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Dose errors: what the adverse event reports actually list

Among the terms reported most often for these drugs are incorrect dose, extra dose and off-label use. Those describe what somebody did, not what the drug did.

Ruth Alvarez6 min read
Frequently reported terms — use-process shadedincorrect dose administeredhow it was usednauseainjection-site paindiarrheavomitingoff-label usehow it was usedextra dose administeredhow it was used243,114 records. The list is not ranked, and none of it is a rate.

Three of the terms turning up repeatedly in these reports are not descriptions of what the drug did to somebody. They are descriptions of what somebody did with the drug, and the authors separate the two explicitly — a distinction a product page never makes.

What a record is

A case-product entry in the FDA’s Adverse Event Reporting System where a GLP-1 drug was named the primary suspect, after removing deleted cases, keeping only the latest version of each, and deduplicating. [1] That produced 243,114 records inside a background of 8,995,547 reports covering everything else.

Somebody — a patient, a clinician, a manufacturer — decided each of those was worth submitting. There is no denominator of users anywhere in it.

Two different kinds of thing in one list

Nausea, vomiting, diarrhea and injection-site pain are effects of a drug. Incorrect dose administered, extra dose administered and off-label use are events in the handling of a product.

The authors put it as medication-use terms reflecting use-process rather than conventional adverse-drug-reaction issues, and they build a whole prioritized domain around medication-use and device events alongside the clinical ones — gastrointestinal intolerance, impaired gastric emptying, pancreatobiliary, renal and dehydration events, and hypoglycemia.

The counts by drug are not a comparison

Tirzepatide accounted for 133,100 records, semaglutide 55,619 and dulaglutide 38,406.

That ordering says nothing about which drug is riskier. Reporting volume follows how many people take something, how long it has been on the market, how much press it has had, and who is being prompted to report — which is why a count of reports is not a count of events, and why the authors say explicitly that none of their sources estimates incidence, comparative risk or causality.

What it is actually for

Deciding what to look at next. The authors describe their output as signal prioritization and medication-safety evidence, cross-checked against Canadian reports and against the FDA’s own labeling changes.

Read that way it is useful and modest: a map of where to point a proper study. Read as a league table of harm it is worthless, and it will be read that way, which is the standing fate of every spontaneous reporting analysis that reaches a headline.

Frequently asked

What gets reported most often for these drugs?
The published list includes incorrect dose administered, nausea, injection-site pain, diarrhea, vomiting, off-label use and extra dose administered. The abstract does not rank them.
Why separate dose errors from side effects?
Because they are different failures. The authors describe medication-use terms as reflecting the use process rather than conventional adverse drug reactions — what somebody did with the product, not what the product did.
Does tirzepatide having more reports mean it is riskier?
No. Reporting volume follows how many people take a drug, how long it has been sold and how much attention it has had. The authors state no source here estimates comparative risk.
Can you get a rate out of this?
No. There is no count of how many people took anything, and the authors say the findings are signal prioritization rather than incidence.

Sources

  1. [1] Ren L, et al. (2026). Postmarketing Safety Signals and Medication-Use Risks of GLP-1-Based Therapies in Diabetes and Obesity: A Multi-Source Pharmacovigilance and Regulatory Evidence-Mapping Study Diabetes, Obesity and Metabolism. PMID 42687799

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