Glp1 Candidacy Myths Checker

---
name: glp1-candidacy-myths-checker
description: Decide whether commonly-excluded patients (eating disorders, elderly ≥75, upper GI disease) can actually receive a GLP-1 receptor agonist. Use when a clinician asks "can I give semaglutide to a patient with binge eating disorder / anorexia / bulimia", "is liraglutide safe in an 80-year-old", "GLP-1 with GERD or chronic gastritis", "GLP-1 in sarcopenic elderly", or anytime a patient is being ruled out for GLP-1 therapy based on a perceived contraindication. Grounded in Gorgojo-Martínez 2023 §6 (Myths or Reality).
---

# GLP-1 Candidacy — Myths Checker

## Purpose

Many patients are falsely excluded from GLP-1 therapy on the basis of commonly-held misconceptions. This skill separates true contraindications from myths and gives the conditions under which "excluded" patients can actually benefit.

## Activation

Trigger when:
- Clinician asks if GLP-1 is safe in a specific "risky" profile.
- Patient is being deferred from GLP-1 based on eating disorder, age, or upper GI disease.

## Decision by Profile

### Eating Disorders

| Subtype | GLP-1 RA allowed? | Condition |
|---|---|---|
| Binge Eating Disorder (BED) | YES | With concurrent psychology/psychiatric care |
| Night-Eating Syndrome | YES | With concurrent psychology/psychiatric care |
| Anorexia nervosa | NO | Absolute contraindication |
| Bulimia with self-induced vomiting | NO | Until psychiatric disorder resolved with psychotherapy/pharmacotherapy; then reconsider |

Add: any eating-disorder patient starting a GLP-1 RA must receive educational input on a healthy lifestyle, not just the prescription.

### Elderly — ≥75 years old

- GLP-1 RA is **beneficial** for cardiovascular + renal morbimortality in this group — do not reflexively exclude.
- Concern is **sarcopenia** — weight loss is mostly fat mass but monitor lean mass.
- **Mitigation:** nutritional advice, protein target ~1.5 g/kg/day, muscle-strengthening exercise (elastic bands, small dumbbells).
- **Dose:** maintenance dose may be below the datasheet maximum — pivotal trials show glycaemic + weight benefit at lower doses in fragile patients.
- **Use Clinical Frailty Scale** to guide dose individualisation.
- **Insulin co-treated elderly:** GLP-1 often lets you reduce insulin → fewer hypos → net benefit.

### Upper GI Disease (chronic gastritis, GERD, hiatal hernia)

- **Tolerated well** in the published study — mild/moderate AEs only, no withdrawals.
- No dose adjustment required.
- Patients with chronic intestinal pathology are also candidates.
- **Caveat:** several GLP-1 RA datasheets still don't recommend use in severe GI disease due to limited experience — respect the label for severe cases.
- In GERD: reinforce small frequent meals, avoid LES-relaxing foods (fat, fried, chocolate, mint, tomato), avoid lying down post-meal; short PPI course is reasonable during titration.

### Weight Loss Driven by GI AEs? (Myth #1)

- **NO** — weight loss with GLP-1 RA is **largely independent of GI AEs**.
- Do not withhold therapy from someone who is symptom-free thinking they "won't lose weight without nausea".
- Do not push someone towards more nausea thinking it will drive more weight loss.

## Rules & Constraints

1. **Anorexia and active bulimia are hard NOs** — everything else is negotiable.
2. **Age alone is not a contraindication** — frailty status is.
3. **"Severe GI disease" per datasheet** — respect the label; chronic gastritis/GERD is NOT severe GI disease.
4. **Sarcopenia prevention is mandatory** in elderly — not optional.
5. **Don't promise weight loss requires nausea** — explicitly debunk.

## Reference

Gorgojo-Martínez JJ et al. *J Clin Med* 2023;12:145. §6 (Myths or Reality), §6.2.