Who Qualifies for GLP-1 Drugs: BMI Criteria, Comorbidities, and Contraindications

The two indication categories

GLP-1 receptor agonists are approved for two distinct indication categories with different qualifying criteria:

1. Obesity / chronic weight management

• Wegovy (semaglutide 2.4 mg)
• Zepbound (tirzepatide up to 15 mg)
• Saxenda (liraglutide 3 mg)

2. Type 2 diabetes management

• Ozempic (semaglutide 0.5–2 mg)
• Mounjaro (tirzepatide 2.5–15 mg)
• Victoza (liraglutide 0.6–1.8 mg)
• Trulicity (dulaglutide)
• Byetta/Bydureon (exenatide)

This article focuses primarily on the obesity/weight management indication, which has the more complex eligibility criteria for non-diabetic patients.

BMI criteria for the obesity indication

All three obesity-indication GLP-1 drugs use the same BMI thresholds, consistent with standard clinical obesity classification:

• BMI ≥30 = obese (qualifies for obesity indication without additional criteria)
• BMI 27–29.9 = overweight (qualifies only with a documented comorbidity)

What counts as a qualifying comorbidity (BMI 27–29.9)

For patients with BMI between 27 and 30, at least one of the following documented conditions is required:

• Type 2 diabetes (or prediabetes in some protocols)
• Hypertension (on medication or with documented readings above 130/80 mmHg)
• Dyslipidaemia (abnormal cholesterol or triglycerides, particularly elevated LDL or low HDL)
• Obstructive sleep apnoea (diagnosed by sleep study or clinical documentation)
• Established cardiovascular disease (prior MI, stroke, peripheral arterial disease, coronary artery disease)

Some prescribers include:

• PCOS (polycystic ovary syndrome) — technically not listed in the FDA label but clinically relevant given the insulin resistance and metabolic overlap
• Non-alcoholic fatty liver disease (NAFLD/NASH)
• Osteoarthritis related to weight

Telehealth prescribers may apply these criteria variably — some are more conservative, some more liberal. The FDA-approved indications are the standard, but prescriber judgement applies in clinical practice. For steps on obtaining a prescription, see how to get a GLP-1 prescription.

Absolute contraindications

These conditions disqualify patients from GLP-1 therapy (all drugs in class):

1. Personal or family history of medullary thyroid carcinoma (MTC)

The black-box warning on all GLP-1 obesity drugs specifically states:

"Contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN2)."

This is based on rodent thyroid C-cell tumour findings. Patients with MTC history or first-degree relatives with MTC should not use GLP-1 obesity drugs.

2. Multiple Endocrine Neoplasia type 2 (MEN2)

MEN2 is a genetic syndrome that predisposes to MTC and phaeochromocytoma. GLP-1 drugs are contraindicated.

3. Pregnancy

GLP-1 receptor agonists should be discontinued at least 2 months before attempting conception. They are contraindicated during pregnancy due to inadequate safety data.

4. Serious hypersensitivity to the drug

Prior anaphylaxis or serious allergic reaction to the specific drug. Not a class-wide contraindication unless allergic to shared components.

Conditions requiring precaution (not absolute contraindication)

These require prescriber discussion and monitoring, but are not absolute disqualifying conditions:

History of pancreatitis: The pancreatitis association is debated (current evidence does not support a causal link), but clinical guidelines recommend caution in patients with prior acute pancreatitis episodes.

Gastroparesis: GLP-1 drugs further slow gastric emptying. Pre-existing gastroparesis is a clinical precaution, not an absolute contraindication in most guidelines, but is clinically significant.

Gallbladder disease: Increased gallstone risk with GLP-1 therapy. Patients with a history of gallstones should discuss this risk with their prescriber.

Diabetic retinopathy: Semaglutide's prescribing label includes a warning about worsening retinopathy, particularly early in treatment. Patients with existing proliferative or non-proliferative diabetic retinopathy should have an eye examination before and during GLP-1 therapy.

Renal impairment: Semaglutide does not require dose adjustment in CKD (and actually has data supporting renal protection). Liraglutide should be used with caution in severe CKD. Tirzepatide data in severe CKD is more limited.

Eating disorders: Not a contraindication, but requires careful screening and monitoring given appetite suppression effects. Active restrictive eating disorders warrant specialist involvement.

T2D patients on metformin: GLP-1 drugs are commonly added to existing metformin therapy — see the GLP-1 and metformin guide for safety and efficacy of the combination.

Age criteria

Adults (18+): Standard eligibility applies.

Adolescents (12–17): Wegovy and Zepbound are FDA-approved for adolescents aged 12+ with obesity. The BMI criteria for adolescents uses age- and sex-specific percentiles rather than the adult BMI cutoffs:

• BMI at or above the 95th percentile for age and sex

Under 12: No GLP-1 drug is FDA-approved for children under 12.

Older adults (65+): No upper age cutoff in the FDA label. Clinical experience in adults over 75 is more limited; some prescribers exercise additional caution regarding nutritional adequacy, bone density, and lean mass preservation in this group.

What happens at the prescribing evaluation

A prescriber assessing eligibility will typically:

1. Calculate BMI (from height and weight)
2. Document comorbidities (if BMI is 27–30)
3. Review medications for interactions (particularly diabetes drugs requiring hypoglycaemia monitoring)
4. Screen for contraindications (thyroid cancer history, pregnancy status, MEN2)
5. Review medical history (pancreatitis, gallbladder, GI history)
6. Lab work (some prescribers order metabolic panel, HbA1c, thyroid function; telehealth services often do not)
7. Prior treatment history (many insurers require documentation of prior failed weight loss attempts)

If you are borderline on BMI criteria

Some patients have BMI just below 27 but have metabolic markers suggesting significant benefit from GLP-1 therapy (elevated HbA1c but not diagnostic for T2D; elevated fasting glucose; insulin resistance; significant cardiovascular risk).

This is a grey area. Some prescribers — particularly obesity medicine specialists — will prescribe based on overall metabolic risk rather than BMI threshold alone. Most telehealth services use the FDA-approved BMI cutoffs as hard criteria.

If you are BMI 25–27 without comorbidities, standard care guidelines do not support GLP-1 prescribing. This is not a cost, access, or availability problem — it is a question of whether the risk-benefit analysis applies at lower BMI. The trial data was conducted in patients meeting the approved criteria.

Summary

GLP-1 obesity drugs (Wegovy, Zepbound) require BMI ≥30 or BMI ≥27 with a documented comorbidity. For a tirzepatide vs semaglutide comparison to help choose between the two approved drugs, see our head-to-head article. T2D-indication GLP-1 drugs (Ozempic, Mounjaro) require confirmed T2D. Absolute contraindications include personal/family history of MTC or MEN2 and pregnancy. Several conditions (pancreatitis history, gastroparesis, eating disorders) require precaution rather than exclusion. Adolescents aged 12+ are eligible under different BMI criteria.