Step by step

1. Who qualifies
   • Type 2 diabetes: triple therapy with metformin and two other oral drugs failed or unsuitableA GLP-1 agonist or tirzepatideBMI 35 or more (adjusted for ethnicity) with obesity-related problemsOr BMI under 35 if insulin would affect their job, or weight loss would help other conditionsWhy? →
   • Weight management, with or without diabetesTirzepatide (Mounjaro)NICE: BMI 35 or more with at least one weight-related condition2.5 lower for Asian, Middle Eastern, Black African or African-Caribbean backgroundsWhy? →
   • Weight management, through a specialist weight management serviceSemaglutide (Wegovy)NICE: BMI 35 or more with at least one weight-related conditionFor up to 2 yearsWhy? →

   Qualifies? Start low and step up slowly

2. Start and step up
   • Tirzepatide, for either useOnce a week, stepped up every 4 weeksInjected under the skin once a weekOn insulin or a sulfonylurea? Lower their doseWarn about side effects at the start and every increaseWhy? →

   Review after 6 months on the highest tolerated dose

3. Review
   • Weight managementLost under 5%? ReassessCheck after 6 months at the highest tolerated doseWeigh up whether to carry onWhy? →
   • Type 2 diabetesContinue only if it’s workingHbA1c down by at least 1.0%And at least 3% of body weight lostWhy? →

Side effects to warn about

• Sickness and diarrhoeaNausea, vomiting, diarrhoea or constipationDrink plenty: dehydration can harm the kidneys
• Pancreatitis: stop at oncePersistent severe tummy pain, maybe into the backNever restart if it is confirmed
• GallstonesGallbladder problems are uncommonPain under the right ribs after meals: check
• Hypos with insulin or a sulfonylureaTirzepatide alone rarely causes themLower the other drug’s dose; never cut insulin suddenly
• Surgery: tell the anaesthetistA slow-emptying stomach can be inhaled under anaesthesiaDon’t stop it without advice
• The pill and pregnancyThe pill may work less well: add condoms or switchAvoid in pregnancy; stop a month before trying