What counseling should be provided to patients with type 2 diabetes or obesity before initiating Ozempic (semaglutide) therapy?

Counseling Patients About Ozempic (Semaglutide)

Critical Pre-Treatment Screening

Before initiating Ozempic, you must absolutely screen for personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2), as these are absolute contraindications. 1

Required Medical History Assessment

• Screen for thyroid disease history: Ask specifically about any thyroid nodules, thyroid cancer (especially medullary type), or family members with thyroid cancer 1
• Assess pancreatic history: Document any history of pancreatitis, as Ozempic has not been studied in patients with prior pancreatitis and alternative therapies should be considered 1
• Evaluate diabetic retinopathy: Patients with existing diabetic retinopathy require careful monitoring, particularly if also on insulin, as rapid glucose improvement may temporarily worsen retinopathy 2, 3
• Check kidney function: Obtain baseline serum creatinine and eGFR, as gastrointestinal side effects can cause dehydration leading to acute kidney injury 1
• Review current medications: Identify if patient is taking sulfonylureas or insulin, as these increase hypoglycemia risk and will require dose reduction 2

Essential Baseline Laboratory Tests

• Obtain HbA1c to establish baseline glycemic control 4
• Check comprehensive metabolic panel including renal function 4
• Measure lipid panel (total cholesterol, LDL, HDL, triglycerides) 4
• Consider thyroid function tests (TSH, T3, T4) if clinically indicated 4
• Note: While calcitonin, pancreatic lipase, and amylase are not routinely required, consider them if clinical suspicion exists 4

Medication Administration Instructions

Ozempic must be injected subcutaneously once weekly on the same day each week, at any time of day, with or without meals. 1

Injection Technique

• Inject into abdomen, thigh, or upper arm - rotate injection sites each week within the same body region 1
• Never inject into muscle or vein - subcutaneous administration only 1
• If using insulin concurrently: Administer as separate injections, never mix together, though both can be given in the same body region if not adjacent 1
• Inspect medication before use: Solution should be clear and colorless; do not use if particulate matter or discoloration is present 1

Dosing Schedule

• Week 1-4: Start with 0.25 mg once weekly (this dose is for treatment initiation only and not effective for glycemic control) 1
• Week 5+: Increase to 0.5 mg once weekly 1
• If additional control needed: After at least 4 weeks on 0.5 mg, may increase to 1 mg once weekly (maximum approved dose for diabetes) 1

Missed Dose Protocol

• If missed dose is within 5 days: Take as soon as possible, then resume regular weekly schedule 1
• If more than 5 days have passed: Skip the missed dose entirely and take next dose on regularly scheduled day 1
• Changing injection day: Allowed if at least 2 days (48 hours) have passed since last dose 1

Expected Benefits and Timeline

Patients should expect gradual improvements in blood sugar control over 4-8 weeks, with weight loss typically becoming noticeable after 8-12 weeks. 2, 5

Glycemic Control

• HbA1c reduction: Expect approximately 1.4-1.5% reduction from baseline 2, 5
• Fasting glucose improvement: Noticeable within first month of therapy 2
• Monitor blood glucose: Check as directed by provider, especially if on insulin or sulfonylureas 1

Weight Loss

• Average weight loss: Approximately 7% of body weight with 1 mg dose in diabetic patients 5
• Timeline: Weight loss becomes apparent after 8-12 weeks, continues for up to 68 weeks 5
• Lifestyle requirement: Must be combined with reduced-calorie diet and increased physical activity 5, 1

Cardiovascular Protection

• For patients with established cardiovascular disease: Ozempic reduces risk of cardiovascular death, nonfatal heart attack, or nonfatal stroke by 26% 2, 5
• This benefit is independent of glucose lowering and weight loss 5

Managing Common Side Effects

Gastrointestinal side effects (nausea, vomiting, diarrhea) are the most common adverse effects, typically mild-to-moderate, and usually improve over time. 2, 3

Nausea Management Strategies

• Start with small meal portions: Eat smaller, more frequent meals rather than large meals 2, 6
• Slow dose titration: The gradual 4-week titration schedule helps minimize nausea 2, 6
• Avoid trigger foods: Limit high-fat, fried, or spicy foods; avoid alcohol and carbonated beverages 2, 6
• Timing considerations: Nausea typically peaks 1-3 days after injection and improves as week progresses 6
• Most patients experience improvement: Gastrointestinal symptoms are usually transient and decrease over time 2, 3

Preventing Dehydration

• Drink adequate fluids: Maintain hydration to prevent kidney problems, especially if experiencing diarrhea or vomiting 1
• Watch for dehydration symptoms: Lightheadedness, orthostasis, weakness 2
• May need diuretic adjustment: If on diuretics and experiencing dehydration symptoms, contact provider 2

Critical Warning Signs Requiring Immediate Medical Attention

Stop Ozempic immediately and seek emergency care if you experience severe abdominal pain that won't go away, with or without vomiting, as this may indicate pancreatitis. 1

Pancreatitis Warning Signs

• Severe, persistent abdominal pain radiating to the back 1
• Nausea and vomiting accompanying severe pain 1
• Stop medication immediately and contact healthcare provider 1

Thyroid Tumor Symptoms

• Mass or lump in the neck 1
• Difficulty swallowing (dysphagia) 1
• Difficulty breathing (dyspnea) 1
• Persistent hoarseness 1

Allergic Reaction Signs

• Severe itching or rash 1
• Difficulty breathing 1
• Stop medication and seek immediate medical help 1

Hypoglycemia Recognition (If on Insulin or Sulfonylureas)

• Symptoms include: Shakiness, sweating, confusion, dizziness, blurred vision, fast heartbeat, headache, slurred speech 1
• Treatment: Consume 15-20 grams of fast-acting carbohydrates immediately 2
• Prevention: Your insulin or sulfonylurea dose will likely need reduction by approximately 20% when starting Ozempic 2

Medication Interactions and Adjustments

If you are taking insulin or sulfonylureas, your doses will need to be reduced by approximately 20% when starting Ozempic to prevent hypoglycemia. 2

Concurrent Diabetes Medications

• Discontinue DPP-4 inhibitors (sitagliptin, linagliptin) before starting Ozempic 2
• Reduce or stop sulfonylureas: Consider discontinuing entirely or reducing dose significantly 2
• Reduce insulin by ~20%: Particularly total daily insulin dose 2
• Monitor glucose closely: Check blood sugar more frequently for first 4 weeks 2

Oral Medication Timing

• Ozempic delays gastric emptying: May affect absorption of oral medications 2
• No specific timing restrictions: Can take other oral medications at usual times 7
• For oral contraceptives: Consider switching to non-oral methods or adding barrier contraception for 4 weeks after initiation and each dose escalation 5

Lifestyle Modifications Required

Ozempic must be used in conjunction with a reduced-calorie diet and increased physical activity - medication alone is insufficient. 5, 1

Dietary Recommendations

• Reduce caloric intake: Aim for 500-calorie reduction below daily requirements 5
• Smaller, more frequent meals: Helps manage gastrointestinal side effects 2, 6
• Avoid high-fat foods: Particularly during dose titration phase 6

Physical Activity Goals

• Minimum 150 minutes per week of moderate-intensity physical activity 5
• Include resistance training: Helps preserve lean body mass during weight loss 5
• Gradual increase: Start slowly if currently sedentary 5

Long-Term Considerations

Ozempic is typically a lifelong medication - stopping treatment results in regain of one-half to two-thirds of lost weight within one year. 5

Treatment Duration

• Plan for indefinite use: Weight loss and glycemic benefits require ongoing treatment 5
• Assess response at 12-16 weeks: If inadequate response (<5% weight loss or insufficient HbA1c reduction), consider treatment intensification 5
• Regular monitoring: Follow-up every 3 months after reaching maintenance dose 5

Cost and Insurance

• Approximate cost: $1,600 per 30-day supply without insurance 5
• Insurance authorization: May require documentation of failed lifestyle modifications and metformin therapy 5
• Prior authorization: Often required, particularly for weight loss indication 5

Special Precautions

Pregnancy and Breastfeeding

• Stop Ozempic 2 months before planned pregnancy: Unknown if it harms unborn baby 1
• Breastfeeding: Unknown if passes into breast milk; discuss with provider 1

Surgery Planning

• Discontinue 3 weeks before elective surgery: Due to delayed gastric emptying and aspiration risk 5
• Inform anesthesiologist: Even if medication stopped, gastric contents may be retained 5

Monitoring Schedule

• Weeks 1-16 (titration phase): Monthly visits to assess tolerance and adjust dose 5
• After reaching maintenance dose: Every 3 months minimum for weight, blood pressure, cardiovascular risk factors 5
• HbA1c monitoring: Every 3-6 months as clinically indicated 5
• Kidney function: Monitor if experiencing significant gastrointestinal symptoms 1