What documentation is required before prescribing Glucagon-like peptide-1 (GLP-1) receptor agonists to a patient with a history of pancreatitis, thyroid cancer, or hypersensitivity reactions, and with known demographic information, renal function, liver function, blood pressure, and lipid profiles?

Documentation Requirements Before Prescribing GLP-1 Receptor Agonists

Before prescribing any GLP-1 receptor agonist, you must document personal and family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN2), history of pancreatitis, hypersensitivity reactions to GLP-1 agents, renal function (eGFR), pregnancy/breastfeeding status, and current medications that may interact (insulin, sulfonylureas, oral contraceptives). 1, 2, 3, 4

Absolute Contraindications to Document

Thyroid Cancer History

• Personal history of medullary thyroid carcinoma (MTC) - this is an absolute contraindication to all GLP-1 receptor agonists 2, 3, 4
• Family history of MTC - document first-degree relatives with MTC, as this also represents an absolute contraindication 2, 3, 4
• Multiple Endocrine Neoplasia syndrome type 2 (MEN2) - personal or family history is an absolute contraindication 1, 2, 3, 4
• Note that other types of thyroid cancer (papillary, follicular) in family members do NOT contraindicate GLP-1 use 2

Hypersensitivity History

• Prior serious hypersensitivity reaction to the specific GLP-1 agent being considered (angioedema, anaphylaxis, severe rash) 3, 4
• Document symptoms if present: swelling of face/lips/tongue/throat, breathing problems, severe rash, fainting, rapid heartbeat 4

Pregnancy and Breastfeeding Status

• Current pregnancy or plans to become pregnant - absolute contraindication 1, 3, 4
• Breastfeeding status - contraindication as it is unknown if GLP-1 agents pass into breast milk 1, 4

Agent-Specific Renal Contraindications

Document eGFR and Apply These Thresholds:

• Exenatide: Contraindicated if eGFR <30 mL/min/1.73 m² or on dialysis; use with caution if eGFR 30-45 mL/min/1.73 m² 5, 3
• Lixisenatide: Contraindicated if eGFR <30 mL/min/1.73 m²; not recommended if eGFR <15 mL/min/1.73 m² 5, 3
• Liraglutide, dulaglutide, semaglutide: No dose adjustment required at any eGFR level, can be used even with eGFR <20 mL/min/1.73 m² 5, 3

Critical Medical History to Document

Pancreatitis History

• Prior acute pancreatitis - document dates, severity, and etiology 1, 4, 6
• Chronic pancreatitis - GLP-1 agents have not been studied in these patients and are not recommended 6
• Document if patient has active or suspected pancreatitis, as this is a contraindication 6

Gastrointestinal Conditions

• Gastroparesis - clinically meaningful gastroparesis is a relative contraindication, as GLP-1 agents delay gastric emptying 1, 3, 4
• Prior gastric surgery including bariatric procedures - requires careful consideration and documentation 1, 3
• Severe gastrointestinal disease or slowed stomach emptying 4

Diabetic Retinopathy

• History of diabetic retinopathy - document presence and severity, as rapid glucose reduction with semaglutide may worsen retinopathy 3

Gallbladder Disease

• History of cholelithiasis or cholecystitis - document as GLP-1 agents increase risk of gallbladder disease 1, 4

Current Medication Documentation

Medications Requiring Dose Adjustment

• Insulin - document current dose, as reduction may be needed to prevent hypoglycemia 1, 3, 4
• Sulfonylureas or glinides - document current dose, as reduction may be needed to prevent hypoglycemia 1, 3, 4

Medications with Absorption Concerns

• Oral contraceptives - document use, as patients may need to switch to non-oral contraception or add barrier method for 4 weeks after initiation and each dose escalation due to delayed gastric emptying 1
• Medications with narrow therapeutic index (e.g., warfarin) - document as delayed gastric emptying may affect absorption 3, 4

Laboratory Values to Document

Baseline Renal Function

• eGFR - essential for agent selection and monitoring 5, 3
• Serum creatinine - baseline value for comparison 4

Baseline Liver Function

• Liver enzymes and bilirubin - document baseline values 4

Baseline Pancreatic Enzymes (if indicated)

• Lipase and amylase - consider baseline values if patient has risk factors for pancreatitis 4

Baseline Calcitonin (controversial)

• Serum calcitonin - while not universally recommended, document if obtained, particularly if >20 ng/L 4

Cardiovascular and Metabolic Parameters

Blood Pressure

• Baseline blood pressure - document as GLP-1 agents may reduce blood pressure 5

Heart Rate

• Baseline heart rate - document as GLP-1 agents typically increase heart rate by 2-5 beats per minute 3, 4

Lipid Profile

• Baseline cholesterol and triglycerides - document as GLP-1 agents improve lipid profiles 1

Glycemic Control

• HbA1c - document baseline value for efficacy monitoring 5
• Current glucose-lowering regimen - document all diabetes medications 4

Documentation for Monitoring Plan

Schedule for Follow-up

• Document plan to assess efficacy and safety at least monthly for first 3 months, then quarterly 1
• Document plan to monitor renal function, especially with severe GI symptoms 1, 4
• Document plan to monitor for signs of gallbladder disease 1, 4
• Document plan to monitor for pancreatitis symptoms 1, 4

Patient Education Documentation

• Document discussion of gastrointestinal side effects and slow dose titration strategy 1, 3, 4
• Document discussion of thyroid tumor risk (FDA black box warning) 1, 4
• Document discussion of symptoms requiring immediate medical attention (severe abdominal pain, persistent vomiting, neck swelling) 4
• Document proper administration instructions, particularly for oral semaglutide (take with ≤4 oz water on empty stomach, wait 30 minutes before eating/drinking/other medications) 6

Common Pitfalls to Avoid

• Do not confuse non-MTC thyroid cancers with MTC - only MTC and MEN2 are contraindications 2
• Do not unnecessarily avoid GLP-1 agents in moderate renal impairment - liraglutide, dulaglutide, and semaglutide require no dose adjustment 5, 3
• Do not forget to document concomitant insulin/sulfonylurea doses - these will likely need reduction 1, 3
• Do not overlook oral contraceptive users - they need specific counseling about potential reduced efficacy 1