Dulaglutide (Trulicity) Safety in Patients with Atrial Fibrillation and Type 2 Diabetes
Dulaglutide (Trulicity) is safe for patients with atrial fibrillation (AFib) and type 2 diabetes, with no evidence suggesting increased risk of AFib events or worsening of existing AFib. 1
Safety Profile in Patients with AFib
- Post-hoc analysis of the REWIND trial showed that dulaglutide treatment was not associated with an increased incidence of atrial fibrillation or flutter in patients with type 2 diabetes 1
- In this analysis of 9,543 participants followed for a median of 5.4 years, incident atrial arrhythmias occurred at similar rates in both dulaglutide (5.6%) and placebo (5.3%) groups 1
- Dulaglutide demonstrated cardiovascular benefits in patients with type 2 diabetes regardless of whether they had pre-existing atrial fibrillation 1, 2
Cardiovascular Effects and Benefits
- Dulaglutide has demonstrated significant reduction in major adverse cardiovascular events (MACE) in patients with type 2 diabetes, making it beneficial for patients with AFib who already have elevated cardiovascular risk 2
- The American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) recommend GLP-1 receptor agonists like dulaglutide for patients with type 2 diabetes and established cardiovascular disease to reduce cardiovascular events 3
- GLP-1 receptor agonists including dulaglutide can also be considered in patients without established cardiovascular disease but with high-risk indicators (age ≥55 years, coronary/carotid/lower extremity artery stenosis >50%, left ventricular hypertrophy, eGFR <60 mL/min/1.73m², or albuminuria) 3
Cardiac Electrophysiological Considerations
- FDA labeling for Trulicity notes a mean increase in heart rate of 2-4 beats per minute and PR interval prolongation of 2-3 milliseconds 4
- First-degree AV block occurred more frequently with dulaglutide (1.7% with 0.75mg dose and 2.3% with 1.5mg dose) compared to placebo (0.9%) 4
- Sinus tachycardia was reported in 2.8% (0.75mg) and 5.6% (1.5mg) of dulaglutide-treated patients versus 3.0% in placebo 4
- These electrophysiological effects are generally mild and not clinically significant for most patients with AFib 4, 1
Monitoring Recommendations
- Regular monitoring of heart rate and rhythm is advisable when initiating dulaglutide in patients with AFib 4
- Consider baseline ECG assessment before starting dulaglutide in patients with AFib to document pre-existing conduction abnormalities 4
- Monitor for symptoms of worsening arrhythmia such as palpitations, dizziness, or syncope 4
Dosing Considerations
- When initiating dulaglutide in patients with AFib who are also on antiarrhythmic medications or rate-controlling agents, be aware of the small increase in heart rate that may occur 4
- Consider starting with the lower 0.75mg weekly dose in patients with AFib and titrating up as tolerated 4
- If a patient is also on insulin or sulfonylureas, consider reducing these doses when starting dulaglutide to minimize hypoglycemia risk 4
Comparative Evidence with Other GLP-1 Receptor Agonists
- Similar to dulaglutide, other GLP-1 receptor agonists have shown neutral effects on AFib risk 3, 5
- A study with albiglutide (another GLP-1 receptor agonist) showed no increased risk of AFib events and even a trend toward fewer AFib events compared to placebo 5
- The European Society of Cardiology guidelines note that GLP-1 receptor agonists have a neutral effect on heart failure hospitalization risk in patients with AFib 3
In conclusion, dulaglutide is a safe option for patients with both atrial fibrillation and type 2 diabetes, with evidence supporting cardiovascular benefits and no increased risk of AFib events or progression. Regular cardiac monitoring is still recommended, particularly when initiating therapy.