What are the considerations for initiating Mounjaro (tirzepatide) therapy?

From the Guidelines

When initiating Mounjaro (tirzepatide) therapy, it is crucial to consider the individual's specific needs and characteristics, including their glycemic goals, cardiovascular risk, and potential for weight management, as tirzepatide has been shown to have cardiovascular safety but its benefits for ASCVD or CKD risk reduction are still under investigation 1.

Key Considerations for Initiating Mounjaro Therapy

• The decision to start Mounjaro should be based on a comprehensive assessment of the patient's health status, including their type 2 diabetes management goals and any comorbid conditions such as cardiovascular disease or kidney disease.
• Given that Mounjaro is a GLP-1 and GIP receptor agonist, its use should be considered in the context of other antihyperglycemic therapies, particularly those with proven cardiovascular benefits like GLP-1 RAs (e.g., dulaglutide, liraglutide, injectable semaglutide) and SGLT2 inhibitors 1.
• The initial dose of Mounjaro is typically 2.5 mg injected subcutaneously once weekly for the first 4 weeks, which helps minimize gastrointestinal side effects, followed by potential dose increases based on glycemic response and tolerability.
• Patients should be educated on the proper administration technique, including rotating injection sites and storing the pens in the refrigerator until use.
• Common side effects such as nausea, vomiting, diarrhea, and decreased appetite should be discussed with the patient, and strategies for managing these side effects should be provided.

Glycemic Control and Cardiovascular Benefits

• The goal of initiating Mounjaro therapy is not only to achieve glycemic control but also to consider its potential benefits on weight management and cardiovascular risk, although the latter is still being investigated in ongoing CVOTs 1.
• The choice of antihyperglycemic therapy should be individualized, taking into account the patient's preferences, access to therapies, and specific health characteristics, with a focus on agents that have proven benefits beyond glycemic control, such as reducing the risk of major adverse cardiovascular events (MACE) or slowing kidney disease progression.
• Regular monitoring of glycemic control, including A1C levels and other glycemic indices, is essential to assess the effectiveness of Mounjaro therapy and make adjustments as needed to achieve and maintain individualized glycemic goals.

From the FDA Drug Label

When initiating MOUNJARO, consider reducing the dose of concomitantly administered insulin secretagogues (e.g., sulfonylureas) or insulin to reduce the risk of hypoglycemia [see Warnings and Precautions (5.3)]. MOUNJARO is contraindicated in patients with: A personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) Counsel patients regarding the potential risk for MTC with the use of MOUNJARO and inform them of symptoms of thyroid tumors (e.g., a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Patients receiving MOUNJARO in combination with an insulin secretagogue (e.g., sulfonylurea) or insulin may have an increased risk of hypoglycemia, including severe hypoglycemia

The considerations for initiating Mounjaro (tirzepatide) therapy include:

• Contraindications: Personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
• Hypoglycemia risk: Consider reducing the dose of concomitantly administered insulin secretagogues (e.g., sulfonylureas) or insulin to reduce the risk of hypoglycemia
• Thyroid tumor risk: Counsel patients regarding the potential risk for MTC with the use of MOUNJARO and inform them of symptoms of thyroid tumors
• Gastrointestinal adverse reactions: MOUNJARO has been associated with gastrointestinal adverse reactions, which may lead to dehydration and acute kidney injury
• Hypersensitivity reactions: Serious hypersensitivity reactions, including anaphylaxis and angioedema, have been reported with MOUNJARO 2
• Drug interactions: MOUNJARO delays gastric emptying and may impact the absorption of concomitantly administered oral medications 2
• Dose administration: Administer MOUNJARO as separate injections and never mix with insulin 2

From the Research

Considerations for Initiating Mounjaro (Tirzepatide) Therapy

• The decision to initiate Mounjaro (tirzepatide) therapy should be based on the patient's individual needs and medical history, as tirzepatide has been shown to be effective in improving glycemic control and reducing body weight in patients with type 2 diabetes 3, 4, 5.
• Patients should be informed about the potential benefits and risks of tirzepatide, including the common adverse events of diarrhea, nausea, and vomiting 3, 5.
• The dosage of tirzepatide should be individualized, with a starting dose of 2.5 mg/week and escalation by 2.5 mg every 4 weeks until the assigned dose is achieved 3.
• Tirzepatide has been shown to be effective as an adjunct to diet and exercise, and as an addition to other medications such as metformin and insulin glargine 3, 6.
• The potential for tirzepatide to improve insulin sensitivity and reduce cardiovascular risk should also be considered, although more research is needed to fully understand its effects on these outcomes 5, 6.

Patient Selection

• Patients with type 2 diabetes who have inadequate glycemic control despite treatment with other medications may be candidates for tirzepatide therapy 3, 5.
• Patients with a history of cardiovascular disease or at high risk for cardiovascular events may also benefit from tirzepatide therapy, although more research is needed to confirm its cardiovascular benefits 5, 6.
• Patients with obesity or overweight may also benefit from tirzepatide therapy, as it has been shown to promote significant weight loss 4, 5.

Monitoring and Follow-up

• Patients initiating tirzepatide therapy should be monitored regularly for changes in glycemic control, body weight, and adverse events 3, 5.
• The dosage of tirzepatide may need to be adjusted based on the patient's response to therapy and the presence of adverse events 3.
• Patients should be educated on the proper use of tirzepatide, including the importance of injecting the medication correctly and following the recommended dosage regimen 6, 7.