How should Mounjaro (tirzepatide) be managed in patients undergoing an endoscopy?

Management of Tirzepatide (Mounjaro) for Patients Undergoing Endoscopy

For patients on tirzepatide (Mounjaro) undergoing endoscopy, the medication should be temporarily withheld according to the risk level of the procedure: omit the morning dose on the day of low-risk procedures, and withhold for at least 48 hours before high-risk endoscopic procedures to minimize bleeding risk. 1

Risk Stratification of Endoscopic Procedures

Low-Risk Procedures

• Diagnostic endoscopy with or without biopsies
• Biliary or pancreatic stenting
• Device-assisted enteroscopy without polypectomy

For these procedures:

• Simply omit the morning dose of tirzepatide on the day of the procedure 1
• No extended period of discontinuation is necessary

High-Risk Procedures

• Polypectomy
• ERCP with sphincterotomy
• Ampullectomy
• Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD)
• Stricture dilation
• Therapy of varices
• Percutaneous endoscopic gastrostomy (PEG)
• Endoscopic ultrasound with fine needle aspiration (EUS-FNA)
• Esophageal, enteral, or colonic stenting

For these procedures:

• Withhold tirzepatide for at least 48 hours before the procedure 1
• This recommendation follows the same principles applied to direct oral anticoagulants (DOACs)

Rationale for Management

While tirzepatide is not specifically an anticoagulant or antiplatelet agent, several factors warrant caution:

1. Gastrointestinal effects: Tirzepatide commonly causes gastrointestinal side effects including nausea, vomiting, and diarrhea, which could complicate endoscopic procedures 2

2. Delayed gastric emptying: As a GLP-1/GIP dual receptor agonist, tirzepatide slows gastric emptying, which could affect visualization during upper endoscopy and increase aspiration risk

3. Procedural considerations: Following the principles for other medications that might affect endoscopic outcomes is prudent when specific guidelines for newer agents like tirzepatide are not yet established

Post-Procedure Management

• Resume tirzepatide at the regular dose and schedule after the procedure once oral intake is established
• If the patient experiences significant post-procedural nausea or vomiting, consider delaying the resumption of tirzepatide until these symptoms resolve

Common Pitfalls to Avoid

1. Failure to communicate medication management: Ensure clear communication between the endoscopist, referring physician, and patient about tirzepatide management

2. Inadequate risk assessment: Properly classify the endoscopic procedure as low or high risk to determine appropriate medication management 1

3. Overlooking renal function: For patients with impaired renal function, consider extending the withholding period similar to recommendations for dabigatran in patients with reduced renal clearance 1

4. Poor adherence to guidelines: Research shows that compliance with medication management guidelines before endoscopy is often suboptimal (49.5% in one study), particularly for anticoagulants 3

By following these recommendations, clinicians can minimize potential complications while ensuring the safety and efficacy of endoscopic procedures in patients taking tirzepatide.