Management of Adverse Effects in Patients on GLP-1 Receptor Agonists

Introduction to GLP-1 Receptor Agonist Side Effects

The American Diabetes Association recommends temporarily discontinuing GLP-1 receptor agonists in patients experiencing adverse effects such as vomiting, to allow symptoms to resolve, as supported by evidence from The Lancet Diabetes and Endocrinology 1

A complete blood count with differential should be obtained to characterize leukocytosis in patients on GLP-1 receptor agonists, with a suspected infection prompting consideration of blood cultures, and vital signs, including temperature, should be assessed to evaluate for fever 1
A complete physical examination should be performed, focusing on abdominal, lung, and skin examinations for signs of infection or other complications 1

Patients on GLP-1 receptor agonists experiencing vomiting should receive supportive care, including antiemetics as needed, a clear liquid diet, and adequate hydration, with monitoring of hydration status and electrolytes, and consideration of holding GLP-1 receptor agonists until vomiting resolves completely, as recommended by the European Society of Endocrinology 1
Dose reduction should be considered when restarting GLP-1 receptor agonists after vomiting has resolved, as evidenced by The Lancet Diabetes and Endocrinology 1

Patients on GLP-1 receptor agonists may be at risk for delayed gastric emptying and retained gastric contents, particularly with persistent vomiting, as reported in Anaesthesia, and are at increased risk of aspiration due to delayed gastric emptying, especially during procedures with sedation, as supported by the American College of Gastroenterology 2
The Endocrine Society advises against attributing leukocytosis solely to dehydration without appropriate workup, and against continuing GLP-1 receptor agonists in the setting of persistent vomiting, which can worsen dehydration 1

Patients should be reassessed within 1 week to evaluate symptoms and determine if the GLP-1 receptor agonist can be restarted, with monitoring of WBC count and hydration status, as recommended by The Lancet Diabetes and Endocrinology 1
The National Comprehensive Cancer Network recommends classifying severity of neutropenia as:

For patients with suspected acute leukemia, the National Comprehensive Cancer Network recommends prompt initiation of appropriate induction therapy, consideration of leukapheresis or hydroxyurea to rapidly reduce WBC count in cases with elevated blast counts, and obtaining blood cultures immediately and starting empiric broad-spectrum antibiotics within 1 hour if febrile neutropenia is present 3, 4
In cases of active infection, the National Comprehensive Cancer Network suggests obtaining appropriate cultures and initiating empiric antimicrobial therapy immediately, with consideration of granulocyte colony-stimulating factor (G-CSF) in consultation with hematology, and considering hospital admission for severe neutropenia (ANC <500/mm³) 3
Patients with elevated blast counts are at higher risk for tumor lysis syndrome and organ dysfunction from leukostasis, and measures to rapidly reduce WBC count, such as apheresis or hydroxyurea, should be taken, followed by prompt institution of definitive therapy, as recommended by the National Comprehensive Cancer Network 3