Consent for GLP-1 RA Treatment

Human-based glucagon-like peptide-1 receptor agonists (GLP-1 RA) such as Semaglutide
(compounded), Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®
Mounjaro® are prescribed as an adjunct to a reduced calorie diet and increased physical activity for
chronic weight management in adults with an initial body mass index (BMI) that is considered outside a
healthy range.

While using a GLP-1 RA it is highly recommended that you:

  • Eat a fibrous diet. Focus on fruits and vegetables that are high in fiber

  • Eat small high protein meals as digestion is slowed down while on this medication

  • Avoid foods high in fat as they take longer to digest

  • Drink at least 32oz of water a day to avoid constipation

    Do not take this medication if:

  • You have a personal or family history of medullary thyroid carcinoma (Thyroid Cancer)

  • You have a personal history Multiple Endocrine Neoplasia syndrome type 2 (MEN2)

  • You are pregnant or plan to become pregnant while taking this medicine

  • You are diabetic and/or taking any medications related to lowering your blood sugar levels

    without speaking with your endocrinologist or primary care provider. Specifically, if you are

    prescribed Insulin because the combination may increase your risk of hypoglycemia (low blood

    sugar) and dosage adjustments by your provider may be necessary.

  • You are allergic to Semaglutide or any other GLP-1 agonist such as: Adlyxin®, Byetta®,

    Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Mounjaro® (THIS IS NOT AN

    ALL-INCLUSIVE LIST)

    Possible drug interactions:

  • Anti-diabetic agents, specifically insulin and sulfonylureas (e.g., glyburide, glipizide, glimepiride,

    tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with

    other GLP-1 agonist medicines such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®,

    Trulicity®, Victoza®, Wegovy® Maunjaro® (THIS IS NOT AN ALL-INCLUSIVE LIST).

  • Blood pressure medications: As weight loss may occur on this medication, it is imperative to

    monitor your blood pressure at home while on this medication and taking blood pressure

    medication at the same time. Weight loss may naturally decrease your blood pressure, which

    may make it necessary to adjust your blood pressure medication dosage. As weight loss occurs,

    it is recommended to keep a blood pressure diary.

  • Possible side effects: 

    Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia,

    dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and

    gastroesophageal reflux disease.

    Possible side effects of subcutaneous injections: itching, burning at site of administration with or

    without thickening of the skin.

    If you notice other side effects not listed above, contact your healthcare provider. A very serious allergic

    reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a

    serious allergic reaction, including rash, itching/swelling (especially of the face/tongue/throat), severe

    dizziness, trouble breathing. 

    GLP-1 RA may cause other serious issues such as possible thyroid tumors, including cancer. Tell your

    health care provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or

    shortness of breath. These may be symptoms of thyroid cancer. In studies with rodents, Semaglutide

    caused thyroid tumors, including thyroid cancer. It is not known if Semaglutide/ GLP-1 RA will cause

    thyroid tumors, or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people.

    Report adverse side effects to your clinician. In the event of any emergency, call 911 immediately.

    IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THIS TREATMENT, OR ANY QUESTIONS CONCERNING THIS PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK NOW BEFORE SIGNING THIS CONSENT FORM.

    By signing, I certify that I have read and understand the contents of this form. I am aware of the possible side effects and drug interactions and give my consent for treatment. I have informed the medical staff of any known allergies to drugs or other substances, and any past adverse reactions I’ve experienced. I have informed the medical staff of all medications and supplements I’m currently taking. I understand there are other ways and programs that can assist me in my desire to decrease my body weight and acknowledge that no guarantees have been made to me concerning my results. 

    This consent covers the initial and all future prescriptions for this medication.

  • I understand that this is a prescription therapy and is not eligible for a refund or reimbursement. 

  • I have read and agree to the above.  My questions have been answered and I understand the treatment and goals. I understand and accept the potential risks associated with GLP-1 RA therapy as stated above and consent to treatment.