How to manage type 2 diabetes with dulaglutide (glucagon-like peptide-1 receptor agonist) in an African American patient with impaired renal function (eGFR of 30)?

Managing Type 2 Diabetes with Dulaglutide in an African American Patient with eGFR of 30

Dulaglutide is an appropriate and safe treatment option for an African American patient with type 2 diabetes and an eGFR of 30 mL/min/1.73m², as it does not require dose adjustment for renal impairment and has demonstrated benefits in slowing eGFR decline in patients with CKD. 1, 2

Understanding Race-Based eGFR Considerations

When evaluating an African American patient with a non-race-adjusted eGFR of 30 mL/min/1.73m², it's important to recognize:

• The NKF-ASN Task Force recommends moving away from race-based eGFR calculations, as they can lead to systematic differences in clinical decisions between racial groups 1
• Using non-race-based eGFR equations (CKD-EPIcr_NB) could increase the number of Black adults meeting eGFR <30 mL/min/1.73m² by up to 52% 1
• This could affect medication dosing decisions, potentially leading to inappropriate drug discontinuation or underdosing in Black patients 1

Treatment Algorithm for This Patient

1. First-line therapy:

   • Continue metformin if already prescribed, but reduce to maximum 1000 mg daily (half the maximum dose) at eGFR 30-44 mL/min/1.73m² 1, 3
   • Add SGLT2 inhibitor if eGFR ≥20 mL/min/1.73m² for cardiorenal protection 1

2. Add GLP-1 receptor agonist (dulaglutide):

   • Dulaglutide is recommended for patients with T2D and CKD who don't meet glycemic targets with metformin/SGLT2i or cannot use these medications 1
   • No dose adjustment is required for dulaglutide in renal impairment, including end-stage renal disease 2
   • Start with 0.75 mg once weekly and titrate to 1.5 mg once weekly as tolerated 4

3. Additional considerations:

   • Add ACE inhibitor or ARB if the patient has albuminuria and hypertension 1, 3
   • Add statin therapy (moderate to high intensity based on ASCVD risk) 1

Evidence Supporting Dulaglutide in CKD

Dulaglutide has demonstrated several benefits in patients with CKD:

• In the AWARD-7 trial, dulaglutide produced similar glycemic control to insulin glargine in patients with moderate-to-severe CKD, with significantly reduced decline in eGFR 4
• At 52 weeks, eGFR was significantly higher with dulaglutide 1.5 mg (34.0 mL/min/1.73m²) and 0.75 mg (33.8 mL/min/1.73m²) compared to insulin glargine (31.3 mL/min/1.73m²) 4
• Dulaglutide treatment resulted in lower UACR values compared to placebo, active comparators, and insulin glargine 5
• The REWIND trial showed that long-term use of dulaglutide was associated with reduced composite renal outcomes in people with T2D 6

Safety Considerations

• Dulaglutide has a lower risk of hypoglycemia compared to insulin, with 4.4 events per patient per year with dulaglutide 1.5 mg versus 9.6 with insulin glargine 4
• Common side effects include nausea (14-20%), vomiting, and diarrhea (16-17%) 4
• These gastrointestinal side effects typically improve with continued use and dose titration 1
• Monitor renal function in patients reporting severe adverse gastrointestinal reactions 2

Common Pitfalls to Avoid

1. Failing to recognize race-based eGFR discrepancies: The non-race-adjusted eGFR of 30 may underestimate actual kidney function in African American patients 1

2. Inappropriate medication discontinuation: Metformin should be reduced (not stopped) at eGFR 30-44 mL/min/1.73m² 1, 3

3. Inadequate monitoring: Continue to monitor eGFR every 3-6 months, with more frequent monitoring if on medications affecting kidney function 3

4. Overlooking cardiovascular benefits: GLP-1 RAs like dulaglutide have demonstrated cardiovascular benefits in addition to glycemic control, which is particularly important in CKD patients who have elevated cardiovascular risk 1, 7

5. Neglecting comprehensive care: Ensure the patient also receives appropriate blood pressure management, lipid control, and lifestyle modifications as part of a comprehensive approach 1, 3

By following this approach, dulaglutide can be safely and effectively used in an African American patient with type 2 diabetes and an eGFR of 30 mL/min/1.73m², providing benefits for both glycemic control and kidney function preservation.