What should I do if a patient on Wegovy (semaglutide) experiences painless vomiting and has a elevated white blood cell count (leukocytosis) of 18?

Management of Painless Vomiting with Leukocytosis in a Patient on Wegovy

For a patient on Wegovy experiencing painless vomiting with leukocytosis (WBC 18), you should temporarily discontinue Wegovy and evaluate for infection or other causes of leukocytosis while providing supportive care for the vomiting.

Initial Assessment and Management

Addressing the Vomiting

• Wegovy (semaglutide) is a GLP-1 receptor agonist that commonly causes gastrointestinal side effects, including nausea and vomiting 1
• Temporarily discontinue Wegovy to allow symptoms to resolve 2
• Provide hydration and antiemetic therapy:
  • Ondansetron 4-8mg orally or IV every 8 hours as needed
  • Ensure adequate fluid intake or provide IV fluids if dehydration is present

Evaluating Leukocytosis

• An elevated white blood cell count of 18 (18,000/mm³) indicates moderate to severe leukocytosis 3
• Obtain a complete blood count with differential to characterize the leukocytosis
• Perform a peripheral blood smear examination to evaluate for abnormal cells 3
• Consider blood cultures if infection is suspected

Diagnostic Workup

Infection Assessment

• Obtain vital signs including temperature to assess for fever
• Complete physical examination focusing on:
  • Abdominal examination for tenderness, rebound, or guarding
  • Lung examination for signs of pneumonia
  • Skin examination for cellulitis or other infections
• Consider additional tests:
  • Urinalysis and urine culture
  • Chest X-ray if respiratory symptoms are present
  • Abdominal imaging if abdominal pathology is suspected

Consideration of GLP-1 Agonist Complications

• Evaluate for pancreatitis, which can occur with GLP-1 receptor agonists 1:
  • Check serum lipase and amylase
  • Abdominal CT scan if pancreatitis is suspected
• Consider portal vein thrombosis, which has been reported with semaglutide 4:
  • Abdominal ultrasound with Doppler if abdominal pain develops

Management Plan

If Infection is Identified

• Initiate appropriate antimicrobial therapy based on the suspected source 3
• Consider hospital admission if severe infection or dehydration is present

If No Infection is Identified

1. Supportive care for vomiting:

   • Antiemetics as needed
   • Clear liquid diet, advancing as tolerated
   • Adequate hydration

2. Wegovy management:

   • Hold Wegovy until vomiting resolves completely
   • When restarting, consider dose reduction 1
   • If vomiting recurs, consider alternative medications for diabetes/weight management

Follow-up and Monitoring

• Reassess WBC count in 48-72 hours to ensure improvement
• Monitor hydration status and electrolytes
• Follow up within 1 week to reassess symptoms and determine if Wegovy can be restarted

Special Considerations

• Persistent vomiting with GLP-1 receptor agonists can lead to delayed gastric emptying and retained gastric contents 2
• Patients on GLP-1 receptor agonists may have prolonged gastric emptying time, which can worsen with dehydration 2
• If the patient requires any procedures requiring sedation, be aware of increased risk of aspiration due to delayed gastric emptying 2

Pitfalls to Avoid

• Don't attribute leukocytosis solely to dehydration without appropriate workup
• Don't continue Wegovy in the setting of persistent vomiting, as this can worsen dehydration
• Don't overlook serious complications like pancreatitis, which can present with vomiting in patients on GLP-1 receptor agonists 1
• Don't restart Wegovy at the same dose after resolution; consider dose reduction to improve tolerability 2