Are kidney stones a contraindication to Ozempic (semaglutide)?

Kidney Stones Are Not a Contraindication to Ozempic (Semaglutide)

Kidney stones are not listed as a contraindication to semaglutide (Ozempic) in current diabetes management guidelines, and you can safely prescribe this medication to patients with a history of nephrolithiasis. 1

Evidence from Diabetes Guidelines

The 2025 American Diabetes Association Standards of Care explicitly addresses semaglutide's use across various patient populations and does not list kidney stones as a contraindication or precaution. 1 The guideline focuses on other considerations such as:

• Thyroid C-cell tumors (identified in rodents; human relevance undetermined)
• Pancreatitis risk (discontinue if suspected)
• Biliary disease (evaluate for gallbladder disease if symptoms develop)
• Gastroparesis (not recommended in these patients)

Notably absent from this comprehensive list is any mention of kidney stones as a contraindication. 1

Kidney Safety Profile of Semaglutide

The renal safety data for semaglutide is actually reassuring:

• Initial eGFR decline is transient: Semaglutide causes an early decline in eGFR (approximately 1-3 mL/min/1.73 m² by week 12-16) that plateaus and does not progress further. 2

• Long-term kidney function remains stable: In the SUSTAIN 6 cardiovascular outcomes trial, overall eGFR decline over 104 weeks was similar between semaglutide and placebo (estimated treatment difference 0.07 to 0.97 mL/min/1.73 m²). 2

• Albuminuria reduction: Semaglutide significantly reduces urinary albumin-to-creatinine ratio by 25-34% compared to placebo, which is nephroprotective. 2, 3

• Safe in advanced CKD: Real-world data demonstrates safety in patients with eGFR as low as 50 mL/min/1.73 m², with stable kidney function over 12 months. 3

Distinguishing Kidney Stones from Other Renal Concerns

It's critical to differentiate kidney stones from conditions that DO require caution with semaglutide:

• Acute kidney injury from volume depletion: If patients develop severe gastrointestinal side effects (nausea, vomiting, diarrhea) leading to dehydration, this can precipitate acute kidney injury. 4 Monitor kidney function if significant GI symptoms occur and ensure adequate hydration.

• Pre-existing moderate-to-severe CKD: While not a contraindication, patients with eGFR <45 mL/min/1.73 m² have limited kidney reserve. 4 The initial eGFR decline with semaglutide is more concerning in this population, though data shows overall safety. 2, 5

Contrast with Medications That DO Increase Stone Risk

Unlike semaglutide, certain other diabetes and obesity medications carry genuine stone-related concerns:

• Topiramate (component of phentermine-topiramate ER): Has carbonic anhydrase inhibitor properties causing metabolic acidosis, elevated urine pH, hypercalciuria, and hypocitraturia—all of which increase kidney stone risk with prolonged exposure. 1 The AGA guideline specifically states "caution is advised in patients with a history of significant nephrolithiasis" for this medication. 1

Semaglutide has no such mechanism and does not alter urinary chemistry in ways that promote stone formation.

Practical Management Approach

For patients with a history of kidney stones:

1. Prescribe semaglutide without hesitation if otherwise indicated for diabetes or weight management. 1

2. Emphasize hydration counseling: The primary stone prevention strategy is maintaining high fluid intake (sufficient to produce >2 liters of urine daily). 1 This is particularly important given semaglutide's GI side effects may reduce oral intake.

3. Monitor for GI side effects: If patients develop significant nausea, vomiting, or diarrhea, check kidney function to detect volume depletion-related AKI early. 4 Discontinue temporarily if AKI develops.

4. Continue standard stone prevention measures: Patients with recurrent stones should maintain their usual metabolic evaluation and preventive therapy (dietary sodium restriction, thiazides, citrate, etc. as indicated). 1 Semaglutide does not interfere with these interventions.

5. Baseline and follow-up kidney function: Obtain baseline eGFR and repeat at 3-6 months to document the expected early decline and subsequent stabilization. 2

Common Pitfall to Avoid

Do not confuse the kidney donor evaluation guidelines with medication prescribing decisions. The evidence provided about kidney stone contraindications in living kidney donors 1 is irrelevant to this clinical question—those guidelines address surgical risk assessment for nephrectomy, not pharmacotherapy safety. Active or recurrent nephrolithiasis may contraindicate kidney donation due to concerns about stone recurrence in a solitary kidney, but this has no bearing on whether a patient with two functioning kidneys can safely take semaglutide.