I get it. You've done the research. You know you want to try semaglutide or tirzepatide. You've probably already figured out your BMI qualifies you. You might be wondering why you need a physician evaluation at all.

The honest answer: because a prescription is the easy part. The hard part is making sure the medication is safe for you specifically, that it's the right medication, at the right starting dose, with the right monitoring plan. And knowing what to watch for once you start.

The medical history matters more than you think.

Before I write anything, I want to understand the full picture. Not a checkbox intake. An actual conversation.

I'm asking about your weight history — when it started, what you've tried, what worked temporarily and why it stopped. I'm asking about your relationship with food, because that tells me whether we're dealing with metabolic dysfunction, behavioral patterns, or both. I'm asking about your energy, your sleep, your mood, your exercise habits, your stress. All of these influence how you'll respond to a GLP-1 and what else might need attention.

Then the specific clinical questions:

Personal and family history of pancreatitis

GLP-1 receptor agonists carry a labeled risk of pancreatitis. If you've had pancreatitis before — or there's a strong family history — that doesn't automatically disqualify you, but it changes the risk-benefit conversation significantly. A yes/no intake field cannot always capture the context that matters clinically.

Thyroid history

Semaglutide and tirzepatide carry a boxed warning about medullary thyroid carcinoma based on animal studies. If you have a personal or family history of MTC, or a history of Multiple Endocrine Neoplasia syndrome type 2, these medications are contraindicated. Period. I'm also evaluating your thyroid function more broadly, because undiagnosed hypothyroidism can contribute to weight gain and needs to be addressed on its own terms.

Gallbladder

Rapid weight loss increases gallstone risk. GLP-1s add to that risk by slowing gastric emptying and altering bile acid metabolism. If you've had gallbladder problems or a cholecystectomy, I need to know. If you still have your gallbladder, I'm monitoring for symptoms as weight loss progresses.

Kidney function

The nausea and decreased appetite that come with GLP-1 therapy can lead to dehydration, which matters if kidney function is already reduced. I check baseline kidney function and make sure hydration is part of the plan.

Diabetes medications

If you're on insulin or a sulfonylurea, adding a GLP-1 agonist creates a real hypoglycemia risk. These medications need to be adjusted simultaneously, not independently. That requires a physician managing the full medication picture.

Pregnancy status or plans for pregnancy

Preconception planning matters, and the specifics depend on which medication you're taking. Current Wegovy (semaglutide) labeling recommends stopping the medication at least two months before a planned pregnancy. Zepbound (tirzepatide) labeling instead recommends discontinuation when pregnancy is recognized, and warns that tirzepatide may reduce the effectiveness of oral hormonal contraceptives for four weeks after initiation and four weeks after each dose increase. If you're pregnant or planning pregnancy, we'll discuss the specific discontinuation timeline based on which medication you're taking. The evidence on breastfeeding is limited for both medications, so that decision is individualized.

Gastroparesis and severe GI disease

GLP-1s slow gastric emptying — that's part of how they work. In patients with gastroparesis or severe gastrointestinal disease, this effect can worsen symptoms significantly. A history of gastroparesis, inflammatory bowel disease, or severe GERD changes the risk-benefit analysis and may affect medication selection or dosing.

Complete medication review

Beyond diabetes medications, GLP-1s can interact with oral contraceptives, warfarin, and other drugs whose absorption depends on gastric emptying. I review every medication you're taking — prescription, over-the-counter, and supplements — to identify interactions and adjust timing or dosing as needed.

Mental health history

GLP-1s change your relationship with food — that's the mechanism. For most people, the reduced food noise is a relief. For some people with a history of eating disorders, it can create a complicated dynamic. I'm not going to refuse treatment based on a checkbox, but I want to know the context.

The lab work.

I order baseline labs not because a protocol says to, but because the results genuinely change my clinical decisions.

The core panel gives me metabolic context: blood counts, a metabolic panel, HbA1c, fasting glucose. This tells me where your metabolic health stands right now — not just "do you qualify for a GLP-1" but "what else is going on that we should be tracking."

Depending on your symptoms and history, I may add thyroid function, testosterone (in men), or other targeted tests. I'm not running a giant panel for the sake of generating data. I'm ordering what's clinically relevant to your situation.

Illustrative example: A patient presents for GLP-1 evaluation after being prescribed semaglutide by an online platform without any lab work. In a case like this, baseline labs might reveal an HbA1c of 7.2% — undiagnosed type 2 diabetes. That changes the entire treatment plan. The semaglutide may still be appropriate, but now the goal is treating diabetes, not just overweight. Dose titration, monitoring schedule, and long-term plan all look different. Without labs, this patient would have been treated as a weight loss patient when they were actually a diabetes patient losing weight.

Choosing the right medication.

Semaglutide and tirzepatide are not interchangeable. They work through different mechanisms — semaglutide is a GLP-1 receptor agonist, tirzepatide is a dual GLP-1/GIP receptor agonist. The weight loss data, side effect profiles, and titration schedules are different.

The choice depends on your clinical picture: how much weight you need to lose, your metabolic profile, your tolerance for GI side effects, your insurance or out-of-pocket situation, and in some cases, which medication is actually available.

I don't have a default medication. I have a default process: evaluate you, then decide.

The titration plan.

Both semaglutide and tirzepatide have FDA-approved dosing and titration frameworks. I work within those frameworks, but individualize the pace and progression to each patient. Most side effects — nausea, constipation, decreased appetite beyond what's helpful — come from going too fast.

Standardized titration schedules work for many patients but don't account for individual variation in tolerance, side effects, or response. I titrate based on how you're responding: your weight trend, your side effects, your energy, your ability to maintain adequate protein intake. Sometimes that means staying at a dose longer. Sometimes it means going slower. Occasionally it means switching medications.

The goal is the dose that works for your body, not the dose the protocol says you should be on by week eight.

What I'm watching for once you start.

The first few weeks tell me a lot. I'm tracking:

Why this process exists.

I'm not doing this to create friction. I'm doing this because a GLP-1 prescription without proper evaluation, appropriate lab work, and ongoing medical management is not medicine. It's a transaction.

Transactions work fine when the stakes are low. The stakes here are not low. You're altering your metabolic physiology, losing weight that includes lean mass if nobody's paying attention, potentially unmasking conditions that were being compensated for, and taking a medication that requires monitoring for real adverse effects.

My job is to make sure the medication works safely, that we're watching the right things, and that what you lose is fat — not muscle, not health, not time.

That takes a physician. Not an algorithm.