It looks like GLP-1s will continue to remain the most discussed topic in weight loss, at least for the near future. The stories on TV and social media are always so uplifting. “I lost 40 pounds on Wegovy and look at me now!” Beautiful before and after pics, big smiles. What you don’t see, unfortunately, are the negative stories that are sure to accompany the overwriting of a prescription by a provider who does not know the nuances of the drug, does not include regular follow-up, and does not include a nutrition plan for the patient.
Given the widespread misconceptions about weight loss injections, I am committed to cutting through the noise to bring you the truth. Whether you’re considering getting on these medications or are already on them, it’s important to be informed about the capabilities of these powerful drugs and the side effects involved. They can be used safely and effectively with the right approach.
What are GLP-1s and How Do They Work?
GLP-1s or glucagon-like peptide-1 receptor agonists, are a class of medications used to treat type 2 diabetes and obesity. In this article, we will refer to these weight loss medications as GLP-1s and weight loss injections or injectables.
Two injectable medications are currently making waves: semaglutide and tirzepatide. You might be familiar with a semaglutide injection for diabetes called Ozempic, which was initially approved in 2015 exclusively for diabetes. In 2021, it was rebranded as Wegovy for weight loss purposes.
Tirzepatide, introduced in May 2022, received approval under the name Mounjaro for diabetes treatment, and later in November 2023, it was approved as Zepbound for weight loss.
Both tirzepatide and semaglutide injections for weight loss require weekly dosing and function by targeting the GLP-1 receptor in our brain, which reduces our sense of hunger. This receptor is also present in our gut, and activating it influences how fat is and insulin are absorbed.
Tirzepatide stands out because it also targets GIP receptors (insulin receptors). It not only aids with food addictions but also appears to curb other vices, like smoking and gambling. It seems to have a positive effect on mood because individuals taking Mounjaro often feel happier and have improved sleep quality. This is believed to be related to serotonin.
Risks to Consider with GLP-1s and How to Minimize Side Effects
GLP-1s can be highly effective when used properly, but first, it’s important to stay vigilant about the potential side effects and unexpected issues that can arise. Here are some of the risks to consider and strategies to minimize side effects.
Appetite Suppression
Risk: These drugs are so powerful that they can shut off your appetite completely. I’ve seen individuals on higher doses lose all interest in food.
How to reduce the risk:
- Try to set an alarm at regular 3-hour intervals to make sure you are eating something—preferably something with protein.
- If this still doesn’t work, consider decreasing the dose to stimulate the appetite. We do this frequently because many folks are overtreated.
Muscle Loss
Risk: Although higher doses of weight loss injections may result in significant weight loss and an attractive scale reading, the accompanying side effects of muscle loss often occur. Losing muscle slows down your metabolism and contributes to weakness making it more challenging to continue losing weight and maintaining that weight loss. This can result in what’s known as being “skinny fat,” where your scale weight and BMI might look favorable, but your body fat percentage is high.
This problem occurs because you’re not consuming enough protein, which is vital for retaining nutrients and maintaining muscle mass. A lack of protein can also reduce albumin levels in your blood, which play a critical role in fighting infections and healing.
How to reduce the risk:
- Being followed by a clinician to track muscle mass and having a solid nutrition plan in place is essential.
- A rule of thumb for maintaining muscle mass is to eat half your weight in grams of protein per day (minimum).
- Strength training can help as well to some degree, but nutrition is #1.
Nausea and Vomiting
Risk: These drugs slow down gastric emptying—the rate at which food passes through the gut. So if you’re someone accustomed to eating quickly, you might find these drugs challenging. They can also make you feel sick when you first start taking them because food doesn’t move through your GI tract as easily. Some patients can get severe nausea and vomiting, especially if they are fast eaters.
How to reduce the risk:
- Eat at a slower pace.
- Take your medication before bed. This way, you sleep through the side effects, and they are not as bad when you wake up.
- Make sure you eat the day after your injection. You might be inclined not to eat because you are nauseous, but even if you just eat a few saltine crackers, it will help your side effects tremendously.
- If you can’t seem to kick it, consider decreasing the dose. Sometimes it takes a while to get used to a certain dose and you just have to be patient. You can stay on a lower dose that can be tolerated. If you get ½-1 pound of weight loss per week, that is a success.
- If symptoms do not improve, make sure to contact your doctor. There may be something else physically going on that needs to be investigated.
- There are medications such as Zofran (Odansetron) that can help with this temporarily as you adjust. Discuss this with your physician for more information.
Dehydration
Risk: GLP-1s can decrease your sense of thirst at higher doses. Not drinking water can lead to extreme dehydration and electrolyte abnormalities. Signs of dehydration are dizziness, fatigue, dry mouth and tongue, muscle weakness, increased heart rate, and concentrated urine (dark and not clear) to name a few. If dehydration does not improve with increasing your water, seek attention from your medical team.
How to reduce the risk:
- Make sure you are getting in 64-82 ounces of water every day, unless you have restrictions.
- If symptoms do not improve with increasing your water, seek attention from your medical team. There may be something else going on.
Constipation
Risk: Constipation is a common side effect of GLP-1s, as they slow down how fast the food goes through your GI tract. If you are struggling with constipation or gastrointestinal issues before starting GLP-1s, it is important to be followed by a doctor very closely. It is not unusual to diagnose gastroparesis while taking this drug which is a contraindication to its use. Patients can be hospitalized if they have this condition and are taking these meds.
If you naturally have slower bowel movements, these drugs could make you prone to bowel obstructions, a serious risk that could require surgery or in severe cases, could be fatal. Consult your doctor if you have gone several days without a bowel movement, or develop severe pain in your abdomen.
How to reduce the risk:
- Drink water. As mentioned above, make sure you are getting 64-82 ounces of water every day unless you have restrictions.
- Make sure you are getting plenty of fiber. For women, the recommendation is 25 grams a day, and for men is 38 grams a day. Raw veggies and fruit are a great source.
- If this isn’t enough, consider over-the-counter magnesium, but check with your doctor first to make sure it is not contraindicated. Senna, Colace, and Miralax are also good options but are not meant to be used long-term.
Dosing of GLP-1s
The proper way to use injectables is to gradually increase the dosage methodically, typically taking about four weeks to progress from the starting dose to the next dose.
Increasing the dosage too quickly can lead to illness, as your gut may not be accustomed to the heightened presence of GLP-1 in your system.
If a patient cannot handle the next highest dose due to side effects or lack of interest in eating or drinking (which does happen at higher doses), the dose should be lowered or the medicine should be discontinued altogether.
If you have to stop taking these drugs due to insurance or supply chain issues, attempting to resume at the previously high dose can make you severely ill. Individuals may experience vomiting for days or even weeks, often without seeking medical advice from a physician or healthcare provider. Remember that even being off by a day can create issues. Stick to the schedule and try not to deviate.
A Balanced Approach: Using Weight Loss Injectables Safely and Effectively
The key takeaway is this: GLP-1s should only be used for the proper patients, in the right way, and with the right dosing. If you decide to use these effective medications, it’s important to follow a multidisciplinary approach.
Here are some of the most important considerations for using these drugs safely:
- Patients need to be seen frequently by a licensed clinician (NP, PA, or MD). This is so that they can be monitored for problems, other medications can be adjusted appropriately with weight loss, and so that the GLP-1s can be titrated correctly.
- The patient must have a meal plan. These meds are powerful and it is very easy to simply not eat and lose muscle mass.
- Muscle must be tracked and you need to have a daily protein intake goal, again tied into a meal plan.
Combination of drugs enables better overall weight loss, can be cheaper, and can also lead to better overall weight loss maintenance.
