GLP-1 agonists and hand tremors is a concern that occasionally arises amongst patients using these diabetes and weight management medications. Glucagon-like peptide-1 (GLP-1) receptor agonists, including semaglutide, dulaglutide, and liraglutide, are widely prescribed in the UK for type 2 diabetes and obesity. Whilst hand tremors are not commonly listed as a direct adverse effect in product literature, patients may experience tremor for various reasons during treatment. Understanding the potential causes—including hypoglycaemia when combined with other medications, underlying conditions, or coincidental factors—is essential for appropriate management. This article examines the relationship between GLP-1 agonists and hand tremors, explores alternative explanations, and provides guidance on when to seek medical advice.

What Are GLP-1 Agonists and How Do They Work?

Glucagon-like peptide-1 (GLP-1) receptor agonists are a class of medications primarily used to manage type 2 diabetes mellitus and, more recently, for weight management in certain patient groups. These medicines include injectable drugs such as semaglutide (Ozempic, Wegovy), dulaglutide (Trulicity), liraglutide (Victoza, Saxenda), and exenatide (Byetta, Bydureon), as well as oral semaglutide (Rybelsus).

GLP-1 agonists work by mimicking the action of naturally occurring GLP-1, an incretin hormone released by the intestine in response to food intake. Their mechanism of action involves several complementary pathways:

• Glucose-dependent insulin secretion: They stimulate pancreatic beta cells to release insulin only when blood glucose levels are elevated, reducing the risk of hypoglycaemia compared to some other diabetes medications

• Glucagon suppression: They inhibit the release of glucagon from pancreatic alpha cells, thereby reducing hepatic glucose production

• Delayed gastric emptying: They slow the rate at which food leaves the stomach, leading to more gradual glucose absorption and increased satiety

• Central appetite regulation: They act on receptors in the brain to reduce appetite and food intake

These medications are typically administered once weekly or once daily via subcutaneous injection, with the exception of Rybelsus which is taken orally. According to NICE guidance (NG28), GLP-1 agonists for type 2 diabetes are recommended in specific clinical scenarios, including for people with a BMI ≥35 kg/m² (adjusted for ethnicity), those for whom insulin would otherwise be considered, and people with a BMI <35 kg/m² where weight loss would benefit obesity-related comorbidities. For weight management, NICE has approved specific GLP-1 agonists (Saxenda, Wegovy) under defined criteria. The MHRA has approved several GLP-1 agonists for use in the UK, with specific indications varying by product.

The Link Between GLP-1 Agonists and Hand Tremors

Hand tremors are not commonly listed as a direct adverse effect of GLP-1 receptor agonists in the Summary of Product Characteristics (SmPC) for these medications. The most frequently reported side effects include gastrointestinal symptoms such as nausea, vomiting, diarrhoea, and constipation, which typically diminish over time as the body adjusts to treatment.

However, patients taking GLP-1 agonists may occasionally experience tremors, and it is important to understand the potential mechanisms. There is no established direct pharmacological link between GLP-1 receptor agonists and tremor as an adverse drug reaction.

When tremors do occur in patients taking GLP-1 agonists, they are more likely to be:

• Indirectly related to hypoglycaemia: Tremor is a classic symptom of hypoglycaemia. While GLP-1 agonists alone have a low intrinsic risk of causing low blood sugar, this risk increases significantly when they are used in combination with insulin or sulphonylureas, as noted in product SmPCs

• Possibly associated with rapid weight loss: Significant weight reduction might potentially lead to electrolyte imbalances or nutritional deficiencies that could contribute to tremor, though this mechanism is not well-established

• Coincidental: Tremors may develop independently of medication use, particularly in older adults or those with other underlying conditions

If you develop new or worsening hand tremors whilst taking a GLP-1 agonist, it is essential to discuss this with your healthcare provider rather than assuming a direct causal relationship. Your doctor will need to conduct a thorough assessment to identify the underlying cause and determine the most appropriate management strategy.

Other Possible Causes of Hand Tremors in Diabetes Treatment

When hand tremors develop in someone with diabetes, particularly during treatment with GLP-1 agonists or other glucose-lowering medications, several alternative explanations should be considered. Hypoglycaemia (low blood glucose) remains the most important differential diagnosis. Classic symptoms include tremor, sweating, palpitations, anxiety, and confusion. This is especially relevant when GLP-1 agonists are combined with:

• Insulin therapy: The combination significantly increases hypoglycaemia risk

• Sulphonylureas (such as gliclazide): These medications stimulate insulin release regardless of glucose levels

• Meglitinides (such as repaglinide): Similar mechanism to sulphonylureas

Essential tremor is a common neurological condition affecting approximately 4% of adults over 40 years of age. It typically causes a bilateral action tremor of the hands and may be hereditary. This condition is unrelated to diabetes medications but may coincidentally emerge during treatment.

Thyroid dysfunction is more prevalent in people with type 2 diabetes. Hyperthyroidism can cause fine tremor, weight loss, palpitations, and heat intolerance. Conversely, hypothyroidism may occasionally present with tremor alongside fatigue and weight gain. NICE recommends annual thyroid function testing in patients with type 1 diabetes (NG17) and considers it in type 2 diabetes when clinically indicated.

Medication-induced tremor may result from other drugs, including:

• Beta-2 agonists (asthma inhalers)

• Certain antidepressants (SSRIs)

• Sodium valproate

• Lithium

• Excessive caffeine intake

Vitamin B12 deficiency should be considered, particularly in patients taking long-term metformin which can reduce B12 levels.

Parkinson's disease typically presents with a resting tremor (often asymmetrical) alongside bradykinesia and rigidity. Anxiety and stress can exacerbate physiological tremor. Alcohol withdrawal and vitamin deficiencies (particularly B12 and thiamine) should also be considered, especially in patients with poor nutritional intake or malabsorption.

When to Seek Medical Advice About Tremors

It is important to know when hand tremors require urgent medical attention and when they can be discussed at a routine appointment. Seek immediate medical help (call 999 or attend A&E) if tremors are accompanied by:

• Severe symptoms of hypoglycaemia: Confusion, loss of consciousness, seizures, or inability to swallow

• Chest pain, syncope, or severe breathlessness with palpitations: Suggesting cardiac involvement

• Sudden onset of weakness, speech difficulties, or facial drooping: Potential signs of stroke

• Severe headache with neck stiffness: Possible meningitis or other serious neurological condition

Contact NHS 111 or your GP practice within 24 hours if you experience:

• New or worsening tremors that interfere with daily activities

• Tremors accompanied by unexplained weight loss, heat intolerance, or palpitations (possible thyroid disorder)

• Frequent episodes of tremor with sweating, hunger, or confusion (suggesting recurrent hypoglycaemia)

• Tremors with other new neurological symptoms such as muscle stiffness, slowness of movement, or balance problems

Arrange a routine GP appointment (within 1–2 weeks) if:

• You notice mild, intermittent tremors that do not significantly affect function

• You wish to discuss tremors that have been present for some time

• You want to review your diabetes medications and their potential side effects

Before your appointment, it is helpful to:

• Keep a symptom diary: Note when tremors occur, their severity, duration, and any associated symptoms

• Monitor blood glucose levels: Check readings when tremors occur to identify any correlation with hypoglycaemia

• List all medications: Include prescription drugs, over-the-counter medicines, and supplements

• Record caffeine and alcohol intake: These substances can influence tremor

Your GP may perform a physical examination, review your medication regimen, check blood glucose patterns, and arrange investigations such as thyroid function tests or referral to specialist services if appropriate.

Managing Hand Tremors While Taking GLP-1 Agonists

If you develop hand tremors whilst taking a GLP-1 agonist, a systematic approach to management is essential. Do not stop your medication without medical advice, as this could lead to deterioration in your diabetes control.

Initial assessment and monitoring:

• Check blood glucose levels when tremors occur to rule out hypoglycaemia. If readings are below 4.0 mmol/L, take 15–20g of fast-acting carbohydrate (e.g., glucose tablets, fruit juice), wait 10–15 minutes, and recheck. If still low, repeat the treatment. Once your blood glucose is above 4.0 mmol/L, eat a longer-acting carbohydrate snack if your next meal is not due

• Do not drive or operate machinery until you have fully recovered from a hypoglycaemic episode

• Review medication timing and dosing with your healthcare team, particularly if you take insulin or sulphonylureas alongside your GLP-1 agonist

• Keep a detailed symptom diary to identify patterns or triggers

Medication adjustments:

Your doctor may consider:

• Reducing doses of insulin or sulphonylureas if hypoglycaemia is identified as the cause

• Reviewing the GLP-1 agonist dose titration schedule to ensure gradual increases that minimise side effects

• Temporarily suspending the GLP-1 agonist to determine whether tremors resolve, though this should only be done under medical supervision after thorough evaluation

Lifestyle modifications:

• Maintain regular meal patterns to stabilise blood glucose levels

• Ensure adequate hydration and nutrition, particularly if experiencing gastrointestinal side effects

• Reduce caffeine intake, as excessive consumption can exacerbate tremor

• Manage stress through relaxation techniques, as anxiety can worsen physiological tremor

• Avoid alcohol or consume only in moderation, as it can affect blood glucose control and tremor

Further investigations:

Depending on clinical assessment, your doctor may arrange:

• Thyroid function tests (TSH, free T4)

• Vitamin B12 and folate levels

• Liver and kidney function tests

• Referral to neurology if an underlying neurological condition is suspected

Most importantly, maintain open communication with your diabetes care team. The NHS provides diabetes specialist nurses and structured education programmes that can support you in managing your condition and any treatment-related concerns. If you suspect your tremors may be a side effect of medication, report this through the MHRA Yellow Card Scheme. If tremors persist despite investigation and management, your healthcare provider may consider alternative diabetes treatments that better suit your individual circumstances.

Frequently Asked Questions