Episode 244: How to Restart a GLP-1s

[00:00:00] Welcome back to the Back on Track: Achieving Healthy Weight Loss, where I help you get on track and stay on track with your weight loss journey. I'm your host, Dr. Alicia Shelly. So let's get started.

[00:00:27] Hello, and welcome back to the Back on Track: Achieving Healthy Weight Loss podcast. I'm your host, Dr. Alicia Shelly. And today's episode is one that I've been getting asked about more and more in my clinic. And that's about, Dr. Shelly, I stopped my GLP-1 medications, can I restart it?

[00:00:46] And even though last week we talked about why people stop their GLP-1s, but today I want to go into a little bit more detail about what to do when it's time to restart. Dr. Now, there are many reasons that I outlined in last week's episode why people stop their GLP-1s.

[00:01:05] Could be their insurance stopped covering it, and that's a lot of it, where all of a sudden they just stop covering it or it's more expensive than it was before and then you're not able to afford it. Also, you know, a couple years back there was a medication shortage where no one can get the medication. Good thing now the medication shortages are better, but sometimes there are certain pharmacies out there that don't stock the GLP-1s.

[00:01:33] So whenever you request them to have it, they have to order it from their supplier. Their supplier has to deliver it, and then you can get your medication. So sometimes that may take one week, two weeks, three weeks, who knows? So these things can occur. And then most importantly, life gets busy. I mean, I don't know about you. Sometimes I'm traveling and I just forget to take my GLP-1 because I'm just on the move.

[00:02:01] And let's say you were having a lot of nausea with it or a lot of the side effects, and you were just like, you know what? I just need to take a break. Whatever the reason may be that you've been off of your GLP-1, you're probably wondering, how do I restart it? And so this episode is for you. We're going to talk about again why people, just a little preview again, why GLP-1s, people stop GLP-1 medications. Feel free to check out last week's episode.

[00:02:28] Also, what happens to your body when you stop? Whether you need to start at the lowest dose or can we start at the last dose that we were on? And then how to minimize the side effects with restarting. So let's dive in. Now, let me just recap why people stop their GLP-1s. And, you know, first off, it happens. People sometimes have to get off of their GLP-1s. They may be having to undergo surgery or colonoscopy where they have general anesthesia.

[00:02:56] And because GLP-1s delay that digestion, what happens is, is that people are at increased risk for having an aspiration or basically fluid from their gut going into their lungs. And so, and that can lead to pneumonia. So sometimes you have to stop it at least one to two weeks prior to general anesthesia so that you won't have those effects. Of course, the most common ones that we see are going to be insurance denials.

[00:03:26] Maybe you did not lose their 5 or 10 percent that they want you to lose so they can be able to continue the medication. Also, too, sometimes, especially in the beginning of the year, you have these high out-of-pocket costs where it is so expensive to continue the medication. Medication shortages where it's just not available at your pharmacy. Side effects, like I just mentioned. Travel. You're going out of the country. You may not be able to keep it there. And then what if you're going through fertility?

[00:03:56] Then you probably will not need to stop your GLP-1. So there's multiple reasons why people stop. One that I see is that if you think you've gotten to your goal weight and you feel like you no longer need the medication, you'll stop it then. And sometimes patients stop intentionally because of that fact. And sometimes the medication is taken away from them. Either way, it happens more often than you think. And when it does, many people feel frustrated, scared, and even guilty. But I do want you to hear this.

[00:04:25] Stopping the medications doesn't mean that you failed. Obesity is a chronic disease. So just like people with high blood pressure may need medication adjustments, people living with obesity may have interruptions in treatment. The key is figuring out what is the safest way forward. So one of the biggest misconceptions is that once you've lost weight, your body simply just stays there. Unfortunately, that is not how our biology works.

[00:04:52] GLP-1 medications help by reducing the hunger, increasing fullness, slowing stomach emptying, and reducing food noise. And they help regulate blood sugar. When the medication is stopped, those effects gradually fade. The hunger starts to come back. You're starting realizing that you can eat a little bit more on that plate than you used to. And then that food noise starts to come back as well.

[00:05:16] Because remember, as you are losing weight, your body is actually increasing your hunger hormone, decreasing your leptin, as well as decreasing your metabolism. Because it wants to defend the body fat. It wants to keep the body fat. I always have to tell people, when we were hunters and gatherers, where we were every day just trying to find our next meal, the people who had more body fat survived. And so that's where our body is trying to go. So that is happening as we are losing weight.

[00:05:46] But when we end the medication, it is stopping you from feeling those effects. But once you stop the medication, they start to come back. And some people are able to maintain their weight. You know, they're able to keep it around the same. They may gain 5 to 10 pounds, but they're still in that same range. And they may do this by physical activity, continuing to use the small portions, even though it's a little bit harder because the food noise has come back. And then there's some people that start to regain.

[00:06:15] And some of that is just biology. Like I said, your body is working against you. And it's not because, you know, all of a sudden you're lazy or you lack willpower. It's just sometimes it's also biology. And I often tell patients that medications did not cure obesity, but it helps to manage it. We don't have a cure for obesity. We just have something that can help manage it.

[00:06:37] And one of the other important questions that you need to make sure that you answer, and this answer determines kind of whether you restart where you left off or whether you need to start over. And that question is, how long have you been off the medication? Have you been off for like a few weeks or have you been off for like multiple, multiple months? That makes a huge difference. So let's break this down.

[00:07:02] If you miss just a few weeks, you know, you may have missed it then last week or you're ready to take it the next week, then you can usually continue your current dose. You can just stay at the same dose. It's okay if you missed a week. Just make sure you do that. Also, too, the recommendation is like make sure there's no four days. And there should be four or more days in between injections. So let's say you forget that you normally take it on Sunday, but then you remember it on Wednesday. That's been three days.

[00:07:31] Then you could take it on Wednesday as long as there's four days in between your next shot, which would be the next Sunday. Also, for daily medications, if you're taking the Wagovi pill, Fundale, if you miss a few days, then you just start where you are. If you miss over seven days with the Wegovy or Fundale, then you probably need to start back at the lower dose. If you have weekly injections, the guidance does change as well.

[00:08:00] So make sure to check the manufacturer's recommendations and that prescription information and the insert that comes with the box. Now, let's say you've been off for months. Like you just life got complicated and you've been off for months. And then, you know, in that case, some of your body may have lost some of its tolerance to the medication.

[00:08:22] And so if you were to restart it at the same high dose that you stopped it, you could have severe nausea, vomiting, abdominal pain, diarrhea or dehydration. And I've seen it all. Some people will like start at a high dose and then they're just sick. And so sometimes you got to start back at a lower dose so that your body can build up that tolerance. And I like to think of it like this.

[00:08:47] If you haven't exercised in six months, you probably wouldn't jump right back into the same workout you were doing before. And that's the same here. You can't just start back. If you have been off for six months, you can't start back at the highest dose or you'll be sick. Now, do you always have to start from the beginning? Not necessarily. It really depends on which medication you're taking, how long you've been off, what dose you were on previously and how well you tolerated before.

[00:09:12] For some patients who have only been off for a short period, they may be able to restart at an intermediate dose. You may just go down a few levels. Others may need to go all the way back down if it's been like six or more months because you want to make sure that you're tapering up, that you're kind of making sure that they're not having any further side effects from it. This is why it's important to discuss your specific situation with your health care provider rather than just guessing, because they may be able to titrate you back up rather quickly.

[00:09:42] Also, trying to save time by jumping back to the higher dose often leads with more problems. And I have patients that ask me, like, do you want me to start off the high dose? No, no, we do not. You will get sick. You will get sick. Now, what side effects can happen when we're starting? So many patients are surprised that side effects can return. It may be like, I never had any side effects on this medication. But then they restart at a higher dose and they feel all these side effects. So even if you tolerate the medication perfectly before,

[00:10:12] the most common side effects that we see are going to be that nausea, constipation, diarrhea, bloating, reflex. You just got to feel that it is working. And the good news, these symptoms are often temporary and will improve over time. But some ways to minimize these side effects are eating smaller meals, prioritizing your protein, because protein does help preserve muscle mass and can help with you feeling full. So it can be helpful. Also, making sure you stay hydrated.

[00:10:41] Many symptoms worsen when you're dehydrated. So feeling tired, fatigue. So aim for consistent fluid intake throughout the day. Also, when you eat smaller meals, know that your stomach may become sensitive again. And so it's important to avoid larger portions during the first few weeks. So just allow your body to get used to it. Eat slowly. I know it sounds kind of simple, but it just helps tremendously. Give your body time to recognize that it's full, you know.

[00:11:09] So just kind of take a break, talk to whoever and then come back to it. Also avoid high fat meals. Though that high fat meals can really cause a lot of GI side effects. So greasy foods often trigger nausea when restarting. Now, what if you regained weight? I know that's kind of hard. It's hard because many people restarted GOP-1 after gaining back some weight after they stopped it. And often they feel embarrassed.

[00:11:38] They may be thinking, oh, I should have tried harder. I messed everything up and I failed. And I do want to challenge that thinking. You know, weight regain seen after stopping treatment is not a character flaw. It's biology. Your body has powerful mechanisms designed to defend against weight loss. And that doesn't mean healthy habits aren't important. They absolutely are. But biology matters too. So if you've regained weight, don't spend your energy beating yourself up.

[00:12:08] Spend your energy creating a plan. It is okay. We've seen this before. And like I said, your body is working against you so that we can't change our biology. We can just manage it as best as we can. So what should you do before you restart? So you should consider these couple of questions. Number one, why did I stop? Was it due to costs? Side effects? Insurance? A life event?

[00:12:36] Understanding that reason helps prevent some of the same issues from happening again. Because if it was costs that stops you, the question is, is there something else that may be better that you can continue and cost effective for you? So it's important to know exactly that reason and try to see if there's a way to make it a little bit easier. Also ask yourself the question, is this still the right medication? Like sometimes another medication may be a better fit. We can taper up on that.

[00:13:03] So just kind of make sure you're taking something that's helping. And then have you asked yourself, have you had any new health changes? Like any new diagnosis, surgeries, pregnancy or medication changes that could affect your treatment plan? Because you may, you know, have a family history now of a mediary thyroid cancer. And that's contraindicated with these medications. So you want to kind of make sure that you kind of do a deep dive, see where you are and see, is this the best fit for me?

[00:13:32] And of course, make sure you talk to your primary care or your obesity medicine doctor because they can guide you in the right direction. Also, it's important to kind of ask yourself, what support systems do I need? Because remember, this medication is a tool and it cannot be used alone.

[00:13:50] The strongest results happen when medication is paired with nutrition, proper nutrition, increased physical activity, making sure you get to sleep, stress management and behavioral support. The biggest mistake that I see patients trying to restart at the, is they're restarting at the exact dose that they stopped months ago.

[00:14:12] So for example, if somebody was taking 2.4 milligrams of Wegovy, they stop it for three months, but they take, they still have some left in the refrigerator. So they take that 2.4 injection thinking everything will be fine. Guess what? It is not. The next day they're miserable with nausea, vomiting, and they just feel sick. So do not do that.

[00:14:36] If you stop for over three months, do not restart at 2.4 because you are going to be in a hurt of pain. And I get it. Sometimes the slower restart may feel frustrating, but it's often safer and more successful. So make sure you reach out to your healthcare provider and develop a restart plan. Now, if you've been off the GLP-1 medication, remember these key points. Number one, stopping treatment does not mean that you failed.

[00:15:05] Appetite and cravings often return because the medication effect wears off. Many people need to restart their medication at a lower dose. Side effects can come back when restarting. Weight regain is often biological and not a lack of willpower. Work with your healthcare provider to create a safe restart plan. And most importantly, do not let a setback become a stopping point.

[00:15:32] Whether you've been off your medication for two weeks, two months, or even a year, you can still get back on track. Progress is rarely a straight line. It is up and down, up and down, just like life. And the goal is not perfection. The goal is persistence. So I thank you so much for joining me today for today's episode of Back on Track Achieving Healthy Weight Loss. If you found this episode helpful, please share it with a friend or family who may be restarting their GLP-1 journey.

[00:16:01] And if you haven't already, subscribe to our newsletter so you will not miss an episode. And until next time, stay strong, stay committed, and stay consistent. Remember, we are stronger together. And we'll see you at the next episode.