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Abstract
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OBJECTIVES: We aim to increase pharmacists' and regulatory agencies' awareness of emerging issues regarding current practices of semaglutide use in the community which has led to increased reports of administration errors and adverse drug events to our regional poison control center.
CASE SUMMARIES: We report three cases of adverse drug events following incorrect administration of semaglutide for weight loss obtained from compounding pharmacies and an aesthetic spa. Two patients self-administered 10-fold dosing errors. All patients experienced notable symptoms of nausea, vomiting, and abdominal pain with most symptoms lasting for days. Other symptoms of headache, anorexia, weakness, and fatigue were reported in one patient. One patient sought evaluation at a healthcare facility and responded well to an antiemetic and intravenous fluids. One patient who received their medication from a compounding pharmacy reported receiving a vial with syringes for self-administration; no pharmacist counseling was provided on proper drug administration. One patient reported dosing in milliliters and units rather than in milligrams.
PRACTICE IMPLICATIONS: These three semaglutide cases highlight the potential for patient harm given current practices. Vials of compounded semaglutide do not employ safety features provided by pre-filled manufactured pens and allow for large overdoses (e.g., 10-fold dosing errors). Use of syringes not intended for semaglutide contribute to the variability of dosing units (milliliters, units, milligrams), contributing to patient confusion. To address such issues, we encourage increased vigilance in labeling, dispensing, and counseling practices to ensure patients are confident in administering their medication regardless of the formulation. We additionally encourage boards of pharmacy and other regulatory agencies to promote proper use and dispensing of compounded semaglutide. Such vigilance and promotion could decrease the risk of more severe adverse drug events and avoidable hospital utilization that may arise from dosing errors.
Language: en |