirements

Wegovy must be used in conjunction with reduced-calorie diet and increased physical activity (goal 150-200 minutes/week). 2, 1 Emphasize that medication alone is insufficient - lifestyle modifications are mandatory for optimal outcomes 2.

Pen Sharing Warning

Counsel patients never to share their Wegovy pen with another person, even if the needle is changed, due to risk of blood-borne pathogen transmission. 3

Long-Term Treatment Expectations

Counsel patients that Wegovy likely needs to be used lifelong for sustained weight management. 2 Weight regain occurs after discontinuation, and obesity is a chronic disease requiring ongoing treatment 2.

Special Populations

Patients with Type 2 Diabetes

Prioritize semaglutide over other anti-obesity medications in patients with type 2 diabetes due to added cardiometabolic benefits. 1 Semaglutide reduces major adverse cardiovascular events (MACE) in patients with type 2 diabetes and established cardiovascular disease 2, 3.

Patients with Cardiovascular Disease

In patients with chronic coronary syndrome, overweight/obesity (BMI >27 kg/m²), and without diabetes, semaglutide should be considered to reduce cardiovascular mortality, MI, or stroke. 2

Patients with Renal Impairment

No dose adjustment is required for renal impairment 2, 1, but use caution when initiating or escalating doses due to potential acute kidney injury risk from dehydration 1.