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

1. Anorexia and active bulimia are hard NOs — everything else is negotiable.
2. Age alone is not a contraindication — frailty status is.
3. "Severe GI disease" per datasheet — respect the label; chronic gastritis/GERD is NOT severe GI disease.
4. Sarcopenia prevention is mandatory in elderly — not optional.
5. 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.