From the Guidelines
Trulicity (dulaglutide) should be withheld for at least 3 half-lives before EGD (Esophagogastroduodenoscopy).
Rationale
- The half-life of dulaglutide is approximately 4.5-5 days, so withholding for 3 half-lives would be around 13.5-15 days 1.
- This recommendation is based on the precautionary principle, as there is insufficient evidence to provide definitive guidance on the ideal cessation period for glucagon-like peptide-1 receptor agonists before elective procedures like EGD 1.
- The use of GLP-1 receptor agonists, including dulaglutide, has been associated with an increased risk of retained gastric contents and pulmonary aspiration during general anesthesia 1.
- However, the benefits of GLP-1 receptor agonists in patients with type 2 diabetes mellitus may outweigh the risks, and discontinuation of the medication for an extended period may not be necessary or practical 1.
- For patients taking dulaglutide for weight loss, cessation for at least 3 half-lives before the procedure may be recommended to minimize the risk of gastric stasis and aspiration 1.
- Gastric ultrasonography and the use of prokinetic drugs like metoclopramide may also be considered to mitigate the risk of pulmonary aspiration 1.
- It is essential to consult with an endocrinologist to determine the best approach for individual patients, taking into account their specific medical conditions and the potential risks and benefits of GLP-1 receptor agonist cessation 1.
From the Research
Withholding Trulicity (Dulaglutide) Before EGD
- The decision to withhold Trulicity (dulaglutide) before an Esophagogastroduodenoscopy (EGD) should be based on individual patient factors and the potential risks and benefits of delaying the procedure 2.
- According to a retrospective study, the use of glucagon-like peptide-1 receptor agonists (GLP-1 RA), such as dulaglutide, may be associated with delayed gastric emptying, but the incidence of clinically significant delayed gastric emptying is low 2.
- Another study found that dulaglutide is effective in patients with type 1 diabetes or type 2 diabetes with absolute insulin deficiency, but gastrointestinal adverse events may be a concern 3.
- A post hoc analysis of two randomized trials found that the incidence of gastrointestinal adverse events, such as diarrhea, nausea, and vomiting, was higher in patients treated with once-weekly dulaglutide, but most events were mild to moderate in severity 4.
- A case-control study found that GLP-1RA use, including dulaglutide, was associated with increased gastric residue on upper endoscopy, particularly in patients with type 2 diabetes, but this did not appear to translate to an increased risk of procedural complications 5.
- A post hoc analysis of the AWARD-11 trial found that the incidence of gastrointestinal events, such as nausea, vomiting, and diarrhea, was highest soon after initiation of dulaglutide treatment, but declined throughout the remainder of the study 6.
Recommendations
- There is no clear consensus on the optimal duration for withholding Trulicity (dulaglutide) before an EGD, but individual patient factors and the potential risks and benefits of delaying the procedure should be considered 2, 5.
- Patients with type 2 diabetes, particularly those with complicated diabetes, may be at higher risk for gastric residue on upper endoscopy while taking dulaglutide, and prolonged fasting and a clear-liquid diet may be protective 5.
- Gastrointestinal adverse events, such as diarrhea, nausea, and vomiting, are common with dulaglutide treatment, but most events are mild to moderate in severity and decline over time 4, 6.