What are the necessary steps and considerations for prescribing Saxenda (liraglutide) to an adult patient with a body mass index (BMI) of 30 or higher, or a BMI of 27 or higher with at least one weight-related condition?

Prescribing Saxenda (Liraglutide 3.0 mg) for Weight Management

Patient Eligibility Criteria

Saxenda is indicated for adults with BMI ≥30 kg/m² or BMI ≥27 kg/m² with at least one weight-related comorbidity (hypertension, dyslipidemia, type 2 diabetes, obstructive sleep apnea, or cardiovascular disease). 1, 2, 3

• For obesity management specifically, the target maintenance dose is 3.0 mg daily, which differs from Victoza (liraglutide 1.2-1.8 mg) used for type 2 diabetes 3, 4
• Saxenda must be used as an adjunct to a reduced-calorie diet (500-kcal deficit) and minimum 150 minutes per week of physical activity 2, 3

Absolute Contraindications - Screen Before Prescribing

Do not prescribe Saxenda to patients with:

• Personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN2) 1, 2, 3, 4
• Serious hypersensitivity reaction to liraglutide or any excipients 4
• Pregnancy or breastfeeding 1, 3

Pre-Treatment Evaluation

Obtain baseline measurements before initiating therapy:

• Body weight and BMI 3
• Blood pressure 2
• Lipid panel (total cholesterol, LDL, HDL, triglycerides) 2
• Fasting glucose and HbA1c if diabetes suspected 2
• Comprehensive metabolic panel including renal function (eGFR) and liver enzymes 2
• Document history of pancreatitis, gallbladder disease, or gastroparesis 1, 2, 4

Review all current medications:

• Identify and consider alternatives for weight-promoting medications 2
• If patient takes insulin or sulfonylureas, plan to reduce doses by 20% at initiation to prevent hypoglycemia 1, 3
• Discontinue any other GLP-1 receptor agonists or DPP-4 inhibitors before starting Saxenda 3

Dosing and Titration Schedule

Follow this mandatory weekly escalation schedule to minimize gastrointestinal side effects:

• Week 1: 0.6 mg subcutaneously once daily 1, 3, 4
• Week 2: 1.2 mg once daily 1, 3, 4
• Week 3: 1.8 mg once daily 1, 3, 4
• Week 4: 2.4 mg once daily 1, 3, 4
• Week 5 onward: 3.0 mg once daily (maintenance dose) 1, 3, 4

If nausea persists at any dose level, maintain the current dose for an additional week before advancing rather than discontinuing therapy, as gastrointestinal symptoms typically diminish over time. 3

Administration Instructions for Patients

• Inject subcutaneously once daily at any time of day, independent of meals 3, 4
• Rotate injection sites within the abdomen, thigh, or upper arm 3, 4
• Inspect solution visually before each injection—only use if clear, colorless, and contains no particles 4
• Never share the Saxenda pen between patients, even if the needle is changed 4
• If using concomitant insulin, administer as separate injections and never mix 4

Monitoring Schedule

During titration phase (first 5 weeks):

• Assess every 4 weeks for gastrointestinal tolerance, weight loss progress, and blood pressure 2, 3
• Monitor glucose levels more frequently if patient has type 2 diabetes, especially with concomitant insulin or sulfonylureas 3

After reaching maintenance dose:

• Evaluate at least every 3 months for continued weight loss progress, cardiovascular risk factors, and medication adherence 2, 3
• Monitor for signs of pancreatitis (persistent severe abdominal pain) and gallbladder disease symptoms 2, 3, 4

Treatment Response Assessment and Discontinuation Criteria

Evaluate treatment efficacy at 16 weeks (4 months) after initiation:

• Discontinue Saxenda if the patient has not lost at least 4% of baseline body weight at 16 weeks 1
• Early responders who achieve ≥5% weight loss after 3 months should continue long-term therapy 2, 3
• If weight loss plateaus or is insufficient despite maximum dose, consider adding metabolic surgery or alternative pharmacologic agents 2

Expected Outcomes

Patients can expect:

• Mean weight loss of 5.24-6.1% at one year 2, 5
• Approximately 40% of patients will experience nausea, which is typically mild-to-moderate and transient 3, 5
• 16% will experience vomiting 3, 5
• Improvements in blood pressure, lipid profiles, and glucose metabolism 3

Critical Safety Warnings

Counsel patients about:

• Risk of thyroid C-cell tumors based on animal studies—instruct patients to report symptoms of thyroid tumors (neck mass, dysphagia, dyspnea, persistent hoarseness) 1, 4
• Pancreatitis risk—discontinue promptly if suspected and do not restart if confirmed 4
• Acute kidney injury risk, usually associated with nausea, vomiting, diarrhea, or dehydration 4
• Acute gallbladder disease—obtain gallbladder studies if cholelithiasis or cholecystitis suspected 1, 4
• Pulmonary aspiration risk during general anesthesia or deep sedation—instruct patients to inform healthcare providers of any planned surgeries or procedures at least 3 weeks in advance 2, 4

Long-Term Management Considerations

Saxenda should be considered lifelong therapy to maintain weight loss and cardiometabolic benefits:

• Discontinuation results in significant weight regain, with patients regaining one-half to two-thirds of lost weight within 1 year 2, 3
• The average wholesale price is approximately $1,619 per 30-day supply, requiring long-term financial planning 2
• Insurance authorization may be challenging, particularly for obesity management without diabetes 2

Common Pitfalls to Avoid

• Do not advance doses too quickly—slow titration is essential to minimize gastrointestinal side effects 1, 3
• Do not wait for treatment failure on multiple interventions before considering Saxenda—early initiation in appropriate candidates leads to better outcomes 2
• Do not prescribe Saxenda with other liraglutide-containing products (Victoza) or other GLP-1 receptor agonists 3, 4
• Do not ignore the peri-operative aspiration risk—discontinue at least 3 weeks before elective surgery 2
• Do not forget to reduce insulin or sulfonylurea doses when initiating Saxenda to prevent hypoglycemia 1, 3