The GLP-1 dosing mistakes sending more patients to poison control
Industry Buzz
Can you imagine something you're supposed to trickle up to, and you're going full blast and seven times more often than you're supposed to?
—Jordan Miller
GLP-1 receptor agonists have transformed the treatment landscape for obesity and type 2 diabetes. But as prescriptions for semaglutide products such as Ozempic and Wegovy have soared, so has another, less welcome trend: Calls to poison control centers.
Recent research examining poison center data found a dramatic increase in GLP-1-related calls following semaglutide’s approval for obesity.[] The overwhelming majority involved therapeutic errors rather than misuse, highlighting an educational gap that has struggled to keep pace with the drug’s popularity.
Related: What docs can't afford to overlook amid the GLP-1 boomFor physicians, the findings are a reminder that prescribing the medication is only part of the job. Ensuring patients understand exactly how to administer it may be just as important.
“When the GLP-1[RA] drugs are being sold to diabetic patients, that’s a completely different story versus when the drug is used for weight management. So, we had to quantify this evidence to show that it stemmed from the FDA approval and how to contain the risk. We need to better educate the public because how this drug behaves in our body and its long-term safety are not yet fully understood,” said David Han, PhD, a professor in the UT San Antonio Department of Statistics and Data Science. []
Where are patients going wrong?
Several dosing mistakes account for most poison center calls. Some patients accidentally inject the medication daily instead of weekly. Others skip the recommended dose-escalation schedule and begin with a much higher dose than prescribed.[]
“Can you imagine something you're supposed to trickle up to, and you’re going full blast and seven times more often than you’re supposed to?" said Jordan Miller, a UT San Antonio student.[]
Still others misunderstand syringe markings when using compounded semaglutide products supplied in multidose vials rather than manufacturer-produced injection pens.[]
Unlike the branded injector pens, compounded formulations often require patients to manually draw up their dose. That introduces opportunities for decimal errors, unit-versus-milligram confusion, and accidental overdoses.
What happens after an overdose?
Fortunately, most cases reported to poison control result in mild to moderate illness.
The most common symptoms include[]:
Nausea
Vomiting
Diarrhea
Abdominal pain
Dehydration from prolonged gastrointestinal losses
Some patients require evaluation in the emergency department, particularly when vomiting is prolonged or dehydration becomes clinically significant.
Severe hypoglycemia appears uncommon in patients taking semaglutide alone but may occur in those receiving concomitant glucose-lowering medications.
Importantly, poison center experts note that many callers simply want guidance after realizing they administered an incorrect dose before significant symptoms develop.
Why the problem has grown
The rise in poison center calls reflects more than just increased prescribing. Semaglutide has expanded beyond endocrinology practices into primary care, obesity medicine, telehealth platforms, medical spas, and online prescribing services. Many first-time users have little prior experience with injectable medications.
Drug shortages over the past several years also drove increased use of compounded semaglutide products, which often require manual dose measurement rather than fixed-dose injection pens.[] Multiple poison control centers have identified compounded products as a frequent source of dosing confusion.[]
As access broadens, opportunities for administration errors naturally increase.
Related: Your patient lost weight on a GLP-1. Now they’re back with all new concerns. Here’s how to respondClinical takeaway
The poison control data suggest that semaglutide’s safety challenges are increasingly related to medication administration rather than pharmacology.
For physicians, several practical strategies may reduce risk:
Demonstrate the first injection whenever possible rather than relying solely on written instructions.
Clearly emphasize that semaglutide is generally administered once weekly, not daily.
Review the dose-escalation schedule at every follow-up visit.
Ask patients to repeat back how much medication they will inject and when.
Exercise additional caution when prescribing compounded formulations that require patients to measure doses manually.
Encourage patients to contact the office or poison control immediately after an accidental overdose rather than waiting for symptoms to worsen.
A few extra minutes spent reviewing administration techniques may prevent an emergency department visit later.
Patient counseling advice
When initiating Ozempic, Wegovy, or another semaglutide product, consider reinforcing these key points with patients:
This is not a medication where “more works better.” Taking extra doses will not speed weight loss but can significantly increase gastrointestinal toxicity.
Know your schedule. Set recurring reminders so weekly injections are not mistaken for daily medications.
Follow the titration plan exactly. The gradual dose increases are designed to improve tolerability.
If using a compounded product, ask for a hands-on demonstration. Patients should understand how milligrams correspond to syringe markings before leaving the pharmacy or clinic.
After a dosing mistake, don’t guess. Contact your prescribing clinician or Poison Control (1-800-222-1222) promptly for individualized guidance.
As GLP-1 prescribing continues to expand, patient education may become one of the most effective interventions physicians have to prevent avoidable medication errors. The poison control data serve as a timely reminder that even highly effective therapies require equally effective instruction.