Acetonemic vomiting: a potential complication of treatment with glucagon-like peptide-1 receptor agonists especially in lean type 2 diabetes patients

Objectives: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are now widely used for treating type 2 diabetes mellitus (T2DM) and obesity. We examined their association with acetonemic vomiting, especially when given to patients with low body weight, in hopes of achieving early recognition of this complication which is potentially life-threatening if not dealt with appropriately. Methods: Cases identified incidentally are described and discussed referring to prior reports. Results: We managed two episodes of acetonemic vomiting, associated with GLP-1 RA use, affecting type 2 diabetes patients with low body weight. The absence of significant abnormalities in regularly tested laboratory data or imaging workup findings in these patients made it difficult to diagnose and recognize the emergent nature of the problem. Conclusion: GLP1-RAs have the potential to induce acetonemic vomiting when prescribed to patients with diabetes, especially those with low body weight. Although it is a potentially life-threatening disorder, acetonemic vomiting is not common in adults, making accurate diagnosis challenging. It is important that clinicians not hesitate to administer a dextrose-containing intravenous bolus, with insulin if necessary, to maintain normal glucose levels and thereby prevent progression to severe outcomes including death.