Semaglutide Prescribing Guidelines

Essential Baseline Laboratory Tests

• The American College of Cardiology recommends assessing renal function using serum creatinine and eGFR, particularly since GLP-1 receptor agonists can be used when eGFR is <45 mL/min/1.73 m², though with reduced glycemic efficacy 1, 2

Critical Clinical History Assessment

• The American College of Cardiology notes that a history of multiple endocrine neoplasia syndrome type 2 (MEN2) is an absolute contraindication to semaglutide use 1
• Patients with a history of diabetic retinopathy should be documented, as semaglutide may increase risk of retinopathy complications 3
• A history of gastroparesis or active gallbladder disease are relative contraindications given the delayed gastric emptying effects of semaglutide 3
• The American College of Cardiology recommends caution in patients with a history of diabetic ketoacidosis 2

Monitoring Recommendations After Initiation

• The American College of Cardiology recommends that patients undergo guideline-recommended eye examinations before starting therapy if not done within the last 12 months 2, 3
• Patients should be instructed to monitor glucose more closely for the first 4 weeks, especially if on insulin, sulfonylureas, or glinides 3
• Renal function should be monitored periodically, particularly when initiating or up-titrating ACE inhibitors or ARBs concurrently 1

Medication Adjustments Based on Baseline Labs

• If HbA1c is well-controlled at baseline, consider reducing sulfonylurea dose by 50% or basal insulin by 20% when starting semaglutide to prevent hypoglycemia 2, 3
• If eGFR <45 mL/min/1.73 m², semaglutide can still be used, though glycemic efficacy may be reduced 1, 2

Laboratory Testing When Starting Semaglutide

Essential Baseline Laboratory Tests

• Repeat thyroid testing (TSH and free T4) before each cycle during the initial treatment period, as recommended by the Journal for ImmunoTherapy of Cancer 4
• Measure total bilirubin and transaminases, as GLP-1 receptor agonists can reduce hepatic steatosis and improve liver function in patients with NAFLD, according to Circulation 5

Renal Function Considerations for Initiating Semaglutide

Baseline Laboratory Requirements

• Baseline serum creatinine and estimated glomerular filtration rate (eGFR) must be obtained before starting semaglutide because the medication does not require dose adjustment across all chronic kidney disease (CKD) stages, even when eGFR is < 30 mL/min/1.73 m²; these values are needed to monitor for acute kidney injury secondary to dehydration. 6

Use in Moderate Renal Impairment (eGFR < 45 mL/min/1.73 m²)

• Semaglutide can be prescribed without dose modification in patients whose eGFR is < 45 mL/min/1.73 m², although the drug’s glycemic efficacy may be somewhat reduced; clinicians should closely observe renal function for any signs of acute kidney injury. 6

Use in Severe Renal Impairment (eGFR < 30 mL/min/1.73 m²)

• Even when eGFR falls below 30 mL/min/1.73 m², no dose adjustment of semaglutide is required, but heightened vigilance for gastrointestinal adverse effects that could lead to dehydration—and consequently renal injury—is essential. 6