Can GLP-1 (Glucagon-like peptide-1) medications, such as liraglutide (Victoza) or semaglutide (Ozempic), be prescribed to adopted patients with unknown family history and type 2 diabetes?

GLP-1 Medications and Unknown Family History in Adopted Patients

Yes, GLP-1 medications can be prescribed to adopted patients with unknown family history, as the only family history-related contraindication is a family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN2)—and if this history is unknown, it cannot be a contraindication. 1

Understanding the Contraindication

The FDA label for semaglutide (and all GLP-1 receptor agonists) lists only two absolute contraindications related to thyroid cancer 1:

• Personal history of medullary thyroid carcinoma (MTC)
• Family history of MTC or MEN2 syndrome

The critical distinction: If family history is genuinely unknown (as in adoption), this contraindication does not apply because the patient cannot have a "known" family history of these conditions. 1

Clinical Approach for Adopted Patients

Pre-Treatment Screening

Screen for personal history only, which is what matters most 2:

• Ask specifically about any personal history of thyroid nodules, thyroid cancer, or thyroid surgery
• Document that family history is unavailable due to adoption
• Perform baseline thyroid examination for palpable nodules
• Do not routinely measure serum calcitonin or perform thyroid ultrasound, as monitoring is of uncertain value and may lead to unnecessary procedures due to low test specificity 1

When to Consider Additional Evaluation

If the patient has any personal thyroid concerns, obtain baseline assessment 1:

• Presence of thyroid nodules on physical examination warrants further evaluation
• Symptoms suggestive of thyroid tumors (neck mass, dysphagia, dyspnea, persistent hoarseness) require investigation before initiating therapy
• If serum calcitonin is measured for any reason and is significantly elevated (>50 ng/L), further evaluation is needed before prescribing GLP-1 agonists

Practical Prescribing Algorithm

For adopted patients with type 2 diabetes or obesity 3:

1. Confirm eligibility criteria are met 3:

   • Type 2 diabetes requiring additional glycemic control, OR
   • BMI ≥30 kg/m², OR
   • BMI ≥27 kg/m² with weight-related comorbidity

2. Document unknown family history 1:

   • Note in medical record that family history is unavailable due to adoption
   • This documentation protects against future liability concerns

3. Screen for personal contraindications only 1:

   • Personal history of MTC (absolute contraindication)
   • Known hypersensitivity to semaglutide or product components
   • History of pancreatitis (relative caution, not absolute contraindication) 2

4. Proceed with standard initiation if no personal contraindications exist 3:

   • Start semaglutide at 0.25 mg weekly for 4 weeks
   • Titrate to 0.5 mg weekly, then 1.0 mg weekly as needed
   • For obesity management, can escalate to 2.4 mg weekly

Common Pitfalls to Avoid

Do not deny treatment based solely on unknown family history 1:

• The contraindication requires a "known" family history of MTC or MEN2
• Unknown history is not equivalent to positive history
• Denying treatment would inappropriately withhold beneficial therapy

Do not order unnecessary thyroid screening tests 1:

• Routine calcitonin monitoring or thyroid ultrasound in asymptomatic patients increases risk of unnecessary procedures
• Only pursue if clinical signs/symptoms warrant investigation

Do not confuse the rodent data with human risk 1:

• Semaglutide causes thyroid C-cell tumors in rodents at clinically relevant exposures
• Human relevance has not been determined
• The boxed warning exists due to animal data, not established human risk

Patient Counseling

Inform adopted patients about the theoretical thyroid risk 1:

• Explain that animal studies showed thyroid tumors, but human relevance is unknown
• Counsel on symptoms of thyroid tumors to monitor: neck mass, difficulty swallowing, difficulty breathing, persistent hoarseness
• Emphasize that without known family history of MTC or MEN2, they can safely receive GLP-1 therapy
• Instruct to report any thyroid-related symptoms promptly

The benefits of GLP-1 therapy typically far outweigh the theoretical thyroid risk in patients without known personal or family history of MTC/MEN2 3, 4:

• Cardiovascular risk reduction of 20-26% in patients with established CVD 3
• Substantial weight loss of 14.9-20.9% depending on agent 3
• Superior glycemic control with HbA1c reductions of 1.4-2.6% 3