Can a pregnant woman continue taking tirzepatide (glucagon-like peptide-1 (GLP-1) receptor agonist) for type 2 diabetes?

Tirzepatide Must Be Discontinued in Pregnancy

No, a pregnant woman cannot continue tirzepatide during pregnancy and must switch to insulin immediately. Tirzepatide is a GLP-1/GIP receptor agonist that lacks safety data in human pregnancy, and current diabetes management guidelines explicitly recommend insulin as the only appropriate pharmacological treatment for diabetes during pregnancy.

Guideline-Based Recommendations for Diabetes Management in Pregnancy

Insulin as the Gold Standard

• Insulin is the preferred and recommended agent for managing both type 1 and type 2 diabetes during pregnancy 1, 2
• None of the currently available human insulin preparations (including NPH insulin) cross the placenta, making them safe options for pregnant patients 2, 3
• Both multiple daily insulin injections and continuous subcutaneous insulin infusion are reasonable delivery strategies during pregnancy 1, 2

GLP-1 Receptor Agonists Are Not Recommended

• Current diabetes management guidelines do not include any GLP-1 receptor agonists (including tirzepatide) among medications discussed for use during pregnancy 4
• Other oral and non-insulin injectable glucose-lowering medications lack long-term safety data and should not be used as first-line agents 1, 4
• The American Diabetes Association explicitly states that medications like sitagliptin (a DPP-4 inhibitor, similar class concern) should not be used during pregnancy due to lack of safety data 4

Limited Evidence on Tirzepatide in Pregnancy

Animal and Human Data Concerns

• Studies in small animals exposed to GLP-1 receptor agonists during pregnancy have shown adverse outcomes including decreased fetal growth, skeletal and visceral anomalies, and embryonic death 5
• While case reports and small cohort studies of GLP-1 receptor agonists have not shown a clear pattern of congenital anomalies, there is insufficient evidence regarding fetal growth restriction, embryonic or fetal death, or other potential complications 5
• A recent large observational study of 938 pregnancies with type 2 diabetes compared GLP-1 receptor agonist exposure to insulin but lacked critical information on maternal glycemic control and diabetic fetopathy, making conclusions about safety impossible 5

Critical Knowledge Gaps

• There is currently no evidence to predict adverse effects, or the lack thereof, from periconceptional exposure to GLP-1 receptor agonists during pregnancy 5
• Tirzepatide specifically has no published human pregnancy data, as it was only approved in 2022 6, 7

Clinical Management Algorithm

Immediate Actions Upon Pregnancy Recognition

1. Discontinue tirzepatide immediately upon pregnancy recognition or when planning pregnancy 4, 5
2. Initiate insulin therapy using either NPH insulin or rapid-acting insulin analogs in a basal-bolus regimen 1, 2, 3
3. Refer to a specialized center offering team-based care for pregnant individuals with diabetes when available 2, 3

Contraception Counseling

• All patients of reproductive age taking tirzepatide should use effective contraception to prevent unintended pregnancy 5
• Preconception counseling is critical for women with diabetes to achieve optimal glycemic control before pregnancy 4

Glycemic Targets During Pregnancy

• Target fasting glucose: 70-95 mg/dL 3
• Target one-hour postprandial glucose: 110-140 mg/dL 3
• Target two-hour postprandial glucose: 100-120 mg/dL 3
• Target A1C: <6% (42 mmol/mol) if achievable without significant hypoglycemia 1, 3

Additional Pregnancy Management Considerations

Adjunctive Therapies

• Prescribe low-dose aspirin 100-150 mg/day starting at 12-16 weeks of gestation to reduce preeclampsia risk 1, 2, 3
• Monitor for gestational diabetes, hypertensive disorders, preterm birth, and fetal growth restriction with close obstetric surveillance 1

Insulin Dosing Dynamics

• Early pregnancy is characterized by enhanced insulin sensitivity requiring lower doses 2, 3
• Insulin requirements typically increase linearly from around 16 weeks, often doubling compared to pre-pregnancy needs 2, 3
• Insulin requirements drop rapidly with delivery of the placenta 1, 2, 3

Common Pitfalls to Avoid

• Do not continue tirzepatide based on successful glycemic control pre-pregnancy - the lack of safety data outweighs any potential benefit
• Do not delay switching to insulin - early pregnancy is the critical period for organogenesis when teratogenic effects are most likely
• Do not assume GLP-1 receptor agonist class data applies to tirzepatide - tirzepatide is a dual GIP/GLP-1 agonist with a unique mechanism and no specific pregnancy data 6, 7, 8
• Avoid metformin as an alternative in women with hypertension, preeclampsia, or at risk for intrauterine growth restriction 1