Congratulations on this result. Let me address your question directly, because it's clinically important.

The expected BP reduction from weight loss alone is approximately 1 mmHg systolic per kg lost.^[1] You've lost ~24 kg, so you'd predict roughly a 24 mmHg systolic drop from weight alone. Your observed systolic reduction (off meds) is approximately 16-18 mmHg net (since you were at 134 on three drugs and are now at 118 off all drugs, the true reduction is much larger).

But GLP-1 RAs do appear to have BP-lowering effects beyond weight loss:

• GLP-1 receptors are expressed in the renal vasculature and promote natriuresis
• GLP-1 RAs improve endothelial function via NO-dependent pathways
• Reduction in sympathetic nervous system activity
• Improvement in arterial stiffness (reduced pulse wave velocity)

In the STEP 1 trial, semaglutide 2.4 mg reduced systolic BP by 6.2 mmHg vs. 1.1 mmHg for placebo at 68 weeks, with weight loss accounting for approximately 60-70% of the effect.^[2] So yes, there appears to be a direct vascular contribution.

^[1] Neter JE, et al. Influence of weight reduction on blood pressure. Hypertension. 2003;42(5):878-884.
^[2] Wilding JPH, Batterham RL, Calanna S, et al. Once-Weekly Semaglutide in Adults with Overweight or Obesity. N Engl J Med. 2021;384(11):989-1002.

Your medication de-escalation was done perfectly — one agent at a time, with monitoring between each step. I've guided about a dozen patients through similar de-escalation protocols on GLP-1 therapy, and the key is patience.

A word of caution: the BP benefit is contingent on continued semaglutide use and maintained weight loss. In the STEP 1 extension data, patients who discontinued semaglutide regained approximately two-thirds of lost weight within a year, and BP rebounded accordingly.

My recommendation: continue home BP monitoring (morning and evening, 7-day averages) and have a clear plan with your PCP for when to restart medications if needed. A systolic average >135 on home monitoring should trigger reassessment.

That's a great point about the weight regain risk. I'm planning to stay on semaglutide long-term. My insurance covers it with my BMI history and I've had zero issues with side effects after the initial titration nausea.

One thing I forgot to mention: my resting heart rate has actually gone up slightly since starting sema, from about 68 to 76 bpm. My PCP says this is a known effect and not concerning at this level, but it was initially confusing since everything else was improving.

This gives me so much hope. I'm 47F, on two BP meds (losartan 100mg and HCTZ 25mg), BMI 34, and just started semaglutide 3 weeks ago. My blood pressure has been creeping up despite the medications — last reading was 142/88.

Did you notice the BP improvements starting early, or was it more gradual? I'm trying to figure out when I should start looking for changes.