What is the recommended usage and dosage of Trulicity (dulaglutide) for patients with type 2 diabetes?

Trulicity (Dulaglutide) Dosage and Usage for Type 2 Diabetes

For patients with type 2 diabetes, Trulicity (dulaglutide) should be initiated at 0.75 mg injected subcutaneously once weekly, with titration to 1.5 mg once weekly after 4 weeks if additional glycemic control is needed, and further increases to a maximum of 4.5 mg once weekly in 1.5 mg increments after at least 4 weeks on the current dosage. 1

Dosing and Administration Protocol

Adult Dosage

• Starting dose: 0.75 mg subcutaneously once weekly
• Maintenance dose: 1.5 mg once weekly (after at least 4 weeks)
• Maximum dose: 4.5 mg once weekly (if additional glycemic control needed)
• Titration schedule: Increase in 1.5 mg increments after at least 4 weeks on current dosage 1

Pediatric Dosage (10 years and older)

• Starting dose: 0.75 mg subcutaneously once weekly
• Maximum dose: 1.5 mg once weekly (after at least 4 weeks) 1

Administration Instructions

• Administer subcutaneously in the abdomen, thigh, or upper arm
• Can be given any time of day, with or without food
• Rotate injection sites with each dose
• When using with insulin, administer as separate injections (never mix) 1

Clinical Indications

Trulicity is indicated for:

1. Improving glycemic control in adults and pediatric patients (≥10 years) with type 2 diabetes as an adjunct to diet and exercise
2. Reducing the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with type 2 diabetes who have:
   • Established cardiovascular disease
   • Multiple cardiovascular risk factors 1

Cardiovascular Benefits

The REWIND trial demonstrated that dulaglutide reduced major adverse cardiovascular events (MACE) with a hazard ratio of 0.88 (95% CI 0.79,0.99) compared to placebo. This benefit was observed in patients both with and without established cardiovascular disease 2.

For patients with type 2 diabetes and established atherosclerotic cardiovascular disease, GLP-1 receptor agonists like dulaglutide have the strongest evidence for MACE benefit 2.

Missed Dose Management

If a dose is missed:

• Administer as soon as possible if ≥3 days (72 hours) until next scheduled dose
• Skip the missed dose if <3 days remain before next scheduled dose
• Resume regular once-weekly dosing schedule afterward 1

Contraindications

Trulicity should NOT be used in patients with:

• Personal or family history of medullary thyroid carcinoma (MTC)
• Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
• Serious hypersensitivity reaction to dulaglutide or any product components 1

Monitoring and Follow-up

• Evaluate glycemic response after initiating therapy
• Monitor for gastrointestinal side effects (nausea, vomiting, diarrhea)
• Watch for signs of pancreatitis (persistent severe abdominal pain) 3
• Consider discontinuation if inadequate glycemic response after appropriate dose titration

Special Populations

Renal Impairment

• No dosage adjustment is required for patients with renal impairment, including those with advanced kidney disease 4

High Cardiovascular Risk

• Dulaglutide can be considered in patients without established CVD but with high-risk indicators:
  • Age ≥55 years with coronary, carotid, or lower extremity artery stenosis >50%
  • Left ventricular hypertrophy
  • eGFR <60 mL/min/1.73 m²
  • Albuminuria 2

Clinical Efficacy

Dulaglutide has demonstrated:

• Significant improvement in glycated hemoglobin (-1.3% at 6 months; -2.0% at 12 months) 5
• Significant weight reduction (-2.0 kg at 6 months; -3.5 kg at 12 months) 5
• Comparable or superior efficacy to other antidiabetic agents including metformin, sitagliptin, exenatide, and insulin glargine 6, 7

Common Adverse Effects

• Gastrointestinal: nausea, vomiting, diarrhea (most common)
• Risk of hypoglycemia (low when used as monotherapy, increased when combined with insulin or insulin secretagogues)
• Injection site reactions
• Rare but serious: acute pancreatitis 3

Important Warnings

• Risk of thyroid C-cell tumors (based on animal studies)
• Pancreatitis risk (not recommended in patients with history of pancreatitis)
• Not for use in type 1 diabetes
• Not recommended in patients with severe gastrointestinal disease, including severe gastroparesis 1

Dulaglutide offers the convenience of once-weekly dosing with a half-life of approximately 5 days, reaching steady state between the second and fourth doses 8. Its pharmacokinetic profile supports consistent glycemic control throughout the week.