Older Patients Have Specific Risks for GLP-1 Use

 As GLP-1s continue to surge in demand, older patients in your practice may inquire about these medications for their weight-loss efforts. Although they are known to improve conditions such as high cholesterol and obesity and help with the management of type 2 diabetes, certain precautions should be considered for patients older than 65 years.

Older adults often do their own research on wellness trends. If they ask about GLP-1 medications, knowing clinical and science-based facts can keep them informed and safe. Some experts say these medications and this patient population should be carefully considered.

Yuval Pinto, MD, DABOM

Yuval Pinto, MD, DABOM, assistant professor of medicine and part of the Healthful Eating, Activity & Weight Program at Johns Hopkins School of Medicine in Baltimore, laid out some of the risks.

High Risk

Sarcopenia. Sarcopenia is an age-related progressive loss of skeletal muscle mass and strength that accelerates after age 65, increasing a patient’s risk for frailty, falls, disability, and functional decline. “GLP-1 RAs [receptor agonists] exacerbate sarcopenia by promoting lean mass loss along with fat mass loss during weight reduction,” said Pinto. “This is particularly concerning in rapid weight-loss scenarios as it may push an already vulnerable population into frailty and increased fall risk.”

Bone loss. This can lead to an increased risk for fractures. “Rapid weight loss reduces mechanical loading on bone, decreases the forces that stimulate bone formation, disrupts bone mineral homeostasis, and leads to decreased bone mineral density,” Pinto said. Older patients with diabetes treated with GLP-1 RAs showed a 12% increased fracture risk compared to those treated with other diabetes medications. Moreover, the FDA labeling for Wegovy (semaglutide) documents hip fracture rates of 1% vs 0.2% with placebo. This is particularly important for postmenopausal women who face elevated baseline osteoporosis risk, research supports.

Dehydration/acute kidney injury. Nausea, vomiting, and diarrhea, which are all common side effects of GLP-1 RAs, reduce fluid intake and increase fluid loss. “Elderly patients, particularly those with baseline reduced kidney function or poor hydration habits, are at high risk for severe dehydration even from mild gastrointestinal [GI] symptoms,” said Pinto.

Moderate Risk

GI side effects. These are common with these medications and can include nausea, diarrhea, abdominal pain, and vomiting. “Symptoms are often tolerable in younger patients; they can precipitate serious medical complications in elderly patients, particularly dehydration and acute kidney injury,” he said.

Hypoglycemia. When used as monotherapy, GLP-1 RAs pose a low hypoglycemia risk; however, when combined with insulin or sulfonylureas, hypoglycemia risk increases significantly, Pinto outlined.

Neurologic changes. Among older adults receiving GLP1-RA treatment, dizziness is the most frequently observed neurologic side effect.

Greater Supervision?

If your assessment leads you to believe that an older patient is a suitable candidate for a GLP-1, more monitoring is warranted.

Shauna Levy, MD, MS

“Older individuals benefit from closer monitoring on GLP-1 medications, and these patients need to closely monitor their muscle mass hydration status and nutritional status,” said Shauna Levy, MD, MS, chief of bariatric surgery at Tulane University School of Medicine and medical director of Tulane University’s Bariatric and Weight Loss Center, both in New Orleans. “These individuals also may overly restrict their calories, which could lead to malnutrition and other complications.”

Also, she said, physicians should regularly check labs on these patients to make sure there are no obvious abnormalities, especially when it comes to hydration status and kidney function.

In addition, advising patients to use only branded GLP-1s is key.

“It is also important that the patient uses branded medications rather than compounded medications to ensure consistent medications and that the dosing schedule can be followed closely,” said Levy.

Levy also provided additional directives to ensure the patient remains healthy:

• The patient should strive for 60-90 g/d of protein and ideally meet with a dietitian to monitor their oral intake.
• The patient should strive for 64 ounces of decaffeinated fluid per day.
• The provider should emphasize resistance training several times per week.
• The medication dose should not be increased until the patient is tolerating the lower dose.

When Not a Good Candidate for a GLP-1

GLP-1 medications aren’t appropriate for all patients. Pinto notes patients in these situations aren’t candidates for the medications.

The absolute contraindications for the initiation of GLP-1 in the older patients are:

• Personal and/or family history of medullary thyroid cancer or multiple endocrine neoplasia type 2 syndrome
• History of bowel obstruction or severe gastroparesis
• End-stage renal disease or dialysis

Consider these strong relative contraindications:

• Moderate-severe dementia or cognitive impairment (“These elderly patients can’t provide feedback on hunger, thirst, or GI symptoms,” he said.)
• CKD stage 4 due to elevated risk for kidney injury
• Baseline sarcopenia or frailty and history of falls
• Severe osteoporosis
• Uncontrolled severe psychiatric illness such as anorexia nervosa, bulimia, or severe depression (“This condition might be worsened when appetite is suppressed,” Pinto said.)

Pinto and Levy reported having no disclosures.

https://www.medscape.com/viewarticle/older-patients-have-specific-risks-glp-1-use-2026a10003bb