Starting Dose for Trulicity (Dulaglutide)
The recommended starting dose of Trulicity is 0.75 mg injected subcutaneously once weekly for both adults and pediatric patients 10 years and older with type 2 diabetes. 1
Adult Dosing Algorithm
- Initial dose: Start at 0.75 mg subcutaneously once weekly 1
- First titration: Increase to 1.5 mg once weekly if additional glycemic control is needed 1
- Subsequent titrations: If further glycemic control is required, increase in 1.5 mg increments (to 3 mg, then 4.5 mg) after at least 4 weeks on the current dose 1
- Maximum dose: 4.5 mg subcutaneously once weekly 1
The decision to escalate beyond 1.5 mg should be driven by inadequate glycemic control—specifically when HbA1c remains above individualized targets despite 4+ weeks at the current dose 2.
Pediatric Dosing (Ages 10 and Older)
- Initial dose: 0.75 mg subcutaneously once weekly 1
- Maximum dose: 1.5 mg once weekly (after at least 4 weeks on 0.75 mg if additional glycemic control is needed) 1
- Pediatric patients are limited to a maximum of 1.5 mg weekly, unlike adults who can titrate up to 4.5 mg 1
Administration Details
- Administer once weekly at any time of day, with or without food 1
- Inject subcutaneously in the abdomen, thigh, or upper arm, rotating injection sites with each dose 1
- The day of weekly administration can be changed if the last dose was administered 3 or more days before the new day 1
Special Population Considerations
No dose adjustment is required for renal impairment, including patients with moderate-to-severe chronic kidney disease (stages 3-4) or end-stage renal disease, making Trulicity straightforward to initiate even in patients with significant kidney dysfunction 3, 2, 4. This is a major advantage over many other antihyperglycemic agents that require dose modifications or are contraindicated in renal impairment 4.
Critical Safety Considerations Before Starting
- Absolute contraindications: Do not use in patients with personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) 1
- History of pancreatitis: Trulicity has not been studied in patients with a history of pancreatitis; consider other antidiabetic therapies in these patients 1
- Severe gastroparesis: Not recommended in patients with severe gastrointestinal disease, including severe gastroparesis 1
Hypoglycemia Risk Management
When initiating Trulicity, consider dose reductions of concurrent insulin or sulfonylureas to prevent hypoglycemia, as dulaglutide has a low inherent hypoglycemia risk but can increase risk when combined with these agents 2. In the AWARD-7 trial, dulaglutide was associated with significantly lower rates of symptomatic hypoglycemia (4.3-4.4 events per patient per year) compared to insulin glargine (9.6 events per patient per year) 4.
Expected Gastrointestinal Side Effects
The gradual dose titration schedule (starting at 0.75 mg) helps minimize gastrointestinal adverse effects, which are the most common side effects 5. Nausea occurs in approximately 15-20% of patients on dulaglutide 1.5 mg, diarrhea in 17%, and vomiting in 4% 6, 4. These effects are typically transient and improve with continued use 7.
Cardiovascular Benefits
Dulaglutide is indicated not only for glycemic control but also to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke) in adults with type 2 diabetes who have established cardiovascular disease or multiple cardiovascular risk factors 3, 1. This cardiovascular benefit supports its use as a first-line injectable agent in appropriate patients 3, 2.