GLP-1 Receptor Agonists in Patients Taking Duloxetine and Mirtazapine

Absolute Contraindications

The American College of Endocrinology and other guideline societies recommend that patients with a personal history of medullary thyroid carcinoma, family history of medullary thyroid carcinoma, or multiple endocrine neoplasia syndrome type 2 should not take GLP-1 receptor agonists 1

The American Diabetes Association and other organizations note that nausea is the most common adverse effect of GLP-1 RAs, occurring in 15-20% of patients, and monitoring for additive GI symptoms is recommended when combined with duloxetine and mirtazapine 2
The Anaesthesia society guidelines suggest starting GLP-1 RAs at low doses and titrating slowly to minimize gastrointestinal side effects, particularly when combining with antidepressants that may have GI effects 3
The American Heart Association and other guideline societies recommend monitoring for enhanced nausea during the first 4-8 weeks of GLP-1 RA initiation, as this is when GI side effects are most prominent 2
The American Society of Anesthesiologists guidelines state that assessing gastric symptoms before procedures and being aware that GLP-1 RAs delay gastric emptying and may increase aspiration risk is crucial, and current guidelines recommend continuing GLP-1 RAs throughout the perioperative period but with enhanced aspiration precautions 5

The American College of Cardiology and other guideline societies recommend considering GLP-1 RAs with proven cardiovascular benefit for patients with type 2 diabetes and cardiovascular disease or risk factors, regardless of antidepressant use 2
The Endocrine Society notes that mirtazapine commonly causes weight gain, while GLP-1 RAs produce weight loss of 1.5-3.5 kg in diabetic patients, and this combination may actually be beneficial if weight gain from mirtazapine is a concern 2
The American Psychiatric Association and other organizations state that duloxetine is generally weight-neutral, so the weight loss effects of GLP-1 RAs would be the dominant factor 2