Starting Mounjaro (Tirzepatide) for a 60-Year-Old Woman with No Comorbidities

Begin tirzepatide at 2.5 mg subcutaneously once weekly for the first 4 weeks, then increase to 5 mg once weekly. 1

Initial Dosing Protocol

Start with 2.5 mg once weekly subcutaneously for 4 weeks as the initial dose, regardless of age or comorbidity status 1
After completing 4 weeks at 2.5 mg, increase to 5 mg once weekly 1
The 2.5 mg starting dose serves as a dose-escalation period to minimize gastrointestinal side effects, which are most common during initial treatment 1, 2

After at least 4 weeks on the 5 mg dose, consider increasing to 10 mg once weekly based on glycemic response and tolerability 1
After at least 4 weeks on the 10 mg dose, the maximum dose of 15 mg once weekly may be used if additional glycemic control is needed 1
Each dose escalation requires a minimum of 4 weeks at the current dose before advancing 1

Administer as a subcutaneous injection once weekly at any time of day, with or without meals 1
The timing of the weekly injection can be flexible and does not need to be coordinated with food intake 1
Use the single-dose prefilled pen for administration 3

No dose adjustments are required for this 60-year-old patient with no comorbidities, as age alone does not necessitate dose modification 4
No renal dose adjustments are needed across all levels of kidney function, including severe renal impairment 1, 4

Gastrointestinal side effects are the most common, occurring in a dose-dependent manner: nausea (10-31%), diarrhea (7-23%), vomiting (2-12%), constipation (3-5%), and abdominal pain (3-5%) 1, 2
These gastrointestinal symptoms are typically mild to moderate in severity and occur primarily during the dose-escalation period in the first 20 weeks, decreasing over time 5, 2, 6
Drug discontinuation due to adverse events occurs in approximately 6-10% of patients, with the highest rates at the 15 mg dose 2

Monitor for signs and symptoms of pancreatitis (severe persistent abdominal pain radiating to the back, with or without vomiting) and discontinue tirzepatide immediately if pancreatitis is suspected 1
Screen for personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia type 2 before initiating therapy, as tirzepatide is contraindicated in these patients due to a black box warning regarding thyroid C-cell tumors 1
Monitor for acute kidney injury, particularly when initiating or escalating doses, as gastrointestinal side effects can lead to dehydration 1
Hypoglycemia risk is low (severe hypoglycemia ≤1%) when tirzepatide is used without concomitant insulin or sulfonylureas 2

Do not skip the 2.5 mg starting dose and begin directly at 5 mg, as this increases the risk of intolerable gastrointestinal side effects leading to discontinuation 1, 2
Do not escalate doses before completing the minimum 4-week period at each dose level 1
Do not assume age-related dose reduction is necessary in a healthy 60-year-old without comorbidities, as no adjustments are indicated 4
Be aware of the 5-day elimination half-life when considering perioperative management or if discontinuation becomes necessary 1