OZEMPIC & GERD

A SHOT A WEEK MAKES MY REFLUX SYMPTOMS PEAK

Peter C. Belafsky, MD, MPH, PhD

 

Dr. Belafsky is a renowned physician known for his exhaustive research, extensive collaboration, crazy ideas, and a bustling medical practice as Director for The Center for Voice and Swallowing, UC Davis. He is a co-founder of Reflux Gourmet.

Waistlines are rapidly expanding. Over 40% of Americans are now obese. As a country, we are eating more and exercising less. The rest of the planet is not far behind and, within 10 years, more than half of the global population will be obese. It’s not just about fitting into smaller jeans; it’s a pandemic of monumental proportions that has more adverse health effects than smoking, drinking, and poverty. Obesity represents one of the greatest health challenges that the world has ever faced. Weight loss is an urgent health priority.

 

But are semaglutides (drugs like Ozempic and Weygovy, for example) the secret weapon to help combat this health crisis?

 

Discovering a potential ally in the journey to shed extra pounds might be as simple as exploring the fascinating world of Ozempic. Beyond its primary role in managing type 2 diabetes, Ozempic has been garnering tremendous interest for its unexpected sidekick role in weight loss.

 

Ozempic, or semaglutide, belongs to a class of medications called glucagon-like peptide-1 (GLP-1) receptor agonists. GLP-1 agonists work by mimicking the effects of the body’s natural GLP-1 hormone.

 

As such, GLP-1 agonists have 3 primary medicinal effects:

 

  1. The drugs helps regulate blood sugar by increasing insulin secretion from the pancreas.
  1. The drugs delay gastric emptying which helps reduce post-meal spikes in blood sugar.
  1. The drugs mimic naturally occurring GLP-1 which trick your brain into feeling full. This promotes satiety and leads to reduced food intake.

Ozempic was approved by the FDA to treat Type II diabetes in 2017. It is not approved to treat weight loss. Weygovy is a medication with a larger dose of semaglutide than Ozempic.  It was approved as a once weekly injection for the treatment of obesity in 2021. Other dosages range from 0.25 to 2.4mg and patients are usually started on the low dose and gradually titrated up to the larger dose over 4 months. Other available GLP-1 agonists include liraglutide and tirzepatide. The FDA approved an oral formulation of semaglutide (Rybelsus 7 and 14mg) for the treatment of Type II diabetes in 2019. Conflicting evidence suggests that the injectable GLP-1 agonsists may be more effective than the oral formulations.

 

The effects of Ozempic and Wegovy on weight loss can be dramatic. In a recent randomized placebo-controlled clinical trial, the mean weight loss with once-weekly subcutaneous 2.4 mg semaglutide was nearly 15% after 17 months of treatment [1]. This weight loss improved both cardiovascular health and overall physical functioning. The ability of these drugs to decrease appetite is so pronounced that large, processed food manufacturers are concerned of the detrimental effects these medications will have on their food sales and weight loss surgeons are looking into alternative career options.

 

Like all things that seem too good to be true, the nearly magical effects of semaglutide come at a cost. There is a black box warning from the FDA that the drugs may cause thyroid cancer. This warning is based solely on animal research in rodents and there is no contemporary data that suggests the medication is associated with an increased risk in humans. Nonetheless, people with a history or family history of certain types of thyroid cancer may choose to steer clear of these drugs. Other potential severe side effects of these medications are rare and include low blood sugar (hypoglycemia), suicidal thoughts, hair loss, kidney and eye problems, and pancreatitis.

 

Common side effects of semaglutide are mostly gastrointestinal and are related to the delayed gastric emptying caused by the medication [2-3]. Retained food, liquid and gas in the stomach can cause nausea, vomiting, bloating, burping and reflux. The normal stomach should empty a reasonably sized meal within 4 or 5 hours. Liquids empty faster than solids and small pieces of food empty faster than larger pieces. The longer food sits in the stomach, the more likely it is to reflux back into the esophagus and throat. Up to a quarter of patients with gastroparesis experience moderate to severe reflux. This side effect is so common, most surgeons and anesthesiologists recommend stopping GLP-1 agonists for one week before surgery to reduce the risk of regurgitation and aspiration of gastric contents during the procedure.

 

Semaglutide and GLP-1 receptor agonist-associated reflux can cause:

 

         – heartburn

         – cough

         – excessive burping

         – nausea

         – abdominal pain and bloating

         – vomiting

         – throat pain      

 

Treatment of these side effects includes behavioral modifications, prescription and OTC antacids, reflux chewing gum, and alginate therapy. Behavioral modifications include

 

            – decreasing meal size

            – wait 4-5 hours after meals before laying down

            – elevate the head of bead while sleeping at least 7 inches

            – avoid tight fitting clothing

            – avoid bending and exercising after meals

 

Thankfully, the reflux can often be managed successfully with these strategies. If not, the medications may need to be stopped. Most of these side effects will remit once the medications have been stopped, although there are scattered reports of prolonged side effects even after going off to the drugs.

 

These medications are exciting new options in our uphill battle against the obesity pandemic. Their use is not without potential complications and an understanding of the side effects is essential for both patients and clinicians. Many of these side effects are GI related and can be managed with a combination of dietary modifications, reflux gum, alginates, and antacid medications when needed.

 

  1. Wilding JPH, Batterham RL, Calanna S, Davies M, Van Gaal LF, Lingvay I, McGowan BM, Rosenstock J, Tran MTD, Wadden TA, Wharton S, Yokote K, Zeuthen N, Kushner RF; STEP 1 Study Group. Once-Weekly Semaglutide in Adults with Overweight or Obesity. N Engl J Med. 2021 Mar 18;384(11):989-1002. doi: 10.1056/NEJMoa2032183. Epub 2021 Feb 10. PMID: 33567185.
  2. Dahl K, Brooks A, Almazedi F, Hoff ST, Boschini C, Baekdal TA. Oral semaglutide improves postprandial glucose and lipid metabolism, and delays gastric emptying, in subjects with type 2 diabetes. Diabetes Obes Metab. 2021 Jul;23(7):1594-1603. doi: 10.1111/dom.14373. Epub 2021 Mar 29. PMID: 33710717; PMCID: PMC8251575.
  3. Maselli DB, Camilleri M. Effects of GLP-1 and Its Analogs on Gastric Physiology in Diabetes Mellitus and Obesity. Adv Exp Med Biol. 2021;1307:171-192. doi: 10.1007/5584_2020_496. PMID: 32077010.
 
 
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