What to do for a patient with T2DM, Parkinson's, asthma, and Vitamin D deficiency on Mounjaro (tirzepatide) experiencing dizziness with normal BP and RBS of 134 mg/dL?

Management of Dizziness in a 69-Year-Old Woman on Mounjaro

The dizziness on day 3 of Mounjaro is most likely medication-related, and you should assess for dehydration, review all concurrent medications that lower blood pressure, ensure adequate hydration, and educate the patient that transient dizziness is a known side effect that often improves with time. 1

Immediate Assessment

Rule Out Hypoglycemia First

• Although her random blood sugar of 134 mg/dL is not hypoglycemic, dizziness is a recognized symptom of low blood sugar with Mounjaro, particularly when combined with other diabetes medications 1
• Check if she is on sulfonylureas or insulin, which significantly increase hypoglycemia risk when combined with tirzepatide 1
• If she experiences recurrent episodes, obtain fingerstick glucose during symptomatic periods to definitively exclude hypoglycemia 1

Assess for Mounjaro-Related Gastrointestinal Fluid Loss

• Nausea, vomiting, and diarrhea are the most common side effects of Mounjaro and can cause dehydration-related dizziness 1
• Specifically ask about these GI symptoms, as fluid loss can worsen her pre-existing conditions and cause orthostatic symptoms even with "normal" blood pressure readings 1
• This is particularly important given her Parkinson's disease, which already predisposes to autonomic dysfunction 2

Orthostatic Hypotension Evaluation

Perform Proper Orthostatic Vital Signs

• Measure blood pressure after 5 minutes lying/sitting, then at 1 and 3 minutes after standing 3
• A positive test is defined as systolic BP drop ≥20 mmHg or diastolic BP drop ≥10 mmHg 3
• A single "normal" BP reading does not exclude orthostatic hypotension, which is the most common cause of medication-related dizziness 3, 4

Medication Review is Critical

• Review ALL medications for those causing hypotension, including alpha-blockers (for urinary symptoms), diuretics, and any antihypertensives 3, 4
• Patients taking multiple medications that lower blood pressure are at significantly increased risk for dizziness 4
• Consider reducing or eliminating offending medications if orthostatic hypotension is confirmed 3

Parkinson's Disease Considerations

Autonomic Dysfunction

• Parkinson's disease itself causes autonomic dysfunction and predisposes to orthostatic hypotension, making her particularly vulnerable to medication-related dizziness 2, 5
• The combination of Parkinson's disease and new GLP-1 agonist therapy creates additive risk for orthostatic symptoms 2
• Disequilibrium from Parkinson's disease can be exacerbated by any medication causing dizziness 5, 6

Management Strategy

Non-Pharmacologic Interventions

• Ensure adequate hydration to prevent dehydration from GI side effects and reduce orthostatic symptoms 3, 4, 1
• Educate the patient to rise slowly from sitting or lying positions 4
• Counsel that transient dizziness is a common side effect of medications and often improves with time without requiring dose reduction 2
• This reassurance is important for medication adherence, as patients often remain compliant when they understand dizziness is a side effect of beneficial therapy 2

When to Continue vs. Modify Mounjaro

• If dizziness is mild and not associated with falls, severe GI symptoms, or confirmed hypoglycemia, continue Mounjaro with supportive measures 2, 1
• If severe GI symptoms with dehydration are present, temporarily hold Mounjaro and ensure rehydration before restarting 1
• Do not discontinue Mounjaro prematurely for mild dizziness alone, as this is often self-limited 2

Red Flags Requiring Further Evaluation

• New focal neurological deficits, inability to walk independently, severe headache, or loss of consciousness require urgent evaluation 7
• True vertigo (spinning sensation) rather than lightheadedness suggests vestibular pathology and warrants Dix-Hallpike maneuver 2, 8
• Progressive symptoms despite hydration and medication review warrant consideration of other etiologies 5, 8

Follow-Up Plan

• Reassess in 1-2 weeks after implementing hydration and medication review 2
• If dizziness persists beyond 2-3 weeks or worsens, consider dose reduction of Mounjaro or alternative diabetes therapy 1
• Monitor for gallbladder symptoms (upper abdominal pain, jaundice) as another potential cause of her symptoms 1