What is the recommended initial dose and treatment plan for a patient with type 2 diabetes starting on Trulicity (dulaglutide)?

Trulicity (Dulaglutide) Initial Dosing and Treatment Plan

Start Trulicity at 0.75 mg subcutaneously once weekly, then increase to 1.5 mg once weekly after at least 4 weeks if additional glycemic control is needed. 1

Initial Dose

• The FDA-approved starting dose is 0.75 mg injected subcutaneously once weekly 1
• Administer at any time of day, with or without food 1
• Inject in the abdomen, thigh, or upper arm, rotating sites with each dose 1

Dose Escalation Algorithm

• After at least 4 weeks on 0.75 mg, increase to 1.5 mg once weekly for additional glycemic control 1
• If further control is needed, increase in 1.5 mg increments after at least 4 weeks on the current dose 1
• Maximum dose is 4.5 mg once weekly for adults 1
• For pediatric patients (≥10 years), maximum dose is 1.5 mg once weekly 1

Foundation Therapy Considerations

Continue metformin unless contraindicated when starting Trulicity, as combination therapy provides superior outcomes 2

Medication Adjustments Before Starting

• Discontinue any DPP-4 inhibitor before initiating Trulicity 2
• If HbA1c is well-controlled at baseline or patient has frequent hypoglycemia, wean or stop sulfonylurea 2
• For patients on insulin, consider reducing total daily insulin dose by up to 20% 2

Monitoring Requirements

• Instruct patients to monitor glucose more closely at home for the first 4 weeks of therapy, especially if on insulin, sulfonylurea, or glinides 2
• Ensure appropriate eye examinations before starting if not done within the last 12 months, as dulaglutide carries potential risk of diabetic retinopathy complications 2

Mitigating Gastrointestinal Side Effects

To reduce nausea, recommend small portion sizes for meals, start at the lowest dose (0.75 mg), and up-titrate as tolerated toward goal doses 2

• Nausea, vomiting, and diarrhea are the most common adverse events 3, 4
• These gastrointestinal effects are typically transient 4

Absolute Contraindications

Do not use Trulicity in patients with: 1

• Personal or family history of medullary thyroid carcinoma (MTC) 1
• Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) 1
• Serious hypersensitivity to dulaglutide or any product components 1

Clinical Situations to Avoid

• Avoid in patients with diabetic gastroparesis or active gallbladder disease 2
• Not studied in patients with severe gastrointestinal disease, including severe gastroparesis 1
• Not studied in patients with history of pancreatitis; consider other therapies in these patients 1

Combination with Insulin

• When using Trulicity with insulin, administer as separate injections and never mix 1
• Injections can be in the same body region but should not be adjacent to each other 1

Missed Dose Instructions

• If a dose is missed and ≥3 days (72 hours) remain until next scheduled dose, administer as soon as possible 1
• If <3 days remain, skip the missed dose and resume regular schedule 1
• The day of weekly administration can be changed if the last dose was ≥3 days before the new day 1

Expected Efficacy

• Dulaglutide 1.5 mg once weekly demonstrated superiority to placebo, metformin, sitagliptin, exenatide twice daily, and insulin glargine in HbA1c reduction 5
• Dulaglutide 1.5 mg (but not 0.75 mg) consistently produces weight reduction from baseline 3
• Glycemic control is maintained during long-term treatment up to 2 years 3
• Early onset of glycemic control lasting up to 104 weeks 5

Cardiovascular Benefits

Trulicity is indicated to reduce the risk of major adverse cardiovascular events (cardiovascular death, non-fatal MI, or non-fatal stroke) in adults with type 2 diabetes who have established cardiovascular disease or multiple cardiovascular risk factors 1