Answer 1 is incorrect. 13.85% chose this answer. “Reduce the metformin by 50% to prevent side effects and maintain B12 levels.” Even though we might monitor B12 levels for people on metformin, especially if they have neuropathy or anemia, we do not need to reduce the dose of metformin when starting tirzepatide. See Medication PocketCard for more info. 

Answer 2 is incorrect. 12.99% of you chose this answer. “Assess TZ’s risk of acidosis before initiating dual therapies.”  Adding tirzepatide therapy to metformin does not increase the risk of acidosis.  Of course, when someone is on metformin, we keep a close eye on their kidney function and reduce the dose if their GFR is less than 45 and stop metformin if it is less than 30 to prevent risk of lactic acidosis. See Medication PocketCard for more info. 

Answer 3 is incorrect. About 6.49% of respondents chose this. “Provide a glucagon emergency kit in case of severe hypoglycemia.”  Since neither of these medication classes causes hypoglycemia, there is no need to prescribe a glucagon rescue medication. See Medication PocketCard for more info. 

Finally, Answer 4 is correct. 66.67% chose this answer. “Suggest using a second form of contraception for at least 4 weeks.”  Yes, this is the best answer!

“The options for contraception should be discussed with all individuals of childbearing potential with diabetes and should include information regarding the potential impact of glucose-lowering medications on the effectiveness of contraception. According to 2025 ADA Standards, medications that impact gastrointestinal emptying time (e.g., GLP-1 RAs or dual GIP and GLP-1 RA) may affect the absorption of orally administered medications, including oral contraception. The impact on gastric emptying with GLP-1 RAs and the dual GIP and GLP-1 RA is highest at initiation and with dosage increases and then diminishes with continued administration (212). Tirzepatide, the dual GIP and GLP-1 RA, was shown to impact the levels of oral contraception during the time of its highest impact on gastric emptying; the GLP-1 RAs may impact the levels of oral contraception as well but to a lesser extent than tirzepatide (213,214). Thus, individuals starting or increasing doses of tirzepatide who also take oral contraception should use a second form of contraception until the maintenance dose of tirzepatide is achieved and used for at least 4 weeks (215).”

We hope you appreciate this week’s rationale! Thank you so much for taking the time to answer our Question of the Week and participate in this fun learning activity!