A Dose of Caution: Identifying Therapeutic Errors Associated with Injectable Semaglutide

Abstract

Specific Aims: To identify major causes of therapeutic errors associated with injectable semaglutide. Methods: Data was collected retrospectively through the ToxSentry database at the Arizona Poison and Drug Information Center where a report was run for all exposures pertaining to semaglutide from January 1, 2020 to March 31, 2025. All cases were reviewed for eligibility based on inclusion and exclusion criteria and data was then analyzed by the author. Results: 91 cases were reviewed: 31.9% male and 68.1% female (mean age 56.2 ± 15.6 [range 24-85] years). The most common causes for error were confused units of measure (36%), patients forgetting they had already taken their medication (13%), misreading the package/instructions (11%), and patients injecting another dose because they didn’t think it went in the first time (11%). Overall, 40.7% of cases were a confirmed compounded product and had an average dosing error of 7.5 ± 3.2-fold [range 2-10], while 59.3% of cases were a non-compounded product and had an average dosing error of 3.2 ± 2.0-fold [range 2-10]. All cases classified under ‘confused units of measure’ involved confirmed compounded semaglutide products, with 51.5% explicitly reporting the use of insulin syringes for administration. The number of compounded semaglutide cases has already surpassed those of non-compounded semaglutide in the first quarter of 2025 and is on track to exceed the total reported in 2024. Conclusion: Therapeutic errors involving injectable semaglutide are largely due to compounded products particularly when patients are required to measure their own doses.