A Doctor’s Guide To GLP-1 Use

We walk through a full GLP-1 primer: how these meds work, who qualifies, what to expect, and how to avoid the common pitfalls that derail success. We also share dosing strategy, travel tips, and why restarts should be slow and guided.

• brief history of GLP-1s and why newer agents lead care
• eligibility criteria and insurance pathways including OSA indications
• how GLP-1s steady glucose and insulin without hypoglycemia
• appetite, food noise, and gastric emptying explained
• side effect prevention with small meals and hydration
• foods to limit during starts and dose increases
• timing the weekly dose for lifestyle fit
• follow-up metrics beyond weight alone
• safe plans for dose interruptions and restarts
• travel guidance and where to find injection tutorials

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Cash Pay GLP-1s:

LillyDirect  is $299 (2.5mg), $399 (5mg), $449 (7.5 & up) per month for brand name Zepbound

NovoCare is $199 (first two months) then $349 per month for brand name Wegovy (weekly injection)

NovoCare is $149 (first two months) then $299 per month for oral Wegovy (pill)

Costco sells lower dose Ozempic pen for $200 which will last 8 weeks at starting dose of 0.25mg and 4 weeks at 0.5mg dose. Cost increases to $350 for 1mg dose and $500 for 2mg dose. You do NOT need a Costco membership to use their pharmacy.

Advocacy Groups:

https://www.obesityaction.org/

https://glp1collective.org/

Copay Assistance:

https://www.panfoundation.org/

Injection Instructions

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Transcript

Welcome & Scope Of GLP-1 Talk

Dr. Lindsay Ogle, MD 0:00

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 treatment. 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. Today I'm gonna share my GLP1 medication spiel that I typically give my patients in my telehealth practice, Missouri metabolic health. So I'm gonna share that here with you today so you can learn more about how GLP1 medications work, what titration looks like, what side effects to look out for, what weight loss as well as metabolic factors we should see improve over time, and when to reach out for help and more. I utilize GLP1 medications very often in my practice. The two that are FDA approved for the treatment of obesity are ZeppBound and Mangovi. So I use those the most often, but sometimes I do utilize Ozempic off label. You can get that at Costco at a discount price if insurance is not covering GLP1 medications. I'll include that link below. Monjaro, I typically only prescribe for patients with type 2 diabetes because that is the only FDA indication that we have right now. And as of right now, we don't have a cash pay option for that medication. So again, most of what I'm going to be talking about today refers to Zeppound and Weakovi, and I'll make distinctions when necessary or appropriate. But GLP1 medications as a class have been used in clinical practice for 20 years now. And that means that they've been studied for even longer. So it's been about 30 years or so that we have been actually studying this medication class to make sure that it is safe and effective. And we've been prescribing it for patients for 20 years. So we have now decades worth of data to ensure and support its safety, especially short and long term. So that's important to know. And with each reiteration of a GLP1 medication, it just gets better and better, better tolerated, and better affects. So the initial GLP1 medications that were first FDA approved in if it's 2004-2005, Baietta was the first one, I believe. That really is not used anymore. Bidurion, Saxenda, Lyriclutide, the generic fertilicity is escaping my brain right now. It starts with a D. And there may be a few others, but we are not using those anymore. Right now we are almost exclusively utilizing semaglutide and trisepatide. And that is because they are better tolerated and more effective, and actually more likely to be approved by insurance and cost effective. These medications were initially only FDA approved for type 2 diabetes. So they do help regulate blood sugar, but they do it in a very safe way that is based on your oral intake, how much you're eating at one time. So it is not the same thing as insulin. It is not going to drop your blood sugar when you take the medication. So you actually do not need to check your blood sugar while on a GLP1 medication, which is a huge benefit. It'll just help to stabilize and steady your blood sugar over an extended period of time. And it actually does the same thing with your insulin levels. It helps your body to produce more insulin at the time of eating, which helps to keep that blood sugar at a healthier range. It prevents those high spikes of blood sugar after eating. And then overall will keep that blood sugar and insulin more of a steady state rather than up and down, which helps a lot of people not only control their blood sugar and keep it in a healthy range and control diabetes or prevent diabetes, but it can help stabilize energy levels as well as cravings. So this is a very great way that the medication works hormonally. Over time, they have had new FDA-approved indications. And as we all are well aware now, we have the indication for the treatment of obesity. So most of the time that means a BMI of 30 or greater. We know that BMI is not a perfect measure of health or obesity because it does not take into account body composition or health status, but it is what we are mostly using in clinical practice as of now, and what insurance is looking for. So BMI of 30 or greater, or a BMI of 27 or greater, which is in the overweight category with a weight-related condition. And that can be many different things. It can be prediabetes or diabetes, high blood pressure, high cholesterol, obstructive sleep apnea, polycystic ovarian syndrome, PCOS. It could be metabolic dysfunction associated, steatatotic liver disease, mastold or fatty liver disease. It may be chronic kidney disease or heart disease. There are several indications that may qualify. Each insurance is a little bit different there. BMI of 27 or greater with a weight-related condition is FDA approved indication for both Weak OV and Zetbound. Now, Zet Bound also carries an FDA approval for obstructive sleep apnea. So I do have some patients right now. An example is Medicare patients. I have a couple who are on Zetbound, they have obesity and they have obstructive sleep apnea. Their insurance will not cover Zetbound for obesity, but it is covering Zbound for obstructive sleep apnea. So that's important to know, kind of a workaround to get your Zbound, and then it's going to treat both chronic conditions at the same time. And this is frustrating because as a medical society, we know and recognize obesity as a chronic medical condition. And even though we have this diagnosis, we have this definition, and we have these effective treatments, as of right now, insurance is not required to cover the medications for this indication. There are many wonderful advocacy groups that are fighting for access. And I will include links below so you can check them out and support in any way that you can. And hopefully, laws will be passed to ensure coverage for all Americans for the treatment of obesity, which is such a chronic medical condition. 40% of Americans have obesity. So that's a little bit about the history of GLP1s and their indications. So how do they work? They work really by three ways. And I already mentioned the hormonal effects on blood sugar and insulin regulation. So we talked about that. The other two ways that it helps with weight management specifically is that it they block hunger signals and cravings to the brain. So it helps to control excessive appetite as well as controlling what people describe as food noise. So if you are somebody who constantly thinks about their next meal, constantly thinks um are thinking things like, should I eat that? Should I have eaten that? Um, what's going to happen if I don't eat this while I have access to food? You know everything that's in your refrigerator. You go to bed thinking about food. While you're eating, you're thinking about your next meal. Um if you eat a meal and are satisfied and then a couple minutes later are hungry again, a GLP1 medication is likely to be extremely helpful to help control that food noise and excessive hunger. And that is a real biological change that occurs in people who have the disease of obesity, that people who do not understand this disease, that are not obesity medicine physicians, and or do not have the disease of obesity themselves, they don't understand this process because they don't experience that food noise. And it can be really difficult for them to understand that difference, but it is real and it is not true, it is not in your head, you're not making it up. You have higher hunger and higher food noise than most people if you are experiencing that. The third way that GLP1 medications help treat obesity is that it slows the emptying of the stomach. And this helps people feel full on less food and for a longer period of time, which can really help with portion control and can help cut out snacking in between meals. But the delayed gastric emptying or the slowing emptying of the stomach is what leads to a lot of the side effects of the GLP1 medications: upset stomach, nausea, um, acid reflux, heartburn, constipation, or even the opposite of that, loose stools or diarrhea, bloating can occur. What we want to do to help mitigate those potential side effects is we want to eat small meals throughout the day. Because if you eat too much at one time, it's going to put too much pressure on the stomach and lead to bloating, upset stomach, reflux. And so sticking to small meals is really important. You also want to avoid an empty stomach because an empty stomach can actually trigger nausea. So I do not recommend intermittent fasting for the majority of people on a GLP1. I highly encourage eating breakfast in the morning to prevent nausea. You also want to ensure that you're staying well hydrated. This is probably the number one mistake that I see for people on a GLP1 medication. They're not drinking enough water, and that leads to nausea, fatigue, constipation, headaches. So make sure you're drinking plenty of water while you're taking a GLP1 medication. The medications, like we talked about, will suppress hunger signals. And sometimes the brain confuses hunger and thirst, so you might have suppressed thirst signals as well. So you have to be on top and be in a habit of drinking water throughout the day. Keeping water near you at all times, having a fun water bottle is extremely helpful. Fluids other than water count. So ideally unsweetened or very lightly sweetened drinks, um, like uh like tea or even coffee, um, electrolyte drinks, uh, that sort of thing do count as fluids. Um and you get some fluids with food, but really um water is what you should be focusing on. And if you're struggling with this, please let your doctor or dietitian know because they will help with tricks to help increase water intake. You also want to avoid spicy and greasy foods. Um, the spicy and greasy foods um unfortunately can really lead to an upset stomach and loose tools and diarrhea. Um, most commonly, I hear pizza is a huge trigger for my patients for an upset stomach. It doesn't mean that you can never have pizza or you can never have fast food or fried foods or spicy foods. It just means that you need to eat them in smaller portions and probably want to avoid them when you're first starting the medication and every time you increase your dose because that is when you're more likely to have side effects. Also, to mitigate side effects, we start at the lowest dose and then are staying at that dose for at least four weeks, and we'll have you come back in four weeks. And if you are experiencing side effects, we'll talk about how to mitigate them and manage them. Um, and we may stay at that dose for a longer period of time, and that's okay. Um, some people don't have side effects at all, and that's wonderful. Um, but if you're having side effects, you should reach out to your doctor to let them know they want to know what's going on and how you're feeling on a new medication. Also, the effects of the medication are strongest the day to three days after taking your medication. So be aware of that when you choose which day of the week you want to take your medication. People typically fall into two categories. One, um, people would rather not be at work if they're feeling ill, so they take their medication on Friday. Um, other people really want to feel great on their days off, and so they take their medication on Sunday, and then everywhere in between. Really, there's no right or wrong. You can choose what's best for you. There also can be some strategy here if you tend to eat really well on your routines during the weekdays but struggle on weekends, then it's probably best to take your medication on Thursday or Friday so you have more of the appetite suppression and fullness over the weekend versus on the weekdays when you typically don't struggle. I also recommend my patients to take their medication in the evening time. So I typically say, especially if you, well, if you're on Zup Bound or we go B and they have single dose pens, um, take your pen out on your injection day when you are preparing dinner. Um, set it on the counter, uh, let it get to room temperature, and then when you're done with dinner sometime before bed, take the pen, give yourself the injection, and then go to bed. This allows you the day of your injection to really focus on hydration, get a good solid base of nutrition, and then the medication is coming into effect overnight. Um, I have heard some people, if they um approach it this way, this can interfere with their sleep. So if that's you, that's okay. You can take it in the morning, no problem. Um, that's just what I recommend starting off with. And then, like I said, you are going to be on your dose for at least a month. And then when you follow up with your doctor, um, or if you are seeing a Missouri metabolic health and you're following up with me, we're gonna see if you're having any side effects. We're gonna talk about the appetite suppression, the fullness, the food noise. What are you experiencing? Have um have you weighed yourself? Have you lost weight? Have you noticed the clothes are fitting different? How's your energy levels? How's your sleep? Are you moving? Has your nutrition changed? What what is your life like now on the medication? All of those factors play a role on if we go up on the dose or not. If for whatever reason you have a dose interruption and you are not taking your medication, whether that is supply issues at the pharmacy or you can't afford it for a period of time, or you have a surgery and your anesthesiologist wants you to hold the medication, or you just decide that you want to take a break for a personal reason, please, please, please let your doctor know that you are stopping the medication and definitely reach out to them before you restart the medicine because it is very likely that you will need to restart at a different dose. Just because you tolerated a higher dose of a GLP1 medication previously does not mean that it is safe to restart at that dose. The medication goes out of your system and your body gets used to not having it, and you likely need to start over at a lower dose. I have had patients who have stopped the medication for a period of time and then restarted at a high dose without telling me and were very, very sick. And I don't want that to happen to you. So just remember you can always and should always communicate with your provider who is prescribing your GLP1 medication if there are any interruptions. Travel is usually um very doable with a GLP1 medication. So check out the instruction labels to see how long your medication can be at room temperature because they can be at room temperature for several weeks, and each brand is a little bit different. So take a look at that and you can definitely travel with your medications. If you have any questions, definitely ask your pharmacist or your physician about the recommendations for your particular case and what your travel looks like. I do plan to have an upcoming episode about travel tips while on a GLP one, so stay tuned for that. One thing I didn't mention is how to actually give yourself the injection. And instead of going through that step-by-step detail because it's different for each brand, it's a little bit different. I am going to include instructional video links below so you can take a look at that if you have any questions. That those are great resources to take a look at. So as you can see, this talk took some time, and that's why you don't always get this level of detail when you see a primary care doctor or even a busy obesity medicine physician or endocrinologist about your GLP1 medications because it takes time. So I hope you found this video helpful. Please share it with anybody who is thinking about a GLP1 medication or maybe is already on one but didn't get great guidance. I hope that this will help support them and to ensure that they are getting the right information so that you and them may be able to stay on the medication longer and troubleshoot any issues that come up. I hope you have a wonderful week. See you next time. 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.