Can a 61-year-old obese man with prediabetes (HbA1c 6.2%) and a frontal gait disorder from prior brain cancer be prescribed semaglutide (Ozempic/Wegovy) or tirzepatide (Mounjaro) for weight loss despite not having diagnosed type 2 diabetes?

Prescribing GLP-1 Receptor Agonists for Weight Loss in Prediabetes

Yes, it is entirely reasonable and evidence-based to prescribe either semaglutide (Wegovy 2.4mg, not Ozempic) or tirzepatide (Mounjaro/Zepbound) for this patient, even without diagnosed type 2 diabetes. His prediabetes (HbA1c 6.2%), obesity, and limited mobility due to frontal gait disorder make him an ideal candidate for pharmacotherapy.

Patient Eligibility

Your patient clearly meets FDA-approved criteria for GLP-1 receptor agonist therapy:

• BMI ≥30 kg/m² qualifies him without any additional requirements 1, 2
• His prediabetes (HbA1c 6.2%) counts as a weight-related comorbidity, which would qualify him even if his BMI were only ≥27 kg/m² 1, 2
• His limited mobility makes lifestyle modification alone insufficient, strengthening the indication for pharmacotherapy 1

Medication Selection: Mounjaro (Tirzepatide) vs. Wegovy (Semaglutide 2.4mg)

For maximum weight loss in this patient, prioritize tirzepatide 15mg weekly as first-line therapy 1:

Tirzepatide Advantages

• Achieves 20.9% total body weight loss at 72 weeks, with approximately 40% of patients losing ≥25% of body weight 1, 3, 4
• Superior to semaglutide by 6% absolute weight loss (20.9% vs 14.9%) 1, 3
• Provides dual GIP/GLP-1 receptor activation, offering enhanced metabolic benefits including better triglyceride reduction and waist circumference reduction 1, 3
• In prediabetes specifically, 23.0-62.4% of patients achieve HbA1c <5.7% (normal range), potentially preventing progression to diabetes 1, 4

Semaglutide 2.4mg (Wegovy) as Alternative

• Achieves 14.9% weight loss at 68 weeks, with 64.9% of patients losing ≥10% body weight 1, 2
• Has proven cardiovascular benefit with 20% reduction in cardiovascular death, MI, or stroke (HR 0.80) in patients with established cardiovascular disease 1, 2
• Choose semaglutide over tirzepatide if the patient has known cardiovascular disease, as it has completed cardiovascular outcome trials 1

Critical Point: Use Wegovy, NOT Ozempic

Ozempic (semaglutide 1mg) is NOT FDA-approved for weight loss in non-diabetic patients 2. Wegovy (semaglutide 2.4mg) is the correct formulation for obesity management 1, 2. Using Ozempic off-label will create insurance authorization problems and provides suboptimal dosing 2.

Absolute Contraindications to Screen For

Before prescribing either medication, you must screen for 1, 2:

• Personal or family history of medullary thyroid cancer
• Multiple endocrine neoplasia syndrome type 2 (MEN2)
• History of severe hypersensitivity to the medication
• Pregnancy or plans for pregnancy

Practical Prescribing Protocol

Tirzepatide Dosing Schedule

Start at 5mg weekly subcutaneously, then titrate every 4 weeks 1:

• Weeks 1-4: 5mg weekly
• Weeks 5-8: 7.5mg weekly (if tolerated)
• Weeks 9-12: 10mg weekly
• Weeks 13-16: 12.5mg weekly
• Week 17+: 15mg weekly (maintenance)

Semaglutide 2.4mg Dosing Schedule

Start at 0.25mg weekly, then titrate every 4 weeks 1, 2:

• Weeks 1-4: 0.25mg weekly
• Weeks 5-8: 0.5mg weekly
• Weeks 9-12: 1.0mg weekly
• Weeks 13-16: 1.7mg weekly
• Week 17+: 2.4mg weekly (maintenance)

Slow titration is essential to minimize gastrointestinal side effects (nausea, vomiting, diarrhea), which occur in 17-44% of patients but are typically mild-to-moderate and transient 1.

Required Lifestyle Interventions

Pharmacotherapy must be combined with 1, 2:

• 500-kcal daily caloric deficit below maintenance requirements
• Minimum 150 minutes per week of physical activity (adapted to his mobility limitations—consider seated exercises, upper body resistance training, aquatic therapy)
• Behavioral counseling and structured lifestyle support

Given his frontal gait disorder, work with physical therapy to develop a safe, adapted exercise program that preserves lean body mass while accommodating his mobility limitations 1.

Monitoring Schedule

During Titration (First 16-20 weeks)

Assess every 4 weeks for 1:

• Gastrointestinal tolerance and adverse effects
• Weight loss progress
• Blood pressure (may decrease, requiring adjustment of any antihypertensives)
• Signs of pancreatitis (persistent severe abdominal pain)
• Signs of gallbladder disease

After Reaching Maintenance Dose

Assess every 3 months for 1:

• Weight stability and continued loss
• HbA1c (to monitor prediabetes status)
• Cardiovascular risk factors
• Medication adherence

Treatment Response Evaluation

At 12-16 weeks on therapeutic dose, discontinue if <5% weight loss 1, 2. Early non-responders are unlikely to benefit from continued therapy 2.

Common Pitfalls to Avoid

1. Don't prescribe Ozempic for weight loss—use Wegovy (semaglutide 2.4mg) or tirzepatide 2
2. Don't skip the slow titration—rapid dose escalation dramatically increases GI side effects and discontinuation rates 1
3. Don't forget to counsel on lifelong treatment—sudden discontinuation results in regain of 50-67% of lost weight within 1 year 1
4. Don't ignore his brain cancer history—ensure no contraindication exists (medullary thyroid cancer is the concern, not brain cancer) 1, 2

Cost Considerations

• Tirzepatide costs approximately $1,272 per 30-day supply 1
• Semaglutide 2.4mg costs approximately $1,600-1,619 per 30-day supply 1, 2
• Insurance authorization may be challenging for obesity management without diabetes, but his prediabetes strengthens the case 2
• Document failed lifestyle modification attempts and weight-related comorbidities (prediabetes, any hypertension, dyslipidemia, sleep apnea) to support authorization 1

Additional Benefits for This Patient

Beyond weight loss, these medications will 1, 4:

• Likely prevent progression from prediabetes to type 2 diabetes, with 23-62% achieving normal HbA1c 1, 4
• Improve cardiovascular risk factors (blood pressure, lipids, inflammatory markers)
• Reduce joint stress and potentially improve mobility despite his gait disorder
• Lower risk of developing obesity-related complications

This patient is an excellent candidate for GLP-1 receptor agonist therapy. Start with tirzepatide for maximum weight loss, or choose semaglutide 2.4mg if he has cardiovascular disease or if insurance preferentially covers it.