Can a 47-year-old woman who is using Ozempic (semaglutide) intermittently and has a hemoglobin A1c of 5.1% discontinue the medication?

Can This Patient Discontinue Ozempic?

No, this patient should not discontinue Ozempic despite the excellent A1c of 5.1%, because intermittent use suggests poor adherence rather than sustained glycemic control, and stopping GLP-1 receptor agonists in patients who have achieved target typically leads to rapid deterioration of glycemic control and weight regain.

Critical Assessment of the Clinical Scenario

The key issue here is the intermittent use pattern, which fundamentally changes the clinical decision-making:

• Intermittent adherence indicates the A1c of 5.1% does not reflect stable, medication-supported control but rather represents a snapshot that may be misleading about true glycemic stability 1
• The American Diabetes Association recommends medication reduction only when A1c is substantially below target (<6.5%) on consistent therapy, not with sporadic use 1, 2
• Discontinuing medications should be considered when A1c is below 6.5% AND there is risk of hypoglycemia from medications like sulfonylureas or insulin—neither of which applies to GLP-1 receptor agonists used alone 3, 2, 4

Why Ozempic Should Be Continued (Not Stopped)

GLP-1 receptor agonists like semaglutide have glucose-dependent mechanisms that make hypoglycemia extremely unlikely:

• Semaglutide stimulates insulin secretion only when glucose levels are elevated, making it inherently safe even at low A1c values 5, 6
• The American College of Cardiology guidelines emphasize that GLP-1 RAs with demonstrated cardiovascular benefit should be maintained for organ protection beyond glucose control 1
• Stopping semaglutide typically results in rapid A1c increases of 1.0-1.5% and weight regain within 3-6 months based on trial extension data 5, 7

The Real Problem: Addressing Intermittent Use

The clinical priority should be optimizing adherence, not discontinuation:

• Intermittent use suggests barriers such as cost, side effects (nausea), or injection aversion that need to be identified and addressed 1
• Consider switching to once-weekly injectable semaglutide if not already prescribed, as weekly dosing improves adherence compared to daily medications 6, 7
• Alternatively, oral semaglutide may improve adherence for patients with injection aversion, though it requires specific dosing instructions (30 minutes before food with minimal water) 8, 7, 9

When Medication Reduction IS Appropriate (Not This Case)

The American Diabetes Association provides clear criteria for deintensification that do not apply here:

• A1c <6.5% on consistent therapy with hypoglycemia-risk medications (sulfonylureas, insulin)—but GLP-1 RAs don't cause hypoglycemia 1, 2
• End-of-life or palliative care settings where treatment burden outweighs benefits—not applicable to a 47-year-old 1, 2
• Organ failure or declining function requiring hypoglycemia prevention—again, not relevant for GLP-1 RAs 1, 2

Specific Action Plan for This Patient

Step 1: Investigate barriers to consistent use:

• Assess for gastrointestinal side effects (nausea, vomiting) that can be mitigated by slower dose titration 1
• Evaluate cost burden and explore patient assistance programs, as GLP-1 RAs are expensive 1
• Determine if injection technique or frequency is a barrier 6

Step 2: Optimize the regimen for adherence:

• If using daily formulations, switch to once-weekly injectable semaglutide (0.5-1.0 mg) for convenience 6, 7
• If injection aversion exists, consider oral semaglutide (7-14 mg daily) with proper administration counseling 8, 7, 9
• Emphasize that consistent use is essential—intermittent dosing provides neither sustained glycemic control nor cardiovascular protection 1

Step 3: Monitor response to improved adherence:

• Recheck A1c in 3 months with consistent medication use to assess true baseline control 1
• If A1c remains <6.5% on consistent therapy and patient is on other hypoglycemia-risk medications, then consider reducing those agents first (not the GLP-1 RA) 3, 2, 4

Critical Pitfalls to Avoid

• Do not discontinue Ozempic based solely on a single low A1c value with intermittent use—this A1c does not reflect medication-supported control and will likely rise rapidly 1, 5
• Do not assume "normal" A1c means diabetes is "cured"—type 2 diabetes is a progressive disease requiring ongoing management 1
• Do not remove the medication providing weight management and potential cardiovascular protection without addressing the adherence issue first 1, 5
• Avoid the misconception that GLP-1 RAs cause hypoglycemia at low A1c—their glucose-dependent mechanism makes them safe even with excellent control 1, 5, 6