Modern Metabolic Health with Dr. Lindsay Ogle, MD

How To Manage GLP-1 Side Effects

• Lindsay Ogle, MD

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0:00 | 14:27

We explain how to tolerate GLP-1 medications without miserable side effects while still reaching weight and metabolic goals. We share dosing strategy, real-world tips, and when to switch medications or choose other tools.

• GLP-1 approvals for diabetes and weight management
• Mechanism behind nausea, constipation and reflux
• Start-low, go-slow dosing with patient control
• Long-term benefits for heart, kidneys and liver
• Injection site swap from abdomen to thigh
• Hydration and electrolyte timing across injection days
• Breakfast first, smaller frequent portions, more protein
• Avoid greasy foods, excess sugar and reflux triggers
• Fiber targets, stool softeners and cautious senna use
• Movement to aid gut motility
• Considering a switch from semaglutide to tirzepatide
• Alternative therapies including bariatric surgery

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Dr. Lindsay Ogle:

Welcome to the Modern Metabolic Health Podcast with your host, Dr. Lindsay Ogle, Board Certified Family Medicine and Obesity Medicine Physician. Here we learn how we can treat and prevent modern metabolic conditions such as diabetes, PCOS, fatty liver disease, metabolic syndrome, sleep apnea, and more. We focus on optimizing lifestyle while utilizing safe and effective medical treatments. Please remember that while I am a physician, I am not your physician. Everything discussed here is provided as general medical knowledge and not direct medical advice. Please talk to your doctor about what is best for you. GLP1 agonists are one of the main medications that I prescribe. These are the super common medications, Ozempic, Weigovi, Monjaro, and ZeppBound. There are many more GLP1 agonists, but these are by far the most common. And while there are some slight differences in each brand, they have very, very similar, if not identical, side effect profiles. And so I'm gonna talk about them as one class altogether. But briefly, I want to kind of identify which one is used in each scenario. So for type 2 diabetes, Ozempic and Monjaro are FDA approved. Ozempic, the generic name, the active ingredient is semaglutide, and for Monjaro, the active ingredient is trisepatide. Ozempic was first approved and then Monjaro was approved later. As far as FDA approval for weight management, we have Uigovi, which is the equivalent or this is very similar to Ozempic, so its active ingredient is semaglutide. We have Zeppbound, which is equivalent to Monjaro, and again the generic active ingredient name is called trisepatide. The most common side effects that patients experience with these medications are related to how they work. So one of the main mechanisms of GLP1 agonists is that they slow the digestive process in our gut. So food tends to sit in the stomach longer, and that can lead to nausea, it can lead to acid reflux, it moves through your intestines at a slower pace, which can lead to constipation, stomach upset, and paradoxically, some people actually have diarrhea. So what can we do to help with these side effects? We have several ways to limit these or reverse them. One of the first and most important things is that these medications should be started at the lowest dose and you should be maintained on that lowest dose for at least four weeks. Now, if any of my patients are experiencing side effects that are affecting them on a regular basis, even as much as a few times per week, I'm going to keep them at that lower dose for a longer period of time to get let their body get used to the medication. Once somebody is tolerating that dose very well and they're not having side effects and they're happy with where they're at, then I will consider increasing the dose. But I still only increase the dose if we need to. If you are losing weight at a lower dose, if your appetite is suppressed, if you're feeling full on less food, if you are seeing your blood sugar levels go down, there's no reason to push to a higher dose. You can stay at those lower doses. That is absolutely fine. What I tend to see, and what people kind of come to me with prior experiences, say that their doctor continuously increased the dose month after month, even when they were having side effects, and it just became too uncomfortable. And really, I'm somebody who looks at the bigger picture. We know that these medications have been shown to improve cardiovascular health. They are now showing evidence of improving kidney function, fatty liver disease. So there are so many benefits in addition to weight management and blood sugar control that we see with these medications. So I'm looking at this person in front of me and thinking about what is their health gonna look like 10, 20, 30 years down the road. And I want to give them the best shot at long-term health, long-term success, and this medication may be a part of that. And so if we can take it slower in the beginning, it may take longer to reach those goals, but we will eventually get there, and that's what matters. So I am not in a rush to increase a dose by any means. And so if you have tried these medications in the past and were consistently increased on your dose and it didn't go well, maybe you didn't have a chance to fully get used to the medication at the lower doses, and it could be worth trying again. So that's something to consider. And if you are considering starting one of these medications, this is something that you can take back to your doctor and comment that maybe you're not ready to increase your dose and you would feel more comfortable staying at a lower dose for a longer period of time. You have that control over your health and well-being. If you are taking your time with increasing the dose and you're still having side effects, we have some tips and tricks to help offset those or minimize them or reverse them. Some of the things that you can do, and a lot of these I actually learned from my patients, and they, you know, were able to try these things and they would share with me what works really well for them. One thing that I find extremely interesting is that I've had several patients tell me that if I do the injection in my abdomen and my belly, then I get more side effects. But if I do the injection in my thigh, I still get the benefit of the medication, but I'm not having as many side effects. I've had multiple people tell me about this, and so now this is something that I share with my patients to help limit their side effects. So that is something very easy that you can try and see if that helps you. Some other lifestyle things that you can try would be making sure that you are staying very well hydrated. These medications they can suppress hunger, but they also can suppress thirst signals to the brain. And so it's very important that you continue to drink lots of water throughout the day, especially the day before, the day of, and the day after your injection. Dehydration can cause us to feel nauseous, and that is a very common trigger. So making sure you're drinking plenty of water and consider adding an electrolyte drink into your routine. Again, those three days of the week would be the main focus in adding that and that electrolyte drink if that is something that you would consider. Of course, looking for sugar-free options for your electrolyte drink. Another thing that I hear time and time again is to avoid an empty stomach. Again, these medications suppress the appetite, so it may be very easy and tempting to skip breakfast or even skip lunch, but I do not recommend this. I recommend eating smaller meals throughout the day when you are on a GLP1 agonist, especially eating breakfast. Very important. And people who eat breakfast tend to maintain their weight loss long term. Eating breakfast while on these medications can help limit or avoid the nauseous feeling that you experience. Also, avoiding excessive amounts of sugar and greasy foods. Those can be big triggers for nausea as well as changes in bowel movement, especially leaning towards the loose tools or diarrhea. And making sure that you are getting an adequate amount of protein. So if you are eating some protein in your meal, that will help with some of the nausea symptoms that you're having. As far as constipation, the typical things that we recommend to help with constipation will help here as well. So making sure you're getting enough fiber in your diet, slowly increasing the fiber will help prevent an upset stomach, but shooting for a goal of 25 to 35 grams of fiber per day. Making sure you're drinking a lot of water. If you are dehydrated, your body is pulling that water so that it can hydrate itself and it's leaving the stool in your gut to be very, very hard and dry and difficult to pass. So that is why dehydration can make constipation worse. So another reason to drink lots of water throughout the day, consider electrolyte drinks as well. And you can take stool softeners. So some of my patients just taking a stool softener at night can be helpful. So when I'm talking about stool softeners, what I'm really talking about is cholase, and that's the active ingredient to look for. If what you are taking has senna in it, then it is what we consider a stimulant laxative, and that is something that you want to avoid on a regular basis because your gut can kind of get used to that. Senna is fine to use as needed along with the colease, but if you're using or needing something on a more regular basis, look for cholase, increase your dietary fiber. You can consider a fiber supplement as well, and that may include metamucil or other generic alternatives, and making sure that you're staying very well hydrated. Physical activity can also be helpful here, so moving your body can help get your GI tract moving as well. On the other side of having an empty stomach, eating too much at one time can really stretch those stomach receptors. That can trigger nausea, upset stomach, and can definitely trigger acid reflux. So having smaller portions at a time, more frequently throughout the day will help prevent that side effect. If you're having a lot of acid reflux, avoid triggers. Common food triggers are caffeine, alcohol, spicy foods, tomato-based products. Those are the main triggers that we think of. And avoid lying down 30 to 60 minutes after eating. When you lay down, you're more likely to have that acid reflux occur. So making sure you're sitting up or standing up or walking around after meal. Last, if you are on semaglutide, so remember that is ozempic or we govy, consider switching to trusepatide, which is manjaro or zep bound. I have many patients who struggled on semaglutide that were able to tolerate trisepatide. Even though these are very similar medications, trusepatide has a second mechanism along with it that helps to offset that stomach upset. And I see this pretty consistently. So if you did not tolerate semaglutide, that does not mean that you will not tolerate trisepatide. It may be worth trying. You may be able to tolerate that and get really great results. Alternatively, whether you are treating your type 2 diabetes or obesity, there are a plethora of other medication options as well as lifestyle options. We should never forget the role of bariatric surgery as well. There are other tools in our toolbox rather than just the GLP 1 agonist. So talk to your doctor, figure out what options may be appropriate for you, but do not forget these tips that may help offset the common side effects of GLP 1 agonist. Thank you for listening and learning how you can improve your metabolic health in this modern world. If you found this information helpful, please share with a friend, family member, or colleague. We need to do all we can to combat the dangerous misinformation that is out there. Please subscribe and write a review. This will help others find the podcast so they may also improve their metabolic health. I look forward to our conversation next week.