Is it safe to use GLP-1 (Glucagon-like peptide-1) receptor agonist therapy, such as semaglutide (generic name) or liraglutide (generic name), in a patient with thrombocytosis and anemia?

Safety of GLP-1 Receptor Agonists in Patients with Anemia

GLP-1 receptor agonists (semaglutide, liraglutide, tirzepatide) are safe to use in patients with anemia, as anemia is not listed as a contraindication or safety concern in any major guidelines or FDA labeling. 1, 2

Established Contraindications (None Related to Anemia)

The absolute contraindications for GLP-1 receptor agonists are limited to:

• Personal or family history of medullary thyroid cancer 1, 2
• Multiple endocrine neoplasia syndrome type 2 (MEN2) 1, 2
• History of serious hypersensitivity reaction to the drug 1
• Severe renal impairment or ESRD (for exenatide and lixisenatide only; semaglutide, liraglutide, and tirzepatide require no dose adjustment across all CKD stages) 1, 3

Relevant Safety Considerations (Not Anemia-Specific)

While anemia itself is not a concern, the following safety issues should be monitored in all patients:

• Gastrointestinal effects (nausea, vomiting, diarrhea) occur in 17-44% of patients but are typically mild-to-moderate and transient 1, 2
• Pancreatitis risk - use with caution in patients with history of pancreatitis, though causality has not been definitively established 1
• Gallbladder disease (cholelithiasis, cholecystitis) - monitor for right upper quadrant pain 1, 2
• Hypoglycemia risk when combined with insulin or sulfonylureas (not as monotherapy) 1

Thrombotic Considerations in Context of Thrombocytosis

If your concern relates to the patient's thrombocytosis rather than anemia specifically:

• One case report documented portal vein thrombosis in a 59-year-old woman on semaglutide, though she had a JAK2 mutation predisposing to thrombosis 4
• No systematic evidence links GLP-1 receptor agonists to increased thrombotic risk in major cardiovascular outcome trials 1
• Cardiovascular benefits are well-established, with semaglutide reducing cardiovascular death, nonfatal MI, or stroke by 26% (HR 0.74,95% CI 0.58-0.95) 2, 3

Clinical Algorithm for Initiation

Proceed with GLP-1 receptor agonist therapy if:

1. No personal/family history of medullary thyroid cancer or MEN2 1, 2
2. No history of serious hypersensitivity to the drug 1
3. Renal function adequate (eGFR >30 for exenatide; no restriction for semaglutide/liraglutide/tirzepatide) 1, 3

Monitor specifically for:

• Gastrointestinal tolerance during titration (every 4 weeks) 2
• Signs of pancreatitis (persistent severe abdominal pain) 1
• Gallbladder symptoms 1, 2
• Blood glucose if on insulin or sulfonylureas (reduce doses by 20% at initiation) 2

The presence of anemia or thrombocytosis does not alter the safety profile or require dose modification of GLP-1 receptor agonists. 1, 2