dromlakhani GLP-1 Candidacy — Myths Checker
Purpose
Many patients are falsely excluded from GLP-1 therapy on the basis of commonly-held misconceptions. This skill separates true contraindications from myths and gives the conditions under which "excluded" patients can actually benefit.
Activation
Trigger when:
- Clinician asks if GLP-1 is safe in a specific "risky" profile.
- Patient is being deferred from GLP-1 based on eating disorder, age, or upper GI disease.
Decision by Profile
Eating Disorders
| Subtype | GLP-1 RA allowed? | Condition |
|---|---|---|
| Binge Eating Disorder (BED) | YES | With concurrent psychology/psychiatric care |
| Night-Eating Syndrome | YES | With concurrent psychology/psychiatric care |
| Anorexia nervosa | NO | Absolute contraindication |
| Bulimia with self-induced vomiting | NO | Until psychiatric disorder resolved with psychotherapy/pharmacotherapy; then reconsider |
Add: any eating-disorder patient starting a GLP-1 RA must receive educational input on a healthy lifestyle, not just the prescription.
Elderly — ≥75 years old
- GLP-1 RA is beneficial for cardiovascular + renal morbimortality in this group — do not reflexively exclude.
- Concern is sarcopenia — weight loss is mostly fat mass but monitor lean mass.
- Mitigation: nutritional advice, protein target ~1.5 g/kg/day, muscle-strengthening exercise (elastic bands, small dumbbells).
- Dose: maintenance dose may be below the datasheet maximum — pivotal trials show glycaemic + weight benefit at lower doses in fragile patients.
- Use Clinical Frailty Scale to guide dose individualisation.
- Insulin co-treated elderly: GLP-1 often lets you reduce insulin → fewer hypos → net benefit.
Upper GI Disease (chronic gastritis, GERD, hiatal hernia)
- Tolerated well in the published study — mild/moderate AEs only, no withdrawals.
- No dose adjustment required.
- Patients with chronic intestinal pathology are also candidates.
- Caveat: several GLP-1 RA datasheets still don't recommend use in severe GI disease due to limited experience — respect the label for severe cases.
- In GERD: reinforce small frequent meals, avoid LES-relaxing foods (fat, fried, chocolate, mint, tomato), avoid lying down post-meal; short PPI course is reasonable during titration.
Weight Loss Driven by GI AEs? (Myth #1)
- NO — weight loss with GLP-1 RA is largely independent of GI AEs.
- Do not withhold therapy from someone who is symptom-free thinking they "won't lose weight without nausea".
- Do not push someone towards more nausea thinking it will drive more weight loss.
Rules & Constraints
- Anorexia and active bulimia are hard NOs — everything else is negotiable.
- Age alone is not a contraindication — frailty status is.
- "Severe GI disease" per datasheet — respect the label; chronic gastritis/GERD is NOT severe GI disease.
- Sarcopenia prevention is mandatory in elderly — not optional.
- Don't promise weight loss requires nausea — explicitly debunk.
Reference
Gorgojo-Martínez JJ et al. J Clin Med 2023;12:145. §6 (Myths or Reality), §6.2.