LS is a 33 year-old woman who was recently diagnosed with type 2 diabetes. She had not seen a primary care doctor in over 5 years. Her A1c is 10.2%. Her doctor also ran some laboratory tests with the results below. LS has a couple of questions about her new medication and her new diagnosis. LS reports that she has gained a significant amount of weight and her healthy lifestyle habits have been on the back burner because of her children’s activities and work.

PMH: Newly diagnosed T2DM, HLD, HTN

Family History:

Mother: HTN, T2DM, living

Father: Hyperlipidemia, Deceased due to myocardial infarction

Medication List:

Losartan 25 mg PO daily

Apo-Hydro 12.5 mg PO daily

Pravachol 20 mg PO daily

Errin 0.35 mg PO daily

Labs:

Ht: 5’2 ft

Wt:178 lbs

BP: 128/76mmHg

Temp: 98.6 F

Glucose 167 mg/dL (fasting)

Scr: 0.9 mg/dL

Total Cholesterol: 220 mg/dL

LDL: 101 mg/dL

HDL: 32 mg/dL

New medication:

Tirzepatide 2.5 mg subcutaneously weekly for 4 weeks, then increase to 5 mg subcutaneously weekly

What would you counsel/ask LS about her new medication? Select all that apply. 

A. Counsel LS on the interaction between Errin and Mounjaro. 

B. LS should have her A1c checked in 6 months.

C. LS should rotate her injection site and should keep tirzepatide in the refrigerator or freezer.

D. Some of the most common side effects may include weight loss, constipation, diarrhea, upset stomach, and decreased appetite.

E. Tirzepatide would be contraindicated due to her family history. 

Answer with Rationale

Glucagon like peptide (GLP-1) and Gastric inhibitory polypeptide (GIP) receptor agonists are becoming increasingly popular agents for weight loss, diabetes, or both depending on the branded agent. Tirzepatide (Mounjaro) is approved for T2DM while Tirzepatide (Zepbound) is approved for overweight and obesity management. While these drugs are effective for treating T2DM, there are some significant side effects such as gastrointestinal upset like nausea and vomiting or even gastroparesis.  As pharmacists, counseling patients on common side effects is essential for patient adherence and treating their T2DM.

Answer A is correct. Tirzepatide causes delayed gastric emptying, which may decrease oral contraceptive absorption rates. Use of alternative barriers of contraception for the first 4 weeks and with each dose increase.

Answer B is incorrect. LS should have her A1c checked every 3 months because this is the general life cycle of a red blood cell with a goal of <7%.

Answer C is incorrect. While rotating the injection site is a must for tirzepatide, it should generally be kept in the refrigerator and definitely not the freezer. Single dose pens or vials may be kept at room temperature for up to 21 days. 

Answer D is correct. Tirzepatide has been shown to show significant weight loss while taking it, but its limiting side effects include GI upset.

Answer E is incorrect. Tirzepatide has a boxed warning in patients with a personal or family history of medullary thyroid carcinoma. This is not present in her family history. 

Generic/Brand: Tirzepatide (Mounjaro), Losartan (Cozaar), Apo-Hydro (Hydrochlorothiazide), Pravastatin (Pravachol)

Naplex Core Competencies Covered:

1.2 From laboratory or diagnostic findings

1.2 From patients: Chief complaint, medical history, family history, lifestyle habits

2.1 Pharmacology, mechanism of action

2.2 Brand, generic

2.3 Boxed warnings

2.4 Therapeutic goals

3.5 Drug route of administration

3.6 Drug contraindications

3.8 Drug interactions

3.7 Adverse drug effects

3.9 Therapeutic monitoring parameters

5.5 Instructions or techniques for drug administration

5.6 Storage