What are the treatment considerations for a patient taking Zepbound?

Treatment Considerations for Zepbound (Tirzepatide)

Critical Safety Warnings and Contraindications

Zepbound is contraindicated in patients with a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2), as it causes thyroid C-cell tumors in rats. 1

Absolute Contraindications

• Personal or family history of MTC 1
• MEN 2 syndrome 1
• Previous serious hypersensitivity reaction to tirzepatide or any excipients 1

High-Risk Populations Requiring Extreme Caution

• History of pancreatitis (exposure-adjusted incidence rate: 1.15 patients per 100 years of exposure) 1
• Active suicidal ideation or history of suicide attempts 1
• Severe gastroparesis or gastrointestinal disease 1
• Patients with type 2 diabetes on insulin or sulfonylureas (hypoglycemia risk increases to 10.3% vs 2.1% without sulfonylurea) 1
• History of diabetic retinopathy 1

Pre-Treatment Evaluation and Screening

Mandatory Baseline Assessments

• Thyroid evaluation: Counsel patients to report neck lumps, persistent hoarseness, dysphagia, or dyspnea 1
• Psychiatric screening: Assess for depression, suicidal ideation, or history of suicide attempts 1
• Gallbladder assessment: Evaluate for cholelithiasis or cholecystitis history 1
• Renal function: Baseline creatinine and monitoring plan for dehydration risk 1
• For diabetic patients: Assess for diabetic retinopathy, particularly non-proliferative requiring acute therapy, proliferative diabetic retinopathy, or diabetic macular edema 1
• Blood glucose monitoring: Establish baseline in diabetic patients 1

Medication Reconciliation

• Insulin or sulfonylureas: Plan dose reduction to mitigate hypoglycemia risk (10.3% incidence with sulfonylureas) 1
• Other weight management products: Discontinue to avoid additive risks 1

Dosing and Administration Protocol

Standard Dosing Escalation

• Start at 2.5 mg subcutaneously once weekly 1
• Escalate by 2.5 mg increments every 4 weeks as tolerated 1
• Maximum maintenance dose: 15 mg once weekly 1

Storage Requirements

• Refrigerate at 2°C to 8°C (36°F to 46°F) 1
• May store unrefrigerated up to 30°C (86°F) for maximum 21 days 1
• Do not freeze; discard if frozen 1
• Protect from light in original carton 1

Monitoring During Treatment

Gastrointestinal Monitoring (Most Common Adverse Effects)

• Severe gastrointestinal reactions: Instruct patients to report severe or persistent nausea, vomiting, diarrhea, or abdominal pain immediately 1
• Dehydration risk: Counsel on fluid intake to prevent acute kidney injury secondary to volume depletion 1
• Pancreatitis surveillance: Discontinue immediately if persistent severe abdominal pain (radiating to back) with or without vomiting occurs 1

Metabolic Monitoring

• Hypoglycemia: In diabetic patients, monitor blood glucose before starting and throughout treatment; reduce insulin/sulfonylurea doses as needed 1
• Weight and edema: Track for fluid retention or unexpected weight changes 1

Psychiatric Monitoring

• Monthly assessment: Screen for emergence or worsening of depression, suicidal thoughts, or unusual mood/behavior changes 1
• Immediate discontinuation: Stop Zepbound if suicidal thoughts or behaviors develop 1

Ophthalmologic Monitoring (Diabetic Patients)

• Monitor for diabetic retinopathy progression, especially with rapid glucose improvement 1
• Instruct patients to report vision changes immediately 1

Perioperative Management

Elective Surgery or Procedures

• Inform anesthesia team: Zepbound delays gastric emptying, increasing pulmonary aspiration risk during general anesthesia or deep sedation 1
• Timing of discontinuation: Available data are insufficient to recommend specific discontinuation timing or modified fasting protocols 1
• Patients must notify all healthcare providers about Zepbound use before any planned procedures 1

Management of Adverse Events

Hypersensitivity Reactions

• Immediate discontinuation: Stop Zepbound for anaphylaxis, angioedema, or severe hypersensitivity (0.1% incidence) 1
• Seek emergency medical attention 1
• Do not rechallenge 1

Acute Gallbladder Disease

• Evaluate for cholecystitis or cholelithiasis if right upper quadrant pain, fever, or jaundice develops 1
• Obtain appropriate imaging and surgical consultation 1

Acute Kidney Injury

• Monitor for oliguria, elevated creatinine, or signs of renal impairment 1
• Aggressive fluid repletion for dehydration-related AKI 1
• Consider dialysis if renal failure occurs 1

Special Populations

Pregnancy and Lactation

• Pregnancy: Advise of potential fetal risk; discontinue if pregnancy occurs or is planned 1
• Pregnancy exposure registry available for monitoring outcomes 1
• Lactation: Unknown if excreted in breast milk; assess risk-benefit 1

Patients with Type 2 Diabetes

• Higher hypoglycemia risk (4.2% vs 1.3% placebo), especially with insulin secretagogues (10.3%) 1
• Reduce insulin/sulfonylurea doses proactively 1
• Monitor for rapid glucose improvement causing temporary diabetic retinopathy worsening 1

Patient Education Checklist

• Report thyroid symptoms (neck mass, hoarseness, difficulty swallowing/breathing) 1
• Recognize hypoglycemia signs/symptoms if diabetic 1
• Maintain adequate hydration to prevent kidney injury 1
• Report severe abdominal pain immediately (pancreatitis) 1
• Notify providers before any surgery or procedure 1
• Report mood changes, depression, or suicidal thoughts immediately 1
• Seek emergency care for allergic reactions 1
• Report vision changes if diabetic 1