A guide to the results that will resolve themselves

The Journal groups these into three categories, and finds the classification more useful than any list. There are results altered by the physiology of energy deficit — the fall in triiodothyronine, the fall in insulin, the rise in ketones and free fatty acids, the shift in bile acid handling. There are results altered by the change in body composition, principally creatinine and the estimates built on it. And there are results altered by the immediate circumstances of the sample: haemoconcentration from reduced intake or vomiting, which raises creatinine, urea, albumin, haematocrit and calcium together, and which resolves with rehydration.

The eight things that break the HbA1c assay

Iron deficiency raises HbA1c independently of glycaemia, by a mechanism involving altered erythrocyte turnover and glycation kinetics; correcting the deficiency lowers it without any change in glucose. Any cause of accelerated erythrocyte turnover — haemolysis, recent transfusion, treatment of a deficiency anaemia, erythropoietin therapy — introduces young cells and lowers the value. Chronic kidney disease shortens erythrocyte survival and lowers it. Splenectomy raises it by extending survival.

Haemoglobin variants, including the common sickle and haemoglobin C traits, interfere with some assay methods, though not with all: ion-exchange chromatography and immunoassay behave differently and a laboratory should state its method when a variant is known. Pregnancy lowers it. Severe hypertriglyceridaemia and hyperbilirubinaemia interfere with some platforms.

Several of these are common in the population taking these drugs. Iron deficiency in particular is prevalent among people eating substantially less, and it pushes HbA1c in the direction that would make glycaemic control look worse than it is. A rising HbA1c during otherwise successful treatment is a reasonable prompt to check a full blood count and iron studies before concluding anything about glycaemia. That is an observation about assay behaviour and not clinical advice.

The creatinine artefact, stated precisely

Serum creatinine is the breakdown product of creatine phosphate in skeletal muscle, produced at a rate approximately proportional to muscle mass and cleared predominantly by glomerular filtration. Estimated glomerular filtration rate is calculated from serum creatinine with adjustments for age and sex, which function as population-average proxies for muscle mass.¹

When actual muscle mass falls, creatinine production falls, serum concentration falls, and the equation reports a higher estimated filtration rate. The magnitude is not trivial: a loss of four to five kilograms of lean tissue can shift estimated filtration rate upward by several millilitres per minute per 1.73 square metres with no change in the kidney whatever. The effect runs in the reassuring direction, which is why it is rarely questioned.

The check is cystatin C, a low-molecular-weight protein produced by all nucleated cells at a rate largely independent of muscle mass. Where creatinine-based and cystatin C-based estimates diverge substantially during rapid weight loss, the divergence is itself informative, and combined equations using both are available and better validated than either alone. Cystatin C has its own confounders — corticosteroids, thyroid dysfunction and adiposity all affect it — which is why the recommendation is to read the two together rather than to substitute one for the other.

The lipid panel: what moves, and because of what

During substantial weight loss on these agents, triglycerides fall markedly — reductions of the order of twenty per cent are reported in the obesity programmes — high-density lipoprotein cholesterol rises modestly, and low-density lipoprotein cholesterol falls only slightly.² That pattern is the signature of weight loss and improved insulin sensitivity rather than of a lipid-lowering drug effect, and it is worth saying so, because the class is sometimes described as though it were one.

Two measurement points matter. Triglycerides have large within-person biological variation, with a reference change value above thirty per cent, so an individual fall of twenty per cent between two panels may be noise even though the group mean fall of twenty per cent in a trial is a solid finding. And fasting is no longer required for routine lipid assessment; non-fasting samples differ trivially for total and LDL cholesterol and modestly for triglycerides, and international consensus has favoured non-fasting measurement for a decade.³

Lipoprotein(a) is worth a separate sentence because it is the exception. It is largely genetically determined, changes little with weight loss, and if it is going to be measured at all it needs measuring once rather than monitored. A person expecting it to improve alongside everything else will be disappointed by a result that was never going to move.

The acute-phase reactants move together

C-reactive protein falls substantially during successful weight loss on these agents, with reductions of the order of a third to a half reported in the obesity programmes, and it fell on treatment in the cardiovascular outcome trial in overweight and obesity without diabetes as well.⁴ Ferritin, fibrinogen and several other acute-phase proteins move in the same direction for the same reason: adipose tissue is an inflammatory organ and there is less of it.

The interpretive trap is ferritin. It is used clinically as a marker of iron stores and it is also an acute-phase reactant, which means it is raised by inflammation independently of iron. A person whose ferritin falls from 140 to 55 during a year of treatment may have depleted their iron stores on a reduced intake, or may have had a falsely reassuring ferritin all along that is now revealing a pre-existing deficiency, or may simply have less inflammation. Transferrin saturation and, where necessary, soluble transferrin receptor distinguish these; ferritin alone does not.

The same logic applies in reverse to any marker that is suppressed by inflammation. The Journal reports these movements as a group because reading them individually is how the mistakes happen: three or four analytes moving together during weight loss is a single physiological story, and treating it as three or four findings multiplies the investigation without adding to the information.

The panel drawn on a bad week

A person in the middle of a difficult dose escalation may be eating little, drinking less than usual and vomiting intermittently. A panel drawn in that state measures the state. Reduced plasma volume raises creatinine, urea, albumin, total protein, haematocrit and calcium together, generally by a modest proportion but sometimes substantially, and the pattern is recognisable precisely because so many analytes move in the same direction at once.

Persistent vomiting adds its own signature: hypokalaemia, hypochloraemia and a metabolic alkalosis, with magnesium frequently low alongside. That combination is a genuine finding requiring attention rather than an artefact, and distinguishing it from simple haemoconcentration is the reason a panel in this situation should include electrolytes and bicarbonate rather than being trimmed to the analytes of interest.

The practical rule the Journal has heard from every laboratory physician we have asked is to repeat rather than investigate: a panel drawn in a state of acute physiological disturbance, with several analytes moving coherently in one direction, is more informatively repeated after rehydration than pursued. Where the disturbance is itself the problem — where the vomiting is what needs addressing — the panel has already told you that, and it did not need a full workup to do it.

Thyroid function during energy restriction

Sustained energy restriction produces a characteristic and benign change in thyroid function tests: triiodothyronine falls, reverse triiodothyronine rises, thyroxine changes little and thyroid-stimulating hormone falls modestly or remains unchanged. This is the low-T3 pattern of adaptation to reduced energy availability, it is not hypothyroidism, and treating it as such is an error that predates this drug class by decades.

The relevant point for monitoring is that a thyroid panel drawn during rapid weight loss will frequently show a low or low-normal free T3, and that this does not indicate thyroid disease, does not require treatment, and reverses when energy balance is restored. Thyroid-stimulating hormone remains the appropriate first-line test for suspected thyroid dysfunction; adding free T3 to a panel during active weight loss reliably generates a result that requires explaining.

Separately and unrelatedly, this class carries a boxed warning in some jurisdictions derived from rodent thyroid C-cell findings. Serum calcitonin monitoring is not recommended for that purpose, and pharmacoepidemiological work examining thyroid cancer incidence in treated populations has not established the association the rodent data raised as a possibility.⁵ The Journal reports the boxed warning as what it is: a precaution derived from a rodent finding whose human relevance remains unestablished.

Readers who order their own panels privately, which a substantial fraction of this publication’s readership does, are in a specific position: they have the data and not the interpretive apparatus, and the apparatus is where the value is. The reference change value for the analyte in question, and the person’s own previous result, do more interpretive work than any reference interval on the printout.