What is the next best step for a patient with type 2 diabetes and an elevated Hemoglobin A1c (HbA1c) level, currently on Trulicity (Dulaglutide) at its lowest dose, which is not effective?

Next Steps for Type 2 Diabetes Patient on Lowest Dose Trulicity with HbA1c of 8.3%

For a patient with type 2 diabetes on the lowest dose of Trulicity (dulaglutide) with an HbA1c of 8.3%, the next best step is to increase the Trulicity dose to the next higher level (from 0.75 mg to 1.5 mg weekly). 1

Rationale for Dose Escalation

• Trulicity (dulaglutide) has demonstrated dose-dependent efficacy with higher doses providing greater HbA1c reduction, as shown in clinical trials 1
• The FDA-approved dosing for Trulicity allows for dose escalation from 0.75 mg to 1.5 mg, and potentially up to 3 mg or 4.5 mg weekly for patients requiring additional glycemic control 1
• Clinical data shows that increasing from 1.5 mg to 4.5 mg resulted in additional HbA1c reduction of 0.2% compared to staying at the 1.5 mg dose, suggesting that dose escalation is an effective strategy 1

Treatment Algorithm for Type 2 Diabetes

1. First step: Evaluate current therapy effectiveness

   • With an HbA1c of 8.3%, the patient is not meeting the typical target of <7.0%, indicating inadequate glycemic control on current therapy 2
   • When a medication is not achieving glycemic targets, intensification of therapy is recommended 2

2. Second step: Consider medication options

   • For injectable GLP-1 receptor agonists like Trulicity, dose optimization should be attempted before adding or switching medications 2
   • Trulicity has shown dose-dependent efficacy with higher doses providing greater HbA1c and weight reductions 1

3. Third step: Implement the change

   • Increase Trulicity from 0.75 mg to 1.5 mg weekly 1
   • Monitor for 3 months to assess response to the dose increase 2

If Dose Escalation Is Insufficient

If after 3 months on the higher dose of Trulicity the patient still has inadequate glycemic control:

• Consider adding basal insulin to the GLP-1 receptor agonist regimen 2
• Alternative option: Add an SGLT2 inhibitor if not contraindicated, which provides complementary mechanism of action 2
• Third option: Consider switching to a different medication class or combination therapy if GLP-1 receptor agonist is not tolerated or ineffective 2

Important Considerations

• Gastrointestinal side effects: Monitor for nausea, vomiting, or diarrhea with dose escalation, which typically improve over time 1, 3
• Cost factors: Ensure the patient can afford the higher dose, as this may affect adherence 4
• Patient education: Reinforce proper injection technique and timing 2
• Comorbidities: Dulaglutide has shown favorable effects in patients with moderate-to-severe chronic kidney disease and may have cardiovascular benefits 5

Common Pitfalls to Avoid

• Delaying treatment intensification: Clinical inertia can lead to prolonged periods of hyperglycemia 2
• Ignoring lifestyle modifications: Continue to emphasize diet, exercise, and education as the foundation of diabetes management 2
• Overlooking hypoglycemia risk: While GLP-1 receptor agonists have lower hypoglycemia risk than insulin, monitor for this possibility, especially if the patient is on other glucose-lowering medications 2, 5

By increasing the Trulicity dose before adding additional agents, you're optimizing the current therapy while minimizing regimen complexity, which may improve adherence and glycemic control while maintaining the favorable weight and hypoglycemia profile of GLP-1 receptor agonists 2, 1, 3.