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Dulaglutide

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Dulaglutide, Trulicity

  • See Also
  1. GLP-1 Agonist
  2. Type II Diabetes Medications
  3. Obesity Medication
  4. Exenatide
  5. Liraglutide
  6. Lixisenatide
  7. Semaglutide
  8. Tirzepatide
  • Indications
  1. See GLP-1 Agonist
  2. Type II Diabetes Mellitus
    1. Very effective for weight loss in comorbid Obesity
    2. May be used in combination with Basal insulin (e.g. Lantus)
    3. Dulaglutide was approved in 2022 for use in age 10 years and older with Type 2 Diabetes Mellitus
  3. Insulin deficiency and Insulin Resistance
    1. Adjunct to Glucophage, Sulfonylureas, Glitazones
  4. Weight Loss
    1. At least 50% of weight regained on stopping GLP-1 agents
    2. Dulaglutide is associated with mean weight loss 6 lbs
      1. Less weight loss than Semaglutide or liraglutude
  • Contraindications
  1. See GLP-1 Agonist
  2. Type I Diabetes Mellitus
  3. Medullary Thyroid Carcinoma (personal or Family History)
  4. Multiple Endocrine Neoplasia syndrome type 2 (active)
  5. Concurrent prandial Insulin (Bolus Insulin)
    1. Basal insulin (e.g. Lantus) may be used
  6. Severe Gastrointestinal Diseases or Gastroparesis
    1. Relative contraindication due to the high Incidence of gastrointestinal side effects with GLP-1 Agonists
  • Mechanism
  1. See GLP-1 Agonist
  2. Glucagon-Like Peptide 1 (GLP-1) Agonist, an Incretin Mimetic, derived from Gila monster Saliva
    1. Increases Glucose dependent Insulin secretion
    2. Inhibits Glucagon secretion
    3. Delays gastric emptying
    4. Decreases food intake (improves satiety and decreases appetite)
      1. Direct effects at the Hypothalamus, Nucleus Accumbens, ventral tegmental areas and Vagus Nerve
  • Medications
  1. Precautions
    1. All GLP-1 Agonists are expensive ($600 to $1300 per month in 2024)
    2. GLP-1 shortages (esp. Semaglutide and Tirzepatide) have resulted in many online resellers
      1. Buy from only licensed pharmacies (U.S.), and appropriately accredited (e.g. compounding pharmacy)
      2. Certificates of analysis confirm active ingredient
  2. Dulaglutide (Trulicity)
    1. Available in single dose pens or prefilled syringes: 0.75 mg or 1.5 mg
  • Dosing
  1. Dulaglutide was approved in 2022 for use in age 10 years and older with Type 2 Diabetes Mellitus
  2. Give subcutaneous doses in the upper arm, Abdomen or thigh (and rotate injection sites)
  3. May be taken at time of day (regardless of meals)
  4. Adults (and children age >=10 years)
    1. Start: 0.75 mg SQ once weekly
    2. May increase to 1.5 mg SQ once weekly (after 4 weeks on lower dose)
  • Adverse Effects
  1. See GLP-1 Agonist
  2. Nausea or Vomiting
    1. Eat smaller meals and more slowly, stopping before fullness (satiety)
    2. Consider short-term Ondansetron
    3. Consider dose reduction until tolerated
  3. Diarrhea
  4. Dizziness
  5. Headache
  6. Hypoglycemia
    1. Alone, GLP-1 Agonists do not significantly increase risk of Hypoglycemia
    2. Avoid combination with Bolus Insulin (Mealtime Insulin) or Insulin Secretagogues (e.g. Sulfonylureas)
    3. With Sulfonylurea: 14.4% at 5 mcg, 35.7% at 10 mcg
    4. With Metformin: 4.5% at 5 mcg, 5.3% at 10 mcg
  7. Pancreatitis (occurs with all GLP-1 Agonists)
    1. Singh (2013) JAMA Intern Med 173(7):534-9 [PubMed]
  8. Gallbladder disease (Cholelithiasis, Cholecystitis, Choledocholithiasis)
    1. Increased by one in 357 patients over 3 years of medication use
    2. Increased with longer use, higher dose and when GLP-1 Agonist is used for weight loss
    3. Faillie (2016) JAMA Intern Med 176(10): 1474-81 +PMID: 27478902 [PubMed]
  9. Diabetic Retinopathy complications (increased Retinal Hemorrhage)
    1. Occurs with Semaglutide, Liraglutide, Dulaglutide
    2. Paradoxically attributed to better Blood Glucose control
  10. Subcutaneous Fat Loss
    1. Desired weight loss (esp. Semaglutide) may result in loose, sagging skin ("Ozempic face")
  11. Other serious but uncommon effects (<1%)
    1. Acute Kidney Injury
    2. Angioedema
    3. Suicidality (case reports, FDA is investigating as of 2024)
  • Safety
  1. Unknown safety in Lactation
  2. Most GLP-1 Agonists have unknown safety in pregnancy (avoid)
    1. High dose weight loss GLP-1 Agonists (e.g. Saxena, Wegovy) are considered Pregnancy Category X
  3. Monitor patients with renal dysfunction
    1. Periodic Renal Function testing
    2. May present with increased gastrointestinal adverse effects
  • Efficacy
  1. Dulaglutide (high dose) is among the most ideal GLP-1 Agonists
    1. Offers potent Glucose control and weight loss, cardiovascular protection, weekly dosing and easy preparation
    2. Liraglutide also offers similar benefits
  2. Lowers Hemoglobin A1C 1.5%
  3. Dulaglutide is also associated with decreased Cardiovascular Risk
    1. Reduces Cardiovascular Risk at 1.5 mg weekly dose
    2. However, does not decrease overall mortality or cardiovascular mortality (unlike Liraglutide)
  • Drug Interactions
  1. Avoid using 2 Incretins (e.g. Byetta with Januvia) in combination
    1. Raises cost, risk of Pancreatitis without significant benefit
    2. (2012) Presc Lett 19(8): 45
  2. Concurrent prandial Insulin (Bolus Insulin)
    1. Basal insulin (e.g. Lantus) may be used
  • Resources
  1. Dulaglutide (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=463050bd-2b1c-40f5-b3c3-0a04bb433309
  • References
  1. (2024) Presc Lett 31(7): 38
  2. (2024) Presc Lett 31(2): 8-9
  3. (2022) Presc Lett 30(2): 7
  4. (2019) Presc Lett 26(11):62-3
  5. (2019) Presc Lett 26(8):46
  6. (2018) Presc Lett 25(2)
  7. (2014) Presc Lett 21(12): 69
  8. (2012) Presc Lett 19(3): 15
  9. Nordt and Kaucher (2023) EM:Rap 23(9)
  10. Dungan (2005) Clin Diabetes 23: 56-62 [PubMed]
  11. Ezzo (2006) Am Fam Physician 73 [PubMed]
  12. Fineman (2003) Diabetes Care 26:2370-7 [PubMed]
  13. Jones (2007) Am Fam Physician 75:1831-5 [PubMed]
  14. Joy (2005) Ann Pharmacol 39:110-8 [PubMed]
  15. Vaughan (2024) Am Fam Physician 109(4): 333-42 [PubMed]