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Colon perforation has been reported in 1-1.5% in cases treated for melanoma and 6.6% of the cases treated for renal cell cancer related to ipilimumab-induced enterocolitis [41-44]

Diarrhea: Oral semaglutide: 8-12% of patients Injectable semaglutide: 30% of patients Injectable tirzepatide: 19-23% of patients Vomiting: Oral semaglutide: 5-8% of patients Injectable semaglutide: 24% of patients Injectable tirzepatide: 9-17% of patients Abdominal Pain: Oral semaglutide: 6-10% of patients Injectable semaglutide: 20% of patients Injectable tirzepatide: 8-11% of patients Unique to Oral Semaglutide: SNAC-Related Side Effects: The absorption enhancer (SNAC) in Rybelsus can cause additional issues: Stomach Irritation: Heartburn or acid reflux Stomach discomfort or pain Gastrointestinal upset beyond typical GLP-1 effects May worsen pre-existing reflux or gastritis Oral Medication Compliance Issues: Difficulty remembering daily dosing Frustration with strict timing requirements Reduced effectiveness if rules not followed perfectly Injectable-Specific Side Effects: Injection Site Reactions: Redness, swelling, or itching where you inject Occurs in 5-10% of patients Usually mild and resolves within days Rotating injection sites minimizes risk Not possible with oral medications (obvious advantage) Serious Side Effects (Both Forms): These rare but serious risks apply to both oral and injectable GLP-1 medications: Pancreatitis: Severe abdominal pain radiating to back Risk: Less than 1% with any GLP-1 medication Requires immediate discontinuation Equal risk with oral or injectable Thyroid Tumors (Black Box Warning): Based on animal studies (not confirmed in humans) Contraindicated with personal or family history of medullary thyroid carcinoma MEN 2 syndrome is absolute contraindication Warning applies to all GLP-1 receptor agonists Gallbladder Problems: Gallstones, cholecystitis Related to rapid weight loss more than medication itself More common with injectable forms due to greater weight loss Kidney Issues: Dehydration from vomiting/diarrhea can affect kidney function Monitor hydration carefully Report decreased urination or swelling Hypoglycemia: Low blood sugar if combined with insulin or sulfonylureas Less common with GLP-1 medications alone Diabetic patients need monitoring Safety Comparison: Oral Semaglutide May Be Safer For: People with bleeding disorders (no injection risks) Patients with skin conditions affecting multiple injection sites Those with psychological trauma related to needles Injectable Forms May Be Safer For: People with gastroesophageal reflux disease (GERD) Those with gastroparesis or slow stomach emptying Patients who struggle with daily medication adherence (weekly dosing reduces missed doses) Contraindications (All GLP-1 Medications): Do not use oral or injectable GLP-1 medications if you have: Personal or family history of medullary thyroid carcinoma Multiple endocrine neoplasia syndrome type 2 (MEN 2) History of severe GLP-1 allergic reaction Pregnancy or planning pregnancy History of pancreatitis (relative contraindication, discuss with provider) Managing Side Effects: For Oral Semaglutide: Take with small amount of water only (no coffee, tea, juice) Wait full 30 minutes before eating to maximize absorption and minimize nausea Start with lowest dose (3 mg) and escalate slowly Report persistent stomach pain (may be SNAC irritation) For Injectable GLP-1s: Start with lowest dose and increase gradually Inject before bed to sleep through initial nausea Eat smaller, more frequent meals Stay well-hydrated Ask provider about anti-nausea medication Rotate injection sites to prevent skin reactions Discontinuation Rates: Due to Side Effects: Oral semaglutide: 4-7% discontinuation rate Injectable semaglutide: 6.9% discontinuation rate Injectable tirzepatide: 6.2% discontinuation rate Despite higher side effect rates, injectable medications dont have significantly higher discontinuation rates because the benefits outweigh temporary discomfort for most patients

In many cases, therapy sessions that arent tied to a formal mental health diagnosis may not be covered

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Over time, net prices of GLP-1s should continue to drop which is great

If plaques improve but flares continue, the immune modulation component may need adjustment