What is the recommended dosage of Mounjaro (tirzepatide) for a patient with type 2 diabetes?

Mounjaro (Tirzepatide) Dosing for Type 2 Diabetes

Start Mounjaro at 2.5 mg subcutaneously once weekly for 4 weeks, then increase to 5 mg once weekly, with potential escalation to 10 mg and ultimately 15 mg once weekly at 4-week intervals based on glycemic response and tolerability. 1

Initial Dosing Protocol

• Week 0-4: Begin with 2.5 mg subcutaneously once weekly 1

  • This initial dose is for tolerability assessment, not therapeutic efficacy 2
  • Inject on the same day each week, at any time of day, with or without meals 2

• Week 5+: Increase to 5 mg once weekly after the initial 4 weeks 1

  • This represents the first therapeutic dose 1

Dose Escalation Strategy

• If additional glycemic control is needed: Increase to 10 mg once weekly after at least 4 weeks on the 5 mg dose 1

• For maximum glycemic control: Further increase to 15 mg once weekly after at least 4 weeks on the 10 mg dose 1

• Titration principle: Tirzepatide is initiated at 2.5 mg/week and escalated by 2.5 mg every 4 weeks until the assigned dose is achieved 3

Expected Outcomes by Dose

Glycemic Control:

• Tirzepatide achieves HbA1c reductions of 1.87-2.59% across all doses 4
• At 10 mg: Mean HbA1c reduction of -2.40% from baseline 3
• At 15 mg: Mean HbA1c reduction of -2.34% from baseline 3
• 23.0-62.4% of patients achieve HbA1c <5.7% (normal range) 5

Weight Loss:

• 5 mg dose: -5.4 kg mean weight loss 3
• 10 mg dose: -7.5 kg mean weight loss 3
• 15 mg dose: -8.8 kg mean weight loss 3

Special Dosing Considerations

Renal Impairment:

• No dosage adjustments are required for patients with normal renal function or mild to moderate renal impairment 1
• Tirzepatide can be used without dose adjustment in patients with reduced kidney function, including eGFR <30 mL/min/1.73 m² 1

Concomitant Medications:

• Reduce insulin by 20% when initiating tirzepatide to minimize hypoglycemia risk 1
• Consider reducing or discontinuing sulfonylureas to prevent hypoglycemia 1
• Discontinue DPP-4 inhibitors before starting tirzepatide, as concurrent use provides no additional benefit 6

Monitoring Schedule

During Titration (First 16 weeks):

• Assess every 4 weeks during dose escalation for gastrointestinal tolerance and adverse effects 6
• Monitor weight loss progress and blood pressure 6

After Reaching Maintenance Dose:

• Evaluate at least every 3 months for continued efficacy, cardiovascular risk factors, and medication adherence 1, 2

Treatment Evaluation:

• Assess efficacy at 12-16 weeks on the maximum tolerated therapeutic dose 1
• If weight loss is <5% after 3 months at therapeutic dose, consider discontinuation and alternative approaches 2

Safety Monitoring

Common Adverse Effects:

• Gastrointestinal effects (nausea 13-18%, diarrhea 12-21%, vomiting) are most common 7, 3
• These are typically mild-to-moderate, dose-dependent, and decrease over time 7
• Slow titration every 4 weeks minimizes these effects 1

Contraindications:

• Personal or family history of medullary thyroid cancer 1
• Multiple endocrine neoplasia type 2 (MEN2) 1
• History of serious hypersensitivity reaction to tirzepatide 1

Use with Caution:

• Clinically meaningful gastroparesis 1
• Prior gastric surgery, including bariatric surgery 1
• History of pancreatitis (monitor closely for signs) 1

Perioperative Management

• For elective surgery requiring anesthesia, discontinue tirzepatide at least 3 weeks before the procedure due to delayed gastric emptying and aspiration risk 1
• This applies even with extended fasting periods, as retained gastric contents are documented in 24.2% of users 6

Critical Pitfall to Avoid

Do not assess treatment efficacy at one month on the 2.5 mg starting dose—this dose is solely for tolerability, not therapeutic effect 2. Wait until the patient has been on a therapeutic dose (5 mg or higher) for at least 12-16 weeks before evaluating glycemic and weight loss response 1, 2.