Abstract | March 24, 2024

Dry Beriberi Resulting From GLP-1 Receptor Agonist and GIP Receptor Agonist Induced Weight Loss

Tim Pham, MD, Internal Medicine, PGY1, Heersink UAB School of Medicine Huntsville Campus, Huntsville, AL

Hinal Rathi, DO, Internal Medicine, PGY1, Heersink UAB School of Medicine Huntsville Campus, Huntsville, AL; Pranayraj Kondapally, MD, Internal Medicine, PGY2, Heersink UAB School of Medicine Huntsville Campus, Huntsville, AL; Nessy Abraham-Phillip, MD, Internal Medicine, Attending Physician, Heersink UAB School of Medicine Huntsville Campus, Huntsville, AL

Learning Objectives

  1. Monitor, identify, and treat unique presentation of acute weight loss with new onset peripheral neuropathy and oral ulcers in patients with recent initiation of GLP-1 Receptor agonists and GIP Receptor agonists

Introduction: Glucagon-like peptide-1 receptor agonists (GLP-1ra) and dual-acting GLP-1 and glucose-dependent insulinotropic polypeptide receptor agonists (DAGLP), such as Tirzepatide, have proven highly effective in simultaneously managing blood sugar levels and promoting weight loss in patients with type 2 diabetes. In this report, we present a patient with uncontrolled T2DM and obesity with worsening bilateral lower extremity pain and angular stomatitis after initiating medication.

Case Presentation: A 22-year-old male with a past medical history of germinoma treated with resection and ventriculoperitoneal shunt resulting in panhypopituitarism and diabetes insipidus, Class 3 obesity, and uncontrolled Type II Diabetes Mellitus with HbA1c of 13 six months prior to presentation. He started treatment with GLP-1ra and changed to DAGLP with a total weight loss of 80lbs. Two months later physical examination revealed angular stomatitis, glossitis, gingival bleeding, absent patellar and achilles reflexes, 0/5 strength on dorsi- and plantarflexion. Imaging studies were unremarkable. Nerve conduction studies were consistent with severe peripheral neuropathy. Lab tests revealed thiamine level of 44nmol/L [normal 70 -180], copper levels of 72mcg/dL [73-129], niacin was <5.0ng/mL [cutoff reference value <5.0], vitamin B6 was 7mcg/L [5-50], and vitamin B12 was 1480pg/mL [232-1245]. He was empirically started on niacin, pyridoxine, thiamine, vitamin C and multivitamins, which significantly improved clinical presentation. Nutrition was monitored and managed by a dietitian. The patient’s symptoms improved rapidly, and he regained functional mobility. He was discharged with recommendations for outpatient physical therapy and close follow up.

Conclusion and Discussion: 22-year-old patient with uncontrolled diabetes and obesity was treated with Semalutide and later Tirzepatide with significant reduction in A1c and weight loss due to decreased appetite. His poor intake led to multiple nutritional deficiencies. He had clinical features of Dry Beriberi, with distal symmetric motor and sensory neuropathy. In addition, he had low normal levels of multiple water-soluble vitamins and Copper, which can also cause peripheral neuropathy, stomatitis, and glossitis. Our patient’s presentation is the first to report the risk of nutritional deficiency after initiating Tirzepatide. This highlights the need to consider micronutrient deficiencies when initiating GLP-1ra and DAGLP in the setting of rapid weight loss.

References and Resources

  1. Stroh C, Meyer F, Manger T. Beriberi, a severe complication after metabolic surgery – review of the literature. Obes Facts. 2014;7(4):246-52. doi: 10.1159/000366012. Epub 2014 Jul 30. PMID: 25095897; PMCID: PMC5644786.
  2. Tucker ON, Szomstein S, Rosenthal RJ. Nutritional consequences of weight-loss surgery. Med Clin North Am. 2007 May;91(3):499-514, xii. doi: 10.1016/j.mcna.2007.01.006. PMID: 17509392.
Back to Abstracts