Effect of Injection Site on the Relative Bioavailability of a Single Dose of Tirzepatide in Subjects With Low and High Body Mass Indices
Phase: PHASE1
Conditions: Healthy
Sponsor: Eli Lilly and Company

 
I8F-MC-GPHI Clinical Pharmacology Protocol 
 
 
Effect of Injection Site on the Relative Bioavailability of a Single Dose of Tirzepatide in 
Subjects with Low and High Body Mass Indices 
 
NCT04050670 
 
 Date: 27-Jun-2019 
 

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Tirzepatide (LY3298176)
Protocol I8F-MC-GPHI
Effect of Injection Site on the Relative Bioavailability of a
Single Dose of Tirzepatide in Subjects with Low and High 
Body Mass Indices
Confidential Information
The information contained in this protocol is confidential and is intended for the use of 
clinical investigators.  It is the property of Eli Lilly and Company or its subsidiaries and 
should not be copied by or distributed to persons not involved in the clinical investigation of 
tirzepatide (LY3298176), unless such persons are bound by a confidentiality agreement 
with Eli Lilly and Company or its subsidiaries.
Note to Regulatory Authorities:  This document may contain protected personal data 
and/or commercially confidential information exempt from public disclosure.  Eli Lilly and 
Company requests consultation regarding release/redaction prior to any public release.  In 
the United States, this document is subject to Freedom of Information Act Exemption 4 and 
may not be reproduced or otherwise disseminated without the written approval of Eli Lilly 
and Company or its subsidiaries.
Tirzepatide (LY3298176)
Eli Lilly and Company
Indianapolis, Indiana USA 46285
Clinical Pharmacology Protocol Electronically Signed and Approved by Lilly on date 
provided below.
Approval Date: 27-Jun-2019 GMT

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Table of Contents
Effect of Injection Site on the Relative Bioavailability of a 
Single Dose of Tirzepatide in Subjects with Low and High 
Body Mass Indices
Section
Page
Protocol I8F-MC-GPHI Effect of Injection Site on the Relative 
Bioavailability of a Single Dose of Tirzepatide in Subjects with Low 
and High Body Mass Indices...............................................................................................1
Table of Contents........................................................................................................................2
1.
Protocol Synopsis................................................................................................................8
2.
Schedule of Activities .......................................................................................................10
3.
Introduction ......................................................................................................................13
3.1.
Study Rationale............................................................................................................13
3.2.
Background..................................................................................................................13
3.3.
Benefit/Risk Assessment..............................................................................................14
4.
Objectives and Endpoints..................................................................................................15
5.
Study Design.....................................................................................................................16
5.1.
Overall Design .............................................................................................................16
5.2.
Number of Participants.................................................................................................18
5.3.
End of Study Definition ...............................................................................................18
5.4.
Scientific Rationale for Study Design...........................................................................18
5.5.
Justification for Dose ...................................................................................................18
6.
Study Population...............................................................................................................19
6.1.
Inclusion Criteria..........................................................................................................19
6.2.
Exclusion Criteria ........................................................................................................21
6.3.
Lifestyle and/or Dietary Requirements .........................................................................23
6.3.1.
Meals and Dietary Restrictions.............................................................................23
6.3.2.
Caffeine, Alcohol, and Tobacco ...........................................................................24
6.3.3.
Activity................................................................................................................24
6.4.
Screen Failures.............................................................................................................24
7.
Treatment..........................................................................................................................25
7.1.
Treatment Administered...............................................................................................25
7.1.1.
Packaging and Labeling .......................................................................................25
7.1.2.
Medical Devices...................................................................................................26
7.2.
Method of Treatment Assignment ................................................................................26
7.2.1.
Selection and Timing of Doses.............................................................................26

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7.3.
Blinding .......................................................................................................................26
7.4.
Dose Modification........................................................................................................26
7.5.
Preparation/Handling/Storage/Accountability...............................................................26
7.6.
Treatment Compliance .................................................................................................26
7.7.
Concomitant Therapy...................................................................................................26
7.8.
Treatment After the End of the Study...........................................................................27
8.
Discontinuation Criteria ....................................................................................................28
8.1.
Discontinuation from Study Treatment.........................................................................28
8.1.1.
Discontinuation of Inadvertently Enrolled Subjects..............................................28
8.2.
Discontinuation from the Study....................................................................................28
8.3.
Subjects Lost to Follow-up...........................................................................................29
9.
Study Assessments and Procedures ...................................................................................30
9.1.
Efficacy Assessments...................................................................................................30
9.2.
Adverse Events ............................................................................................................30
9.2.1.
Serious Adverse Events........................................................................................31
9.2.1.1.
Suspected Unexpected Serious Adverse Reactions..........................................32
9.2.2.
Complaint Handling.............................................................................................32
9.3.
Treatment of Overdose.................................................................................................32
9.4.
Safety...........................................................................................................................32
9.4.1.
Clinical Laboratory Tests .....................................................................................32
9.4.1.1.
Amylase and Lipase Measurements ................................................................32
9.4.2.
Glucose Monitoring .............................................................................................33
9.4.2.1.
Hyperglycemia and Hypoglycemia Reporting.................................................33
9.4.3.
Vital Signs ...........................................................................................................34
9.4.4.
Electrocardiograms ..............................................................................................35
9.4.5.
Injection-Site Reactions .......................................................................................35
9.4.6.
Hypersensitivity Reactions...................................................................................36
9.4.7.
Safety Monitoring ................................................................................................36
9.4.7.1.
Hepatic Safety................................................................................................37
9.5.
Pharmacokinetics .........................................................................................................37
9.5.1.
Bioanalysis...........................................................................................................37
9.5.2.
Exploratory Assessments .....................................................................................38
9.5.2.1.
Fat Deposition at Injection Site.......................................................................38
9.5.2.2.
Waist, Upper Arm, and Thigh Circumference.................................................38
9.6.
Pharmacodynamics ......................................................................................................38
9.7.
Immunogenicity Assessments.......................................................................................38
9.8.
Genetics .......................................................................................................................39
9.9.
Biomarkers...................................................................................................................40

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9.10. Health Economics ........................................................................................................40
10.
Statistical Considerations and Data Analysis.....................................................................41
10.1. Sample Size Determination ..........................................................................................41
10.2. Populations for Analyses..............................................................................................41
10.2.1.
Study Participant Disposition ...............................................................................41
10.2.2.
Study Participant Characteristics ..........................................................................41
10.3. Statistical Analyses ......................................................................................................41
10.3.1.
Safety Analyses....................................................................................................41
10.3.1.1.
Clinical Evaluation of Safety..........................................................................41
10.3.1.2.
Statistical Evaluation of Safety.......................................................................42
10.3.2.
Pharmacokinetic Analyses....................................................................................42
10.3.2.1.
Pharmacokinetic Parameter Estimation...........................................................42
10.3.2.2.
Pharmacokinetic Statistical Inference .............................................................42
10.3.3.
Evaluation of Immunogenicity .............................................................................43
10.3.4.
Data Review During the Study.............................................................................44
10.3.5.
Interim Analyses..................................................................................................44
11.
References ........................................................................................................................45
12.
Appendices .......................................................................................................................46

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List of Tables
Table
Page
Table GPHI.1.
Objectives and Endpoints .......................................................................15
Table GPHI.2.
Treatments Administered via Autoinjector..............................................25

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List of Figures
Figure
Page
Figure GPHI.1.
Illustration of Study Design for Protocol I8F-MC-GPHI.........................17

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List of Appendices
Appendix
Page
Appendix 1.
Abbreviations and Definitions ................................................................47
Appendix 2.
Clinical Laboratory Tests........................................................................51
Appendix 3.
Study Governance, Regulatory and Ethical Considerations.....................52
Appendix 4.
Hepatic Monitoring Tests for Treatment-Emergent Abnormality ............55
Appendix 5.
Blood Sampling Summary......................................................................56
Appendix 6.
Classification of Contraceptive Methods.................................................57
Appendix 7.
Pancreatic Monitoring ............................................................................58

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1. Protocol Synopsis
Title of Study:
Effect of Injection Site on the Relative Bioavailability of a Single Dose of Tirzepatide in Subjects with Low and 
High Body Mass Indices.
Rationale: 
Study I8F-MC-GPHI (GPHI) will investigate the effect of injection site on the relative bioavailability of a single 
5 mg dose of tirzepatide injected subcutaneously (SC) into the upper arm (Test 1) or thigh (Test 2) compared to SC 
injection into the abdomen (Reference).  During previous Phase 1 and Phase 2 clinical trials, tirzepatide has been 
administered by SC injection into the abdomen.  However, patients in clinical practice may prefer to self-administer 
tirzepatide at different body sites.  In addition, a difference in adiposity and/or absorption profile may lead to 
increased variability and suboptimal glycemic control.  This will be explored in the current study by enrolling 
subjects with both low and high body mass indices (BMI).
Objectives/Endpoints:
Objectives
Endpoints
Primary
To determine the relative bioavailability of SC 
tirzepatide 5 mg injection into the thigh and upper arm 
compared to the abdomen.
AUC(0-∞) and Cmax
Secondary
To determine the relative bioavailability of SC 
tirzepatide 5 mg injection in subjects with different 
BMIs.
To evaluate the safety and tolerability of SC tirzepatide 
5 mg injection.
AUC(0-∞) and Cmax
Incidence of TEAEs
Abbreviations:  AUC(0-∞) = area under the concentration versus time curve from zero to infinity; BMI = body mass 
index; Cmax = maximum drug concentration; SC = subcutaneous; TEAE = treatment-emergent adverse event.
Summary of Study Design:
This is a single-center, open-label, 3-period, 3-sequence, randomized, crossover study conducted in overtly healthy 
male and female subjects in 2 BMI groups (low [18.5 to 27.0 kg/m2] and high [27.1 to 45.0 kg/m2]).  
Treatment Arms and Planned Duration for an Individual Subject:  
The study involves a comparison of:

A single dose of 5 mg tirzepatide administered SC to the upper arm (Test 1) versus a single dose of 5 mg 
tirzepatide administered SC to the abdomen (Reference)

A single dose of 5 mg tirzepatide administered SC to the thigh (Test 2) versus a single dose of 5 mg 
tirzepatide administered SC to the abdomen (Reference)

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The study duration for individual subjects, inclusive of screening is expected to be approximately 20 weeks, divided
as follows: 

Screening:  up to 27 days prior to Day -1

Treatment Periods 1, 2, and 3:  Day 1 to Day 36, including single dosing with tirzepatide on Day 1 of each 
Treatment Period

Washout:  at least 35 days between tirzepatide injections

Follow-up:  Treatment Period 3, Day 36 will be considered the final follow-up visit
Number of Subjects:
Approximately 54 subjects will be enrolled to ensure that at least 36 evaluable subjects complete the study, with at 
least 12 subjects completeing per treatment sequence. 
Statistical Analysis:
The primary pharmacokinetic parameters for analysis will be Cmax and AUC(0-∞).
Pharmacokinetic parameter estimates will be evaluated to delineate effects of injection site.  Log-transformed 
AUC(0-∞) and Cmax will be evaluated in a linear mixed-effects model with fixed effects for injection site, period, 
and sequence.  Subject nested within sequence will be fitted as a random effect.  Differences will be 
back-transformed to present the ratios of geometric least squares means and the corresponding 90% confidence 
interval (CI).
For the primary endpoint, a model comparing the differences between the upper arm (Test 1) and the abdomen 
(Reference) and between the thigh (Test 2) and the abdomen (Reference) will be used.  For the secondary endpoint, 
BMI group and the BMI group-by-injection site interaction term will be added to the above model.  
All investigational product and protocol procedure adverse events (AEs) and study device complaints will be listed, 
and if the frequency of events allows, safety data will be summarized using descriptive methodology.
Safety parameters that will be assessed include AE, safety laboratory parameters (including amylase, lipase, and 
blood glucose), and vital signs.  The parameters will be listed and summarized using standard descriptive statistics, 
where appropriate.  Physical examinations and electrocardiograms will be performed for safety monitoring purposes 
and will not be presented.  
Incidence of erythema, induration, pain, itching, and edema will be listed and summarized.  
Additional analyses may be performed, if appropriate.

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2. Schedule of Activities

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Study Schedule Protocol I8F-MC-GPHI
Screening
Treatment Periods 1 to 3 Study Days (≥35 days washout between Day 1 doses)
EDc
Comments
Procedure
D-28 to
D-2
D-1b
D1
D2
D3
D4
D5
D6
D7
D8
D15
D21
D36
(±1)b
Informed Consent
X
Subject Admission to 
CRU
X
Subject Discharge 
from CRU
X
Subjects’ CRU stay may be extended at the 
investigator’s discretion for safety monitoring.
Outpatient Visit
X
X
X
X
X
Tirzepatide Dosing
0 hour
Study drug will be administered after an overnight 
fast of at least 8 hours.
Medical History
X
Physical Examination 
/Medical Assessment
X
X
X
X
X
Full physical examination at screening. Thereafter, 
targeted reviews and medical assessments as 
appropriate.
Weight and Height
X
X
X
X
Height is required to be taken at screening only.
Temperature
X
Predose
Safety 12-Lead ECG 
(hours postdose)a
X
Predose
24
72
X
X
X
Single safety ECGs will be collected.  ECGs must be 
recorded before collecting any blood samples.  
Subjects must be supine for approximately 5 to 
10 minutes before ECG collection, and remain 
supine but awake during ECG collection.
Supine Vital Signs 
(hours postdose)a
X
Predose,
12
24
48
72
X
X
X
X
X
Additional time points may be added, if warranted 
and agreed upon between Lilly and the investigator.
Clinical Laboratory 
Tests
X
X
X
X
X
X
X
See Appendix 2 for details. Subjects will be fasted at 
least 8 hours before sampling.
Urine Drug Screen
X
X
Alcohol Breath Test
X
Pregnancy Test
X
X
X
X
Female subjects only.  See Appendix 2 for details.
AEs/Concomitant 
Medications
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Waist, Upper Arm,
and Thigh 
Circumference and 
Skinfold Thickness
X
Circumference of the injection site for the specific 
period should be measured in triplicate and the mean
recorded.  Waist circumference is measured for the 
abdomen injection site. 
Fat Deposition 
Assessment at 
Injection Site - DEXA 
Scan 
X
DEXA scan of the relevant injection site may be 
performed any time between Day -4 and Day -1.
Pharmacogenetic 
Samplea
Predose
Single sample in Treatment Period 1 only.

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Screening
Treatment Periods 1 to 3 Study Days (≥35 days washout between Day 1 doses)
EDc
Comments
Procedure
D-28 to
D-2
D-1b
D1
D2
D3
D4
D5
D6
D7
D8
D15
D21
D36
(±1)b
PK Sampling
(hours postdose)a
Predose,
8, 12
24, 
36
48
72
96
120
144
168
336
480
X
X
Up to a 10% deviation from the nominal collection
time is permissible as long as actual sampling time is 
recorded.
Blood Glucose 
Monitoring
(hours postdose)a
Predose,
12
24, 
36
48
72
Performed using a bedside glucose monitor.  
Additional unscheduled measurements may be taken 
at the discretion of the investigator where clinically 
indicated.
Immunogenicitya
Predose
X
X
X
Where applicable, collection times should match 
with PK sampling time points. In the event of 
immediate or non-immediate drug hypersensitivity 
reactions, unscheduled samples will be collected as 
detailed in Section 9.4.6.  Subjects with clinically 
significant TE ADA at follow-up/ED will undergo 
additional follow-up as detailed in Section 9.7.
Abbreviations:  AE = adverse event; CRU = clinical research unit; D = Day; DEXA = dual energy x-ray absorptiometry; ECG = electrocardiogram; ED = early 
discontinuation; PK = pharmacokinetic(s); TE ADA = treatment-emergent anti-drug antibodies.  
Note:  All sampling times are given relative to dosing (Time 0 hour) with tirzepatide (predose or hours postdose).  Unless otherwise indicated, predose procedure 
may be performed any time prior to dosing.
If multiple procedures take place at the same time point, the following order of the procedures should be used:  ECGs, vital signs, PK sample (record of actual 
PK sampling time is the priority), clinical laboratory sample, immunogenicity, DEXA scan, blood glucose, and pharmacogenetic sample.
a
Specified times are approximate and actual times will be recorded.  Actual sampling/assessment time should not exceed 1 hour prior to dosing for the predose 
sample/assessment.
b
The Day 36 visit of a treatment period may occur at the same time as the Day -1 visit of the subsequent treatment period, therefore assessments that occur on 
both visits will only be performed once.  All results must be reviewed prior to dosing on Day 1 of each treatment period.  The Day 36 visit of Treatment 
Period 3 will be considered the final follow-up visit.  
c
Within 14 days upon confirmation of early discontinuation.

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3. Introduction
3.1.
Study Rationale
Tirzepatide is being developed for the treatment of type 2 diabetes mellitus (T2DM) as an 
adjunct to diet and exercise.  In addition, it is being developed as a therapy for the indications of 
chronic weight management and nonalcoholic steatohepatitis (NASH).  It is administered once
weekly by subcuteanous (SC) injection.
Study I8F-MC-GPHI (GPHI) will investigate the effect of injection site on the relative 
bioavailability of a single 5 mg dose of tirzepatide injected SC into the upper arm (Test 1) or 
thigh (Test 2) compared to SC injection into the abdomen(Reference).
During previous Phase 1 and Phase 2 clinical trials, tirzepatide has been administered by SC
injection into the abdomen.  However, patients in clinical practice may prefer to self-administer 
tirzepatide at different body sites.  
In addition, a difference in adiposity and/or absorption profile may lead to increased variability 
and suboptimal glycemic control.  This will be explored in the current study by enrolling subjects 
with both low and high body mass indices (BMIs), measuring skinfold thickness with skinfold 
calipers, and dual energy x-ray absorptiometry (DEXA) scanning to estimate fat deposition at 
their injection site locations.
3.2.
Background
The available preclinical and clinical data indicate that co-stimulation of glucose-dependent 
insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptors may enhance 
insulin secretion, improve insulin sensitivity, and reduce body weight beyond the effect of 
selective GLP-1 receptor stimulation (Frias et al.  2018; Coskun et al.  2018).  
Tirzepatide is a 39-amino acid synthetic peptide, dual GIP and GLP-1 receptor agonist.  Its 
structure is based on the GIP sequence and includes a C20 fatty di-acid moiety that prolongs the 
duration of action.  It has a chemical structure and pharmacologic profile that is distinct from the 
GLP-1 receptor agonists due to the addition of GIP, which is unique among the marketed incretin 
mimetics.
In a Phase 1 study (Coskun et al.  2018) that included single and multiple ascending dose (SAD, 
MAD) parts, tirzepatide has been administered as single SC doses up to 8 mg in healthy subjects. 
In the MAD part, higher doses up to 10 mg were attained in healthy subjects via dose escalation.  
Doses up to 15 mg were achieved in patients with T2DM via dose escalation.
In the above-mentioned study, gastrointestinal (GI) adverse events (AEs) (nausea, vomiting, 
diarrhea, abdominal distension) and decreased appetite were the most frequently reported events 
by both healthy subjects and patients with T2DM and were dose related.  Most AEs were mild in 
severity, a few were moderate, and none were reported as severe.  During the SAD study, the 
high incidence of GI AEs, notably vomiting, were considered to be dose limiting at the 8-mg 
dose; therefore, the 5-mg dose was considered the maximum tolerated dose (MTD).  

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Tirzepatide (LY3298176)
A dose-dependent increase in heart rate was detected for both healthy subjects and patients with 
T2DM who received tirzepatide, similar to what was observed with selective GLP-1 receptor 
agonists.  A few subjects experienced transient elevations in lipase and/or amylase levels, but 
these episodes were not associated with any relevant clinical outcomes. 
Once-weekly doses of 1, 5, 10, and 15 mg have been further investigated in a Phase 2 study 
(Frias et al, 2018).  An additional dose level of 12 mg and alternate dose escalation schemes 
were investigated in a 12-week Phase 2 study.  Doses above 5 mg of tirzepatide were attained via 
step-wise dose escalation.   Results from the two Phase 2 studies demonstrated that tirzepatide at 
doses between 5 and 15 mg provided clinically meaningful efficacy in both glucose- and body 
weight-lowering.  Gastrointestinal-related AEs (nausea, diarrhea, vomiting) were the most 
frequently reported AEs in Phase 2 studies.  The majority of the treatment-emergent adverse 
events (TEAEs) were mild or moderate in severity. 
There were no other clinically relevant safety observations in the Phase 1 and 2 studies.
Tirzepatide terminal half-life was estimated to be approximately 5 days, thus supporting a 
once-weekly dosing regimen, with maximum drug concentration (Cmax) occurring 24 to 
72 hours postdose.   
Overall, the safety and tolerability, and pharmacokinetic (PK)/pharmacodynamic (PD) profiles of 
tirzepatide support further development of tirzepatide in patients with T2DM.  Further details can 
be found in the Investigator’s Brochure (IB).
3.3.
Benefit/Risk Assessment
Risks of tirzepatide have been consistent with risks associated with other GLP-1 receptor 
agonists currently marketed.  Potential risks include, but are not limited to, GI effects, acute 
pancreatitis, increases in heart rate, and hypoglycemic events (GLP-1 receptor agonist class 
effect).
No clinically significant safety or tolerability concerns have been identified during clinical 
investigation of tirzepatide up to the highest single-dose level of 8 mg or multiple weekly doses, 
when titrated up to 15 mg. Based on this information, the 3 × single 5-mg doses to be 
administered in Study GPHI, in subjects with low and high BMIs, are reasonably anticipated to 
be tolerable in this group of otherwise healthy subjects.
There is no anticipated therapeutic benefit for the subjects.
More information about the known and expected benefits, risks, serious adverse events (SAEs) 
and reasonably anticipated AEs of tirzepatide are to be found in the IB.

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4. Objectives and Endpoints
Table GPHI.1 shows the objectives and endpoints of the study.
Table GPHI.1.
Objectives and Endpoints
Objectives
Endpoints
Primary
To determine the relative bioavailability of SC 
tirzepatide 5-mg injection into the thigh and upper arm 
compared to the abdomen.
AUC(0-∞) and Cmax
Secondary
To determine the relative bioavailability of SC 
tirzepatide 5-mg injection in subjects with different 
BMIs.
To evaluate the safety and tolerability of SC tirzepatide 
5-mg injection.
AUC(0-∞) and Cmax
Incidence of TEAEs 
Exploratory
To explore the relationship between adiposity at 
injection site with tirzepatide exposure.
AUC(0-∞) and Cmax
Abbreviations: AUC(0-∞) = area under the concentration versus time curve from zero to infinity; BMI = body mass 
index; Cmax = maximum drug concentration; SC = subcutaneous; TEAE = treatment-emergent adverse event.

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5. Study Design
5.1.
Overall Design
This is a single-center, open-label, 3-period, 3-sequence, randomized, crossover study conducted 
in overtly healthy male and female subjects in 2 BMI groups (low and high).  The BMI groups 
will be as follows:

Low BMI:  18.5 to 27.0 kg/m2

High BMI:  27.1 to 45.0 kg/m2 : every effort will be made to enroll subjects so that
approximately half of this group have a BMI above 35.0 kg/m2
Subjects will be admitted to the clinical research unit (CRU) on Day -1 and will receive a single 
SC injection of tirzepatide 5 mg into 1 of 3 injection sites on Day 1, of each of the 3 treatment 
periods, with injection site sequence determined by the randomization.
The injection sites are:

upper arm (Test 1)

thigh (Test 2)

abdomen (Reference)
Subjects will remain in the CRU until the scheduled assessments have been completed on Day 8.  
Subjects may be required to remain inpatient for a longer period if deemed necessary by the 
investigator for safety monitoring reasons.  Subjects will attend 3 outpatient visits on Days 15, 
21, and 36 of each treatment period for safety monitoring and PK sampling.  The Day 36 visit of 
Treatment Period 3 will be considered the final follow-up visit.  
There will be a washout period of at least 35 days between tirzepatide injections.
Pharmacokinetic blood sampling and safety assessments, including vital sign measurements, 
physical examinations, clinical laboratory tests, glucose monitoring, electrocardiograms (ECGs),
injection site reactions, hypersensitivity reactions, and AE recording will be performed according 
to the Schedule of Activities (Section 2).
Study governance considerations are described in detail in Appendix 3.
Figure GPHI.1 illustrates the study design.  This tirzepatide injection sequence shown is an 
illustrative example only.  Each subject enrolled will be assigned a treatment sequence according 
to the actual randomization schedule provided to the site.

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Figure GPHI.1.
Illustration of Study Design for Protocol I8F-MC-GPHI.

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5.2.
Number of Participants
Approximately 54 subjects will be enrolled in the study to ensure that at least 12 evaluable 
subjects in each treatment sequence complete the 3 treatment periods. Approximately equal 
numbers of subjects with high and low BMI will be enrolled in each treatment sequence. 
For purposes of this study, a subject completes the study when all scheduled procedures shown 
in the Schedule of Activities (Section 2) have been finished.
5.3.
End of Study Definition
End of the study is the date of the last visit or last scheduled procedure shown in the Schedule of 
Activities (Section 2) for the last subject.
5.4.
Scientific Rationale for Study Design
A healthy subject population will allow assessments of the PK, safety, and tolerability of 
tirzepatide with a reduced likelihood of physiologic variability.  Also, healthy subjects are 
usually devoid of other confounding factors, such as concomitant medication.
In order to minimize any potential period-effect and to allow each subject to act as his/her own 
control, a randomized, 3-sequence, crossover design has been selected.  A washout period of at 
least 35 days between doses is considered sufficient to minimize any carryover of tirzepatide 
concentrations from one period into the next period.
This study will be open-label as the study primary endpoint PK measures are objective rather 
than subjective.
5.5.
Justification for Dose
Results from the Phase 1 study, GPGA, indicate the 5-mg dose of tirzepatide was well tolerated 
by healthy subjects and patients with T2DM, and is also planned as one of the doses to be 
investigated in Phase 3 studies.  Doses higher than 5 mg were achieved via step-wise dose 
escalation and a 5-mg dose was considered the MTD when administered as a single dose.

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Tirzepatide (LY3298176)
6. Study Population
Eligibility of subjects for the study will be based on the results of screening medical history, 
physical examination, vital signs, clinical laboratory tests and ECG.  
The nature of any conditions present at the time of the physical examination and any preexisting 
conditions will be documented.
Screening may occur up to 28 days prior to enrollment.  Subjects who are not enrolled within 
28 days of screening may be subjected to an additional medical assessment and/or clinical 
measurements to confirm their eligibility.
If the investigator decides not to administer the dose to a subject or not to enroll a subject on a 
particular day, the subject’s visit may be rescheduled (e.g., to another cohort) and any 
assessments or procedures performed up to that point may be repeated to confirm their 
eligibility.
Prospective approval of protocol deviations to recruitment and enrollment criteria, also known as 
protocol waivers or exemptions, are not permitted.
6.1.
Inclusion Criteria
Subjects are eligible for inclusion in the study only if they meet all of the following criteria at 
screening and/or Day -1, unless stated otherwise:
[1]
are overtly healthy males or females, as determined by medical history and 
physical examination.
[1a] male subjects: men, regardless of their fertility status, with non-pregnant 
women of childbearing potential partners must agree to either remain 
abstinent (if this is their preferred and usual lifestyle) or use condoms plus 
one additional highly effective (less than 1% failure rate) method of 
contraception (such as combination oral contraceptives, implanted 
contraceptives, or intrauterine device) or effective method of contraception 
(such as diaphragms with spermicide or cervical sponge) for the duration of 
the study and for at least 90 days after dosing.  A full list of permitted highly 
effective and effective methods of contraception is presented in Appendix 6.
o
Men and their partners may choose to use a double-barrier method of 
contraception.  Barrier protection methods without concomitant use of 
a spermicide are not an effective or acceptable method of 
contraception.  Thus, each barrier method must include use of a 
spermicide.  It should be noted, however, that the use of male and 
female condoms as a double-barrier method is not considered 
acceptable due to the high failure rate when these barrier methods are 
combined.
o
Periodic abstinence (e.g., calendar, ovulation, symptothermal, 
post-ovulation methods), declaration of abstinence just for the duration 

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Tirzepatide (LY3298176)
of a study, and withdrawal are not acceptable methods of 
contraception.
o
Men with pregnant partners should use condoms during intercourse for 
the duration of the study and until the end of estimated relevant 
potential exposure in women of childbearing potential.
o
Men who are in exclusively same-sex relationships (as their preferred 
and usual lifestyle) are not required to use contraception.
o
Men should refrain from sperm donation for the duration of the study 
and for at least 90 days after dosing.
[1b] female subjects: women of childbearing potential are excluded from the 
study.  Women not of childbearing potential may participate and include 
those who are:
A. infertile due to surgical sterilization (hysterectomy, bilateral oophorectomy, or 
tubal ligation), congenital anomaly such as mullerian agenesis; or
B. postmenopausal – defined as either:
i.
A woman at least 50 years of age with an intact uterus, not on hormone
therapy, who has had either:
a) cessation of menses for at least 1 year, or
b) at least 6 months of spontaneous amenorrhea with a 
follicle-stimulating hormone >40 IU/mL; or
ii.
A woman 55 or older not on hormone therapy, who has had at least 
6 months of spontaneous amenorrhea; or
iii.
A woman at least 55 years of age with a diagnosis of menopause prior to 
starting hormone replacement therapy.
[2]
are between 18 and 70 years of age, inclusive, at the time of screening.
[3]
have a BMI of:
o
18.5 to 27.0 kg/m2, inclusive (low BMI group), or 
o
27.1 to 45.0 kg/m2, inclusive (high BMI group).
[4]
have clinical laboratory test results within normal reference range for the 
population or investigative site, or results with acceptable deviations that are 
judged to be not clinically significant by the investigator.
[5]
have venous access sufficient to allow for blood sampling as per the protocol.
[6]
are willing to receive study treatment by SC injections.
[7]
have given written informed consent approved by Lilly and the institutional 
review board (IRB) governing the site.

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[8]
have blood pressure, pulse rate, and an ECG reading that are considered to be 
within normal reference range for the population or investigative site, or 
results with acceptable deviations that are judged to be not clinically 
significant by the investigator.
6.2.
Exclusion Criteria
Subjects will be excluded from study enrollment if they meet any of the following criteria at 
screening and/or Day -1, unless stated otherwise:
[9]
are investigative site personnel directly affiliated with this study and their 
immediate families.  Immediate family is defined as a spouse, biological or 
legal guardian, child, or sibling.
[10]
are Lilly employees or are employees of a third-party organization involved 
with the study.
[11]
are currently enrolled in a clinical study involving an investigational product
(IP) or any other type of medical research judged not to be scientifically or 
medically compatible with this study.  
[12]
have received treatment with a drug that has not received regulatory approval 
for any indication within 30 days of screening.
[13]
have previously completed or withdrawn from this study or any other study 
investigating tirzepatide, and have previously received the IP.  
[14]
have had any exposure to tirzepatide, other GLP-1 analogs, or other related 
compounds within 3 months prior to dosing, or any history of allergies to 
these medications.
[15]
have any abnormality in the 12-lead ECG at screening that, in the opinion of 
the investigator, increases the risks associated with participating in the study.  
[16]
have a significant history of or current cardiovascular (e.g., myocardial 
infarction, congestive heart failure, cerebrovascular accident, venous 
thromboembolism), respiratory, hepatic, renal, GI, endocrine, hematological 
(including history of thrombocytopenia) or neurological disorders capable of 
significantly altering the absorption, metabolism, or elimination of drugs, or 
of constituting a risk when taking the study medication, or of interfering with 
the interpretation of data.
[16a] Subjects in the high BMI group with stable medical conditions (e.g., 
controlled hyperlipidemia and/or hypertension, stable fatty liver condition) 
may be enrolled if the investigator (or designee) agrees that the condition 
will not introduce an additional risk factor, and will not interfere with the 
study objectives, procedures, or PK of tirzepatide. 
[17]
have evidence of significant active neuropsychiatric disease, as determined by 
the investigator.

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[18]
regularly use known drugs of abuse and/or show positive findings on drug 
screening.
[19]
have evidence of human immunodeficiency virus (HIV) infection and/or are 
positive for human HIV antibodies.
[20]
have evidence of hepatitis C and/or are positive for hepatitis C antibodies. 
[21]
have evidence of hepatitis B and/or are positive for hepatitis B surface 
antigen.  
[22]
smoke >10 cigarettes per day, or the equivalent, or are unable or unwilling to 
refrain from nicotine while resident in the CRU.
[23]
have used or plan to use over-the-counter or prescription medication, and/or 
herbal supplements (with the exception of vitamin/mineral supplements, any 
hormone replacement therapy, and/or thyroid replacement therapy) within 
14 days prior to dosing and for the duration of the study, including any 
medications that reduce GI motility, including, but not limited to, 
anticholinergics, antispasmodics, 5-hydroxytryptamine-3 receptor antagonists, 
dopamine antagonists, and opiates.  Exceptions to this criterion may be made
on a case-by-case basis at the investigator’s (or designee’s) discretion, in 
consultation with the Lilly Clinical Pharmacologist (CP)/Clinical Research 
Physician (CRP) (or designee).  
[23a] Subjects in the high BMI group with stable (for at least 3 months prior to 
screening) doses of lipid-lowering or blood pressure-lowering medications 
may be enrolled if the investigator (or designee), in consultation with the 
Lilly CP/CRP (or designee), where necessary, agrees that the medication 
will not interfere with the trial objectives, procedures, or PK of tirzepatide.  
[24]
have donated blood of more than 450 mL in the last 3 months, have 
participated in a clinical study that required a similar blood volume be drawn 
in the last 3 months, or have had any blood donation within the last month 
prior to screening.
[25]
have an average weekly alcohol intake that exceeds 21 units per week (males) 
or 14 units per week (females), OR are unwilling to stop alcohol consumption 
24 hours prior to each dosing until discharge from the CRU, and 24 hours 
prior to each outpatient visit (1 unit of alcohol = 12 oz or 360 mL of beer; 5 oz 
or 150 mL of wine; 1.5 oz or 45 mL of distilled spirits).

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[26]
have a history or presence of pancreatitis (history of chronic pancreatitis or 
idiopathic acute pancreatitis), elevation in serum amylase or lipase (>1.5-fold 
the upper limit of normal [ULN]), GI disorder (e.g., relevant esophageal 
reflux or gall bladder disease), or any GI disease which impacts gastric 
emptying (e.g., gastric bypass surgery, pyloric stenosis [with the exception of 
appendectomy]) or could be aggravated by GLP-analogs or dipeptidyl 
peptidase IV (DPP-IV) inhibitors.  Subjects with dyslipidemia and subjects 
who had cholecystolithiasis (with removal of gallstones), cholecystectomy 
(removal of the gall bladder), and/or uncomplicated appendectomy or hernia 
repair in the past, with no further sequelae, may be included in the study, at 
the discretion of the investigator.
[27]
have a history of Gilbert’s syndrome or clinical laboratory results that are 
suggestive of Gilbert’s syndrome.
[28]
have a history of atopy or clinically significant multiple or severe drug 
allergies, intolerance to topical corticosteroids, or severe posttreatment 
hypersensitivity reactions (including, but not limited to, erythema multiforme 
major, linear immunoglobulin A dermatosis, toxic epidermal necrolysis, or 
exfoliative dermatitis).
[29]
have a personal or family history of medullary thyroid carcinoma or have 
multiple endocrine neoplasia syndrome type 2.
[30]
have serum aspartate aminotransferase (AST) or alanine aminotransferase 
(ALT) >3 × ULN or total bilirubin (TBL) >2 × ULN.
[31]
have a history of malignancy within 5 years prior to screening.
[32]
have a serum triglyceride (TG) ≥5 mmol/L (442.5 mg/dL) at screening.
[33]
have been treated with prescription drugs that promote weight loss (e.g., 
Meridia® [sibutramine], Sanorex® [mazindol], Adipex® [phentermine], 
Belviq® [lorcaserin], Mysimba® [naltrexone/bupropion], Saxenda®
[liraglutide]), or similar other body weight loss medications, including 
over-the-counter medications (e.g., Alli®) within 3 months prior to screening.
[34]
are deemed unsuitable by the investigator for any other reason.
6.3.
Lifestyle and/or Dietary Requirements
Throughout the study, subjects may undergo medical assessments and review of compliance with 
requirements before continuing in the study.  
6.3.1. Meals and Dietary Restrictions
Subjects will be required to fast overnight for at least 8 hours before being given any SC dose of 
tirzepatide, and when clinical laboratory test samples are taken (see Schedule of Activities, 
Section 2).  A meal will be offered to study subjects at around 2 hours postdose.  During 
inpatient stays, subjects may not consume any food other than that provided by the CRU.  Water 
may be consumed freely.

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6.3.2. Caffeine, Alcohol, and Tobacco 
No alcohol will be allowed from 24 hours prior to each dosing until discharge from the CRU, 
and 24 hours prior to each outpatient visit.  No nicotine/tobacco use will be permitted while in 
the CRU.  While not resident in the CRU, subjects must not consume more than 10 cigarettes or 
the equivalent per day.
Subjects will be allowed to maintain the regular caffeine consumption throughout the study 
period (except during specific fasting time periods).
6.3.3. Activity
No strenuous physical activity will be allowed for 48 hours prior to each dosing until discharge 
from the CRU, and 24 hours prior to each outpatient visit.
6.4.
Screen Failures
Individuals who do not meet the criteria for participation in this study (screen failure) may not be 
re-screened.  However, screening tests such as clinical laboratory tests and vital signs/ECGs may 
be repeated once at the discretion of the investigator.  

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7. Treatment
7.1.
Treatment Administered
This study involves a comparison of tirzepatide administered as single 5-mg SC injections
delivered via an autoinjector to the upper arm and thigh in comparison to the abdomen.  
Table GPHI.2 shows the treatment regimens.
When administered in the abdomen, the injection will be administered to the lower abdominal 
quadrant, approximately 5 cm from the umbilicus. Detailed instructions for use of the 
autoinjector will be provided by the sponsor.  Only a limited number of clinical site staff will 
perform the SC administration for consistency reasons. 
Table GPHI.2.
Treatments Administered via Autoinjector
Treatment Name
Test 1
Test 2
Reference
Injection Site
upper arm
thigh
abdomen
Dosage Formulation
solution for injection
solution for injection
solution for injection
Dose
5 mg tirzepatide / 0.5 mL
5 mg tirzepatide / 0.5 mL 5 mg tirzepatide / 0.5 mL
Route of 
Administration
SC injection
SC injection
SC injection
Delivery Method
autoinjector
autoinjector
autoinjector
Abbreviations:  SC = subcutaneous
The investigator or clinical site designee is responsible for:

explaining the correct use of the IP to the clinical staff.

verifying that instructions are followed properly.

maintaining accurate records of IP dispensing and collection.

returning all unused medication to Lilly or its designee at the end of the study.
Note: In some cases, sites may destroy the material if, during the investigative site selection, the 
evaluator has verified and documented that the site has appropriate facilities and written 
procedures to dispose of clinical materials.
7.1.1. Packaging and Labeling
Tirzepatide will be supplied by the sponsor or its designee in accordance with current good 
manufacturing practice, labeled according to the country’s regulatory requirements.

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Each tirzepatide autoinjector is designed to deliver 5 mg of tirzepatide.
7.1.2. Medical Devices
The investigator or designee will ensure that the instructions have been followed properly; 
maintaining accurate records of study devices, dispensing, and collection. The used or unused 
autoinjectors may be destroyed by a qualified vendor. 
7.2.
Method of Treatment Assignment
Subjects will be randomly assigned to 1 of 3 treatment sequences based on injection site and 
stratified into 2 groups based on BMI (18.5 to 27.0 kg/m2 and 27.1 to 45.0 kg/m2, inclusive)
using a computer-generated allocation code.
7.2.1. Selection and Timing of Doses
The actual time of all dose administrations will be recorded in the subject’s electronic case report 
form (eCRF).
7.3.
Blinding
This study is open-label.
7.4.
Dose Modification
Dose modification is not permitted in this study.
7.5.
Preparation/Handling/Storage/Accountability
The investigator or designee must confirm appropriate temperature conditions have been 
maintained, as communicated by sponsor, during transit for all IP received and that any 
discrepancies are reported and resolved before use of the study treatment.
Only subjects enrolled in the study may receive IP or study materials, and only authorized site 
staff may administer IP.  All IP should be stored in an environmentally controlled and monitored 
(manual or automated) area in accordance with the labeled storage conditions with access limited 
to the investigator and authorized site staff.
The investigator is responsible for study treatment accountability, reconciliation, and record 
maintenance (such as receipt, reconciliation and final disposition records).
7.6.
Treatment Compliance
The IP will be administered at the clinical site, and documentation of treatment administration 
will occur at the site.
7.7.
Concomitant Therapy
In general, concomitant medication should be avoided; however, paracetamol (up to 1 g per 
dose, maximum 3 g/24 hours) may be administered at the discretion of the investigator for 
treatment of headaches etc.  If the need for concomitant medication (other than paracetamol) 
arises, inclusion or continuation of the subject may be at the discretion of the investigator, 

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Tirzepatide (LY3298176)
preferably after consultation with a Lilly CP/CRP or designee.  Any medication used during the 
course of the study must be documented.
For subjects enrolled in the high BMI group, treatment with chronic stable medications that are 
necessary for maintaining the subject’s clinical status will be permitted if approved by the 
investigator (or designee) and Lilly CP/CRP.  The subject must have been on a stable dose for a 
minimum of 3 months prior to screening and throughout the trial, unless required for the 
treatment of an AE.  
As per exclusion criterion 23, vitamin/mineral supplements, hormone replacement therapy, 
and/or thyroid replacement therapy are acceptable concomitant medications during the course of 
the study.  
On Day 1 of each treatment period, administration of medications may be withheld for at least 
2 hours predose until 4 hours postdose, as deemed clinically appropriate by the investigator.   
7.8.
Treatment After the End of the Study
Not applicable.

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8. Discontinuation Criteria
Subjects discontinuing from the study and treatment prematurely for any reason should complete 
AE and other follow-up procedures per Schedule of Activities (Section 2) of this protocol.
8.1.
Discontinuation from Study Treatment
Discontinuation of the IP for abnormal liver tests should be considered by the investigator when 
a subject meets 1 of the following conditions after consultation with the Lilly-designated medical 
monitor:

ALT or AST >5× ULN for healthy subjects 

ALT or AST >3× ULN for healthy subjects sustained for more than 2 weeks 

ALT or AST >3× ULN and TBL >2× ULN or international normalized ratio >1.5 

ALT or AST >3× ULN with the appearance of fatigue, nausea, vomiting, right 
upper-quadrant pain or tenderness, fever, rash, and/or eosinophilia (>5%)

alkaline phosphatase (ALP) >3× ULN

ALP>2.5× ULN and TBL >2× ULN

ALP>2.5× ULN with the appearance of fatigue, nausea, vomiting, right quadrant pain or 
tenderness, fever, rash, and/or eosinophilia (>5%)
8.1.1. Discontinuation of Inadvertently Enrolled Subjects
If the sponsor or investigator identifies a subject who did not meet enrollment criteria and was 
inadvertently enrolled, a discussion must occur between the Lilly CP/CRP and the investigator to 
determine if the subject may continue in the study.  If both agree it is medically appropriate to 
continue, the investigator must obtain documented approval from the Lilly CP/CRP to allow the 
inadvertently enrolled subject to continue in the study with or without continued treatment with 
IP.  
8.2.
Discontinuation from the Study
Subjects will be discontinued in the following circumstances:

Enrollment in any other clinical study involving an IP or enrollment in any other type of 
medical research judged not to be scientifically or medically compatible with this study

Participation in the study needs to be stopped for medical, safety, regulatory, or other 
reasons consistent with applicable laws, regulations, and good clinical practice (GCP)

Investigator decision
o
the investigator decides that the subject should be discontinued from the study

Subject decision
o
the subject, or legal representative, requests to be withdrawn from the study

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8.3.
Subjects Lost to Follow-up
A subject will be considered lost to follow-up if he or she repeatedly fails to return for scheduled 
visits and is unable to be contacted by the study site.  Site personnel are expected to make 
diligent attempts to contact subjects who fail to return for a scheduled visit or were otherwise 
unable to be followed up by the site.

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9. Study Assessments and Procedures
Section 2 lists the Schedule of Activities, detailing the study procedures and their timing 
(including tolerance limits for timing).
Appendix 2 lists the clinical laboratory tests that will be performed for this study.
Appendix 5 provides a summary of the approximate number and volume of invasive samples, for
all sampling, during the study.
The specifications in this protocol for the timings of safety and sample collections are given as 
targets to be achieved within reasonable limits.  Modifications may be made to the time points 
based upon emerging clinical information.  The scheduled time points may be subject to minor 
alterations; however, the actual time must be recorded correctly in the electronic CRF (eCRF).  
Failure or delays (i.e., outside stipulated time allowances) in performing procedures or obtaining 
samples due to legitimate clinical issues (e.g., equipment technical problems, venous access 
difficulty, or subject defaulting or turning up late on an agreed scheduled procedure) will not be 
considered as protocol deviations but the CRU will still be required to notify the sponsor in 
writing via a file note.
Unless otherwise stated in subsections below, all samples collected for specified laboratory tests 
will be destroyed within 60 days of receipt of confirmed test results.  Certain samples may be 
retained for a longer period, if necessary, to comply with applicable laws, regulations, or 
laboratory certification standards.
9.1.
Efficacy Assessments
Not applicable.
9.2.
Adverse Events
Investigators are responsible for monitoring the safety of subjects who have entered this study 
and for alerting Lilly or its designee to any event that seems unusual, even if this event may be 
considered an unanticipated benefit to the subject.
The investigator is responsible for the appropriate medical care of subjects during the study.
Investigators must document their review of each laboratory safety report.
The investigator remains responsible for following, through an appropriate health care option, 
AEs that are serious or otherwise medically important, considered related to the IP or the study, 
or that caused the subject to discontinue the IP before completing the study.  The subject should 
be followed until the event resolves, stabilizes with appropriate diagnostic evaluation, or is 
reasonably explained.  The frequency of follow-up evaluations of the AE is left to the discretion 
of the investigator.
The investigator will record all relevant AE and SAE information in the eCRF.  After the 
informed consent form (ICF) is signed, study site personnel will record, via eCRF, the 
occurrence and nature of each subject’s preexisting conditions, including clinically significant

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signs and symptoms of the disease under treatment in the study.  Additionally, site personnel will 
record any change in the condition(s) and the occurrence and nature of any AEs.  
The investigator will interpret and document whether or not an AE has a reasonable possibility 
of being related to study treatment, the autoinjector, and/or a study procedure, taking into 
account the disease, concomitant treatment or pathologies.  
A “reasonable possibility” means that there is a potential cause and effect relationship between 
the IP, study device and/or study procedure and the AE.
Planned surgeries should not be reported as AEs unless the underlying medical condition has 
worsened during the course of the study.
If a subject’s IP is discontinued as a result of an AE, study site personnel must report this to Lilly 
or its designee via eCRF.  
9.2.1. Serious Adverse Events 
An SAE is any AE from this study that results in one of the following:

death

initial or prolonged inpatient hospitalization

a life-threatening experience (that is, immediate risk of dying)

persistent or significant disability/incapacity

congenital anomaly/birth defect

important medical events that may not be immediately life-threatening or result in death 
or hospitalization but may jeopardize the subject or may require intervention to prevent 
one of the other outcomes listed in the definition above

when a condition related to the use of the tirzepatide autoinjector device necessitates 
medical or surgical intervention to preclude either permanent impairment of a body 
function or permanent damage to a body structure, the serious outcome of “required 
intervention” will be assigned
Study site personnel must alert the Lilly CRP/CP, or its designee, of any SAE as soon as 
practically possible.
Additionally, study site personnel must alert Lilly Global Patient Safety, or its designee, of any 
SAE within 24 hours of investigator awareness of the event via a sponsor-approved method.  If 
alerts are issued via telephone, they are to be immediately followed with official notification on 
study-specific SAE forms.  This 24-hour notification requirement refers to the initial SAE 
information and all follow-up SAE information.
Investigators are not obligated to actively seek AEs or SAEs in subjects once they have 
discontinued from and/or completed the study (the subject summary eCRF has been completed).  
However, if the investigator learns of any SAE, including a death, at any time after a subject has

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been discharged from the study, and he/she considers the event reasonably possibly related to the 
study treatment or study participation, the investigator must promptly notify Lilly.  
Pregnancy (paternal exposure to IP) does not meet the definition of an AE.  However, to fulfill 
regulatory requirements any pregnancy should be reported following the SAE process to collect 
data on the outcome for both mother and fetus.
9.2.1.1.
Suspected Unexpected Serious Adverse Reactions 
Suspected unexpected serious adverse reactions (SUSARs) are serious events that are not listed 
in the IB and that the investigator reports as related to IP or procedure.  Lilly has procedures that 
will be followed for the recording and expedited reporting of SUSARs that are consistent with 
global regulations and the associated detailed guidances.
9.2.2. Complaint Handling
Lilly collects product complaints on IPs and drug delivery systems used in clinical trials in order 
to ensure the safety of study participants, monitor quality, and to facilitate process and product 
improvements.
Subjects should be instructed to contact the investigator as soon as possible if he or she has a 
complaint or problem with the IP or drug delivery system so that the situation can be assessed.
9.3.
Treatment of Overdose
For the purposes of this study, an overdose of tirzepatide is considered any dose higher than the 
dose assigned through randomization.
There is no specific antidote for tirzepatide.  In the event of an overdose, the subject should 
receive appropriate supportive care and any AEs should be documented.
Refer to the IB.
9.4.
Safety
9.4.1. Clinical Laboratory Tests
For each subject, clinical laboratory tests detailed in Appendix 2 should be conducted according 
to the Schedule of Activities (Section 2).  
9.4.1.1.
Amylase and Lipase Measurements
Serum amylase and lipase measurements will be collected as part of the clinical laboratory 
testing and as specified in the Schedule of Activities (Section 2).  Additional measurements may 
be performed at the investigator’s discretion.  Further diagnostic assessments will be 
recommended as per the algorithm (refer to Appendix 7) for the monitoring of pancreatic events 
whenever lipase and/or amylase is confirmed to be ≥3× ULN at any visit postdose, even if the 
subject is asymptomatic.

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9.4.2. Glucose Monitoring
For safety purposes, blood glucose measurements will be performed using a bedside glucose 
monitor as specified in the Schedule of Activities (Section 2).  Additional safety blood glucose 
monitor measurements may also be taken during the study as deemed necessary by the 
investigator.
9.4.2.1.
Hyperglycemia and Hypoglycemia Reporting
Episodes of hyperglycemia (fasting plasma/serum glucose >270 mg/dL [15 mmol/L]) or 
hypoglycemia (plasma/serum glucose ≤70 mg/dL [3.9 mmol/L]) will be reported by the 
investigator or designated physician who will be responsible for advising the subject on what 
further actions to take. Additional monitoring may be requested at the investigator’s discretion.
If the fasting plasma/serum glucose during Treatment Periods 1, 2, and/or 3 exceeds the 
acceptable level defined as hyperglycemia on 3 or more separate days over any 2-week period 
between screening and the end of the dosing period, the subject will be evaluated further at the 
study site. If fasting plasma/serum glucose continues to exceed the acceptable level, treatment 
with an appropriate antidiabetic agent may be initiated by the investigator. If hyperglycemia 
occurs during the follow-up period, the subject will remain in the study until completion of the 
planned follow-up.
Hypoglycemia episodes will be recorded on specific eCRF pages. Hypoglycemia will be treated 
appropriately by the investigator and additional monitoring of plasma/serum glucose levels may 
be performed.  The following categories of the 2017 American Diabetes Association position 
statement on glycemic targets (ADA 2017) based on recommendations of the International 
Hypoglycaemia Study Group (IHSG 2017) should be applied for reporting in the eCRF and 
evaluating hypoglycemic events.
Hypoglycemia will be described using the following definitions:  

Documented Glucose Alert Level (Level 1), Plasma Glucose (PG) ≤70 mg/dL 
(3.9 mmol/L):  
o
Symptomatic hypoglycemia:  an event during which typical symptoms of 
hypoglycemia are accompanied by PG ≤70 mg/dL (3.9 mmol/L)
o
Asymptomatic hypoglycemia: an event not accompanied by typical symptoms 
of hypoglycemia but with PG ≤70 mg/dL (3.9 mmol/L)
o
Unspecified hypoglycemia: an event during which PG ≤70 mg/dL (3.9 mmol/L) 
but no information relative to symptoms of hypoglycemia was recorded

Documented Clinically Significant Hypoglycemia (Level 2) PG <54 mg/dL 
(3.0 mmol/L):
o
Symptomatic hypoglycemia: an event during which typical symptoms of 
hypoglycemia are accompanied by PG <54 mg/dL (3.0 mmol/L)
o
Asymptomatic hypoglycemia: an event not accompanied by typical symptoms 
of hypoglycemia but with PG <54 mg/dL (3.0 mmol/L)
o
Unspecified hypoglycemia: an event during which PG <54 mg/dL (3.0 mmol/L) 
but no information relative to symptoms of hypoglycemia was recorded

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
Severe hypoglycemia (Level 3): an event requiring assistance of another person to 
actively administer carbohydrate, glucagon, or other resuscitative actions.  During these 
episodes, the subject has an altered mental status and cannot assist in their care, is 
semiconscious or unconscious, or experienced coma with or without seizures and may 
require parenteral therapy. Plasma glucose measurements may not be available during 
such an event, but neurological recovery attributable to the restoration of blood glucose 
concentration to normal is considered sufficient evidence that the event was induced by a 
low PG concentration (PG ≤70 mg/dL [3.9 mmol/L])
o
Severe hypoglycemia requiring medical attention: a severe hypoglycemic 
event when subjects require therapy by healthcare professionals (e.g., emergency 
medical technicians, emergency room personnel)
Other Hypoglycemia:

Nocturnal hypoglycemia: any hypoglycemic event (documented symptomatic, 
asymptomatic, probable symptomatic, or severe hypoglycemia) that occurs between 
bedtime and waking

Relative hypoglycemia: an event during which typical symptoms of hypoglycemia, that
do not require the assistance of another person, are accompanied by PG >70 mg/dL 
(3.9 mmol/L), but these levels may be quickly approaching the 70 mg/dL (3.9 mmol/L) 
threshold

Overall (or total) hypoglycemia: This optional category combines all cases of 
hypoglycemia. If an event of hypoglycemia falls into multiple subcategories, the event is 
only counted once in this category

Probable symptomatic hypoglycemia: An event during which symptoms of 
hypoglycemia are not accompanied by a PG measurement but that was presumably 
caused by a blood glucose concentration ≤70 mg/dL (3.9 mmol/L).
The determination of a hypoglycemic event as an episode of severe hypoglycemia as defined 
above will be made by the investigator based on the medical need of the subject to have required 
assistance and is not predicated on the report of a subject simply having received assistance.
Hypoglycemic events will be recorded in the hypoglycemia module of the eCRF to allow for the 
collection of comprehensive safety information relating to these events.  All episodes of severe 
hypoglycemia will additionally be reported as SAEs (see Section 9.2.1 for details regarding SAE 
reporting).
9.4.3. Vital Signs
For each subject, vital signs measurements should be conducted according to the Schedule of 
Activities (Section 2) 
Blood pressure and pulse rate should be measured after at least 5 minutes in the supine position.
Unscheduled orthostatic vital signs should be assessed, if possible, during any AE of dizziness or 
posture-induced symptoms.  Additional vital signs may be measured during each treatment
period if warranted.

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9.4.4. Electrocardiograms
For each subject, single 12-lead ECGs should be collected according to the Schedule of 
Activities (Section 2).  
Any clinically significant findings from ECGs that result in a diagnosis and that occur after the 
subject receives the first dose of the IP, should be reported to Lilly, or its designee, as an AE via 
eCRF.  
Electrocardiograms must be recorded before collecting any blood samples.  Subjects must be 
supine for approximately 5 to 10 minutes before ECG collection and remain supine but awake 
during ECG collection.  Electrocardiograms may be obtained at additional times, when deemed 
clinically necessary.  All ECGs recorded should be stored at the investigational site.
Electrocardiograms will be interpreted by a qualified investigator (a physician or qualified 
designee) at the site as soon after the time of ECG collection as possible, and ideally while the 
subject is still present, to determine whether the subject meets entry criteria at the relevant 
visit(s) and for immediate subject management, should any clinically relevant findings be 
identified.  
If a clinically significant finding is identified (including, but not limited to, changes in QT/QTc 
interval from baseline) after enrollment, the investigator will determine if the subject can 
continue in the study.  The investigator, or qualified designee, is responsible for determining if 
any change in subject management is needed, and must document his/her review of the ECG 
printed at the time of collection.  Any new clinically relevant finding should be reported as an 
adverse event.
9.4.5. Injection-Site Reactions
Injection-site assessments for local tolerability will be conducted, when reported as:

an AE from a subject, or

a clinical observation from an investigator.
Reported injection-site reactions will be characterized within the following categories:

edema

erythema

induration

itching

pain
All injection-site reactions reported as AEs will be closely monitored until resolution.  The report 
of a clinically significant AE of injection-site reaction may prompt notification of the sponsor, 
clinical photography, and referral for dermatologic evaluation and consideration of a skin biopsy 

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and laboratory evaluations (ALT, AST, complete blood count with percent eosinophils, and 
additional immunogenicity testing).
Investigational site staff will be provided with separate instructions/training on how to evaluate 
injection-site reactions and their severity in a consistent manner.  Photographs of injection-site 
reactions may be taken in a standardized manner for record-keeping purposes; however, the 
photographs will not be used to evaluate the severity of injection-site reaction.
9.4.6. Hypersensitivity Reactions
All hypersensitivity reactions will be reported by the investigator as either AEs or, if any serious 
criterion is met, as SAEs.
In the event of suspected drug hypersensitivity reactions (immediate or non-immediate) in 
subjects who experience moderate-to-severe injection reactions as assessed by the investigator, 
unscheduled blood samples will be collected for PK and anti-drug antibody (ADA) analyses at 
the following time points:  

as close as possible to the onset of the event

at the resolution of the event

30 (±3) days following the event  
Additionally, unscheduled serum samples for immune safety laboratory testing (including, but 
not limited to β tryptase, total immunoglobulin E, complement and cytokine panel testing) 
should also be collected at approximately 60 to 120 minutes and 4 to 6 weeks after the onset of 
the event in these subjects.  
Instructions for the collection and handling of blood samples will be provided by the sponsor.  
The actual date and time (24-hour clock time) of each sampling will be recorded.
9.4.7. Safety Monitoring
The Lilly CP or CRP/scientist will monitor safety data throughout the course of the study.
Lilly will review SAEs within timeframes mandated by company procedures.  The Lilly CP or 
CRP will periodically review the following data:

trends in safety data

laboratory analytes including glucose, amylase, and lipase

serious and nonserious AEs, including AEs of special interest
Further diagnostic assessments will be recommended whenever lipase and/or amylase are 
confirmed to be ≥3× ULN at any visit postdose even if the subject is asymptomatic (as per the 
algorithm for the monitoring of pancreatic events in Appendix 7) and, if pancreatitis is suspected, 
the case will be further defined during an adjudication process.
When appropriate, the Lilly CP or CRP will consult with the functionally independent Global 
Patient Safety therapeutic area physician or clinical research scientist.  

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9.4.7.1.
Hepatic Safety
If a study subject experiences elevated ALT ≥3× ULN, ALP ≥2× ULN, or elevated TBL ≥2×
ULN, liver tests (Appendix 4) should be repeated within 3 to 5 days including ALT, AST, ALP, 
TBL, direct bilirubin, gamma-glutamyl transferase (GGT), and creatine kinase to confirm the 
abnormality and to determine if it is increasing or decreasing.  If the abnormality persists or 
worsens, clinical and laboratory monitoring should be initiated by the investigator based on 
consultation with the Lilly CP or CRP.  Monitoring should continue until levels normalize and/or 
are returning to approximate baseline levels. 
Additional safety data should be collected if 1 or more of the following conditions occur: 

elevation of serum ALT to ≥5× ULN on 2 or more consecutive blood tests

elevated serum TBL to ≥2× ULN 

elevation of serum ALP to ≥2× ULN on 2 or more consecutive blood tests 

subject discontinued from treatment due to a hepatic event or abnormality of liver 
tests

hepatic event considered to be a SAE
9.5.
Pharmacokinetics
At the visits and times specified in the Schedule of Activities (Section 2), venous blood samples 
of approximately 3 mL each will be collected to determine the plasma concentrations of 
tirzepatide.  A maximum of 3 unscheduled samples may be collected at additional time points 
during the study if warranted and agreed upon between both the investigator and sponsor.  
Instructions for the collection and handling of blood samples will be provided by the sponsor.  
The actual date and time (24-hour clock time) of each sampling will be recorded.
Failure or being late (i.e., outside stipulated time allowances) to perform procedures or obtain 
samples due to legitimate clinical issues (e.g., equipment technical problems, venous access 
difficulty, or subject defaulting or turning up late on an agreed scheduled procedure) will not be 
considered as protocol deviations but the CRU will still be required to notify the sponsor in 
writing via a file note. 
9.5.1. Bioanalysis
Samples will be analyzed at a laboratory approved by the sponsor and stored at a facility 
designated by the sponsor.
Concentrations of tirzepatide will be assayed using a validated liquid chromatography tandem 
mass spectrometry method.
Bioanalytical samples collected to measure IP concentrations will be retained for a maximum of 
2 years following last subject visit for the study.  During this time, samples remaining after the 
bioanalyses may be used for exploratory analyses, such as metabolism work, protein binding, or 
bioanalytical method cross-validation.

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9.5.2. Exploratory Assessments
9.5.2.1.
Fat Deposition at Injection Site
The relationship between exposure to tirzepatide and adiposity at the injection site will be 
explored by use of skinfold calipers and DEXA scanning.  
DEXA scanning will be performed at the times specified in the Schedule of Activities 
(Section 2).  A whole body scan will be performed using a narrow angle fan beam DEXA 
scanner to estimate the total fat at the site of injection for the specific dosing period.
Skinfold thickness will be measured using skinfold calipers at the planned injection site of the 
specific dosing period.  As far as possible, the same skinfold calipers will be used on each 
occasion for all subjects.  Only a limited number of site personnel will perform the skinfold 
measurements for consistency.
Instructions will be provided separately to the investigator detailing the skinfold calipers and 
DEXA measurements. 
9.5.2.2.
Waist, Upper Arm, and Thigh Circumference
Waist, thigh, and upper arm circumference will be measured in triplicate, and the mean recorded,
as specified in the Schedule of Activities (Section 2).
9.6.
Pharmacodynamics
Not applicable.
9.7.
Immunogenicity Assessments
For immunogenicity testing, venous blood samples of approximately 10 mL will be collected 
from each subject according to the Schedule of Activities (Section 2) to determine antibody 
production against tirzepatide.  Up to 3 additional samples may be collected if there is a 
possibility that an AE is immunologically mediated.  All samples for immunogenicity testing 
should have a time-matched sample for PK analysis where relevant.  In the event of drug 
hypersensitivity reactions (immediate or non-immediate), additional unscheduled samples should 
be collected as detailed in Section 9.4.6.  Instructions for the collection and handling of blood 
samples will be provided by the sponsor.  The actual date and 24-hour clock time of each 
sampling will be recorded.
Immunogenicity will be assessed by a validated assay designed to detect ADA in the presence of 
tirzepatide at a laboratory approved by the sponsor.  Antibodies may be further evaluated for 
their ability to neutralize the activity of tirzepatide on GIP and GLP-1 receptors.  Positive 
tirzepatide ADA samples will be tested for cross-reactivity with native GIP and GLP-1, and, if 
positive, may then be tested for neutralizing antibodies against native GIP and/or GLP-1.  
All subjects will have an ADA sample measured at early discontinuation or at the last planned 
study visit.  A risk-based approach will be used to monitor subjects who develop 
treatment-emergent ADA (TE ADA), defined in Section 10.3.3 (Evaluation of Immunogenicity).

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Clinically significant TE ADA will be defined as any TE ADA at the last visit with:

a high titer (1280) or an increasing titer from last measured value

an association with a moderate-to-severe injection site reaction
Subjects who have clinically significant TE ADA at early discontinuation or at the follow-up
visit should be followed with ADA testing every 3 months until the ADA titers have return to the 
baseline ADA titer (defined as ADA titer within 2-fold of baseline) or for up to 1 year, 
whichever is lesser.  A PK sample may be collected at the follow-up immunogenicity 
assessment(s), if warranted and agreed upon by the investigator and sponsor.
Every attempt should be made to contact subjects for the follow-up immunogenicity assessment; 
however, if subjects are unwilling or unable to return for the visit, this is not considered a 
protocol deviation.
Subjects followed for at least 1 year after dosing who have not returned to baseline, as defined 
above, will be assessed for safety concerns and, if no clinical sequelae are recognized by the 
clinical team, no further follow-up will be required.  Subjects who have clinical sequelae that are 
considered potentially related to the presence of TE ADA may also be asked to return for 
additional follow-up testing.
Samples will be retained for a maximum of 15 years after the last subject visit, or for a shorter 
period if local regulations and IRB allows, at a facility selected by the sponsor.  The duration 
allows the sponsor to respond to future regulatory requests related to the tirzepatide.  Any 
samples remaining after 15 years will be destroyed.  
9.8.
Genetics
A blood sample will be collected for pharmacogenetic analysis as specified in the Schedule of 
Activities (Section 2), where local regulations allow.  
Samples will not be used to conduct unspecified disease or population genetic research either 
now or in the future.  Samples will be used to investigate variable exposure or response to 
tirzepatide and to investigate genetic variants thought to play a role in T2DM.  Assessment of 
variable response may include evaluation of AEs or differences in efficacy.  
All samples will be coded with the subject number.  These samples and any data generated can 
be linked back to the subject only by the investigative site personnel. 
Samples will be retained for a maximum of 15 years after the last subject visit, or for a shorter 
period if local regulations and/or IRBs impose shorter time limits, for the study at a facility 
selected by Lilly or its designee.  This retention period enables use of new technologies, response 
to regulatory questions, and investigation of variable response that may not be observed until 
later in the development of tirzepatide or after tirzepatde is commercially available.  
Molecular technologies are expected to improve during the 15-year storage period and therefore 
cannot be specifically named.  However, existing approaches include whole genome or exome 
sequencing, genome wide association studies, multiplex assays, and candidate gene studies.  

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Regardless of technology utilized, data generated will be used only for the specific research 
scope described in this section.  
9.9.
Biomarkers
Not applicable.  
9.10. Health Economics
This section is not applicable for this study.

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10.
Statistical Considerations and Data Analysis
10.1. Sample Size Determination
Approximately 54 subjects will be enrolled to ensure that at least 36 evaluable subjects complete 
the study, with at least 12 subjects completing per treatment sequence.  With 36 subjects, we 
expect the two one-sided t-tests (TOST) for equivalence applied to the log-normal mean ratio to 
have a power of at least 98% for each of the 4 tests on the primary objective.  This assumes a 
nominal expected mean ratio of 1.05, a coefficient variation of 19.6%, and significance level of 
0.05 of each one-sided test when testing against an upper limit of 1.25 and lower limit of 0.80.  
The source of the choice of coefficient of variation is from the final results of study 
I8F-MC-GPGE.  For balance and the evaluation of the secondary objective of effect of BMI, the 
54 subjects will be enrolled according to their BMI category such that each category enrolls 
approximately 27 subjects and retains 6 completers per treatment sequence.
10.2. Populations for Analyses
10.2.1. Study Participant Disposition
A detailed description of subject disposition will be provided at the end of the study.  All 
subjects who discontinue from the study will be identified, and the extent of their participation in 
the study will be reported.  If known, a reason for their discontinuation will be given.  
10.2.2. Study Participant Characteristics
The subject’s age, sex, weight, height, BMI, or other demographic characteristics will be 
recorded and may be used in the PK and safety analyses as classification variables.
10.3. Statistical Analyses
Statistical analysis of this study will be the responsibility of Eli Lilly and Company or its 
designee.
Pharmacokinetic analyses will be conducted on data from all subjects who receive at least one 
dose of the IP and have evaluable data.  
Safety analyses will be conducted for all subjects who receive at least one dose of the IP, 
whether or not they completed all protocol requirements.
Additional exploratory analyses of the data will be conducted as deemed appropriate.  Study 
results may be pooled with the results of other studies for population PK analysis purposes.  
10.3.1. Safety Analyses
10.3.1.1. Clinical Evaluation of Safety
All IP and protocol procedure AEs will be listed and study device complaints, and if the 
frequency of events allows, safety data will be summarized using descriptive methodology.

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The incidence of symptoms at each treatment period will be presented by severity and by 
association with IP as perceived by the investigator.  Symptoms reported to occur prior to 
enrollment will be distinguished from those reported as new or increased in severity during the 
study.  Each symptom will be classified by the most suitable term from the medical regulatory 
dictionary.
The number of IP-related SAEs will be reported.
10.3.1.2. Statistical Evaluation of Safety
Safety parameters that will be assessed include AEs, safety laboratory parameters (including 
amylase, lipase, and blood glucose), and vital signs.  The parameters will be listed, and 
summarized using standard descriptive statistics, where appropriate. 
Physical examinations and ECGs will be performed for safety monitoring purposes and will not 
be presented.
Incidence of reported injection site reactions for erythema, induration, pain, itching, and edema 
will be listed and summarized.
If warranted, additional analyses will be performed upon review of the data.
10.3.2. Pharmacokinetic Analyses
10.3.2.1. Pharmacokinetic Parameter Estimation
Pharmacokinetic parameter estimates for tirzepatide will be calculated by standard 
noncompartmental methods of analysis.
The primary PK parameters for analysis will be Cmax and area under the concentration versus 
time curve from zero to infinity (AUC[0-∞]).  Other noncompartmental parameters, such as time 
to Cmax (tmax), area under the concentration versus time curve from zero to the last measrurable 
concentration (AUC[0-tlast]), half-life associated with the terminal rate constant in 
noncompartmental analysis (t1/2), apparent clearance (CL/F), and apparent volume of distribution
(V/F) may be reported.
10.3.2.2. Pharmacokinetic Statistical Inference
Pharmacokinetic parameter estimates will be evaluated to delineate effects of injection site. 
Log-transformed AUC(0-∞) and Cmax will be evaluated in a linear mixed-effects model with 
fixed effects for injection site, period, and sequence.  Subject nested within sequence will be 
fitted as a random effect.  
For the primary endpoints, the following comparisons will be assessed:
Ratio of AUC(0-∞) (90% confidence interval [CI]) and Cmax (90% CI) for:

Upper arm (Test 1) : Abdomen (Reference)

Thigh (Test 2) : Abdomen (Reference)

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Differences will be back-transformed to present the ratios of geometric least squares means and 
the corresponding 90% CI.
For the secondary endpoint, BMI group and the BMI group-by-injection site interaction term will 
be added to the above model.  Subject nested within sequence and BMI group will be fitted as a 
random effect.  The effect of BMI group will be assessed overall, within each injection site, as 
well as between injection sites.  The comparisons that will be assessed are the following:
Ratio of AUC(0-∞) (90% CI) and Cmax (90% CI) for:

Low BMI group (Test) : High BMI group (Reference) - Overall

Low BMI group (Test) : High BMI group (Reference) - Abdomen

Low BMI group (Test) : High BMI group (Reference) - Arm

Low BMI group (Test) : High BMI group (Reference) - Thigh

Upper arm (Test 1) : Abdomen (Reference) - Low BMI 

Upper arm (Test 1) : Abdomen (Reference) - High BMI

Thigh (Test 2) : Abdomen (Reference) - Low BMI 

Thigh (Test 2) : Abdomen (Reference) - High BMI
Injection site will be deemed to show evidence of equivalence if the 90% CI is fully contained 
within the 0.80 to 1.25 range.
In addition, AUC(0-tlast) will also be analyzed as an exploratory parameter using the same 
methodology.
The tmax will be analyzed, using a non-parametric approach for all of the above comparisons. 
Estimates of the median difference, 90% CIs, and p-values from the Wilcoxon signed rank test 
will be calculated.
Relationship between exposure to tirzepatide and adiposity/body composition parameters (i.e., 
skinfold thickness and fat deposition) at the injection sites and waist, thigh, and upper arm 
circumference may be explored if deemed appropriate.
Additional analyses, such as subgroup analyses, may be carried out if appropriate.
10.3.3. Evaluation of Immunogenicity
The frequency and percentage of subjects with preexisting ADA and with TE ADA+ to 
tirzepatide will be tabulated.  Treatment-emergent ADA are defined as those with a titer 2-fold 
(1 dilution) greater than the minimum required dilution if no ADA were detected at baseline 
(treatment-induced ADA) or those with a 4-fold (2 dilutions) increase in titer compared to 
baseline if ADA were detected at baseline (treatment-boosted ADA).  The minimum required
dilution of the ADA assay is 1:10.  For the TE ADA+ subjects the distribution of maximum titers 

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will be described.  The frequency of neutralizing antibodies, if assessed, and cross reactivity to
native GIP and GLP-1 may also be tabulated in TE ADA+ subjects.
10.3.4. Data Review During the Study
Neither the Lilly study team nor the investigator is blinded as the study is open-label.  Data may 
be accessed while the trial is ongoing, but no changes to the study design are planned.  An 
assessment committee will not be formed.
10.3.5. Interim Analyses
No interim analyses are planned for this study.  If an unplanned interim analysis is deemed 
necessary, the Lilly CP, CRP/investigator, or designee will consult with the appropriate medical 
director or designee to determine if it is necessary to amend the protocol.

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11.
References
American Diabetes Association. 6. Glycemic targets: Standard of Medical Care in Diabetes –
2018. Diabetes Care. 2018;41(Suppl.  1):S55-S64 2017 © by the American Diabetes 
Association.  
Banks PA, Freeman ML.  Practice guidelines in acute pancreatitis. Am J Gastroenterol.  
2006;101(10):2379-2400.
Coskun T, Sloop K, Loghin C, Alsina-Fernandez J, Urva S, Bokvist KB, Cui X, Briere DA,
Cabrera O, Roell WC, Kuchibhotla U, Moyers JS, Benson CT, Gimeno RE, D’Alessio DA,
Haupt A. LY3298176, a novel dual GIP and GLP-1 receptor agonist for the treatment of type 
2 diabetes mellitus: From discovery to clinical proof of concept. Molecular metabolism.  
2018;18:3-14.
Frias JP, Nauck MA, Van J, Kutner ME, Cui X, Benson C, Urva S, Gimeno RE, Milicevic Z,
Robins D, Haupt A. Efficacy and safety of LY3298176, a novel dual GIP and GLP-1 receptor
agonist, in patients with type 2 diabetes: a randomised, placebo-controlled and active
comparator-controlled phase 2 trial. The Lancet. 2018;392(10160): 2180-2193.
International Hypoglycemia Study Group.  Glucose Concentrations of Less Than 3.0 mmol/L
(54 mg/dL) Should Be Reported in Clinical Trials: A Joint Position Statement of the
American Diabetes Association and the European Association for the Study of Diabetes. 
Diabetes Care. 2017;40(1):155-157.
Koizumi M, Takada T, Kawarada Y, Hirata K, Mayumi T, Yoshida M, Sekimoto M, Hirota M, 
Kimura Y, Takeda K, Isaji S, Otsuki M, Matsuno S; JPN. JPN Guidelines for the management 
of acute pancreatitis: diagnostic criteria for acute pancreatitis. J Hepatobiliary Pancreat Surg. 
2006;13(1):25-32.
Steinberg WM, Buse JB, Ghorbani MLM, Ørsted DD, Nauck MA; LEADER Steering 
Committee; LEADER Trial Investigators. Amylase, lipase, and acute pancreatitis in people 
with type 2 diabetes treated with liraglutide: results from the LEADER Randomized Trial.  
Diabetes Care. 2017a;40(7):966-972.
Steinberg WM, Rosenstock J, Wadden TA, Donsmark M, Jensen CB, DeVries JH.  Impact of 
liraglutide on amylase, lipase, and acute pancreatitis in participants with overweight/obesity 
and normoglycemia, prediabetes, or type 2 diabetes: secondary analyses of pooled data from 
the SCALE clinical development program.  Diabetes Care. 2017b;40(7):839-848.

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12.
Appendices

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Appendix 1.
Abbreviations and Definitions

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Term
Definition
ADA
anti-drug antibody
AE
adverse event:  Any untoward medical occurrence in a patient or clinical investigation 
subject administered a pharmaceutical product that does not necessarily have a causal 
relationship with this treatment.  An AE can therefore be any unfavorable and unintended 
sign (including an abnormal laboratory finding), symptom, or disease temporally associated 
with the use of a medicinal (investigational) product, whether or not related to the medicinal 
(investigational) product.
ALP
alkaline phosphatase
ALT
alanine aminotransferase
assent
Agreement from a child or other individual who is not legally capable of 
providing consent, but who can understand the circumstances and potential 
risks involved in participating in a study (required by some institutional 
review boards [IRBs]/ethical review boards [ERBs]).  
AST
aspartate aminotransferase
AUC(0-∞)
area under the concentration versus time curve from zero to infinity
AUC(0-tlast)
area under the concentration versus time curve from zero to the last measurable 
concentration
BMI
body mass index
CI
confidence interval
Cmax
maximum drug concentration
complaint
A complaint is any written, electronic, or oral communication that alleges deficiencies 
related to the identity, quality, purity, durability, reliability, safety or effectiveness, or 
performance of a drug or drug delivery system.
compliance
Adherence to all the study-related requirements, good clinical practice (GCP) requirements, 
and the applicable regulatory requirements.
confirmation
A process used to confirm that laboratory test results meet the quality requirements defined 
by the laboratory generating the data and that Lilly is confident that results are accurate.  
Confirmation will either occur immediately after initial testing or will require that samples 
be held to be retested at some defined time point, depending on the steps required to obtain 
confirmed results.
CP
Clinical Pharmacologist
CRF/eCRF
case report form/electronic case report form

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CRP
Clinical Research Physician:  Individual responsible for the medical conduct of the study.  
Responsibilities of the CRP may be performed by a physician, clinical research scientist, 
global safety physician or other medical officer.
CRU
clinical research unit
DEXA
dual energy x-ray absorptiometry
ECG
electrocardiogram
enroll
The act of assigning a subject to a treatment.  Subjects who are enrolled in the study are 
those who have been assigned to a treatment.
enter
Subjects entered into a study are those who sign the informed consent form directly or 
through their legally acceptable representatives.
GCP
good clinical practice
GI
gastrointestinal
GIP
glucose-dependent insulinotropic polypeptide
GLP-1
glucagon-like peptide-1
IB
Investigator’s Brochure
ICF
informed consent form
ICH
International Council for Harmonization
informed consent
A process by which a subject voluntarily confirms his or her willingness to participate in a 
particular study, after having been informed of all aspects of the study that are relevant to 
the subject’s decision to participate.  Informed consent is documented by means of a 
written, signed and dated informed consent form.  
IP
investigational product: A pharmaceutical form of an active ingredient or placebo being 
tested or used as a reference in a clinical study, including products already on the market 
when used or assembled (formulated or packaged) in a way different from the authorized 
form, or marketed products used for an unauthorized indication, or marketed products used 
to gain further information about the authorized form.
investigator
A person responsible for the conduct of the clinical study at a study site.  If a study is 
conducted by a team of individuals at a study site, the investigator is the responsible leader 
of the team and may be called the principal investigator.
IRB
institutional review board
Legal 
Representative
An individual or judicial or other body authorized under applicable law to consent, on 
behalf of a prospective subject, to the subject’s participation in the clinical study.
MAD
multiple ascending dose
MTD
maximum tolerated dose

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open-label
A study in which there are no restrictions on knowledge of treatment allocation, therefore 
the investigator and the study participant are aware of the drug therapy received during the 
study.
randomize
the process of assigning subjects/patients to an experimental group on a random basis
PG
plasma glucose
PK
pharmacokinetic(s)
SAD
single asending dose
SAE
serious adverse event
SC
subcutaneous(ly)
screen
The act of determining if an individual meets minimum requirements to become part of a 
pool of potential candidates for participation in a clinical study.  
SUSAR
suspected unexpected serious adverse reaction
T2DM
type 2 diabetes mellitus
TBL
total bilirubin
TE ADA
treatment-emergent anti-drug antibody
TEAE
treatment-emergent adverse event:  Any untoward medical occurrence that emerges during 
a defined treatment period, having been absent pretreatment, or worsens relative to the 
pretreatment state, and does not necessarily have to have a causal relationship with this 
treatment 
tmax
time of maximum plasma concentration
ULN
upper limit of normal

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Appendix 2.
Clinical Laboratory Tests
Safety Laboratory Tests
Hematologya
Clinical Chemistrya
Hematocrit
Sodium
Hemoglobin
Potassium
Erythrocyte count (RBC)
Bicarbonate
Mean cell volume 
Chloride
Mean cell hemoglobin 
Calcium
Mean cell hemoglobin concentration 
Glucose (fasting)
Leukocytes (WBC)
Blood urea nitrogen
Platelets
Total protein
Albumin
Absolute counts of:
Total bilirubin
Neutrophils
Alkaline phosphatase
Lymphocytes
Aspartate aminotransferase
Monocytes
Alanine aminotransferase
Eosinophils
Creatinine
Basophils
Amylase
Lipase
Triglycerides
Urinalysisa
Specific gravity
Hepatitis B surface antigenc
pH
Hepatitis C antibodyc
Protein
HIV or HIV antibodyc
Glucose
Pregnancy testd
Ketones
FSHc,d
Bilirubin
Urine drug screen
Urobilinogen
Alcohol breath test
Blood
Nitrite
Leukocytes (WBC)
Microscopic examination of sedimentb
Abbreviations:  FSH = follicle-stimulating hormone; HIV = human immunodeficiency virus; RBC = red blood cells; 
WBC = white blood cells.
a
Performed by local laboratory.  Results will be validated by the laboratory at the time of initial testing.
b
Test only if dipstick result is abnormal (i.e., positive for blood, protein, or nitrites) if clinically indicated, per 
investigator discretion.
c
Performed by local laboratory at screening only.  
d
For women only.  Serum pregnancy test will be performed at screening and urine pregnancy tests at subsequent 
visits.  For women who are considered to be postmenopausal, a blood sample for follicle-stimulating hormone 
should be drawn at screening to confirm postmenopausal status as defined in inclusion criterion [1b]; women 
with confirmed nonchildbearing potential status can be exempted from further pregnancy tests during the study 
after screening.

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Appendix 3.
Study Governance, Regulatory and Ethical 
Considerations
Informed Consent
The investigator is responsible for:

ensuring that the subject understands the nature of the study, the potential risks and 
benefits of participating in the study, and that their participation is voluntary.

ensuring that informed consent is given by each subject or legal representative.  This 
includes obtaining the appropriate signatures and dates on the ICF prior to the 
performance of any protocol procedures and prior to the administration of IP.

answering any questions the subject may have throughout the study and sharing in a 
timely manner any new information that may be relevant to the subject’s willingness to 
continue his or her participation in the study.

providing a copy of the ICF to the participant or the participant’s legal representative and 
retaining a copy on file.
A legal representative must give informed consent for a child to participate in this study.  In 
addition to informed consent given by the legal representative, the child may be required to give 
documented assent, if capable.
Recruitment
Lilly or its designee is responsible for the central recruitment strategy for subjects.  Individual 
investigators may have additional local requirements or processes.  Study-specific recruitment 
material should be approved by Lilly.
Ethical Review
The investigator must give assurance that the IRB was properly constituted and convened as 
required by International Council for Harminosation (ICH) guidelines and other applicable laws 
and regulations.
Documentation of IRB approval of the protocol and the ICF must be provided to Lilly before the 
study may begin at the investigative site.  Lilly or its representatives must approve the ICF 
before it is used at the investigative site.  All ICFs must be compliant with the ICH guideline on 
GCP.
The study site’s IRB should be provided with the following:

the current IB and updates during the course of the study

ICF

relevant curricula vitae

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Regulatory Considerations
This study will be conducted in accordance with the protocol and with:
1) consensus ethics principles derived from international ethics guidelines, 
including the Declaration of Helsinki and Council for International 
Organizations of Medical Sciences (CIOMS) International Ethical Guidelines 
2) applicable ICH GCP Guidelines 
3) applicable laws and regulations
Some of the obligations of the sponsor will be assigned to a third party organization.
Protocol Signatures
The sponsor’s responsible medical officer will approve the protocol, confirming that, to the best 
of his or her knowledge, the protocol accurately describes the planned design and conduct of the 
study.  
After reading the protocol, the principal investigator will sign the protocol signature page and 
send a copy of the signed page to a Lilly representative.
Final Report Signature
The investigator or designee will sign the clinical study report for this study, indicating 
agreement with the analyses, results, and conclusions of the report.
The sponsor’s responsible medical officer and statistician will sign/approve the final clinical 
study report for this study, confirming that, to the best of his or her knowledge, the report 
accurately describes the conduct and results of the study.
Data Quality Assurance
To ensure accurate, complete, and reliable data, Lilly or its representatives will do the following:

provide instructional material to the study site, as appropriate.

provide training to instruct the investigators and study coordinators.  This training will 
give instruction on the protocol, the completion of the eCRFs, and study procedures.

make periodic visits to the study site.

be available for consultation and stay in contact with the study site personnel by mail, 
telephone, and/or fax.

review and evaluate eCRF data and/or use standard computer edits to detect errors in data 
collection.

conduct a quality review of the database.

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In addition, Lilly or its representatives will periodically check a sample of the subject data 
recorded against source documents at the study site.  The study may be audited by Lilly and/or 
regulatory agencies at any time.  Investigators will be given notice before an audit occurs.
The investigator will keep records of all original source data.  This might include clinical 
laboratory tests, medical records, and clinical notes.  If requested, the investigator will provide 
the sponsor, applicable regulatory agencies, and applicable IRBs with direct access to the 
original source documents.
Data Collection Tools/Source Data
An electronic data capture system will be used in this study.  The site must define and retain all 
source records and must maintain a record of any data where source data are directly entered into 
the data capture system.
Data Protection
Data systems used for the study will have controls and requirements in accordance with local 
data protection law.  
The purpose and use of subject personal information collected will be provided in a written 
document to the subject by the sponsor.
Study and Site Closure
Discontinuation of Study Site
Study site participation may be discontinued if Lilly or its designee, the investigator, or the IRB 
of the study site judges it necessary for medical, safety, regulatory, or other reasons consistent 
with applicable laws, regulations, and GCP.
Discontinuation of the Study
The study will be discontinued if Lilly or its designee judges it necessary for medical, safety, 
regulatory, or other reasons consistent with applicable laws, regulations, and GCP.

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Appendix 4.
Hepatic Monitoring Tests for Treatment-
Emergent Abnormality
Selected tests may be obtained in the event of a treatment-emergent hepatic abnormality and may 
be required in follow-up with subjects in consultation with Lilly or its designee CRP.
Hepatic Monitoring Tests
Hepatic Hematologya
Haptoglobina
Hemoglobin
Hematocrit
Hepatic Coagulationa
RBC
Prothrombin time
WBC
Prothrombin time, INR
Neutrophils
Lymphocytes
Hepatic Serologiesa,b
Monocytes
Hepatitis A antibody, total
Eosinophils
Hepatitis A antibody, IgM
Basophils
Hepatitis B surface antigen
Platelets
Hepatitis B surface antibody
Hepatitis B core antibody
Hepatic Chemistrya
Hepatitis C antibody
Total bilirubin
Hepatitis E antibody, IgG
Conjugated bilirubin
Hepatitis E antibody, IgM
Alkaline phosphatase
ALT
Anti-nuclear antibodya
AST
Alkaline phosphatase isoenzymesa
GGT
Creatine kinase
Anti-smooth muscle antibody (or anti-actin 
antibody)a
Abbreviations:  ALT = alanine aminotransferase; AST = aspartate aminotransferase; GGT = gamma-glutamyl 
transferase; Ig = immunoglobulin; INR = international normalized ratio; RBC = red blood cells; WBC = white 
blood cells.
a
Assayed by Lilly-designated or local laboratory.
b
Reflex/confirmation dependent on regulatory requirements and/or testing availability.

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Appendix 5.
Blood Sampling Summary
This table summarizes the approximate number of venipunctures and blood volumes for all 
blood sampling (screening, safety laboratories, and bioanalytical assays) during the study.  
Protocol I8F-MC-GPHI Sampling Summary
Purpose
Blood Volume per 
Sample (mL)
Number of Blood 
Samples
Total Volume 
(mL)
Screening testsa
19.5
1
19.5
Clinical laboratory testsa
12.5
5 x 3 periods = 15
187.5
Pharmacokineticsb
3
14 x 3 periods (+3 
unscheduled) = 45
135
Immunogenicityb
10
3 × 3 periods (+3 
unscheduled) = 12
120
Blood glucosea
0.3
6 (+ 5 discard for 
cannula patency) x 3 
periods = 33
9.9
Pharmacogenetics
10
1
10
Total
481.9
Total for clinical purposes (rounded up to the nearest 10 mL)
490
a
Additional samples may be drawn if needed for safety purposes.
b
Up to 3 additional unscheduled samples may be drawn based on emerging data.

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Appendix 6.
Classification of Contraceptive Methods
As per inclusion criterion [1a], male subjects must use condoms plus one additional highly 
effective method of contraception or effective method of contraception as described below:
Highly Effective (Less Than 1% Failure Rate) Methods of Contraception:

Combined oral contraceptive pill and mini pill

NuvaRing

Implantable contraceptives

Injectable contraceptives (such as Depo-Provera®)

Intrauterine device (such as Mirena® and ParaGard®)

Contraceptive patch – ONLY women <198 pounds or 90 kg

Vasectomy – for men in clinical trials
Effective Methods of Contraception:

Diaphragm with spermicide

Cervical sponge

Cervical cap with spermicide

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Appendix 7. Pancreatic Monitoring
Glucagon-like peptide-1 agonists have been associated with a possible risk of acute pancreatitis.  
In 2006, the United States prescribing information for exenatide was revised to include the event 
of pancreatitis.  In 2007, the United States prescribing information for this medication was 
amended to include pancreatitis under “Precautions.”  Epidemiologic studies have indicated that 
there is an increased incidence and prevalence of pancreatitis in persons with T2DM.
To enhance understanding of the natural variability of pancreatic enzymes in the T2DM 
population and, in order to assess for any potential effects of tirzepatide on the exocrine 
pancreas, amylase and lipase values will be monitored in all current and future clinical trials with 
tirzepatide.
Additional monitoring will be requested for amylase or lipase values ≥3× the ULN at any visit, 
even in asymptomatic subjects (see figure below).  Lipase and amylase may also be obtained at 
any time during the clinical trials for any subject suspected of having symptoms suggestive of 
exenatide pancreatitis (such as severe GI signs and/or symptoms), at the investigator’s discretion.
Acute pancreatitis is an AE defined as an acute inflammatory process of the pancreas that may 
also involve peripancreatic tissues and/or remote organ systems (Banks and Freeman 2006).  
The diagnosis of acute pancreatitis requires 2 of the following 3 features:

abdominal pain characteristic of acute pancreatitis (Banks and Freeman 2006; 
Koizumi et al.  2006)

serum amylase and/or lipase ≥3× ULN

characteristic findings of acute pancreatitis on computed tomography scan or 
magnetic resonance imaging
Most subjects with acute pancreatitis experience abdominal pain that is located generally in the 
epigastrium, and radiates to the back in approximately one-half of the cases. The pain is often 
associated with nausea and vomiting.  However, experience with GLP-1 agonists has 
demonstrated that some subjects asymptomatic for classic pancreatitis may demonstrate 
significant elevations of lipase and/or amylase.  For subjects considered by investigators to be 
asymptomatic for pancreatitis, but whose value(s) for lipase and/or amylase are ≥3× ULN, an 
algorithm is in place to follow these subjects safely and to quickly reach (or not reach) a 
diagnosis of pancreatitis.

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Abbreviations:  CBC = complete blood count; CT = computed tomography; MRI = magnetic resonance imaging; 
ULN = upper limit of normal.

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Subjects diagnosed with pancreatitis will be discontinued from the study.  Investigators will be 
responsible for following, through an appropriate healthcare option, these pancreatitis AEs until 
the events resolve or are explained.  Adverse events that meet the diagnostic criteria of acute 
pancreatitis will be captured as SAEs.  For all other pancreatic AEs (such as idiopathic or 
asymptomatic pancreatic enzyme abnormalities), the investigator will be responsible for 
determining the seriousness of the event (AE or SAE) and the relatedness of the event to study 
drug.

Leo Document ID = 229f3842-d70a-45ec-a6fb-c336a6729db9
Approver: 
Approval Date & Time: 26-Jun-2019 18:35:03 GMT
Signature meaning: Approved
Approver: 
Approval Date & Time: 27-Jun-2019 14:05:52 GMT
Signature meaning: Approved
PPD
PPD