Should we increase the dose of dulaglutide (Trulicity) if the patient's A1c remains unchanged?

Should You Increase Dulaglutide Dose for Stable A1C of 6.8%?

No, do not increase the dulaglutide dose—an A1C of 6.8% is already at or below the standard glycemic target of <7.0% for most adults with type 2 diabetes, and further intensification would increase treatment burden and hypoglycemia risk without meaningful benefit. 1

Why This A1C Does Not Require Dose Escalation

• The American Diabetes Association establishes an A1C target of <7.0% (53 mmol/mol) as appropriate for most nonpregnant adults with diabetes 1
• Your patient's current A1C of 6.8% already meets this target, indicating adequate glycemic control 1
• Further lowering A1C below 7.0% in patients without specific indications does not provide additional microvascular or macrovascular benefit and increases the risk of hypoglycemia and treatment burden 1

When A1C Goals Should Be Individualized

While the standard target is <7.0%, certain patient characteristics warrant different approaches:

More stringent targets (A1C <6.5%) may be appropriate if:

• The patient is newly diagnosed with short diabetes duration 1
• They can achieve this target without significant hypoglycemia or treatment burden 1
• They have a long life expectancy and no significant cardiovascular disease 1

Less stringent targets (A1C <8.0%) are more appropriate if:

• The patient has a history of severe hypoglycemia 1
• They have limited life expectancy due to comorbidities 1
• They have advanced microvascular or macrovascular complications 1
• They have extensive comorbid conditions 1

The Cardiovascular Benefit Consideration

• GLP-1 receptor agonists like dulaglutide provide cardiovascular and renal benefits that are independent of A1C lowering 1
• The REWIND trial demonstrated that dulaglutide reduced 3-point MACE by 12% (HR 0.88,95% CI 0.79-0.99) in patients with established cardiovascular disease or cardiovascular risk factors 1
• These cardiovascular benefits occur regardless of baseline A1C or A1C reduction achieved 1
• The patient is already receiving these cardiovascular benefits at the current dose—increasing the dose will not enhance cardiovascular protection 1

What Dulaglutide Dose Escalation Would Achieve

If you were to increase from 0.75 mg to 1.5 mg weekly:

• Additional A1C reduction of approximately 0.2-0.3% based on AWARD trials 2, 3
• This would lower A1C from 6.8% to approximately 6.5-6.6%—a change with no proven clinical benefit at this range 1
• Increased gastrointestinal side effects: nausea occurs in 20% with dulaglutide 1.5 mg versus 14% with 0.75 mg 4
• Greater treatment burden without meaningful outcome improvement 1

Critical Pitfall to Avoid

Do not confuse "stable A1C" with "treatment failure"—if the A1C is at target, stability indicates treatment success, not inadequacy. 1 The question implies concern about an unchanged A1C, but an A1C of 6.8% that remains stable over time represents excellent glycemic control.

When to Consider Treatment Modification

You should reassess the regimen if:

• A1C rises above 7.0% on repeat testing 1
• The patient develops cardiovascular disease and is not yet on a GLP-1 receptor agonist with proven cardiovascular benefit (dulaglutide qualifies) 1
• The patient experiences recurrent hypoglycemia, warranting deintensification 1
• New comorbidities emerge that change the risk-benefit balance 1

Alternative Focus Areas

Rather than intensifying glucose-lowering therapy, optimize:

• Blood pressure control (target <130/80 mmHg for most patients with diabetes) 1
• Lipid management with statin therapy 1
• Lifestyle modifications including diet and physical activity 1
• Screening for diabetes complications (retinopathy, nephropathy, neuropathy) 1