Dr. Sarah Stombaugh:
This is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight Podcast.

Announcer:
Welcome to the Conquer Your Weight Podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here’s your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh.

Dr. Sarah Stombaugh:
If you have been taking a GLP medication like Zepbound or Wegovy for any length of time, you’ve probably missed a dose of your medication at some point. And if you are relatively new to the medication, unfortunately what I can probably promise is there will be a time that you miss a dose of your medication. This happens for so many different reasons, but when this happens, people are often wondering, okay, what should I do? When should I take my next dose? How long is it okay to miss the dose before I need to be concerned about it? In today’s episode, we are going to walk through what you need to know, some specifics with different medications so that you can make a plan if you miss your dose. It happens for all sorts of different reasons. Maybe you’re traveling and forgot to bring the medication with you.

Maybe your pharmacy wasn’t able to get the medication or you’ve had a change in insurance, so you no longer have an approved prior authorization, or maybe you have one but your prior authorization expired, so you’re waiting to get that renewed. Maybe you’ve had surgery or so you’re preparing for surgery or you’ve just had surgery. There are all sorts of different reasons why people might miss their dose of medication. And the biggest question is, well, can I resume my medication? We’re going to get into the details of that in today’s episode. I am Dr. Sarah Stombaugh, board certified obesity medicine physician, and I want you to feel comfortable taking your GLP medication. So let’s talk about what this looks like. Let’s say you forgot your dose of medication. A lot of times, ideally we get into a routine where we have the same day of the week every week that we’re taking the medication.

So we know that every Thursday, for example, or every Sunday or whichever day it is that this is my medication day. And if you look at the guidelines both for brand name Wegovy, brand name Zepbound, they actually have recommendations about that saying, “Hey, look, if you miss a dose, no big deal. If it’s been close to when you’re due for your second dose, just go ahead and wait till that next dose is due,” because they’re trying to keep you into that routine. Both of these medications are pretty long-acting medications. Zepbound has a half-life of five days and Wegovy has a half-life of seven days. So what that means is it really takes about three to four weeks for these medications to build up in your system, and it takes about three to four weeks for these medications to also leave your system entirely or significantly.

So if you miss a single week in there, it’s really not that big of a deal. So if it’s been one week or less, no big deal, or I should say one missed week or less, so about two weeks from your last dose, no big deal, you can absolutely resume that medication. The specific advice for the Wegovy medication is if it has been more than two weeks since your last dose, reach out to your prescriber. The specific advice for the Zepbound medication is if it’s been more than 21 days or three weeks that you should consider re-titrating alongside of course your prescriber from a lower dose of medication. But let’s say you’re in the midst of that, especially if you don’t have access to the medication or maybe you’re preparing for surgery or like, “I wish I could take this medication, but I was told that I’m not allowed to,” it can be really scary to be off the medication for a period of time.

People will notice that they may feel more hungry. They may notice that they’re eating more during meals, so that fullness signal is coming up very differently. But what I want you to know is that medication hasn’t completely disappeared from the body, especially if you’re in that first couple of weeks window. So we might see some weight fluctuations, we might notice that our hunger signals are more significant, and I want you to know that that is okay. We may have to rely on other things. We might have to rely on, let me make sure I’m really well hydrated, let me eat large volumes of fiber-rich foods. So relying on volume eating, for example, with lots of vegetables can be an incredibly effective way to helping fill up the body, especially if you’ve partnered that with proteins and fats that can give you some lasting satiety, but recognizing we’ll get you back on your medication and it’s going to be okay.

But sometimes you don’t have your next dose available and you don’t know when that’s coming. I dare to even say it, we’ve not been running into a lot of medication shortages recently, but there was definitely a period of time last year and the last two years that we were having significant issues with patients being able to access their medication. So they would go to the pharmacy, they would say, “Hey, I’m here to pick up my refill.” And they would say, “We don’t have it in stock and we don’t know when we’re going to get it.” And patients may be calling all over town. We might be switching them from one medication to another. We might be increasing or decreasing their dose just so that they were able to access something. Luckily, I have not been running into that in my practice at all recently, but it is something that happened.

The situation that’s a little bit more common is right now you’ve changed insurance, maybe your prior authorization has expired, you’re due for the next dose and you don’t yet have insurance coverage for it, and so you’re waiting maybe to hear back from your insurance company to get that medication coverage so that you can move forward with getting your medications at a decent price. And this can be really pretty scary when you’re in this situation. And again, if it’s more than one week, if you’re hitting that two week mark, no big deal, you can absolutely resume the medication probably even within three weeks. But if it starts getting beyond that, what we get worried about is that you may need to restart from a lower dose. So we know that GI side effects are really common with these medications, and as we titrate up on the dose of medication, our body might experience side effects, but we’ll get used to those.

Usually within a month of taking the dose of medication, the most significant side effects have really started to decrease and we are mindful when we’re thinking about making dosing adjustments. But when someone is off of their medication for a period of time, let’s say they’re off of it for a whole month, for example, if we restarted from where they were at, especially if they were someone who was having some of those more significant side effects, they are likely to experience some of those side effects. So we’re thinking about questions like how long has it been since you’ve been off the medication? If it’s one week or two weeks, probably no big deal. But once you’ve missed a few consecutive doses, we’re going to be a lot more concerned about it. The other question is what dose were you taking? Someone who’s on one of the introductory doses of medication, let’s say they’re on the starting dose of either Zepbound or Wegovy, even if you missed it for eight weeks, it’s not that big of a deal.

If we restarted, we would start you back at the starting dose of medication so you could certainly resume your medication. But if you’ve been titrating up over time and you’re on one of the higher doses of medication, particularly if you were someone who was having side effects, we may need to bring you back down to a lower dose of medication. The other question is why did you stop? It’s of course very different to stop for reasons like difficult to get it covered or you forgot or you had surgery versus the person who had to stop because of the severity of their side effects. Certainly that person, we’re going to want to think about going back to a lower dose of medication. So the biggest thing though is you don’t need to make up missed doses. If you missed the dose, you miss the dose, you skip it, you add it on to the end, but you never should be taking two doses in a single week for the weekly meds.

For the daily meds, you shouldn’t be taking two pills in a single day. If you miss the dose, you missed it, don’t try to take extra medication or make it up, you’ll just get back on track the following week. So that is one of the most important things here. The other thing is a lot of times we make assumptions about things like surgeries or procedures we’ve been told or maybe we think we might need to hold the medication. I will say this is actually one of the biggest challenges that we run into at this time. It is very common that hospitals or surgery centers will have recommendations saying that you need to stop your medication, your GLP medication for one or even two weeks before surgery. And that can make a really big difference for someone in terms of what it means to be off that medication and how they feel in the surgery.

Now, the reason that these recommendations exist is because the GLP medications can cause a slowing down of gastric emptying, so that delayed gastric emptying, food and other contents can sit in the stomach for a longer period of time. And then when you’re asleep under anesthesia, you’re laying horizontally, your body’s totally relaxed, and if there are any stomach contents that put you at increased risk for those regurgitating and then you aspirating or basically getting those stomach contents into your lungs, and that can be an incredibly dangerous or even life-threatening complication of surgery. A lot of times when people have surgery, they’re worried about the surgery itself, and of course surgery does have some risk, but it’s the anesthesia that in a lot of surgeries is actually even more significant risk compared to the surgery itself. So we start thinking about that delayed gastric emptying effect, and we do know that these medications could put patients at increased risk of delayed gastric emptying, which could have that sort of reflux and aspiration side effect.

So that is why a lot of these hospital systems have blankets head, you need to hold the medication for one week, you need to hold the medication for two weeks before surgery. What I will tell you though is that this will vary significantly from hospital to hospital. So make sure that your surgeon, that you’re having a conversation with them, that they are aware of the recent guidance from their own hospital. We have seen guidance even from the American Society of Anesthesiologists basically saying that if patients are not having symptoms of delayed gastric emptying, it may be appropriate to continue the GLP medication throughout the surgical period. And so symptoms of delayed gastric emptying are nausea, vomiting, certainly reflux or regurgitation that’s happening at baseline. People who are having those symptoms may be at higher risk, so they might be the type of people who should hold their medication, maybe someone who’s recently titrated or increased their dose of medication, someone who might need to be thinking about stopping, but the person who’s been stable on their dose and is not having some of those symptoms like regurgitation or vomiting, they may be actually okay to continue the medication through the perioperative period.

So we’ve seen a lot of changing in the guides, but honestly, what’s the most important thing is you know what’s the date of your surgery, you’ve shared with your surgeon all of the medications that you’re on, especially if you’re getting compounded medications from a medical spa online that might not be part of your medical list otherwise, and you want to make sure that they are aware of those medications so that you can follow the recommendations for pausing that medication before surgery. You may also, if you’ve had surgery, not be sure when to resume medication afterwards. We usually tell our patients it’s okay to resume afterwards if you’re otherwise back to eating normally, drinking normally, your bowels are moving normally, but you may want those things to stabilize before you reintroduce your medication. So it’s a very common period of time that patients may be off of the medication, and that is absolutely a scenario where you want to connect with your physician and say, “Hey, I was on this dose. I have to be off it for this length of time. What do you recommend in terms of resuming?” It is very common that we will bring someone back to a lower dose of medication. You may not need to go all the way back down to the starting dose, but you may take a step back so that you’re not going to deal with some of those side effects. These are the questions that can make your weight loss journey honestly really stressful and having a care provider who knows what is going on, how to support you and that you can reach out to is one of the most important tools for being successful in your weight loss journey. If you were looking for a doctor to support you in your weight loss journey, I would love to be that person. I see patients in person in Charlottesville, Virginia and throughout the states of Illinois, Tennessee, and Virginia, and we help to address the questions that our patients have, including, okay, this is my situation, what do I do?

We help patients get back on their medication as soon as they can and decrease some of those interruptions in care. If you’re interested in learning more, visit www.sarahstombaughmd.com. You can find that information in the show notes. Thank you for joining us for this week’s episode. I’ll see you all next week.