Scientific Poster Session II - Case Reports

Abstract

Glucagon-like peptide receptor agonists (GLP-1RA) have emerged as an innovative treatment for type 2 diabetes (DM2). Published case reports, including dulaglutide, have noted an association with acute kidney injury (AKI).^1-9

Case:

This case describes a 58-year-old male with DM2 and chronic kidney disease, who presented to the emergency department with nausea and vomiting leading to AKI and hypercalcemia. One month prior the dose of dulaglutide was escalated from 0.75mg weekly to 3mg weekly. Subsequently, the patient reported use of calcium carbonate to treat gastrointestinal symptoms. Notably, the patient discontinued dulaglutide two weeks prior to admission yet continued to treat symptoms with calcium carbonate. Dulaglutide, its prolonged elimination half-life and excessive calcium carbonate use were pivotal considerations raising suspicions of their contribution to AKI. The Naranjo adverse drug reaction probability scale indicated a probable relationship (score of 5) between AKI and dulaglutide.¹⁴ Upon admission serum creatinine was 13.84 mg/dl, a tenfold increase from baseline, and calcium was 15.1 mg/dl. Renal biopsy revealed nephrocalcinosis, suggesting a link between hypercalcemia and calcium carbonate. Milk-Alkali Syndrome, seen in excessive calcium and alkali consumption, was considered.^10,12

Discussion:

The authors believe AKI and MAS occurred within several weeks of a dulaglutide dose escalation. AKI was likely a direct result of volume depletion in the setting of nausea and vomiting related to dulaglutide dose escalation with MAS resulting from excessive calcium carbonate consumption.

Conclusion:

With a national shortage of GLP1-RAs medications, necessitating patients to transition to alternative GLP1-RAs formulations, it is imperative that healthcare providers exercise careful titration procedures when initiating or adjusting GLP1-RAs to ensure optimal therapeutic outcomes and patient safety. Patient counseling regarding the use over-the-counter products for treatment of gastrointestinal symptoms should occur. Pharmacists are uniquely positioned to recognize potential drug interactions and adverse effects, providing essential guidance to patients and prescribers.

Presenting Author

Authors