Most GLP-1 Prescriptions Miss the Mark: Are Yours?

GLP-1 receptor agonists, including semaglutide, are now widely used for weight loss, offering substantial weight reduction, improved metabolic health, and reduced cardiovascular risk. However, effective treatment involves more than simply prescribing drugs, and ongoing clinical oversight is crucial. Based on recommendations published in JAMA Internal Medicine, the following five tips can help physicians avoid common pitfalls and deliver optimal patient care.

Track Weight

GLP-1 receptor agonists typically result in 15%-21% weight loss, depending on the drug and individual response. However, weight loss alone does not define treatment success. A comprehensive clinical assessment that incorporates both quantitative and qualitative factors is essential.

Weight should be monitored monthly during the initial phase of treatment, particularly during dose titration. Once the dose is stabilized, quarterly follow-up is usually sufficient. If the weight loss remains below 5% after 12-16 weeks, this may signal an inadequate response. In such cases, clinicians should assess adherence, consider dose adjustments, or evaluate the need to switch to another GLP-1 receptor agonist.

Marked weight loss should be evaluated clinically and not just numerically. Red flags include a BMI below 18.5, calorie intake under 800 kcal/d, hormonal disturbances such as amenorrhea or reduced libido, signs of protein deficiency, and psychological symptoms. In such cases, secondary causes should be investigated, dose reduction should be considered, and referral to clinical nutrition or psychosomatic medicine may be warranted.

Preserve Muscle

Physicians should be mindful of lean body mass loss when treating patients with GLP-1 receptor agonists. Research indicates that up to 40% of the total weight loss during therapy may be attributed to muscle loss, which is a clinically relevant concern, particularly in older adults or those with limited physical function.

Targeted prevention of muscle loss is essential and begins with adequate protein intake. At least 1.0-1.5 g/kg body weight per day is recommended, with even higher amounts (> 1.5 g/kg) advised for older adults or patients who have undergone bariatric surgery. If appetite is significantly reduced, protein-rich supplements, such as shakes containing at least 20 g of protein per serving, can be a practical option.

Physicians should also recommend structured and individualized physical activities. In addition to approximately 150 minutes of moderate endurance exercise per week, such as brisk walking or cycling, strength training should be incorporated two to three times weekly. This approach can limit muscle loss by up to 95%, according to studies, while also improving metabolic health. Many patients report noticeable gains in energy, mobility, and quality of life.

Monitor Micronutrients

GLP-1 receptor agonists reduce food intake and slow gastric emptying, which may worsen preexisting micronutrient deficiencies. Individuals with obesity frequently have deficiencies in vitamin D, vitamin B12, folate, iron, zinc, calcium, and magnesium prior to treatment.

Therefore, targeted laboratory testing is recommended before starting treatment or at the latest when clinical signs of deficiency appear. High-risk patients should receive early referrals for professional dietary counselling, such as from a registered dietitian. If direct access is unavailable, the validated screening tool, the Rapid Eating Assessment for Participants — Shortened Version, offers an efficient and time-saving alternative for initial screening.

Based on the test results, clinicians can recommend an individualized approach focusing on a nutrient-rich diet rather than calorie counting. Targeted supplementation may be appropriate in many cases.

Manage Side Effects

Nausea, bloating, reflux, and constipation are among the most common side effects of GLP-1 receptor agonists, particularly during treatment initiation or when the dose is increased. Patient education and symptom-specific interventions can significantly improve the tolerability of these treatments.

• For nausea: Advise small, low-fat meals; avoid fried foods; and consider ginger tea for symptom relief.
• For constipation: Encourage fluid intake of more than 2-3 L/d, a high-fiber diet such as oatmeal and vegetables with their peel, and short-term use of osmotic laxatives, if needed.
• For reflux: Recommend smaller meals, maintain an upright position after eating, and avoid spicy or caffeinated beverages.

Prevent Relapse

Many patients regain weight after discontinuing semaglutide or other GLP-1 receptor agonists, with studies showing an average weight regain of 7%-12% within a year. This risk highlights that obesity is not a temporary condition but a chronic disease that should be managed accordingly.

Setting realistic expectations and developing long-term strategies from the start of treatment are essential. A structured discontinuation plan, such as gradual dose reduction with close follow-up, can help prevent the risk for relapse.

Lifestyle interventions should also be consistently maintained, including a balanced, nutrient-rich diet, regular physical activity, and psychological support when needed. If the weight gain exceeds 5%, further treatment with GLP-1 receptor agonists may be advisable.

This story was translated from Medscape’s German edition.