How to manage side effects of Ozempic (semaglutide)?

Managing Ozempic (Semaglutide) Side Effects

Start with slow dose titration (0.25 mg weekly for 4 weeks, then 0.5 mg, then 1 mg if needed) to minimize gastrointestinal side effects, which are the most common adverse events and typically transient. 1, 2

Gastrointestinal Side Effects (Most Common)

Initial Management Strategy

• Nausea, vomiting, diarrhea, constipation, and abdominal pain occur in the majority of patients but are typically dose-dependent and transient. 1, 2, 3
• Begin with 0.25 mg weekly for 4 weeks before escalating to minimize GI symptoms. 3
• If a patient tolerates a submaximal dose well and achieves adequate response, continue that dose long-term rather than escalating. 2

Specific GI Symptom Management

• For nausea and vomiting: Reduce meal size and avoid high-fat foods. 2
• For reflux symptoms: Limit alcohol and carbonated drinks. 2
• For constipation: Avoid high-fat diets and ensure adequate hydration. 2
• If more than 2 consecutive doses are missed but the patient previously tolerated the medication, resume at the same dose; if 3 or more doses are missed, restart the titration schedule. 2

When to Discontinue for GI Issues

• Discontinue if severe abdominal pain that won't resolve occurs, as this may indicate pancreatitis. 3
• Consider discontinuation if severe constipation, small bowel obstruction, or ileus progression develops. 1, 2

Serious Adverse Events Requiring Monitoring

Pancreatitis

• Stop semaglutide immediately if pancreatitis is suspected (severe, persistent abdominal pain radiating to the back with or without vomiting). 3
• Do not restart if pancreatitis is confirmed. 3
• Use caution in patients with a history of pancreatitis; consider alternative therapy. 2, 3

Acute Kidney Injury

• Monitor renal function closely when initiating or escalating doses, especially in patients with pre-existing kidney disease. 1, 2
• Dehydration from severe GI side effects (nausea, vomiting, diarrhea) can precipitate acute kidney injury. 3
• Ensure adequate fluid intake to prevent dehydration-related kidney injury. 3
• Unlike exenatide, semaglutide requires no dose adjustment for renal impairment but warrants careful monitoring for GI side effects that could lead to dehydration. 2

Gallbladder Disease

• Monitor for cholelithiasis (gallstones) and cholecystitis, which occur at increased rates. 1, 2
• Watch for right upper quadrant pain and nausea as warning signs. 4

Diabetic Retinopathy Complications

• Monitor patients with a history of diabetic retinopathy closely for progression, particularly if also treated with insulin. 2, 3
• The rapid improvement in glycemic control may temporarily worsen retinopathy. 3

Hypoglycemia Management

• Semaglutide has minimal intrinsic hypoglycemia risk when used alone due to glucose-dependent insulin secretion. 2
• When combined with insulin or sulfonylureas, reduce the dose of these medications to prevent hypoglycemia. 1, 3
• Educate patients on hypoglycemia symptoms: dizziness, shakiness, sweating, confusion, fast heartbeat, blurred vision. 3

Cardiovascular Monitoring

• Monitor for elevated heart rate, which is a common side effect. 1, 2
• If symptomatic cardiac arrhythmia or tachycardia occurs, consider monitoring and beta blockers. 2

Drug Interactions and Absorption Issues

• Semaglutide delays gastric emptying and may affect absorption of concomitantly administered oral medications. 2, 3
• Pay particular attention to medications with narrow therapeutic indices (e.g., warfarin). 2
• For patients using oral hormonal contraceptives, switch to non-oral contraception or add barrier method for 4 weeks after initiation and each dose escalation. 2

Monitoring Schedule

• Assess efficacy and safety at least monthly for the first 3 months, then at least quarterly thereafter. 1
• Monitor renal function, especially with severe GI symptoms. 1, 2
• Check for signs of gallbladder disease periodically. 1, 2
• Monitor blood glucose regularly and adjust concomitant diabetes medications as needed. 3

Absolute Contraindications

• Personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). 2, 3
• Pregnancy or breastfeeding; discontinue at least 2 months before planned pregnancy due to long washout period. 2, 3
• Known hypersensitivity to semaglutide or any product components. 3

Special Populations Requiring Caution

• Patients with clinically meaningful gastroparesis should avoid semaglutide as it delays gastric emptying and may worsen symptoms. 2
• Patients with severe renal impairment require careful monitoring but no dose adjustment is needed. 1, 2
• Patients with prior gastric or bariatric surgery require careful consideration. 2

Common Pitfalls to Avoid

• Do not escalate doses too rapidly; this is the primary cause of intolerable GI side effects. 1, 2
• Do not share pens between patients even if needle is changed due to infection risk. 3
• Do not mix semaglutide and insulin in the same injection. 3
• Do not discontinue prematurely for mild-to-moderate GI symptoms; these typically resolve with continued use. 2, 5