Trulicity (Dulaglutide) Dosing for Glycemic Control
For adults with type 2 diabetes, start Trulicity at 0.75 mg subcutaneously once weekly, then increase to 1.5 mg once weekly for additional glycemic control, with further dose escalations in 1.5 mg increments every 4 weeks as needed, up to a maximum of 4.5 mg weekly. 1
Adult Dosing Algorithm
Initial dose: 0.75 mg subcutaneously once weekly 1
First escalation: Increase to 1.5 mg once weekly if additional glycemic control is needed 1
Subsequent escalations: 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
Pediatric Dosing (Age ≥10 Years)
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 control needed) 1
- Pediatric patients are limited to a maximum of 1.5 mg weekly, unlike adults who can escalate to 4.5 mg 1
Renal Dosing Considerations
No dose adjustment required for any level of renal impairment 2
- Dulaglutide does not require dose adjustment in mild, moderate, or severe renal impairment 2
- Unlike exenatide or lixisenatide, dulaglutide is safe in patients with eGFR <30 mL/min/1.73 m² 2
- Monitor eGFR when initiating or escalating doses, particularly in patients with chronic kidney disease who report severe gastrointestinal reactions 2
- In the AWARD-7 trial, dulaglutide demonstrated efficacy and safety in patients with moderate-to-severe chronic kidney disease (stages 3-4) 3
Administration Details
Timing: Once weekly, any time of day, with or without food 1
Route: Subcutaneous injection in abdomen, thigh, or upper arm; rotate injection sites with each dose 1
Missed dose protocol: If a dose is missed, administer as soon as possible if ≥3 days (72 hours) remain until the next scheduled dose; if <3 days remain, skip the missed dose 1
Critical Contraindications and Warnings
Absolute contraindications: 1
- Personal or family history of medullary thyroid carcinoma (MTC)
- Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
- Serious hypersensitivity reaction to dulaglutide
Important precautions:
- Not studied in patients with history of pancreatitis; consider alternative agents in this population 1
- Not recommended in patients with severe gastrointestinal disease or severe gastroparesis 1
- Should not be used in type 1 diabetes mellitus 1
Perioperative Management
For elective surgery: Consider holding dulaglutide for one week before procedures due to delayed gastric emptying effects, though evidence on aspiration risk with long-term use remains uncertain 2
- The half-life of dulaglutide ranges from 4.5 to 4.7 days depending on dose 2
- GLP-1 receptor agonists are associated with delayed gastric emptying, raising theoretical concerns about pulmonary aspiration risk 2
Common Adverse Effects
Gastrointestinal effects are the most frequently reported adverse events 4, 5, 3:
- Nausea (14-20% vs 5% with insulin glargine) 3
- Diarrhea (16-17% vs 7% with insulin glargine) 3
- Vomiting 4
Hypoglycemia risk: Low inherent risk (4.3-4.4 events per patient-year vs 9.6 with insulin glargine) 5, 3
Rare but serious: Acute pancreatitis has been reported, though uncommon 6
Clinical Efficacy Context
- Dulaglutide demonstrated non-inferiority to liraglutide 1.8 mg daily and superiority to metformin, sitagliptin, exenatide, and insulin glargine in glycemic control 4, 7
- The REWIND trial showed significant reduction in major adverse cardiac events (MACE) at median 5.4 years follow-up 5
- Dulaglutide 1.5 mg (but not 0.75 mg) consistently reduces body weight from baseline 4
- In patients with moderate-to-severe CKD, dulaglutide reduced decline in eGFR compared to insulin glargine 3