Comprehensive Australian-Aligned Telehealth Guideline for GLP-1 Receptor Agonist Prescribing for Weight Loss

Patient Eligibility Criteria

Adults with BMI ≥30 kg/m² qualify for GLP-1 receptor agonist therapy without additional requirements, while those with BMI ≥27 kg/m² require at least one weight-related comorbidity such as hypertension, dyslipidemia, type 2 diabetes, or obstructive sleep apnea. 1, 2

Absolute Contraindications (Must Screen Before Prescribing)

Personal or family history of medullary thyroid cancer 1, 3, 4
Multiple endocrine neoplasia syndrome type 2 (MEN2) 1, 3, 4
Pregnancy or planning pregnancy 2
History of severe hypersensitivity reaction to semaglutide or tirzepatide 3

Relative Contraindications (Use Caution)

History of pancreatitis (use with caution, though causality not definitively established) 1, 3
Severe gastroparesis or gastrointestinal motility disorders 1
Recent heart failure decompensation 1

Pre-Treatment Telehealth Assessment

Medical History Requirements

Document failed lifestyle modifications (diet and exercise attempts) for insurance authorization 1
Screen for personal/family history of medullary thyroid cancer or MEN2 syndrome 1, 3
Review history of pancreatitis, gallbladder disease, or severe gastrointestinal disorders 1, 3
Assess cardiovascular disease history (prioritize semaglutide if established CVD present) 1, 3
Review all current medications to identify weight-promoting drugs (antipsychotics, tricyclic antidepressants, glucocorticoids) and consider alternatives 2, 1

Required Laboratory Testing Before Initiation

Lipid panel (total cholesterol, LDL, HDL, triglycerides) to assess baseline cardiovascular risk 1
Comprehensive metabolic panel including renal function (eGFR) and liver enzymes (ALT, AST) 1
Fasting glucose and HbA1c to screen for undiagnosed diabetes 1
Thyroid function tests (TSH, free T4) - optimize before starting treatment 1
Calcium levels with ionized calcium and PTH if any concern for hypercalcemia to rule out primary hyperparathyroidism 1

Physical Examination Components (Can Be Conducted via Telehealth)

Weight and height for BMI calculation (patient self-reported with verification plan) 1
Blood pressure measurement (patient home monitoring acceptable with validated device) 1
Waist circumference (patient self-measurement with instructions) 1
Screen for signs of thyroid nodules or masses (patient neck self-palpation with video guidance if feasible) 1

Medication Selection Algorithm

First-Line Choice: Tirzepatide 15mg Weekly

Prioritize tirzepatide when maximum weight loss is the primary goal, achieving 20.9% weight loss at 72 weeks versus semaglutide's 14.9%. 1, 3

Superior efficacy: 20.9% weight loss at 72 weeks 1, 3, 5
Greater HbA1c reduction if diabetes present 1
Superior cardiometabolic benefits (triglycerides, waist circumference, fasting glucose) 1
Cost: approximately $1,272 per 30-day supply 1

Second-Line Choice: Semaglutide 2.4mg Weekly

Choose semaglutide for patients with established cardiovascular disease due to proven 20% reduction in cardiovascular death, nonfatal MI, or nonfatal stroke. 1, 3

Weight loss: 14.9% at 68 weeks 1, 3, 5
Proven cardiovascular benefit (HR 0.80 for MACE) 1, 3
Cardiovascular safety demonstrated in non-diabetic patients with CVD 3
Cost: approximately $1,557-$1,619 per 30-day supply 1

Third-Line Choice: Liraglutide 3.0mg Daily

Consider liraglutide only when weekly injections are refused or not tolerated, accepting lower efficacy of 5.2-6.1% weight loss. 1, 4

Modest weight loss: 5.2-6.1% 1, 4
Daily injection requirement 1, 4
Higher discontinuation rates due to gastrointestinal effects 4
Cost: approximately $1,619 per 30-day supply 1

Dosing and Titration Schedules

Semaglutide 2.4mg Titration (16-Week Schedule)

Weeks 1-4: 0.25mg weekly 1, 6
Weeks 5-8: 0.5mg weekly 1, 6
Weeks 9-12: 1.0mg weekly 1, 6
Weeks 13-16: 1.7mg weekly 1, 6
Week 17 onwards: 2.4mg weekly (maintenance) 1, 6

Tirzepatide Titration (Minimum 16-Week Schedule)

Weeks 1-4: 5mg weekly 1
Weeks 5-8: 7.5mg weekly (optional intermediate step) 1
Weeks 9-12: 10mg weekly 1
Weeks 13-16: 12.5mg weekly (optional intermediate step) 1
Week 17 onwards: 15mg weekly (maintenance) 1

Administration Instructions

Inject subcutaneously in abdomen, thigh, or upper arm 6
Administer at any time of day, with or without meals 6
If dose missed, administer within 5 days; if >5 days, skip and resume next scheduled dose 6
Rotate injection sites to prevent lipodystrophy 6

Mandatory Lifestyle Interventions (Non-Negotiable)

GLP-1 receptor agonists must be combined with lifestyle modifications throughout treatment - medication alone without lifestyle changes is inadequate and does not meet FDA approval criteria. 1, 2

Caloric deficit: 500-kcal reduction below daily requirements 2, 1
Physical activity: Minimum 150 minutes per week 2, 1
Resistance training: Essential to preserve lean body mass and prevent muscle loss 1
Behavioral counseling: Ongoing support and lifestyle modification programs 1

Monitoring Schedule and Follow-Up Protocol

Initial Titration Phase (Months 1-4)

Assess patients monthly during the first 3 months for efficacy and safety, then at least every 3 months thereafter. 1, 2

Monthly telehealth visits during dose escalation 1
Monitor for gastrointestinal tolerance (nausea, vomiting, diarrhea) 1, 3
Track weight loss progress 1
Monitor blood pressure (may require antihypertensive adjustment) 1, 3
Screen for signs of pancreatitis (persistent severe abdominal pain) 1, 3
Screen for gallbladder symptoms (right upper quadrant pain) 1, 3

Critical 12-Week Efficacy Assessment

Discontinue medication if weight loss is <5% after 12 weeks at maintenance dose, as this predicts poor long-term response. 1, 2

Measure total weight loss from baseline 1, 2
If <5% weight loss: discontinue and consider alternative approaches 1, 2
If ≥5% weight loss: continue long-term therapy 1, 2

Maintenance Phase (After Month 4)

Continue assessment at least every 3 months after reaching maintenance dose. 1

Quarterly telehealth visits minimum 1
Monitor weight stability 1
Assess cardiovascular risk factors (blood pressure, lipids) 1
Evaluate medication adherence 1
Screen for adverse effects 1
Monitor for signs of weight regain 1

Laboratory Monitoring Schedule

Baseline: Lipid panel, CMP, HbA1c, fasting glucose, TSH, calcium 1
3 months: Repeat lipid panel, CMP, HbA1c (if diabetic) 1
6 months: Lipid panel, liver enzymes, HbA1c (if diabetic) 1
Annually: Comprehensive metabolic panel, lipid panel, HbA1c, TSH 1

Concomitant Medication Management

Medications Requiring Dose Reduction

Insulin: Reduce basal insulin by 20% when initiating GLP-1 RA 1
Sulfonylureas: Discontinue or reduce by 50% to prevent hypoglycemia 1, 3
Antihypertensives: Monitor closely as weight loss may necessitate dose reduction 1, 3

Medications to Avoid

Other GLP-1 receptor agonists: Never combine (pharmacologically redundant) 1
DPP-4 inhibitors: Discontinue before starting GLP-1 RA 1

Oral Contraceptive Considerations

Women using oral contraceptives should switch to non-oral methods or add barrier contraception for 4 weeks after initiation and each dose escalation (tirzepatide specific) 1

Adverse Effect Management

Common Gastrointestinal Effects (Expected in 40-53% of Patients)

Nausea: 17-44% of patients 1, 3, 4
Diarrhea: 12-32% of patients 1, 4
Vomiting: 7-25% of patients 1, 4
Constipation: 10-23% of patients 1, 4

Mitigation Strategies

Slow titration every 4 weeks minimizes symptoms 1, 3
Reduce meal size and eat slowly 1
Limit alcohol and carbonated beverages 1
Symptoms typically mild-to-moderate and decrease over time 1, 3

Serious Adverse Events Requiring Immediate Discontinuation

Pancreatitis: Persistent severe abdominal pain radiating to back 1, 3, 4
Gallbladder disease: Right upper quadrant pain, fever, jaundice 1, 3
Severe hypersensitivity reactions: Anaphylaxis, angioedema 3
Acute kidney injury: Monitor in patients with renal impairment 2

Perioperative Management

For elective surgery requiring anesthesia, discontinue semaglutide or tirzepatide at least 3 weeks (three half-lives) before surgery due to delayed gastric emptying and aspiration risk. 1, 3

Semaglutide/tirzepatide: Hold 3 weeks pre-operatively 1, 3
Liraglutide: Hold 3 days pre-operatively 1
Consider gastric ultrasound pre-operatively to assess residual gastric contents 1, 3
Retained gastric contents documented even after extended fasting (24.2% vs 5.1% controls) 1, 3

Treatment Duration and Long-Term Considerations

GLP-1 receptor agonists require lifelong treatment to maintain weight loss - sudden discontinuation results in regain of one-half to two-thirds of lost weight within 1 year. 1

Early responders (≥5% weight loss at 3 months) should continue long-term 1, 2
Weight regain of 50-67% occurs within 12 months of discontinuation 1
Patients must understand this is chronic disease management requiring ongoing therapy 1, 3
Cost considerations: $1,272-$1,619 per month requires long-term financial planning 1

Special Population Considerations

Patients with Cardiovascular Disease

Prioritize semaglutide 2.4mg for proven cardiovascular benefit (20% MACE reduction) 1, 3
Avoid sympathomimetic agents (phentermine) 2

Patients with Chronic Kidney Disease

No dose adjustment required for semaglutide, tirzepatide, or liraglutide across all CKD stages 1
Reduces albuminuria and slows eGFR decline 1

Patients with Type 2 Diabetes

Prioritize tirzepatide or semaglutide for dual benefits (glycemic control + weight loss) 1, 2
Greater HbA1c reduction with tirzepatide (1.87-2.59%) 1

Patients with Hypothyroidism

Generally safe with thyroid disease 1
Optimize thyroid function before starting treatment 1
Monitor thyroid function during therapy 1

Treatment Failure and Intensification

When to Discontinue

<5% weight loss after 12 weeks at maintenance dose 1, 2
Intolerable adverse effects despite mitigation strategies 1, 2
Development of contraindications (pregnancy, MTC diagnosis) 1

Treatment Intensification Options

Switch to higher-efficacy agent (liraglutide → semaglutide → tirzepatide) 1
Add structured lifestyle management programs 1
Consider metabolic surgery if BMI ≥30 kg/m² and medical management fails 2, 1

Critical Pitfalls to Avoid

Never prescribe as monotherapy - must combine with lifestyle modifications 1, 2
Never continue beyond 12 weeks at maintenance dose if <5% weight loss - represents treatment failure 1, 2
Never combine two GLP-1 receptor agonists - pharmacologically redundant and potentially harmful 1
Never ignore perioperative aspiration risk - hold medication 3 weeks before elective surgery 1, 3
Never prescribe without screening for MTC/MEN2 history - absolute contraindication 1, 3
Never delay follow-up beyond 3 months in maintenance phase - may miss treatment failure 1
Never start at full dose - slow titration essential to minimize gastrointestinal effects 1, 3
Never ignore persistent severe abdominal pain - may indicate pancreatitis requiring immediate discontinuation 1, 3

Documentation Requirements for Telehealth Prescribing

BMI calculation with documented weight and height 1
Weight-related comorbidities if BMI 27-29.9 kg/m² 1, 2
Failed lifestyle modification attempts 1
Negative screening for MTC/MEN2 family history 1, 3
Baseline laboratory results 1
Patient education on lifelong treatment requirement 1
Informed consent including aspiration risk and need for perioperative discontinuation 1, 3
Plan for monthly monitoring during titration 1
Plan for quarterly monitoring in maintenance phase 1

Patient Education Checklist

Medication must be used lifelong - stopping leads to weight regain 1
Requires concurrent lifestyle changes (diet, exercise) 1, 2
Expect gastrointestinal side effects initially (nausea, diarrhea) - usually improve over time 1, 3
Report persistent severe abdominal pain immediately (pancreatitis risk) 1, 3
Report right upper quadrant pain (gallbladder disease risk) 1, 3
Must discontinue 3 weeks before elective surgery 1, 3
Carry glucose tablets if on insulin or sulfonylureas 1
Do not skip meals if on insulin or sulfonylureas 1
Rotate injection sites 6
Store medication properly (refrigerate until first use) 6

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