Tirzepatide Titration to Reduce Side Effects in Individuals With Obesity (TiTRE)

Tirzepatide Titration to Reduce Side Effects (TiTRE) in Individuals With Obesity

The goal of this clinical trial is to determine whether a flexible, symptom-guided titration strategy for tirzepatide can reduce gastrointestinal side effects while maintaining weight-loss effectiveness in adults with obesity without diabetes. The main questions it aims to answer are:

1. Does flexible, symptom-guided titration reduce nausea and vomiting compared with standard per-label titration?
2. Does flexible titration achieve weight loss comparable to standard titration?

Researchers will compare standard per-label titration with a click-based, symptom-guided titration approach to assess differences in tolerability and treatment effectiveness.

Participants will:

• Be randomly assigned to standard or flexible tirzepatide titration
• Use a click-based dosing method that allows small dose increases based on tolerability (flexible group)
• Attend study visits over 76 weeks for safety and outcome assessments

This study addresses the lack of evidence for individualized titration strategies in obesity treatment and aims to improve tolerability, adherence, and long-term treatment outcomes.

Study Overview

• Status: Not yet recruiting
• Conditions: Obesity
• Intervention / Treatment: Drug: Tirzepatide (Per-label titration); Drug: Tirzepatide (Flexible titration)

Detailed Description

Tirzepatide is an effective treatment for obesity, but gastrointestinal adverse events during dose escalation may limit tolerability and adherence. Current labeling recommends a fixed titration schedule that does not account for individual differences in symptom tolerance. Evidence supporting individualized titration strategies in obesity treatment remains limited.

This randomized clinical trial aims to evaluate whether a flexible, symptom-guided titration strategy for tirzepatide can reduce gastrointestinal side effects while maintaining weight-loss effectiveness in adults with obesity without diabetes. Participants will be randomly assigned to either standard per-label titration or a flexible, click-based titration approach that allows smaller dose increments based on individual tolerability.

Participants in the standard group will follow the approved fixed dose-escalation schedule, while participants in the flexible group will advance doses according to gastrointestinal symptom severity, with the goal of minimizing nausea and vomiting. All participants will attend study visits over 76 weeks for assessment of weight change, tolerability, safety, and treatment adherence.

This study will compare gastrointestinal tolerability and weight-loss outcomes between titration strategies and aims to inform individualized dosing approaches that may improve adherence and long-term obesity treatment outcomes.

• Study Type: Interventional
• Enrollment (Estimated): 68
• Phase: Not Applicable

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Adults aged 18 years and older
2. A diagnosis of obesity (BMI ≥ 27 kg/m2) at screening with self-reported unsuccessful dietary efforts to lose weight.
3. No diagnosis of diabetes mellites.
4. Able to understand and sign the consent form
5. Able to undergo DEXA scan.

Exclusion Criteria:

• 1. History of type 1 or type 2 diabetes mellites. 2. Obesity-related:

  • A self-reported change in body weight >5 kg (11 lbs) within 90 days before screening irrespective of medical records.
  • Treatment with any medication for the indication of obesity within the past 90 days before screening.
  • Previous or planned (during the trial period) obesity treatment with surgery or a weight-loss device. However, the following are allowed: (1) liposuction and/or abdominoplasty, if performed >1 year before screening; (2) lap banding, if the band has been removed >1 year before screening; (3) intragastric balloon, if the balloon has been removed >1 year before screening; or (4) duodenal-jejunal bypass sleeve, if the sleeve has been removed >1 year before screening.

  • Uncontrolled thyroid disease, defined as thyroid stimulating hormone >6.0 mIU/L or <0.4 mIU/L as measured by the central laboratory at screening.

    3. Mental health:

  • History of major depressive disorder within 2 years before screening.
  • Diagnosis of other severe psychiatric disorder (e.g. schizophrenia, bipolar disorder).
  • A Patient Health Questionnaire-9 score of ≥15 at screening.
  • A lifetime history of a suicidal attempt.
  • Suicidal behavior within 30 days before screening. 4. General safety:
  • Use of non-herbal Chinese medicine or other non-herbal local medicine with unknown/unspecified content within 90 days before screening.
  • Presence of acute pancreatitis within the past 180 days prior to the day of screening.
  • History or presence of chronic pancreatitis.
  • Personal or first-degree relative(s) history of multiple endocrine neoplasia type 2 or medullary thyroid carcinoma.
  • Renal impairment measured as estimated glomerular filtration rate value of <15 mL/min/1.73 m2 as defined by KDIGO 2012 by the central laboratory at screening.
  • History of malignant neoplasms within the past 5 years prior to screening. Basal and squamous cell skin cancer and any carcinoma in-situ are allowed.
  • Any of the following: myocardial infarction, stroke, hospitalization for unstable angina, or transient ischemic attack within the past 60 days prior to screening.
  • Subject presently classified as being in New York Heart Association Class IV.
  • Surgery scheduled for the duration of the trial, except for minor surgical procedures, in the opinion of the investigator.
  • Known or suspected abuse of alcohol or recreational drugs.
  • Known or suspected hypersensitivity to trial product(s) or related products.
  • Previous participation in this trial. Participation is defined as signed informed consent.
  • Participation in another clinical trial within 90 days before screening.
  • Female who is pregnant, breast-feeding, or intends to become pregnant, or is of child-bearing potential and not using a highly effective contraceptive method.
  • Any disorder, unwillingness, or inability, not covered by any of the other exclusion criteria, which in the investigator's opinion, might jeopardize the subject's safety or compliance with the protocol.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Per-label arm (Control); Participants receive tirzepatide with dose escalation according to the manufacturer's prescribing information.	Drug: Tirzepatide (Per-label titration); Tirzepatide is administered by subcutaneous injection once weekly. Dose escalation follows the manufacturer's prescribing information, with advancement through labeled dose levels at prespecified intervals to the assigned maintenance dose
Experimental: Flexible titration arm (Intervention); Participants receive tirzepatide administered with a flexible dose escalation schedule.	Drug: Tirzepatide (Flexible titration); Tirzepatide is administered by subcutaneous injection once weekly. Dose escalation follows a flexible titration schedule as defined in the study protocol.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Vomiting episodes per patient assessed using the Modified Index of Nausea, Vomiting, and Retching (M-INVR)	Vomiting episodes per patient will be assessed using the validated Modified Index of Nausea, Vomiting, and Retching (M-INVR). The vomiting component is administered weekly, with scores ranging from 0 (no vomiting) to 4 (severe or frequent vomiting), where higher scores indicate worse outcomes. Vomiting burden will be summarized as: Weekly vomiting severity scores based on M-INVR, and; An exposure-adjusted rate of vomiting episodes (episodes per patient-week), calculated by dividing the total number of reported vomiting episodes by the total duration of follow-up for each participant. This approach accounts for differences in treatment duration and follow-up time.	From enrollment (at baseline) to the end of treatment at 76 weeks.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence, frequency, and duration of vomiting assessed using the MASCC Antiemesis Tool - Modified Index of Nausea and Vomiting (M-INVR)	Vomiting is assessed weekly using the MASCC Antiemesis Tool - Modified Index of Nausea and Vomiting (M-INVR), a validated patient-reported outcome measure. The vomiting subscale score is calculated as the sum of relevant vomiting items, with scores ranging from 0 to 16, where higher scores indicate greater incidence, frequency, and duration of vomiting (worse outcome).	Baseline to Week 76
Change in body weight	Absolute and percentage change in body weight from baseline.	Baseline to Week 76
Proportion of participants remaining on active study medication	Number of participants continuing to receive active study medication at the end of the trial.	Week 76
Change in glycated hemoglobin (HbA1c)	Change in HbA1c from baseline.	Baseline to Week 76
Change in lean body mass assessed by dual-energy X-ray absorptiometry (DEXA)	Change in total lean body mass measured by dual-energy X-ray absorptiometry (DEXA).	Baseline to Week 76
Change in visceral adiposity assessed by dual-energy X-ray absorptiometry (DEXA)	Change in visceral adipose tissue measured by dual-energy X-ray absorptiometry (DEXA).	Baseline to Week 76
Change in fat body mass assessed by dual-energy X-ray absorptiometry (DEXA)	Change in total fat body mass measured by dual-energy X-ray absorptiometry (DEXA).	Baseline to Week 76
Change in Alanine Aminotransferase (ALT)	Change from baseline in serum alanine aminotransferase (ALT) levels in U/L, measured using standard laboratory methods.	Baseline to Week 76
Change in Aspartate Aminotransferase (AST)	Change from baseline in serum aspartate aminotransferase (AST) levels in U/L, measured using standard laboratory methods.	Baseline to Week 76
Change in Gamma-Glutamyl Transferase (GGT)	Change from baseline in serum gamma-glutamyl transferase (GGT) levels in U/L, measured using standard laboratory methods.	Baseline to Week 76
Change in Alkaline Phosphatase (ALP)	Change from baseline in serum alkaline phosphatase (ALP) levels in U/L, measured using standard laboratory methods.	Baseline to Week 76
Change in Fibrosis-4 (FIB-4) index	Change from baseline in the Fibrosis-4 (FIB-4) index, a composite score calculated as: FIB-4 = (Age × AST) / (Platelet count × √ALT), where age is measured in years, AST and ALT in U/L, and platelet count in 10⁹/L. The FIB-4 index is reported as a unitless value, with higher values indicating greater liver fibrosis. Values typically range from approximately 0 to 10.	Baseline to Week 76
Change in Total Cholesterol	Change from baseline in fasting total cholesterol levels measured using standard laboratory methods.	Baseline to Week 76
Change in Low-Density Lipoprotein Cholesterol (LDL-C)	Change from baseline in fasting low-density lipoprotein cholesterol (LDL-C) levels measured using standard laboratory methods.	Baseline to Week 76
Change in High-Density Lipoprotein Cholesterol (HDL-C)	Change from baseline in fasting high-density lipoprotein cholesterol (HDL-C) levels measured using standard laboratory methods.	Baseline to Week 76
Change in Triglycerides	Change from baseline in fasting triglyceride levels measured using standard laboratory methods.	Baseline to Week 76
Change in estimated glomerular filtration rate (eGFR)	Change from baseline in estimated glomerular filtration rate (eGFR) calculated using a standard equation.	Baseline to Week 76
Change in serum creatinine	Change from baseline in serum creatinine measured using standard laboratory methods.	Baseline to Week 76
Change in urinary microalbumin	Change from baseline in urinary microalbumin concentration measured using standard laboratory methods.	Baseline to Week 76
Change in urine albumin-to-creatinine ratio (ACR)	Change from baseline in urine albumin-to-creatinine ratio (ACR) measured using standard laboratory methods.	Baseline to Week 76
Change in thyroid-stimulating hormone (TSH)	Change from baseline in serum thyroid-stimulating hormone (TSH) measured using standard laboratory methods.	Baseline to Week 76
Change in free thyroxine (free T4)	Change from baseline in serum free thyroxine (free T4) measured using standard laboratory methods.	Baseline to Week 76
Change in interleukin-6 (IL-6)	Change from baseline in circulating interleukin-6 (IL-6) concentration measured using standard laboratory methods.	Baseline to Week 76
Change in interleukin-10 (IL-10)	Change from baseline in circulating interleukin-10 (IL-10) concentration measured using standard laboratory methods.	Baseline to Week 76
Change in interleukin-1 receptor antagonist (IL-1Ra)	Change from baseline in circulating interleukin-1 receptor antagonist (IL-1Ra) concentration measured using standard laboratory methods.	Baseline to Week 76
Change in tumor necrosis factor-alpha (TNF-α)	Change from baseline in circulating tumor necrosis factor-alpha (TNF-α) concentration measured using standard laboratory methods.	Baseline to Week 76
Change in health-related quality of life assessed using the 36-Item Short Form Health Survey (SF-36)	Health-related quality of life is assessed using the 36-Item Short Form Health Survey (SF-36), a validated patient-reported outcome measure. The SF-36 yields an overall score ranging from 0 to 100, with higher scores indicating better health-related quality of life.	Baseline to Week 76
Change in dietary intake patterns	Changes in macronutrient composition and total caloric intake assessed using multiple-pass 24-hour dietary recalls.	Baseline to Week 76
Incidence of adverse events and laboratory abnormalities	Incidence of treatment-emergent adverse events and clinically significant laboratory abnormalities.	Baseline to Week 76
Change in retinal nerve fiber layer thickness assessed by optical coherence tomography (OCT)	Change from baseline in retinal nerve fiber layer thickness measured by optical coherence tomography	Baseline to Week 76
Change in arterial stiffness measured by pulse wave velocity (PWV)	Change from baseline in arterial stiffness assessed by carotid-femoral pulse wave velocity.	Baseline to Week 76
Change in sudomotor function assessed by Sudoscan	Change from baseline in sudomotor function measured by electrochemical skin conductance using Sudoscan.	Baseline to Week 76

Collaborators and Investigators

• Sponsor: Dasman Diabetes Institute
• Collaborators: University of Ulster

Study record dates

Study Major Dates

• Study Start (Estimated): May 15, 2026
• Primary Completion (Estimated): May 15, 2029
• Study Completion (Estimated): December 31, 2029

Study Registration Dates

• First Submitted: April 19, 2026
• First Submitted That Met QC Criteria: May 5, 2026
• First Posted (Actual): May 8, 2026

Study Record Updates

• Last Update Posted (Actual): June 3, 2026
• Last Update Submitted That Met QC Criteria: June 1, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Nutrition Disorders; Overnutrition; Body Weight; Overweight; Pathological Conditions, Signs and Symptoms; Nutritional and Metabolic Diseases; Signs and Symptoms; Obesity; Amino Acids, Peptides, and Proteins; Proteins; Glucagon-Like Peptide-1 Receptor; Glucagon-Like Peptide Receptors; Receptors, G-Protein-Coupled; Receptors, Cell Surface; Membrane Proteins; Receptors, Gastrointestinal Hormone; Receptors, Peptide; Tirzepatide
• Other Study ID Numbers: RA HM-2026-06

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No