You’ll see patients coming in on the new injectable tirzepatide (Mounjaro)...the first “twincretin” for type 2 diabetes.
Think of it as similar to a glucagon-like peptide-1 (GLP-1) agonist...but it’s also a glucose-dependent insulinotropic polypeptide (GIP) agonist. More twincretins are in the works.
Both hormones are secreted in the gut in response to food...so the dual mechanism doesn’t seem to increase risk of hypoglycemia.
Adding once-weekly tirzepatide to metformin reduces A1c by up to 2.3%...similar to semaglutide (Ozempic), the most “potent” GLP-1 agonist...when either is titrated to max doses.
You’ll hear about significant weight loss with tirzepatide.
Patients with obesity and diabetes may lose up to 25 lb...about 10 lb more than injectable semaglutide. Patients withOUT diabetes may lose up to 47 lb...much higher than any weight loss med.
But for now, tirzepatide is only approved for type 2 diabetes.
Point out that tirzepatide has GI side effects similar to GLP-1 agonists...and also carries warnings of rare pancreatitis, gallbladder disease, and thyroid tumors.
And it has a similar cost of about $1,000/month.
Look for tirzepatide to be added to metformin when maximizing weight loss is a priority in patients with type 2 diabetes.
But tirzepatide’s CV outcome data aren’t expected until 2025.
When a metformin add-on is needed for a high-CV-risk patient, anticipate that a GLP-1 agonist or SGLT2 inhibitor with proven CV benefit will still be preferred.
Don’t expect tirzepatide to be on your formulary. It’s okay to hold it during an admission.
At discharge, generally restart tirzepatide at the patient’s home dose. But consider re-titrating if more than 2 weekly doses are missed...especially if it’s caused nausea in the past.
- N Engl J Med. 2021 Aug 5;385(6):503-515
- Lancet Diabetes Endocrinol. 2021 Sep;9(9):563-574
- N Engl J Med. 2022 Jun 4. doi: 10.1056/NEJMoa2206038
- Medication pricing by Elsevier, accessed Jun 2022