Should You Lower the GLP-1 Receptor Agonist Dose?
No, you should not lower the tirzepatide dose—instead, you should discontinue the medication entirely because your patient has achieved a normal BMI (23.6) and no longer meets criteria for pharmacotherapy. 1
Rationale for Discontinuation
Pharmacotherapy for obesity is indicated only for patients with BMI ≥30 kg/m² or BMI ≥27 kg/m² with weight-related comorbidities. 1 Your patient now has a BMI of 23.6, which is well within the normal range (18.5-24.9), and therefore no longer meets the threshold for continued anti-obesity medication treatment.
Key Clinical Considerations
The American Gastroenterological Association guidelines explicitly state that obesity pharmacotherapy should be used in patients with BMI ≥30 or BMI ≥27 with comorbidities such as hypertension, type 2 diabetes, dyslipidemia, or obstructive sleep apnea. 1
Your patient's only documented comorbidity is hyperlipidemia, and with her current normal BMI, the risk-benefit ratio of continuing GLP-1 receptor agonist therapy no longer favors treatment. 1
Weight regain is expected after GLP-1 receptor agonist discontinuation—studies show significant weight regain occurs within one year of stopping therapy, with approximately 6.0 kg regained after liraglutide cessation. 2, 3
Transition Strategy
Immediate Actions
Discontinue tirzepatide now rather than tapering, as there is no evidence supporting gradual dose reduction for discontinuation. 1
Implement intensive lifestyle interventions immediately, as medications should never be used alone but always in combination with comprehensive lifestyle programs. 1
Long-Term Maintenance Plan
Establish a structured follow-up program using office visits, phone calls, texting, emails, or apps to maintain continuum interaction with your patient. 1
Monitor weight monthly for the first 3 months post-discontinuation, then at least every 3 months thereafter to detect early weight regain. 1
The addition of supervised exercise to GLP-1 therapy during treatment improves weight maintenance after discontinuation—patients who combined exercise with GLP-1 agonists maintained 5.1 kg greater weight loss one year after stopping medication compared to those on medication alone. 3
Critical Pitfall to Avoid
Do not continue obesity pharmacotherapy in patients who have achieved normal BMI simply because "weight regain might occur." 1 This represents off-label use without evidence of benefit and exposes patients to unnecessary risks including:
- Gastrointestinal adverse events (nausea, vomiting, diarrhea) that are common with GLP-1 receptor agonists. 1, 2
- Potential for excessive weight loss below healthy BMI ranges.
- Unnecessary medication costs and injection burden.
If Weight Regain Occurs
Reinitiate pharmacotherapy only if BMI returns to ≥27 with weight-related comorbidities or ≥30 without comorbidities. 1
Assess for inadequate lifestyle intervention adherence first before restarting medication, as this is the most common cause of weight regain. 1
Consider that one-third of patients maintain ≥5% weight loss at 72 weeks after starting GLP-1 agonists, suggesting some patients can maintain weight loss with lifestyle interventions alone after medication discontinuation. 4