Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Select licensed weight-management medicines through current NICE and commissioning criteria, prescribe with reproductive and acute-adverse-effect safeguards, and stop or escalate treatment using agreed outcomes.
Medicine selection starts after a complete obesity assessment: treatment goals, prior attempts, eating pattern, mental health, pregnancy plans, diabetes therapy, pancreatitis or gallbladder history, renal function, gastrointestinal motility, concomitant medicines and likely follow-up. BMI is part of eligibility but should not eclipse comorbidity and shared priorities.
Tirzepatide and GLP-1 agonists reduce appetite and delay gastric emptying, producing substantial average weight loss but also nausea, vomiting, diarrhoea, constipation and dehydration. Gallbladder disease can accompany rapid loss. Rare pancreatitis is a class safety focus, and semaglutide has a 2026 MHRA warning about very rare non-arteritic anterior ischaemic optic neuropathy; sudden visual deterioration requires urgent eye assessment.
Access is unusually volatile and must be separated into three decisions: UK marketing authorisation, NICE recommendation and local commissioning. On 27 August 2026, NICE TA875 described specialist NHS semaglutide injection up to 2.4 mg weekly. The MHRA had separately authorised 7.2 mg injected Wegovy for adults with obesity, oral Wegovy titrated to 25 mg daily (the approval announcement said it was not then available through the NHS), and Foundayo (orforglipron) for weight management and type 2 diabetes on 10 August 2026. These authorisations did not by themselves create NICE funding, NHS availability or a local prescribing route. Check the live SmPC, NICE guidance and commissioner before selecting a product, formulation or dose.
The person meets the live appraisal and local criteria, has weight-related risk likely to benefit, understands administration and adverse effects, and can access structured follow-up.
Severe persistent upper-abdominal pain, often radiating to the back with nausea or vomiting, is not ordinary titration discomfort; stop the incretin medicine and arrange urgent assessment.
Persistent vomiting or diarrhoea, postural symptoms, low urine output and rising creatinine indicate dehydration; temporarily review nephrotoxic or blood-pressure medicines and assess urgently when severe.
Sweating, tremor, confusion or low glucose is more likely when an incretin is combined with insulin or sulfonylurea, requiring proactive glucose and dose planning.
A delayed period, planned conception or confirmed pregnancy requires prompt prescriber contact and stopping the incretin under current MHRA advice; do not continue for weight control during gestation.
Oily spotting, faecal urgency and steatorrhoea increase with high dietary fat and may impair adherence; jaundice, severe abdominal symptoms or anticoagulant instability needs clinical review.
Sudden painless monocular visual loss or rapid deterioration may represent NAION; the 2026 MHRA communication advises urgent medical or eye-casualty assessment rather than waiting for routine review.
Avoid pregnancy and breastfeeding; stop at least one month before planned conception under current MHRA advice. Add barrier or use non-oral contraception for four weeks after starting and each dose increase; assess pancreatitis, dehydration, gallbladder and anaesthetic aspiration risk.
NICE limits this indication and recommends considering stopping for less than 5% loss after 6 months. Avoid pregnancy, stop at least two months before conception, assess pancreatitis and aspiration risk, and urgently evaluate sudden visual loss under 2026 MHRA NAION advice.
The same molecule may have different licensed indications, pens and doses; a diabetes product should not be silently converted into a weight-management regimen.
Mild transient nausea is common during escalation, but persistent vomiting, inability to drink or focal severe pain demands assessment rather than automatic reassurance.
MHRA authorisation establishes a product's UK licence; NICE appraisal assesses NHS use; commissioners determine local access. At the 27 August 2026 snapshot, newer semaglutide formulations and Foundayo were licensed but should not be presented as automatically funded or available.
Ask explicitly before anaesthesia, acute abdominal assessment and diabetes dose change, because online or private prescriptions may not populate NHS records.
Biological appetite returns when therapy stops. Maintenance support and an alternative plan reduce the chance that predictable regain is experienced as personal failure.
Promising an NHS medicine solely from BMI without checking the live appraisal and local rollout.
Escalating despite ongoing vomiting or dehydration because the calendar says four weeks.
Missing insulin-associated hypoglycaemia as appetite and glucose improve.
Reassuring severe radiating abdominal pain as an expected gastrointestinal side effect.
Using an incretin during pregnancy, planned conception or breastfeeding.
Forgetting tirzepatide's temporary additional contraception requirement with the oral pill.
Stopping treatment before anaesthesia without involving the procedural team, or failing to disclose it at all.
Buying, recommending or administering an unregulated pen or compounded powder from social media.
Your practice draft is saved in this browser.
A patient taking tirzepatide develops severe persistent epigastric pain radiating to the back with vomiting. What is the safest immediate medicine action?
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Apply the TA664 stopping rule and live access criteria. Avoid pregnancy and breastfeeding, review pancreatitis, gallbladder, dehydration and aspiration risk, and reconcile any other GLP-1 prescription to prevent duplication.
Continue beyond 12 weeks only if the BNF response criterion is met, usually more than 5% baseline loss. Counsel on oily stool, fat-soluble vitamins, warfarin and ciclosporin interactions, malabsorption and pregnancy; dietary fat excess worsens adverse effects.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes