Ozempic Safety in Patients with Thyroid Nodules
Ozempic (semaglutide) can be used for weight loss in patients with a history of thyroid nodules, provided they do not have a personal or family history of medullary thyroid cancer (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). 1
Absolute Contraindications
The FDA label explicitly states that Ozempic is contraindicated only in patients with:
- Personal or family history of medullary thyroid carcinoma (MTC) 1
- Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) 1, 2
Thyroid nodules alone are NOT a contraindication to semaglutide use. 1
Evidence Supporting Safety in Thyroid Nodule Patients
A large 2025 retrospective cohort study using the TriNetX database evaluated 171,460 patients who had both thyroid nodules and GLP-1 analog use, with 98,142 developing thyroid nodules after starting GLP-1 analogs. 3
Key findings from this study:
- Survival probability (not developing thyroid cancer) was 91.042% in the GLP-1 cohort 3
- Risk ratio of 0.99 (95% CI: 0.96-1.03) compared to metformin users, indicating no significant difference in thyroid cancer risk 3
- The study concluded a "relatively low incidence of thyroid cancer among patients with thyroid nodules treated with GLP-1 analogues" 3
A 2023 systematic review and meta-analysis of 37 RCTs and 19 real-world studies found no increased risk of thyroid cancer with semaglutide compared to placebo (OR 2.04,95% CI: 0.33-12.61; P = 0.44) or active controls (OR 1.19,95% CI: 0.15-9.66; P = 0.87). 4
Critical Pre-Treatment Screening Requirements
Before initiating semaglutide, the American Heart Association recommends screening for: 5
- Personal history of medullary thyroid cancer 5
- Family history of medullary thyroid cancer or MEN 2 5
- Current pregnancy or breastfeeding status 5
The FDA label specifies that patients with thyroid nodules noted on physical examination or neck imaging should be further evaluated, but this does not preclude semaglutide use. 1
Monitoring Recommendations During Treatment
The FDA label states that routine monitoring of serum calcitonin or thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with Ozempic. 1 Such monitoring may increase the risk of unnecessary procedures due to low test specificity and high background incidence of thyroid disease. 1
However, counsel patients regarding symptoms of thyroid tumors including: 1
- A mass in the neck
- Dysphagia (difficulty swallowing)
- Dyspnea (shortness of breath)
- Persistent hoarseness
If serum calcitonin is measured and found to be significantly elevated (>50 ng/L), the patient should be further evaluated. 1
Dosing Protocol for Weight Loss
The American College of Cardiology recommends the following titration schedule for weight loss: 5
- Weeks 1-4: 0.25 mg once weekly 5
- Weeks 5-8: 0.5 mg once weekly 5
- Weeks 9-12: 1.0 mg once weekly 5
- Weeks 13-16: 1.7 mg once weekly 5
- Week 17 onward: 2.4 mg once weekly (maintenance dose) 5
This gradual titration minimizes gastrointestinal side effects, which occur in the majority of patients but are typically transient and dose-dependent. 2, 5
Common Pitfalls to Avoid
A 2025 study evaluating pre-treatment assessment practices found that despite 98.6% of patients having at least one relevant disease history, only 1.8% had comprehensive disease history checks performed prior to semaglutide initiation. 6 This represents a critical gap in clinical practice.
Do not skip the family history assessment for MTC or MEN 2, as this is an absolute contraindication. 1 The presence of benign thyroid nodules without this family history does not preclude safe use of semaglutide for weight loss.