Practical
How to Choose a GLP-1 Prescriber
A five-question online form and a pen in the post is not medical care. Here is what a good prescriber actually does, what the red flags look like, and the questions that separate them in about ninety seconds.
I want to be even-handed here. Telehealth has given a lot of people access to treatment they could not otherwise get, and plenty of online services provide genuinely good care. The delivery model is not the issue.
The issue is that this market grew very fast, and the gap between the best and worst providers is wider than in almost any area of medicine I can think of. So this is a guide to telling them apart — which takes about ninety seconds if you know what to look for.
The one question that reveals everything
Did they ask about your family history of medullary thyroid carcinoma or MEN2?
That is the single absolute contraindication in this drug class. It is on every label, in a boxed warning, and it takes one question to screen for. A prescriber who did not ask has not screened you against the one rule that has no exceptions — and if they skipped that, it is reasonable to wonder what else they skipped. The background is in the thyroid cancer warning explained.
Everything below is elaboration on that principle.
What proper assessment includes
Before a first prescription, a competent prescriber establishes:
- Personal or family history of medullary thyroid carcinoma or MEN2 — the one absolute contraindication, and a 30 second question
- Prior pancreatitis, gallbladder disease, severe gastroparesis — each needs an individual conversation
- Pregnancy, breastfeeding, or plans to conceive — these drugs are not for use in pregnancy
- Your full medication list, particularly insulin and sulfonylureas, which usually need dose reduction
- History of an eating disorder — a genuine caution, discussed in food noise and mood
- Kidney disease, which changes the sick-day planning rather than the dose — no dose adjustment is required even in severe impairment
- What you have already tried, which matters clinically and for any insurance appeal
The full list is in who should not take a GLP-1. A service whose intake is five questions and a payment page has not done this.
Red flags
Dosing in “units” rather than milligrams. This is the highest-risk pattern in the market and it deserves its own paragraph. When a compounded product is supplied in a vial with a syringe, instructions given in units or in fractions of a syringe are easy to misread by a factor of ten, and there have been real overdoses from exactly this. A legitimate instruction is a dose in milligrams. If you cannot state your dose in milligrams, ask until you can.
No titration schedule in writing. Standard schedules step up every 4 weeks over 16–20 weeks, and titration is not administrative. It is the mechanism by which people tolerate the drug, and the most effective intervention for side effects is slowing it — which requires a plan to slow.
No way to reach a clinician. When you develop severe upper abdominal pain at week nine, you need a human within a day. A chatbot and a support email are not that.
Automatic refills without review. Convenience is the selling point and the absence of review is the product defect.
Pressure toward a proprietary compounded blend. Compounded semaglutide combined with B12, or with anything else, is not an FDA-approved product, and the additions exist for marketing rather than clinical reasons. The FDA has published safety communications about compounded products, including dosing errors and salt forms that are not the studied molecule.
Guarantees. Nobody can promise you a percentage. Response varies substantially and unpredictably between individuals, which is the honest position in semaglutide versus tirzepatide.
No discussion of stopping. This is the one people notice last and it matters most. Weight regain after discontinuation is well documented — the STEP 1 extension found participants regained roughly two-thirds of lost weight within 12 months of stopping. A provider who never raises this is selling you a subscription and calling it a treatment. What happens when you stop covers it properly.
Green flags
- Takes a history and asks about the contraindications by name
- Gives you a written titration plan, with the dose in milligrams
- Discusses protein and resistance training — 1.2–1.6 g/kg a day, 2 sessions a week — at the start rather than after you have lost muscle
- Orders or requests baseline labs
- Explains what to do about missed doses — the rescue window runs from 48 hours to 5 days depending on the product — and about sick days
- Names a maintenance plan, including what happens if you stop
- Tells you to inform an anaesthetist before any procedure — see GLP-1s, surgery and procedures
- Is reachable, by a human, within 1–2 days
The labs worth having
Not legally required in every setting, and genuinely useful — mostly because they let you tell later whether something changed.
| Test | Why |
|---|---|
| Kidney function and electrolytes | Baseline before a drug whose main acute risk is dehydration |
| Liver function | Common comorbidity; baseline for comparison |
| HbA1c | Identifies undiagnosed diabetes and tracks benefit |
| Lipid panel | Improves with treatment; worth documenting |
| Vitamin D, B12, ferritin | These are what run low by month 4, and a baseline makes the result interpretable |
Reading your own labs covers how to interpret them.
The ninety-second script
If you are considering a service, ask these five questions before paying:
- “What dose will I start on, in milligrams, and what is the escalation schedule?”
- “Who do I contact if I get severe abdominal pain, and how fast will someone respond?”
- “What baseline tests do you want, and will you review them?”
- “What is the plan when I reach my target — do I stay on it, and at what dose?”
- “Is this an FDA-approved product or a compounded one, and if compounded, from which pharmacy?”
Clear answers to all five is a good sign. Evasion on any of them tells you what you need to know, and you have lost 90 seconds.
One more worth asking if you are prescribed a compounded product: how many mg are in the vial, and how many mg is my dose? If nobody can answer in milligrams, do not inject it.
If you are already with a poor provider
You do not have to start over, and you do have options. Your own primary care clinician can usually take over prescribing or at least monitoring, and is generally glad to be told rather than to find out later. Ask your current service for your records — you are entitled to them. And get the baseline labs done even if late, because a value at month six is more useful than no value at all.
The drug is the same molecule whoever posts it. What differs is whether anyone is watching, and that is the part you are actually choosing.
Questions I get about this month
- What should a prescriber ask before starting me on a GLP-1?
- At minimum: your personal and family history of medullary thyroid carcinoma and MEN2, any history of pancreatitis, gallbladder disease or severe gastroparesis, whether you are pregnant or planning pregnancy, your full medication list including insulin and sulfonylureas, and any history of an eating disorder. They should also discuss what happens when you stop, because that determines whether this is a plan or a purchase. A service that asks none of these has not assessed you.
- Do I need blood tests before starting a GLP-1?
- Not by regulation in every setting, and it is good practice. Kidney function, liver function, HbA1c and a lipid panel give you a baseline to compare against, and vitamin D, B12 and ferritin are worth having because they predict the problems that show up at month four. A prescriber who orders nothing at all is not doing anything unlawful, and they are giving up the ability to tell later whether something changed.
- Is it safe to get a GLP-1 from a telehealth service?
- It can be, and the model is not the problem — the standard of care within it is. Good telehealth takes a proper history, screens contraindications, gives a written titration plan, arranges or requests labs, and provides a way to reach a clinician when something goes wrong. Poor telehealth is a form, a payment page and a package. Judge the service on what it does, not on whether it happens to be online.
- What are the warning signs of a bad GLP-1 provider?
- No questions about contraindications; no titration schedule in writing; dosing given in syringe units rather than milligrams; no way to contact a clinician; automatic refills without review; pressure toward a proprietary compounded blend; claims that sound like guarantees; and no discussion of what happens when you stop. Any one of those is a reason to ask more questions. Several together is a reason to go elsewhere.
Sources
- 01FDA. Medicines containing semaglutide marketed for type 2 diabetes or weight loss — safety information on compounded products.
- 02FDA prescribing information, Wegovy (semaglutide) injection.
- 03FDA prescribing information, Zepbound (tirzepatide) injection.
- 04Wilding JPH et al. Weight regain and cardiometabolic effects after withdrawal of semaglutide (STEP 1 extension). Diabetes, Obesity and Metabolism, 2022.
- 05Mechanick JI et al. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures. Obesity, 2020.
Elise Hall, MD
Board-certified internist in Los Angeles, twenty-one years in practice. She writes about GLP-1 medications and metabolic health for people who want the reasoning, not just the conclusion — and publishes her own year on one of these drugs alongside it.
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