Can dulaglutide (Trulicity) be used in patients with type 2 diabetes and reduced ejection fraction (left ventricular dysfunction)?

Dulaglutide in Patients with Type 2 Diabetes and Reduced Ejection Fraction

Dulaglutide (Trulicity) can be used in patients with type 2 diabetes and reduced ejection fraction (HFrEF), but SGLT2 inhibitors are preferred as first-line therapy for these patients due to their proven cardiovascular benefits in heart failure.

Treatment Algorithm for Type 2 Diabetes with HFrEF

First-line therapy:

• SGLT2 inhibitor with proven cardiovascular benefit 1
  • Recommended regardless of baseline HbA1c or individualized HbA1c target
  • Reduces risk of worsening heart failure and cardiovascular death
  • Improves symptoms, physical limitations, and quality of life

When to consider dulaglutide:

1. If SGLT2 inhibitors are contraindicated or not tolerated 1
2. In patients with advanced CKD (eGFR <30 mL/min/1.73 m²) 1
3. As add-on therapy to SGLT2 inhibitors for additive cardiovascular and renal benefits 1
4. If no recent heart failure decompensation 1

Evidence for Dulaglutide in Heart Failure

The American Heart Association and Heart Failure Society of America guideline specifically addresses dulaglutide use in heart failure patients 1:

• GLP-1 receptor agonists (including dulaglutide) should be avoided if there has been recent heart failure decompensation
• Can be considered in stable heart failure patients with no recent decompensation

The REWIND trial 2 demonstrated that dulaglutide reduced major adverse cardiovascular events (MACE) in patients with type 2 diabetes, including those with cardiovascular risk factors. However, it's important to note that:

• The trial showed no significant effect on heart failure hospitalization specifically
• Limited data characterized the type of heart failure, so differential effects by ejection fraction remain unknown

Practical Considerations for Dulaglutide in HFrEF Patients

Dosing:

• Start with the lowest dose (0.75 mg weekly) and titrate gradually to minimize gastrointestinal side effects 3
• Consider dose adjustment in patients with renal impairment 1

Monitoring:

• Monitor for signs of heart failure worsening
• Watch for gastrointestinal adverse effects (nausea, vomiting, diarrhea) 4
• Assess renal function regularly

Combination therapy:

• When using dulaglutide with insulin, reduce insulin dose by approximately 20% to avoid hypoglycemia 3
• Discontinue DPP-4 inhibitors before starting dulaglutide 3

Important Caveats

1. SGLT2 inhibitors are preferred first-line therapy for patients with type 2 diabetes and HFrEF 1
2. Avoid dulaglutide in patients with recent heart failure decompensation 1
3. Consider combination therapy with both SGLT2 inhibitor and dulaglutide for additive cardiovascular and renal benefits in appropriate patients 1
4. Dulaglutide has demonstrated cardiovascular benefits but not specifically for heart failure outcomes 2

In summary, while SGLT2 inhibitors should be the first choice for patients with type 2 diabetes and reduced ejection fraction, dulaglutide can be safely used in stable heart failure patients without recent decompensation, particularly when SGLT2 inhibitors are contraindicated or as part of combination therapy for additional glycemic control and cardiovascular risk reduction.