A 68- year old male presented with a weight of 204.9 lbs and a BMI of 31.2 kg/m2. On exam, fat distribution was primarily central. Patient had a history of prediabetes, with an A1c of 5.9% at presentation.
Patient was unable to lose weight despite multiple lifestyle interventions for obesity. He has had numerous consultations with registered dietitians over the past five years and had made dietary modifications. The patient maintains a consistent exercise routine as he walks briskly at least 5 miles on weekdays and 6 miles on weekends. Additionally, the patient is very knowledgeable about obesity and weight management as he is a practicing endocrinologist. In the past, he used dulaglutide and semaglutide but had to discontinue these medications because of gastrointestinal side effects such as nausea and abdominal cramping.
The patient has a past medical history of prediabetes, obesity, coronary artery disease, fatty liver disease, hypercholesterolemia, benign prostatic hyperplasia, acute prostatitis, and cough. Medications he takes include atorvastatin 10 mg daily, albuterol as needed, alfuzosin HCL ER 10 mg daily, ezetimibe 10 mg daily, and finasteride 5 mg daily. On initial evaluation in September 2020, body composition (via seca mBCA 514) measurements demonstrated weight of 202.1 lbs, BMI of 30.7 kg/m2, fat mass of 70.1 lbs (34.7%), fat-free mass of 131.9 lbs (65.3%), and skeletal muscle mass of 62.8 lbs (31.1%). In June 2022, body composition was repeated and demonstrated total weight of 204.9 lbs, BMI of 31.3 kg/m2, fat mass of 73.5 lbs (35.9%), fat-free mass of 131.4 lbs (64.1%), and skeletal muscle mass of 63.8 lbs (31.1%).
Laboratory values from June 2022 were reviewed and demonstrated blood glucose (BG) of 121 mg/dL, HgbA1c of 5.9%, triglycerides of 145 mg/dL, total cholesterol of 163 mg/dL, high density lipoproteins (HDL) of 39 mg/dL, low-density lipoproteins (LDL) of 95 mg/dL, non high-density lipoproteins (Non-HDL) of 124 mg/dL, aspartate aminotransferase (AST) of 33 U/L, and alanine transaminase (ALT) of 50 U/L [Table 1].
Table 1
Anthropometric and Laboratory Values*
| Jun-22 | Aug-23 |
Anthropometric Measures | | |
Weight (lbs) | 204.92 | 176.26 |
BMI (kg/m2) | 31.26 | 26.8 |
Body Fat (lbs) | 73.5 | 54.54 |
Body Fat (%) | 35.9 | 30.9 |
Skeletal Muscle Mass (lbs) | 63.8 | 53.9 |
Lab Values | | |
Blood Glucose (mg/dL) | 121 | 95 |
HgbA1c (%) | 5.9 | 5.3 |
Lipid Panel | | |
Triglycerides (mg/dL) | 145 | 60 |
Total Cholesterol (mg/dL) | 163 | 105 |
HDL (mg/dL) | 39 | 37 |
LDL (mg/dL) | 95 | 57 |
Non-HDL (mg/dL) | 124 | 69 |
AST (SGOT) (U/L) | 33 | 30 |
ALT (SGPT) (U/L) | 50 | 35 |
BMI, body mass index |
HDL, high density lipoprotein |
LDL, low density lipoprotein |
AST, aspartate aminotransferase |
ALD, alanine aminotransferase |
*All changes are from baseline to week 61. |
On evaluation in June 2022, the patient initiated a treatment of tirzepatide at a dose of 2.5 mg weekly. He reported decreased hunger, slight gastrointestinal discomfort, decreased cravings and early satiety. Within the first weeks of tirzepatide treatment, weight and BMI gradually decreased. Patient attempted to titrate up the dose of tirzepatide to 5 mg weekly multiple times, but each time discontinued the higher dose because of gastrointestinal side effects.
Over nine months, total body weight decreased by 28.7 lbs or 13.9% (see Fig. 1). BMI decreased to 26.6 kg/m2 (at this point indicative of overweight status rather than obese). HgbA1c decreased to 5.3% (at this point no longer in the pre-diabetes range). Fat mass decreased by 18.9 lbs or 25.8% (see Fig. 2). Skeletal muscle mass decreased by 9.9 lbs or 15.5% (see Fig. 2).
During subsequent follow up in July 2023, serum glucose was 95 mg/dL, HgbA1c was 5.3%, triglyceride level was 60 mg/dL, total cholesterol was 105 mg/dL, HDL was 37 mg/dL, LDL was 57 mg/dL, Non-HDL was 69 mg/dL, AST was 30 U/L, and ALT was 35 U/L (see Table 1).