What patient education is necessary when considering a Glucagon-like peptide-1 (GLP-1) receptor agonist, such as liraglutide (Victoza) or semaglutide (Ozempic), for weight loss?

Patient Education for GLP-1 Receptor Agonists for Weight Loss

Critical Safety Information

Patients must be counseled that GLP-1 receptor agonists are contraindicated if they or any family member have ever had medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2), as these medications caused thyroid C-cell tumors in animal studies. 1

• Instruct patients to immediately report any neck lump, hoarseness, difficulty swallowing, or shortness of breath, as these may indicate thyroid cancer 1

Medication Administration and Dosing

GLP-1 receptor agonists require gradual dose escalation over 16 weeks to minimize gastrointestinal side effects. 2, 3

Semaglutide (Wegovy) Titration Schedule:

• Start at 0.25 mg weekly for 4 weeks 2, 3
• Increase to 0.5 mg weekly for 4 weeks 2, 3
• Increase to 1.0 mg weekly for 4 weeks 2, 3
• Increase to 1.7 mg weekly for 4 weeks 2, 3
• Reach maintenance dose of 2.4 mg weekly after 16 weeks 2, 3

Liraglutide (Saxenda) Titration Schedule:

• Start at 0.6 mg daily for 7 days 2
• Increase to 1.2 mg daily for 7 days 2
• Increase to 1.8 mg daily for 7 days 2
• Increase to 2.4 mg daily for 7 days 2
• Reach maintenance dose of 3.0 mg daily after 4 weeks 2

Injection Technique:

• Administer subcutaneously in the abdomen, thigh, or upper arm 1
• Rotate injection sites with each dose to prevent lumps under the skin 1
• Can be given at any time of day, with or without food 1
• Never share pens with others, even if the needle is changed, due to infection risk 1

Expected Weight Loss Outcomes

Patients should understand that semaglutide 2.4 mg produces approximately 14.9% total body weight loss over 68 weeks, while tirzepatide achieves superior weight loss of 20.9% at 72 weeks. 3

• Weight loss is greater in patients without diabetes (6.1-17.4%) compared to those with diabetes (4-6.2%) 3
• These medications must be used lifelong, as significant weight regain (11.6% of lost weight) occurs after cessation 3
• Medications must be combined with reduced-calorie diet and increased physical activity for optimal results 3

Common Side Effects and Management

Gastrointestinal side effects—particularly nausea, vomiting, diarrhea, and constipation—are the most common adverse effects and typically diminish over time. 2, 3, 1

Strategies to Minimize GI Side Effects:

• Slow dose titration is essential for tolerability 2, 3
• Reduce meal size and avoid high-fat foods 3
• Limit alcohol and carbonated beverages 3
• These symptoms are usually mild-to-moderate and decrease with continued use 3

Serious Risks Requiring Immediate Medical Attention

Patients must seek immediate care for persistent severe abdominal pain, which may indicate pancreatitis. 1

• The pain may radiate to the back and may occur with or without vomiting 1
• Discontinue medication immediately and contact physician if this occurs 1

Patients should report symptoms of gallbladder disease, including right upper abdominal pain, fever, or jaundice. 3, 1

• GLP-1 receptor agonists increase risk of cholelithiasis and cholecystitis 3, 1

Hypoglycemia Risk and Monitoring

The risk of low blood sugar is minimal when GLP-1 receptor agonists are used alone, but increases significantly when combined with insulin or sulfonylureas. 2, 1

• Patients taking insulin or sulfonylureas may require dose reductions of these medications 2
• Educate patients on hypoglycemia symptoms: shakiness, sweating, confusion, rapid heartbeat 1
• Glucose-dependent mechanism means very low hypoglycemia risk as monotherapy 2, 3

Surgical and Procedural Considerations

Patients must inform all healthcare providers—especially anesthesiologists—that they are taking a GLP-1 receptor agonist before any surgery or procedure requiring anesthesia. 3, 1

• These medications delay gastric emptying, increasing aspiration risk during anesthesia 3, 1
• Retained gastric contents have been documented even after extended fasting periods 3
• Specific perioperative management protocols may be required 3

Missed Dose Instructions

If a dose is missed, patients should take the next scheduled dose—never double up to make up for a missed dose. 1

For Semaglutide:

• If 2 consecutive doses are missed, resume at the same dose if previously well-tolerated 2
• If 3 or more consecutive doses are missed, restart the titration schedule 2

For Liraglutide:

• If more than 3 days have elapsed since the last dose, reinitiate at 0.6 mg to minimize GI symptoms 1
• Retitrate gradually at physician's discretion 1

Drug Interactions and Precautions

GLP-1 receptor agonists should never be used with other GLP-1 receptor agonists or DPP-4 inhibitors. 2

• Delayed gastric emptying may affect absorption of oral medications requiring rapid onset 2
• Women using oral contraceptives should switch to non-oral methods or add barrier contraception for 4 weeks after initiation and each dose escalation (particularly with tirzepatide) 3

Dehydration Prevention

Patients must maintain adequate hydration, especially during the initial weeks when nausea and vomiting are most common. 1

• Dehydration can lead to acute kidney injury, potentially requiring dialysis 1
• Take precautions to avoid fluid depletion during GI side effects 1

Cardiovascular Benefits

Beyond weight loss, semaglutide reduces risk of cardiovascular death, heart attack, and stroke by 20% in patients with established cardiovascular disease and obesity. 3

• This represents an additional benefit beyond glycemic control and weight reduction 3
• Blood pressure often improves with weight loss, potentially requiring adjustment of antihypertensive medications 3

Monitoring Requirements

Patients should be evaluated at least every 3 months for weight loss progress, side effects, and medication adherence. 3

• Monitor for signs of pancreatitis, gallbladder disease, and dehydration 3, 1
• Blood pressure monitoring is important as antihypertensive needs may decrease 3
• Efficacy should be assessed at 12-16 weeks on maximum tolerated dose 3

Realistic Expectations and Long-Term Commitment

Patients must understand these medications require lifelong use and work best when combined with lifestyle modifications. 3

• Resistance training should be incorporated to preserve lean body mass 3
• Diet and exercise remain essential components of treatment 3
• Early response at 1 month may predict long-term efficacy 4
• Some patients achieve adequate response at submaximal doses and can continue that dose long-term 2