Chronic Constipation is NOT an Absolute Contraindication to Wegovy (Semaglutide) for Medically Necessary Weight Loss
Chronic constipation alone does not contraindicate Wegovy use, but it requires careful assessment and management since semaglutide commonly causes gastrointestinal side effects including constipation in 11-24% of patients. 1, 2 The decision depends on the severity of baseline constipation and the patient's overall clinical picture.
Absolute Contraindications to Wegovy
Before proceeding, verify the patient does NOT have these absolute contraindications 1, 3:
- Personal or family history of medullary thyroid cancer
- Multiple endocrine neoplasia syndrome type 2 (MEN2)
- Pregnancy or breastfeeding
- History of severe hypersensitivity reaction to semaglutide
Assessment of Constipation Severity
Determine if the constipation represents a relative contraindication:
Proceed with Caution if:
- Severe gastroparesis or clinically meaningful gastric motility disorders - semaglutide delays gastric emptying and will worsen symptoms 1, 3
- History of small bowel obstruction or ileus - semaglutide may cause severe constipation progressing to obstruction 3
- Prior gastric surgery - requires extreme caution due to altered GI anatomy 3
Generally Safe to Proceed if:
- Mild-to-moderate functional constipation that is well-controlled with current management 1
- No history of bowel obstruction or severe motility disorders 3
- Patient can maintain adequate hydration 3
Risk Mitigation Strategy
If proceeding with Wegovy in a patient with chronic constipation:
Initiation Protocol
- Start with the standard 0.25 mg weekly dose and follow slow titration schedule (0.25 mg → 0.5 mg → 1.0 mg → 1.7 mg → 2.4 mg, with 4 weeks at each dose) 1, 3
- Slow titration minimizes gastrointestinal side effects, which are dose-dependent 1, 3
Proactive Constipation Management
- Optimize baseline constipation management before initiating Wegovy 3
- Ensure adequate fluid intake (minimum 8-10 glasses daily) to prevent dehydration-related worsening 3
- Consider prophylactic stool softeners or osmotic laxatives 3
- Avoid high-fat diets which worsen constipation 3
- Implement dietary fiber modifications 1
Monitoring Requirements
- Assess gastrointestinal tolerance every 4 weeks during titration 1
- Monitor for signs of bowel obstruction (severe abdominal pain, inability to pass stool or gas, vomiting) 3
- Check renal function if severe GI symptoms develop, as dehydration can precipitate acute kidney injury 3
- Evaluate at 12-16 weeks on maximum tolerated dose - if constipation becomes intolerable despite management, consider discontinuation 1
Clinical Context: Benefits vs. Risks
The decision should weigh the cardiovascular and metabolic benefits against GI risks:
- Wegovy provides 14.9% mean weight loss at 68 weeks, with 64.9% of patients achieving ≥10% weight loss 1
- For patients with established cardiovascular disease, semaglutide reduces cardiovascular death, nonfatal MI, or stroke by 20% (HR 0.80) 4, 1
- Gastrointestinal effects are typically mild-to-moderate, transient, and decrease over time 1, 3
When to Discontinue
Stop Wegovy immediately if: 3
- Severe, persistent abdominal pain suggesting pancreatitis or bowel obstruction
- Inability to maintain adequate oral intake or hydration
- Progression to small bowel obstruction or ileus
- Intolerable constipation despite aggressive management
Alternative Considerations
If constipation proves prohibitive, consider discussing with the patient 1:
- Tirzepatide - similar GI side effect profile but may be better tolerated in some patients
- Liraglutide 3.0 mg daily - lower weight loss efficacy (5.2-6.1%) but daily dosing allows more flexible titration
- Metabolic surgery if BMI ≥35 kg/m² with comorbidities and pharmacotherapy fails
The key is individualized risk assessment: mild-to-moderate chronic constipation that is well-managed does not preclude Wegovy use, but severe gastroparesis or motility disorders represent relative contraindications requiring alternative approaches. 1, 3