Fifty-five year-old Gujarat resident Ravi* had heard of the weight-loss properties of semaglutide, a diabetes regulating drug with spin-off effects on obesity. While he found it difficult to take the injectable drug, he bought oral pills over-the-counter from a local pharmacy. Several months later he decided to go to Dr Anoop Misra’s clinic to get evaluated, worried about the side effects he had read about.
While undergoing tests, he was diagnosed with medullary thyroid cancer. In fact, he had a family history of this type of cancer, and, therefore, belongs to a group of patients unsuited for new-age weight loss drugs. Some animal studies have linked an increase in the risk of this type of cancer with the use of GLP-1 drugs such as semaglutide. “Those with a family history of this type of cancer should not be prescribed semaglutide — the drug comes with a warning. This is why we need to carefully select patients who are given GLP-1 drugs. The drug should not be prescribed by anyone other than diabetologists, internal medicine specialists, or in some cases cardiologists. And, it should definitely not be taken without the advice of a doctor,” says Dr Anoop Misra, chairman, Fortis C-Doc, Diabetes and Allied Sciences, New Delhi.
While this was a very prominent case where the patient should not have received the drug at all, Dr Misra is worried about many self-medicators, taking both oral and injectable versions on their own. This number has increased to one case every 10 days at his clinic since the injectable drugs became available in India last year. “These numbers are likely to go up further with cheaper generic versions of semaglutide now available in the market,” he says.
As for side effects, he has seen patients come in with gastrointestinal symptoms such as nausea or vomiting or in some cases other more severe symptoms such as pancreatic pain. “These drugs can lead to substantial weight loss and improve blood sugar control, making them attractive options for obesity and diabetes management. But the protocol has to be customised according to the patient’s profile.”
Who should not take the drug?
Thyroid Cancer Risk: Individuals with a personal or family history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN2) should avoid these medications due to potential cancer risks.
Pregnancy and Breastfeeding: GLP-1s are not safe during pregnancy (should stop 2 months before conception) or while breastfeeding.
Pancreatitis: A history of pancreatitis is a contraindication as these drugs can increase the risk of pancreatic inflammation.
Severe Gastrointestinal Disease: Those with severe gastrointestinal issues, particularly gastroparesis (slow stomach emptying), should not use these drugs.
Allergy: Known serious allergies (anaphylaxis) to GLP-1 agonists or their ingredients.
Who needs vigil
Diabetic Retinopathy: Individuals with vision damage from diabetes should consult a doctor, as rapid blood sugar improvement can temporarily worsen this condition.
Mental Health Conditions: A history of eating disorders or depression requires careful evaluation.
Kidney Impairment: People with an eGFR below 30. Patients with advanced kidney disease may require careful monitoring, particularly because nausea, vomiting and dehydration can worsen renal function.
The correct dosage
Selecting the correct dose and scaling it up slowly is the right way to ensure weight loss drugs do their job, according to Dr V Mohan, chairperson of Dr. Mohan’s Diabetes Specialities Centre in Chennai. “This is the reason why the medicine should always be taken under the guidance of a doctor,” he adds. The drug is meant for people with a body mass index over 30 or between 27 and 30 if they have other obesity-related conditions such as diabetes or hypertension.
Take the case of 50 year-old Chennai resident Sangeeta* who took a very high dose for her first shot. She mistakenly dialled a high 1 mg instead of 0.1 mg on her pre-filled pen. She ended up in a hospital with severe vomiting, which took doctors nearly two days and several saline drips to control properly. “Most patients experience nausea and vomiting initially, some may also experience diarrhoea. But every patient reacts differently. Some experience the symptoms initially even with the smallest doses, but don’t experience it later with the higher doses once they have adjusted to it. Others might experience such symptoms only on higher doses and thus have to maintained on a lower one. Some may need to continue with the lower dose longer than the recommended four weeks before scaling up or they may need to skip a week in between. This is the reason they have to be constantly followed up,” says Dr Mohan.
This dose adjustment, other than selection of the patient, also plays an important role in safe use of the drug. Dr Mohan adds, “Even before the generic versions entered the market, there were some unscrupulous gym trainers, beauticians, and wellness studios who were prescribing the drug to people. That’s how the trend of Mounjaro brides began, where women take the drug before their wedding to shed the extra kilos. While most patients experience just gastrointestinal symptoms, the drugs also have some serious side effects.”
The GLP-1 drugs have been linked with an increased risk of thyroid cancer, pancreatitis, stomach paralysis and even a specific type of blindness. “The drugs have also been linked to depression. If anything happens to a person, who will take care of the symptoms, who will be responsible? If a doctor prescribes the medicine, they would be responsible for managing the side effects as well,” says Dr Mohan.
Increased prescription
With cheaper generic versions costing up to 90 per cent lower than the innovator molecule, their prescription has increased. “There has certainly been an increase in prescription of the GLP-1 drugs with the generic versions becoming available and the innovators dropping prices. What this essentially means is that people, for whom the price might have been a barrier earlier, are now considering using the drugs,” says Dr Ambrish Mithal, Chairman and Head of Endocrinology and Diabetes at Max Healthcare.
While he hasn’t seen patients landing up with acute side effects in his clinic, he does see patients who have started taking the drug without consultation but later reach out to him after family or friends advise against it.
“While there are strict guidelines as to who should be prescribing the medicine, enforcing it can be a challenge. Some doctors may also prescribe it because they know if they don’t, someone else will. But it should definitely be given only to those it is meant for. When appropriately prescribed and monitored, GLP-1 drugs remain safe and effective for many patients,” says Dr Mithal.
*Names changed to protect privacy
Weight-loss drugs risk: A Gujarat man diagnosed with cancer after taking semaglutide without medical advice highlights growing concerns over unsafe and unsupervised use. (Representative Image) 
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