Since their inception several years ago, GLP-1 medications have proliferated among the patient population — as many as 1 in 8 Americans report having taken them. Originally intended for diabetes, popular drugs like Wegovy and Ozempic quickly moved into obesity treatment, as well. Now, ongoing research indicates the drug class may have indications for other conditions, too, such as cardiovascular disease, Alzheimer’s disease, and substance-use disorder. Suffice it to say that going forward, you’ll be treating more patients taking GLP-1s.

Despite the drug classes efficacy, they are not without complications, and when encountering a patient on a GLP-1, there are several boxes to check, beginning with intake. “A thorough medication review is in order from the outset,” said Tammy Lyn Kindel, MD, PhD, a bariatric surgeon at Froedtert Hospital in Milwaukee. “Unlike other medications, a patient’s history with these drugs matters.”

Be cognizant of the fact that some patients receive their GLP-1 prescriptions from places like medi-spas or compounding pharmacies, and in those cases, may be reluctant to disclose the fact that they’re using the drugs. “You need to gain the patients’ trust and get full disclosure about them,” said Kindel. “Ask when they took their last dose and how long they’ve been on the drug. Learn if they’re currently in an escalation phase.” 

Alongside that, before making any changes, you must consider the pharmacokinetics of these agents, said Jeremy Gurewitz, CEO and co-founder at Solace Health, a health tech company on a mission “to empower patients, improve outcomes, and restore the promise of the US healthcare system,” according to the website. “We’ve been re-evaluating how our inpatient teams approach treating patients using these new agents,” he said. “We need to be careful about jumping straight into NPO [nil per os] or major diet changes without first addressing the pharmacokinetics of these agents.”

GLP-1s suppress appetite, decrease/slow gastric emptying, and increase insulin secretion from the pancreas. It’s the delayed gastric emptying that should be the primary consideration when admitting patients who are taking these medications. “We flag GLP-1s during medication reconciliation and develop structured orders for when to hold, taper, or restart based on the reason for admission and the presence of GI [gastrointestinal] symptoms,” said Gurewitz.

Several drug classes may counteract GLP-1s and their weight-loss purpose. If prescribing a beta-blocker, for instance, be cognizant of the fact that they can cause weight gain. Think of alternatives that may not have that impact, undoing some of the good the GLP-1 may have accomplished. If prescribing a corticosteroid, remember that it may impair glucose tolerance. Likewise, some antipsychotics and depression meds may increase food cravings.

Also, consider the absorption of oral meds, said Gurewitz. “We are somewhat concerned with drugs of low therapeutic window — like warfarin or digoxin — for which if we continue GLP-1s, its levels are proactively measured or replaced by IV [intravenous] alternatives,” he said.

At their highest dose, patients may experience weight loss of about 15%-20%. That level of success may mean that an admitted patient would be reluctant to take a break from a GLP-1, which can be another complicating factor to address. “If the person prescribing the weight-loss meds can’t be present, think through why the patient is on them and what the importance is of them remaining on them,” said Kindel.

Another important consideration upon admittance is the patient’s presenting symptoms and what role the GLP-1s might have in those symptoms. “GI side effects like nausea, diarrhea, and vomiting are common,” said Efren C. Manjarrez, MD, associate professor of clinical medicine in the Division of Hospital Medicine at Miller School of Medicine, University of Miami, Miami. “For instance, the patient could be hypoglycemic. Did the GLP-1 play a role in this?” 

Digging into the patient’s history with the medication is critical here. Recent increases in dosage or if the patient is new to the weight-loss drug may be the cause of these GI symptoms, said Manjarrez. “These medications have a long half-life and if the patient is nutritionally unstable, that could contribute to hypoglycemia,” he said.

For all these reasons, Manjarrez recommends careful consideration about continuing GLP-1 treatment while a patient is in the hospital. “If they are stable metabolically, then it’s probably fine,” he said. “But I typically take them off while inpatient.” 

When Surgery Is in Order 

While admittance is a time for medication evaluation, you enter a new phase of consideration when a patient is headed to surgery. Here the GLP-1 stakes can get even higher. “Surgery is the number one issue to sort through when a patient is admitted on these medications,” said Kindel. “There have been some reports of increased aspiration events, which can be significant.”

Opinions and guidance surrounding this issue vary, so determining how long a patient should stay off a GLP-1 prior to surgery can be difficult. The American Society of Anesthesiologists released guidance in 2023. It suggests that for patients who dose daily, holding the meds for 1 day is sufficient. For those patients on a weekly dosing schedule, however, the society suggests holding the drugs for a full week.

More recent guidance from multiple medical societies, however, gives a nod to an individualized approach. These recommendations highlight the importance of considering stage of dosing, cadence of dosing, the presence of GI symptoms, and medical conditions beyond GLP-1 usage that may also contribute to delayed gastric emptying. 

For hospitalists, this can be a tricky territory to navigate. “Most of the guidance is aimed toward elective procedures,” said Kindel. “Hospitalists are in a different situation, usually emergent or urgent. The decision to hold should involve thought about why the patient is presenting.”

For instance, if a patient is admitted for a broken hip, it might be easier to follow the guidance from the American Society of Anesthesiologists, or even keep them on the meds, perhaps at a lower dosage. If the patient is admitted for GI distress and requires a procedure, removing them from their GLP-1s is likely critical.

To ensure the best patient outcome, then, it’s important to have a full team consult about GLP-1 dosing. “This should involve the patient, the prescribing doctor or surrogate, the anesthesiologist, and the surgeon,” said Kindel. “Allow the patients to voice their concerns because they may worry about losing access to the meds and needing to step back.”

Your patients, no matter what brought them to the hospital, will be leaving at some point, and if they are on a GLP-1, you must consider these medications in discharge orders, too. “If we took them off for medication-related GI symptoms, we need to think about the reasons for putting them back on,” said Manjarrez. “If I feel comfortable, I will restart them, but if not, I would consult with their prescribing doctor.”

The bottom line, said Gurewitz, is to avoid treating GLP-1s as an afterthought. “They can actively alter GI physiology and can influence almost everything else,” he said.

Kindel agrees, especially in light of the fact that the drugs’ usage will likely continue to grow. “We need awareness of the significance of their side effects,” she said. “A thorough history is essential following admittance.”