Pre-Initiation Requirements for Wegovy (Semaglutide 2.4 mg)
Absolute Contraindications – Screen Before Prescribing
Do not prescribe Wegovy if the patient has any of the following:
- Personal or family history of medullary thyroid carcinoma (MTC) 1, 2
- Multiple endocrine neoplasia syndrome type 2 (MEN 2) 1, 2
- Pregnancy or breastfeeding 3, 2
- History of severe hypersensitivity reaction to semaglutide 1
These are absolute contraindications based on FDA labeling and carry a black box warning for thyroid C-cell tumors observed in rodent studies 2.
Required Baseline Laboratory Tests
Obtain the following labs before initiating Wegovy:
- Comprehensive metabolic panel (renal function [eGFR], liver enzymes) 1
- Lipid panel (total cholesterol, LDL, HDL, triglycerides) to assess baseline cardiovascular risk 1
- Fasting glucose and HbA1c if diabetes status is uncertain 1
- Thyroid function tests (TSH, free T4) – particularly important given thyroid contraindications 1
No dose adjustment is required for any degree of renal impairment, including end-stage renal disease, but baseline renal function must be documented to monitor for acute kidney injury risk from dehydration 1, 2.
Eligibility Criteria – Who Qualifies for Wegovy?
Prescribe Wegovy for adults meeting one of these BMI thresholds:
- BMI ≥30 kg/m² (obesity) without additional requirements 3, 1
- BMI ≥27 kg/m² (overweight) with at least one weight-related comorbidity, including:
For cardiovascular risk reduction specifically: Wegovy is FDA-approved to reduce cardiovascular death, MI, and stroke in adults aged ≥45 years with BMI ≥27 kg/m² and established cardiovascular disease (prior MI, stroke, peripheral arterial disease, or revascularization) 1.
Relative Cautions – Use With Careful Monitoring
Exercise caution and intensify monitoring in patients with:
- History of pancreatitis – causality not definitively established, but pancreatitis has been reported in trials 1, 2
- Severe gastroparesis or clinically meaningful GI motility disorders – semaglutide delays gastric emptying and may worsen symptoms 1, 2
- Severe renal impairment (eGFR <30 mL/min/1.73 m²) – no dose adjustment needed, but monitor closely for dehydration from GI side effects 1, 2
- History of diabetic retinopathy – monitor for progression, as increased risk of retinopathy complications was observed in SUSTAIN-6 2
- Prior gastric surgery (including bariatric surgery) – delayed gastric emptying may cause complications 2
- Untreated closed-angle glaucoma 2
- Recent heart failure decompensation – avoid GLP-1 RAs in this setting 1
Concomitant Medication Review and Adjustments
Before starting Wegovy, adjust or discontinue the following medications:
If Patient Is on Insulin or Sulfonylureas:
- Reduce basal insulin by 20% immediately to prevent hypoglycemia 1
- Discontinue sulfonylureas or reduce dose by 50% – reassess need after 3 months, as Wegovy often achieves glycemic control alone 1
If Patient Is on Oral Contraceptives:
- Switch to non-oral contraception or add barrier method for 4 weeks after initiation and each dose escalation, due to delayed gastric emptying affecting absorption 2
Review Weight-Promoting Medications:
- Consider alternatives for medications that promote weight gain (e.g., replace mirtazapine or amitriptyline with other antidepressants) 1
Do Not Combine With:
- Other GLP-1 receptor agonists (e.g., Ozempic, Trulicity) – pharmacologically redundant and potentially harmful 1
- DPP-4 inhibitors – no additional benefit 1
Pre-Treatment Patient Counseling and Documentation
Document the following before prescribing:
- Failed lifestyle modifications (diet and exercise attempts) – required for insurance authorization 1
- Patient understanding that Wegovy must be combined with:
- Lifelong treatment is typically necessary – sudden discontinuation results in regain of 50–67% of lost weight within 1 year 1
- Cost discussion – average wholesale price is approximately $1,619 per 30-day supply 1
Perioperative Considerations
If elective surgery is planned:
- Discontinue Wegovy at least 3 weeks (three half-lives) before surgery due to delayed gastric emptying and aspiration risk during anesthesia 1
- Retained gastric contents are documented even after extended fasting periods (24.2% of semaglutide users vs. 5.1% of controls) 1
- Consider gastric ultrasound pre-operatively to assess residual gastric contents 1
Baseline Physical Examination Findings to Document
Record the following at baseline:
- Weight and BMI 1
- Waist circumference 1
- Blood pressure – will require monitoring as weight loss may necessitate antihypertensive adjustment 1
- Signs of gastroparesis (early satiety, bloating, nausea) – if present, Wegovy is not recommended 2
- Thyroid examination – palpate for nodules given MTC contraindication 2
Special Populations Requiring Additional Screening
Patients With Cardiovascular Disease:
- Wegovy is preferred over other obesity medications due to proven 20% reduction in cardiovascular death, nonfatal MI, or nonfatal stroke (HR 0.80) 1
- Ensure statin therapy is optimized 1
Patients With Chronic Kidney Disease:
- No dose adjustment required for any eGFR, including <30 mL/min/1.73 m² 3, 1
- Monitor closely for dehydration from GI side effects 2
Patients With Type 2 Diabetes:
- Wegovy offers dual benefits of weight loss and improved glycemic control 1
- Reduce insulin/sulfonylureas as noted above 1
Common Pitfalls to Avoid
- Do not skip the family history screen for MTC/MEN 2 – this is an absolute contraindication with FDA black box warning 1, 2
- Do not start at high doses – always begin at 0.25 mg weekly and titrate slowly over 16 weeks to minimize GI side effects 1
- Do not prescribe without documented lifestyle modification attempts – insurance will deny authorization 1
- Do not ignore perioperative aspiration risk – discontinue 3 weeks before elective surgery 1
- Do not combine with other GLP-1 RAs – this is pharmacologically redundant and potentially harmful 1