Wegovy (Semaglutide 2.4 mg) Guidelines for a 14-Year-Old with Obesity
Wegovy is FDA-approved for adolescents aged 12 years and older with obesity (BMI ≥95th percentile for age and sex), making a 14-year-old an appropriate candidate if they meet the BMI threshold. 1
Eligibility Criteria
- Age requirement: The patient must be 12 years or older to qualify for Wegovy treatment. 1
- BMI threshold: The adolescent must have a BMI at or above the 95th percentile for their age and sex (obesity classification in pediatrics). 1
- Absolute contraindications: Screen for personal or family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia type 2 (MEN 2)—these are absolute contraindications to semaglutide therapy. 2, 3
Dosing and Titration Protocol
- Start at 0.25 mg subcutaneously once weekly for 4 weeks, then increase every 4 weeks following this schedule: 0.5 mg weekly (weeks 5–8), 1.0 mg weekly (weeks 9–12), 1.7 mg weekly (weeks 13–16), and finally 2.4 mg weekly as the maintenance dose (week 17 onward). 2
- Slow titration is essential to minimize gastrointestinal adverse events (nausea, vomiting, diarrhea), which occur in 17–44% of patients but typically resolve within 4–8 weeks. 2, 4
- Administer as a once-weekly subcutaneous injection in the abdomen, thigh, or upper arm on the same day each week; timing relative to meals is flexible. 2
Mandatory Lifestyle Interventions
- Combine medication with a reduced-calorie diet (approximately 500 kcal daily deficit below total energy requirements) and at least 150 minutes per week of moderate-intensity physical activity. 2, 4
- Emphasize resistance training to preserve lean body mass, as GLP-1 receptor agonists can cause muscle loss alongside fat loss. 2, 4
- Behavioral counseling and structured lifestyle-modification support are recommended as part of the comprehensive treatment plan. 2
Expected Efficacy
- Mean weight loss of 14.9% at 68 weeks in adults; pediatric data show similar clinically meaningful weight reduction in adolescents aged 12 and older. 2, 5
- 86.4% of patients achieve ≥5% weight loss, 69.1% achieve ≥10% weight loss, and 50.5% achieve ≥15% weight loss at 68 weeks. 5
- Real-world data from the WeGoTogether program demonstrate sustained weight loss of 20.4% at 24 months in adults, suggesting long-term efficacy when combined with patient support. 6
Safety Profile and Monitoring
Common Adverse Events
- Gastrointestinal symptoms (nausea, vomiting, diarrhea) are the most frequent side effects, occurring in 17–44% of patients, but are typically mild-to-moderate and transient. 2, 7
- Nausea occurs in 18–40% of patients, diarrhea in 12–32%, and vomiting in 7–25%; these symptoms usually resolve within 4–8 weeks after reaching a new dose. 2
Serious Adverse Events
- Pancreatitis and gallbladder disease (cholelithiasis, cholecystitis) have been reported; instruct the patient to report persistent severe abdominal pain immediately and discontinue Wegovy if pancreatitis is suspected. 2, 7
- Serious adverse events occur 38% more frequently with semaglutide versus placebo, including pancreatitis, acute gallbladder disease, and severe gastrointestinal complications. 3, 7
Monitoring Schedule
- Assess every 4 weeks during dose titration for gastrointestinal tolerance, weight loss progress, and blood pressure. 2
- After reaching maintenance dose (2.4 mg), monitor at least every 3 months for weight stability, cardiovascular risk factors, and medication adherence. 2
- Evaluate treatment response at 12–16 weeks on the maximum tolerated dose; discontinue if weight loss is <5% after 3 months, as early non-responders are unlikely to benefit. 2
Dietary Recommendations
- Implement a structured caloric deficit of 500 kcal below daily requirements to optimize weight loss outcomes. 4
- Prioritize protein intake to preserve lean body mass, as GLP-1 receptor agonists can cause muscle loss alongside fat loss. 4
- Limit sodium intake to 2,300 mg per day and substitute foods higher in unsaturated fats for those higher in trans or saturated fats. 4
- Take medication with food or 15 minutes after a meal if gastrointestinal symptoms persist during titration. 4
- Do not skip meals, as this can worsen gastrointestinal side effects and disrupt metabolic adaptation. 4
Contraindications and Precautions
- Absolute contraindication: Personal or family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2 (MEN 2). 2, 3
- Relative caution: History of pancreatitis (causality not definitively established, but vigilance is advised). 2
- Avoid in patients with symptomatic gallbladder disease, as semaglutide increases the risk of cholelithiasis and cholecystitis by approximately 38% versus placebo. 2
Long-Term Considerations
- Wegovy must be used long-term in conjunction with sustained lifestyle changes, as cessation leads to significant weight regain (11.6% of lost weight regained after 52 weeks). 2
- Patients should be counseled that antiobesity medications may need to be used lifelong to maintain weight loss. 2
- Cost is a significant consideration, with an average wholesale price of approximately $1,619 per 30-day supply; insurance authorization may be challenging. 2
Common Pitfalls to Avoid
- Do not initiate Wegovy in normal-weight adolescents (BMI <95th percentile for age and sex), as no safety or efficacy data exist for this population, and the risk-benefit ratio is unacceptable. 3
- Do not prescribe Wegovy without concurrent lifestyle modifications (reduced-calorie diet and physical activity), as medication alone without lifestyle modification will be suboptimal. 2, 4
- Do not overlook the need for resistance training, as GLP-1 receptor agonists can cause loss of lean body mass without concurrent exercise. 2, 4
- Do not delay follow-up beyond 3 months in the maintenance phase, as this may miss treatment failure or adverse effects. 2