Persistence on incretin therapy is decided in the first three months, and the reasons people stop are mostly foreseeable: nausea that nobody warned them about, a month where the drug was unaffordable, a dose escalation that arrived faster than their tolerance.
Two minutes at the first prescription buys most of it back. Say plainly that nausea is common, usually settles, and is a reason to slow the escalation rather than to stop. Agree what happens if a dose is missed, and what happens if cost becomes a problem — an honest conversation about switching to a cheaper agent beats a silent discontinuation.
Then ask the question that rarely gets asked: what is the plan if this is stopped? A patient who understands that weight and glycaemia will return is a patient who tells you before they stop, rather than after.
- Warn about gastrointestinal effects at the first prescription, not at the first complaint.
- Escalate the dose on the patient's tolerance, not on the packaging schedule.
- Ask directly about cost at every review — a patient rationing doses will not volunteer it.
- Agree in advance what to do if the drug is stopped, and book a review for four weeks after any stop.
- Keep metformin and the SGLT2 inhibitor going if an incretin is withdrawn; do not leave the patient on nothing.
Why it matters
Most of the benefit of these drugs is lost by people who stopped, not by people in whom they failed.
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