Avoid These Mistakes When Dosing GLP-1 Agonists

Holly Lofton, MD


September 19, 2023

This transcript has been edited for clarity.

I'm Dr Holly Lofton, clinical associate professor of surgery and medicine at NYU Langone Health, and I direct the medical weight management program. My practice is solely based on chronic weight management for adults. Today I'll talk about the various doses of GLP-1 agonists that you may prescribe to your patients.

Being that this is based around weight management, I'll start with the weight management medications, the first of which is Saxenda. This is liraglutide 3 mg for chronic weight management. The studies that were done with this medication were intended to get the patient to the 3-mg dosing, which is what's prescribed for weight management, and not the 1.8-mg dosing which is prescribed for type 2 diabetes. However, you may deliver different doses to your patients depending on your goal.

You see that this makes a lot of clicking noise. When the patient starts Saxenda and has their pen, there will be this clear fluid. It's important to remind them that this is a multiuse pen and that they should use it over and over again until it's empty.

This medication has various doses in the same pen. You want to increase weekly as long as the patient is tolerating it. And by that, I mean not having significant side effects such as nausea, constipation, or other stool changes. When a patient receives the pen, it will start with 0. In the first week, we do 0.6 mg daily. The next week we do 1.2 mg daily. The third week we do 1.8 mg daily. The next week we do 2.4 mg daily, and then the goal is to get the patient to 3 mg, which is the maintenance dose. Ideally, the patient would stay there for their chronic weight management. However, if a patient can't tolerate the dose, you can also have them go to a lower dose for 7 more days and try again.

Wegovy, which is semaglutide 2.4 mg, is also prescribed for chronic weight management. This is a single-use cartridge, so the pen will deliver only the dose that you prescribe to the patient. This as well is intended to increase monthly as long as the patient is tolerating it and not having too many significant GI side effects such as nausea, constipation, or loose stool. With this pen, the doses are 0.25 mg, 0.5 mg, 1 mg, 1.7 mg, and 2.4 mg. You increase it monthly or every 4 weeks, depending on the patient tolerance. However, if a patient is not able to tolerate the highest dose, you can prescribe the maximally tolerated dose for that patient.

The next new GLP-1 I'll talk about is Ozempic [semaglutide] prescribed for type 2 diabetes. The goals of titrating this medication really depend more on your patient's glycemic control, as this is used for glycemic management. Here we have the red labels and big pen, and this delivers either 0.25 mg or 0.5 mg.

The recommendation for this medication is to use 0.25 mg for 4 weeks. Assess the patient's glycemic control, and if needed, increase to 0.5 mg after 4 weeks. Again, this pen delivers either 0.25 mg or 0.5 mg only.

This blue-green–label Ozempic [semaglutide] delivers 1-mg dosing, so when your patient turns this one all the way to the end, the only number they will see will be 1. If your patient does not have optimal glycemic control with the lower doses, a 1-mg pen can be prescribed and the patient can continue on that, optimizing their glucose, or you can increase to a 2-mg pen [yellow label], which delivers only 2 mg.

This is a single-use cartridge for Trulicity [dulaglutide]. The various doses of Trulicity are 0.75 mg, 1.5 mg, 3 mg, and 4.5 mg. This pen will deliver only the dose that's prescribed, and you can titrate up to optimize glycemic control for your patient. The higher the dose, the better the improvement in glucose and hemoglobin A1c.

This is the pen for Mounjaro, which is tirzepatide. At the time of this recording, this medication is intended for type 2 diabetes management. It's a single-use cartridge, and the different doses vary from 2.5 mg, 5 mg, 7.5 mg, 10 mg, 12.5 mg, to the highest dose, 15 mg. Again, this should be titrated to optimize glycemic control for your patient, and you can increase or decrease the dose based on the patient's tolerance.

Some of the more common prescribing errors I see with the GLP-1 agonists include not increasing the dose to titrate for effect where the goal is glycemic control or weight management. Starting with Trulicity, for example, this medication comes in doses of 0.75 mg up to 4.5 mg. I've seen patients on 0.75 mg for 9 months not achieving their goals of glycemic control and tolerating the medication well; but with the prescribers not increasing the dose, we're not achieving the desired outcome. So, it's important to reassess your patient and the goals of either weight management or glycemic control, and consider titrating the dose for that patient.

Another common prescribing error with these medications is that some providers say, "Well, this patient needs to lose a lot of weight so let me go to the highest dose." So, they may give them Wegovy 2.4 mg, because that's the dose for weight management, and start them there. Now, we know that this medication slows down the rate of stomach emptying. And if we do that too quickly, going from 0 to 2.4 mg, the patient is very likely to have adverse outcomes such as vomiting, because a stomach that slows down too quickly will definitely not feel pleasant to the patient. So, it is important with GLP-1 agonists to slowly increase the dose, whether it be monthly or daily, depending on the medication, to optimize the patient's outcomes but also minimize adverse effects.

I'm Dr Holly Lofton. Thank you for your time and attention during this discussion of dosing and administration of GLP-1 agonists.

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