Should Trulicity (dulaglutide) be discontinued in a patient experiencing chronic diarrhea?

Discontinuing Trulicity in a Patient with Chronic Diarrhea

Yes, Trulicity (dulaglutide) should be discontinued in this patient experiencing chronic diarrhea, as it is likely the cause of the persistent gastrointestinal symptoms and discontinuation would improve the patient's quality of life.

Rationale for Discontinuation

Medication-Induced Diarrhea Assessment

The patient is currently taking multiple medications, but Trulicity (dulaglutide) is a well-documented cause of diarrhea:

• Dulaglutide is a GLP-1 receptor agonist that commonly causes gastrointestinal side effects
• According to clinical evidence, diarrhea is one of the most frequently reported adverse events in clinical trials of dulaglutide 1
• The 2020 American College of Cardiology consensus pathway acknowledges diarrhea as a common adverse effect of dulaglutide that requires monitoring 2

Algorithm for Management

1. Identify the likely culprit medication

   • Trulicity (dulaglutide) is the most likely cause of chronic diarrhea among the patient's medications
   • Diarrhea is a well-established side effect of GLP-1 receptor agonists

2. Assess severity and impact

   • Chronic diarrhea significantly impacts quality of life
   • Persistent diarrhea can lead to dehydration, electrolyte imbalances, and malnutrition
   • The patient's multiple other medications may be affected by altered absorption due to rapid intestinal transit

3. Management approach

   • Discontinue Trulicity
   • Consider alternative diabetes management options
   • Monitor for improvement in diarrhea symptoms
   • Reassess glycemic control after discontinuation

Evidence Supporting Discontinuation

The 2020 Canadian Association of Gastroenterology clinical practice guideline on management of bile acid diarrhea notes that "medications that cause diarrhea may increase the need for treatment" 2. While this guideline focuses on bile acid diarrhea specifically, the principle applies to medication-induced diarrhea generally.

The 2018 ESMO Clinical Practice Guidelines on diarrhea in cancer patients emphasizes the importance of adjusting medications when they are the cause of diarrhea 2. Although this guideline is specific to cancer patients, the principle of removing offending agents applies broadly.

Alternative Diabetes Management Options

After discontinuing Trulicity, consider these alternatives for diabetes management:

1. Oral antihyperglycemic agents

   • The patient is already on metformin, which can be continued
   • Consider dose adjustment of current metformin if needed

2. Other injectable options with potentially less GI effects

   • Insulin therapy (if needed for glycemic control)
   • Consider a different GLP-1 receptor agonist with potentially lower incidence of diarrhea, though all have some risk

Important Considerations and Monitoring

• Monitor glycemic control after discontinuation of Trulicity
• Watch for resolution of diarrhea - improvement would confirm Trulicity as the cause
• Assess for dehydration and electrolyte abnormalities that may have developed due to chronic diarrhea
• Consider temporary antidiarrheal therapy such as loperamide to manage symptoms while waiting for resolution after Trulicity discontinuation 2

Common Pitfalls to Avoid

1. Failing to recognize medication-induced diarrhea - Always consider medications as potential causes of chronic diarrhea
2. Adding antidiarrheal medications without addressing the underlying cause - Removing the offending agent is more effective than symptomatic treatment alone
3. Overlooking the impact of chronic diarrhea on medication absorption - The patient's other medications may be less effective due to rapid intestinal transit
4. Delaying discontinuation - Continuing Trulicity despite chronic diarrhea can lead to worsening quality of life and potential complications

By discontinuing Trulicity, the patient's quality of life is likely to improve significantly, and alternative diabetes management can be implemented to maintain glycemic control.