Tirzepatide 

Our California countdown is at T-5 days.

Recently, I took a look at the new JAMA study, Effect of Subcutaneous Tirzepatide vs Placebo Added to Titrated Insulin Glargine on Glycemic Control in Patients With Type 2 Diabetes – The SURPASS-5 Randomized Clinical Trial, and I have some thoughts.

First, the management of type 2 diabetes is very challenging in the primary care setting because of our fragmented, unequal health care system. Certainly a public health approach, along with a single payer/ Medicare-for-all system would make an enormous difference in the quality of diabetes care. For example, consider the exorbitant price of insulin and difficulty getting continuous glucose monitoring, CGM for many patients.

But say we’re stuck in our current system. Is tirzepatide the answer?

First, consider the delivery system. It’s subcutaneous. That puts it in the category such as insulin and dulaglutide (Trulicity), another Eli Lilly drug. Patients will accept subcutaneous shots, weekly or daily. But they rarely love them.

Now, lets’ think about the trial itself. I always take a hard look at the limitations provided by the authors. They discuss the racial disparities in trial enrollment, which are striking. Can we really extrapolate this drug to our diverse patient populations? Is it appropriate that a trial like this would be published with so few African American and Hispanic/Latino patients in JAMA in 2022?

The patient population was limited in other ways. Patients with psychiatric illness were excluded, along with those with alcohol use disorder. This homogenous patient population is not representative of patients with diabetes treated in many clinical settings. We have large numbers of patients with depression and problematic alcohol use who are also diabetic.

Regarding the results, tirzepatide did reduce HbA1c at week 40. Would it be sustained beyond that duration in a real world setting? Perhaps, but we don’t know.

Finally, the study was funded by Eli Lilly, and there were potential conflicts of interest. This is a huge market, and a large cost for the health care system if it were to be used widely.

In summary, tirzepatide had an effect, but I’m not sure this drug is ready for prime time. A better approach, from my clinical experience, is to focus on nutrition and intensive exercise, and have a low threshold to add CGM along with an insulin pump. I think this approach, along with cognitive behavioral therapy and support groups is much more effective because it minimizes injections and fingersticks and helps patients on the road to healing.

Below, a video from yesterday’s 5K race at Jamaica Pond. I completed it in 25:55. Thanks for reading my blog entry! If you enjoyed this blog post, please feel free to leave a reply or share with others. And remember, my website is always free.

https://www.youtube.com/watch?v=_ED3HFjSBA4&t=14s