If you pay any attention to the medical field, you are probably aware that a new class of drugs has recently gained a lot of attention. Sometimes called glips, these are collectively known as glucagon-like peptide-1 receptor agonists (GLP-1 RAs). You might also have heard of semaglutide, the generic name for the GLP-1 RA found in certain brands: Ozempic, Rybelsus, and Wegovy.
GLP-1 RAs are injectable drugs, administered with the same kind of pen-like instrument that many insulin users may have. They were first approved for use in the context of type 2 diabetes in 2005,¹ but now about 12 percent of United States adults—including many who don’t have diabetes—have used a version at some point.²
The public demand in the US for these drugs is especially remarkable because they cost about $1,000 per month. They are often not covered by health insurance or Medicare, so they are a substantial out-of-pocket expense.
In this article, we look at GLP-1 RAs, how they work, and who they’re for. We discuss well-recognized risks and adverse effects, and we explore some unexpected benefits. Most importantly, we conclude with a critical thinking exercise about a fictional client who starts using Ozempic and would like to use massage therapy as part of their self-care routine.
What Are GLP-1 RAs?
GLP-1 RAs are drugs that affect how bodies use food. They mimic GLP-1, a hormone released by the gastrointestinal tract. Naturally occurring GLP-1 acts on the pancreas to stimulate the release of insulin. GLP-1 RAs do the same thing, but they also suppress the secretion of glucagon (a pancreatic hormone that tells the liver to release blood sugar). GLP-1 RAs act on the brain to suppress appetite and on the stomach to delay emptying. Consequently, users feel less hungry and feel full for longer after a meal.
GLP-1 RAs were originally developed for people with type 2 diabetes. They are typically prescribed when other diabetes management strategies (i.e., metformin, supplemented insulin, and other drugs) are not successful at bringing down A1c levels.
More recently, GLP-1 RAs were approved for use in treating overweight and obese clients, specifically among people who are at high risk for a cardiovascular event—that is, a heart attack or stroke. Some GLP-1 RAs are used for weight loss, some are used for diabetes, and some can be used in both situations. The dose for weight loss is typically higher than the dose for diabetes management.
When GLP-1 RAs were approved as a weight-loss drug, things really took off. At the time this article was published, about 6 percent of people in the US (about 15 million) were using these drugs to manage diabetes, lower heart disease risk, or lose weight.³ As the drugs have found widespread use, reports of adverse effects have emerged. This is inevitable. When more people use a drug, more problems arise. Most of the adverse effects of GLP-1 RAs are not long lasting or threatening, but some have been very serious. However, another result of widespread use has also arisen: GLP-1 RA drugs may carry a variety of benefits that no one predicted.
GLP-1 RA Drugs Adverse Effects
Skin Irritation
Most GLP-1 RAs are injected into the subcutaneous layer of the skin, usually on the belly, outer thighs, back of the arms, or upper buttocks. Some people develop irritation or even allergic reactions to these injection sites. One drug has been released in an oral form to avoid this, but its dosage has to be adjusted for degradation in the GI tract.
GI Tract Problems
Nausea, vomiting, and diarrhea are common side effects as patients adjust to these medications. These effects usually pass with time, and dosages are corrected according to the patient’s tolerance.
A few more serious adverse effects have been reported about gastrointestinal function for GLP-1 RA users. Some patients report extremely slow gastric motility and delayed stomach emptying. Gastroparesis is an occurrence where the smooth muscle tissue of the stomach and intestines becomes weak and peristalsis slows or even stops. Bowel obstructions may occur. This can cause complications like pain, constipation, bloating, and long-term challenges with digestive health.
Pancreatitis
A small number of GLP-1 RA users have developed pancreatitis. The drugs act on the pancreas, so it’s not surprising that this organ might develop problems. The mechanism by which pancreatitis develops in GLP-1 RA users is not clear. Nonetheless, pancreatitis can be dangerous, and even life-threatening, so anyone with a history of this disorder cannot use these drugs.
“Ozempic Face”
“Ozempic face” refers to the hollow cheeks, sunken eyes, and sagging skin that sometimes develop when a person loses weight quickly—not necessarily through weight-loss drugs. It is purely a cosmetic issue and is not in any way connected to complications or physical risk.
Other Risks
Animal testing of GLP-1 RAs suggests a slightly higher than average risk of thyroid cancer. Human testing and surveys have not found this to be an issue, but it’s something that needs to be considered. Also, gallbladder disorders show a correlation with use, especially with high doses over a prolonged period.
Other problems may arise. The most serious side effects—pancreatitis or bowel obstruction—have been reported in under 1 percent of users per year of use.4 These drugs have been on the market for almost 20 years and appear to be safe and effective for most people when used appropriately.
One issue that every GLP-1 RA user should know, however, is that the changes these drugs bring about are not sustained when a person no longer takes the drug. To maintain diabetes control or weight loss, the patient makes a long-term, possible lifelong, commitment to using this medication. For many users, loss of appetite and ongoing low-level nausea outweigh weight loss and other advantages, so they don’t continue to use the drug. Consequently they regain the weight and lose other benefits.
GLP-1 RA Drugs: Positive Effects
The GLP-1 RAs were developed to help manage blood sugar for people with type 2 diabetes that is difficult to control. The drugs do this without causing weight gain and hypoglycemia (two common and problematic side effects of supplemented insulin). It was a side benefit that these drugs turned out to be effective for weight loss, but it has become their main market. Again, the specific targets for this benefit are overweight and obese people who are identified as high-risk for cardiovascular events.However, many doctors now prescribe them for patients who have a hard time with weight loss, regardless of heart disease or stroke risk.
Having a large group of users under medical supervision has created an opportunity to gather a lot of observational data—that is, information collected from the medical records of many (often tens of thousands) people to look for trends. And this has revealed some surprising results.
Some of the observed benefits of GLP-1 RAs include:
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Lower systolic and diastolic blood pressure
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Lower total cholesterol
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Improved cardiac output
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Decreased inflammation in the cardiovascular system
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Increased glucose uptake in muscles
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Improved fatty liver disease
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Lower risk of kidney disease
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Less risk of diabetic neuropathy
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Less risk of obesity-related cancers
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Lower all-cause mortality
Additionally, there are hints that people who use GLP-1 RAs can manage substance use disorders (i.e., drug use, alcohol use) more effectively. There are signs of improved neuroplasticity and protection from neurodegenerative diseases like Alzheimer’s and Parkinson’s, and the list goes on. At this point most of this data is observational, rather than experimental, so we can’t make definitive claims without further research.
GLP-1 RAs are not for everyone, obviously. Some people who should not use them are:
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Those with serious GI tract problems, like any variety of inflammatory bowel disease; they are specifically contraindicated.
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Those with a history of any kind of pancreatitis.
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Those with a history of certain endocrine cancers.
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Those who are pregnant or who might become pregnant; the drugs’ effects on pregnancy are unknown.
Implications for Massage Therapy
We have covered a lot of information about GLP-1 RAs, which is important because most massage therapists probably have clients who are using them. But does any of this information impact clinical decisions about bodywork? Let’s put this through a simplified critical thinking exercise.
The Situation
Your 56-year-old client, Hal, had a mild heart attack two years ago. He has type 2 diabetes and is overweight. Two months ago, he started a course of low-dose Ozempic. His dose will increase as he adjusts to the medication—he’s had some nausea, but it’s getting better. He is watching his diet and exercising, his A1c readings have fallen, and he’s already lost some weight, so he feels he has some momentum toward better health. To celebrate his success, and to take further steps in his self-care, he would like to start receiving massage therapy regularly.
GLP-1 RAs were originally developed for people with type 2 diabetes. More recently, GLP-1 RAs were approved for use in treating overweight and obesity.
The Question
It seems like the main question is, “Is it safe for someone who uses a GLP-1 RA to receive massage therapy?” However, I would argue that isn’t the key question—partly because massage can mean so many things, but mainly because the key question, as always, is, “What are this client’s goals for massage?” With that information, we can make informed decisions about what type of massage we might use, and what kinds of cautions or accommodations might be necessary. If this client wants massage to shorten his recovery time as he trains for his first half-marathon, that sets up different parameters than if he wants massage as a reward for his weight-loss progress. For this case, let’s suggest that Hal hopes to feel more energetic in general, and that some minor aches and pains in his back and neck might be relieved. He hopes to visit at least once a month, more if he can afford it.
Variables
We need to collect information on Hal’s underlying conditions. We know he’s had a heart attack, he has type 2 diabetes, and he has been using Ozempic for a couple of months, among several other medications. We need to find out about side effects from any of his meds, long-term limitations (if any) related to his heart attack, and any complications related to diabetes—especially about renal function or nerve issues. For example, we know that Hal has had nausea, so we want to be sure not to make that worse. With this information, it is possible to start planning a safe and effective session.
Considerations or Assumptions
Because we have virtually no information about how massage therapy might interact with Ozempic, we cannot predict specific outcomes. The dose recommendations for GLP-1 RAs vary, and Hal’s dose may increase if he continues to tolerate it well. The safest assumption is that less is better until we know more about Hal’s tolerance for massage, especially given his medical history.
What Have Others Done in Similar Situations?
We don’t know. We have data on massage therapy and diabetes, and massage therapy and cardiovascular disease, but nothing yet on massage therapy and GLP-1 RAs. Because these drugs work to manage blood glucose levels and because we know that massage therapy consistently drops blood glucose levels at least temporarily,5 it would be interesting to track numbers on Hal’s blood glucose levels, if he’s willing. This could be the beginning of a case report that might reveal some important information.
Possible Treatment Plan
Hal is using Ozempic and other interventions to manage weight, blood glucose, and the risk of cardiovascular disease. He is also exercising regularly. Hal’s cardiovascular and kidney health might be compromised, and we don’t want to challenge that until we have a better idea of his resilience and overall capacity for adaptation. That said, exercise is recommended for GLP-1 RA users. Some data suggests it makes the drugs more effective.6 Adding massage therapy to this mix is unlikely to have any significant negative long-lasting impact, and it may help with his general energy levels. But for the sake of safety, I suggest starting slowly before challenging him with bodywork that requires a lot of adaptation on his part.
Evaluation
If Hal’s main goals are to use massage therapy to reward himself with his progress, then your work is successful when he feels rewarded. Helping him with the fatigue and inevitable aches and pains that accompany a new exercise routine can also help him stay on track. As he progresses, he may want to establish more specific goals about what he would like to be able to do that massage can help him with, but “staying on track with my self-care” is a great goal in itself.
A Final Word
I confess to being surprised by what I learned about GLP-1 RAs to prepare this column. I expected to find suppressed reports about serious side effects or wildly overstated success stories. I assumed that these drugs are another weight-loss gimmick and fad in a culture that struggles to have healthy attitudes toward food and body size. But I was happy to find that these drugs can be extremely helpful to the populations who need them most.
The role of massage therapy in this context has yet to be explored. But since GLP-1 RA users are encouraged to exercise, it is reasonable to suggest that massage therapy can be safe as well (as long as other underlying conditions and medications have been addressed in a treatment plan).
Furthermore, devices like continuous blood glucose monitors can track changes in real time. This would allow a massage therapist, with the client’s permission, to gather baseline, midsession, end-of-session, and delayed readings. What useful data that could be for figuring out how best to help clients achieve their goals!
For your clients who use GLP-1 RAs, that’s wonderful! I encourage you to move forward with appropriate caution and with lots of enthusiasm for your privilege in being part of their health-care strategies.
Notes
1. Cleveland Clinic, “GLP-1 Agonists,” accessed October 2024, https://my.clevelandclinic.org/health/treatments/13901-glp-1-agonists.
2. Emily Harris, “Poll: Roughly 12% of US Adults Have Used a GLP-1 Drug, Even If Unaffordable,” JAMA 332, no. 1 (June 7, 2024): 8, https://doi.org/10.1001/jama.2024.10333.
3. Deidre McPhillips, CNN, “1 in 8 Adults in the US Has Taken Ozempic or Another GLP-1 Drug, KFF Survey Finds,” May 10, 2024, https://cnn.com/2024/05/10/health/ozempic-glp-1-survey-kff/index.html.
4. Nadine Eckert, Medscape, “What Is the Dark Side of GLP-1 Receptor Agonists?” accessed October 2024, https://medscape.com/viewarticle/998986.
5. Davood Bayat et al., “The Effect of Massage on Diabetes and Its Complications: A Systematic Review,” Crescent Journal of Medical and Biological Sciences 7, no. 1 (January 2020): 22–8, https://cjmb.org/uploads/pdf/pdf_CJMB_413.pdf.
6. Beth Ann Mayer, Healthline, “Exercise Is Still Important for Weight Loss While Taking Drugs Like Ozempic,” November 16, 2023, https://healthline.com/health-news/exercise-important-while-taking-ozempic.
Resources
Catanese, L. Harvard Health Publishing. “GLP-1 Diabetes and Weight-Loss Drug Side Effects: ‘Ozempic Face’ and More.” February 5, 2024. https://health.harvard.edu/staying-healthy/glp-1-diabetes-and-weight-loss-drug-side-effects-ozempic-face-and-more.
Collins, L., and Ryan A. Costello. Glucagon-Like Peptide-1 Receptor Agonists. Treasure Island, Florida: StatPearls Publishing, 2024. https://ncbi.nlm.nih.gov/books/NBK551568.
Eccles, M. Politico, “Can Ozempic Help Drug Addicts, Too? A Mega New Study Suggests It Might.” Accessed October 2024. https://politico.eu/article/ozempic-drugs-study-research-mounjaro-alcohol-addiction.
Filippatos, T. D., T. V. Panagiotopoulou, and M. S. Elisaf. “Adverse Effects of GLP-1 Receptor Agonists.” The Review of Diabetic Studies 11, nos. 3–4 (Fall-Winter 2014): 202–30. https://pubmed.ncbi.nlm.nih.gov/26177483.
Johnson, A. Forbes. “How Ozempic, Wegovy, Mounjaro, Zepbound May Help Treat other Diseases: Here’s What to Know.” Accessed October 2024. https://forbes.com/massage-and-bodywork-magazine/sites/ariannajohnson/2024/09/04/how-ozempic-wegovy-mounjaro-zepbound-may-help-treat-other-diseases-heres-what-to-know.
Montero, A. et al. KFF. “KFF Health Tracking Poll May 2024: The Public’s Use and Views of GLP-1 Drugs.” May 10, 2024. https://kff.org/health-costs/poll-finding/kff-health-tracking-poll-may-2024-the-publics-use-and-views-of-glp-1-drugs.
Nachawi, N., P. P. R. Rao, and V. Makin. “The Role of GLP-1 Receptor Agonists in Managing Type 2 Diabetes.” Cleveland Clinic Journal of Medicine 89, no. 8, (August 2022): 457–64. https://doi.org/10.3949/ccjm.89a.21110.
O’Mary, L. Web MD. “Ozempic May Protect Against Cognitive Decline and Addiction.” July 15, 2024. https://webmd.com/obesity/news/20240715/ozempic-may-protect-against-cognitive-decline-and-addiction.
Pelc, C. MedicalNewsToday. “Who Uses GLP-1 Drugs, and for What? Is It Worsening Diabetes Drug Shortages?” July 25, 2024. https://medicalnewstoday.com/articles/glp-1-drugs-diabetes-drug-shortages.
Popoviciu, M. S. et al. “Emerging Role of GLP-1 Agonists in Obesity: A Comprehensive Review of Randomised Controlled Trials.” International Journal of Molecular Sciences 24, no. 13 (2023): 10449. https://doi.org/10.3390/ijms241310449.
Shetty, R. et al. “Adverse Drug Reactions of GLP-1 Agonists: A Systematic Review of Case Reports.” Diabetes & Metabolic Syndrome: Clinical Research & Reviews 16, no. 3 (March 2022): 102427. https://doi.org/10.1016/j.dsx.2022.102427.
