Parameters Needed to Start Trulicity (Dulaglutide) on a Diabetic Patient
Before initiating dulaglutide in an adult with type 2 diabetes, you must verify the absence of absolute contraindications, assess baseline renal function (though no dose adjustment is required), and ensure the patient is on appropriate foundational therapy such as metformin unless contraindicated. 1
Absolute Contraindications to Screen For
Screen every patient for these absolute contraindications before prescribing dulaglutide:
- Personal or family history of medullary thyroid carcinoma (MTC) – dulaglutide is contraindicated based on animal studies showing thyroid C-cell tumors with GLP-1 receptor agonists 1, 2
- Multiple endocrine neoplasia syndrome type 2 (MEN 2) – absolute contraindication to all GLP-1 receptor agonists 1, 2
- History of severe hypersensitivity reaction to dulaglutide – prior anaphylaxis or angioedema to dulaglutide precludes its use 2
Required Baseline Laboratory Assessment
Obtain these baseline parameters before initiating dulaglutide:
- HbA1c – to establish baseline glycemic control and set individualized targets (typically <7% for most adults, though targets vary by patient characteristics) 1
- Estimated glomerular filtration rate (eGFR) – dulaglutide requires no dose adjustment across all stages of chronic kidney disease, including eGFR <30 mL/min/1.73 m² or even end-stage renal disease, but baseline renal function should be documented 1, 3
- Comprehensive metabolic panel – to assess baseline renal function, electrolytes, and liver enzymes 2
- Fasting glucose – to guide titration of other diabetes medications and monitor response 1
- Lipid panel – to assess cardiovascular risk factors, as GLP-1 receptor agonists provide cardiometabolic benefits beyond glucose lowering 2
Clinical History and Physical Examination Essentials
Document these specific clinical parameters:
- Body weight and BMI – dulaglutide consistently produces modest weight loss (2.8–3.9 kg with 1.5 mg dose), which is a therapeutic benefit in most patients with type 2 diabetes 4, 5
- Blood pressure – GLP-1 receptor agonists improve blood pressure, and antihypertensive medications may require adjustment as weight decreases 2
- History of pancreatitis – use dulaglutide with caution if present, though causality between GLP-1 receptor agonists and pancreatitis is not definitively established 1, 2
- History of gastroparesis or severe gastrointestinal motility disorders – relative caution, as dulaglutide delays gastric emptying 2
- Cardiovascular disease status – dulaglutide is preferred for patients with established atherosclerotic cardiovascular disease or high cardiovascular risk, as GLP-1 receptor agonists reduce major adverse cardiovascular events 1
- Chronic kidney disease stage – dulaglutide is specifically recommended for patients with CKD (eGFR 20–60 mL/min/1.73 m² and/or albuminuria) to minimize CKD progression and reduce cardiovascular events 1
Foundational Therapy Requirements
Ensure appropriate background diabetes therapy:
- Continue metformin unless contraindicated – metformin remains the foundation of type 2 diabetes therapy and should be continued when initiating dulaglutide 1, 6
- Assess and adjust sulfonylureas – reduce sulfonylurea dose by approximately 50% or discontinue entirely when starting dulaglutide to prevent hypoglycemia 1, 2
- Discontinue DPP-4 inhibitors – do not use dulaglutide with other GLP-1 receptor agonists or DPP-4 inhibitors due to overlapping mechanisms and lack of additional benefit 2
- Reduce insulin doses if applicable – when adding dulaglutide to insulin therapy, reduce basal insulin by approximately 20% to prevent hypoglycemia 2
Specific Indications for Dulaglutide Initiation
Dulaglutide is indicated and should be prioritized in these clinical scenarios:
- Type 2 diabetes with inadequate glycemic control (HbA1c >7% on current therapy) despite metformin and/or SGLT2 inhibitor 1
- Type 2 diabetes with established atherosclerotic cardiovascular disease – GLP-1 receptor agonists reduce cardiovascular events by approximately 20–26% 1, 2
- Type 2 diabetes with chronic kidney disease (eGFR 20–60 mL/min/1.73 m² and/or albuminuria) – dulaglutide minimizes CKD progression and reduces cardiovascular events 1
- Type 2 diabetes with obesity (BMI ≥30 kg/m² or ≥27 kg/m² with weight-related comorbidities) – dulaglutide provides dual benefits of glycemic control and weight loss 1, 2
- Type 2 diabetes with heart failure with preserved ejection fraction (HFpEF) – GLP-1 receptor agonists improve symptoms and physical function 2
Dosing and Administration Protocol
Start dulaglutide with this standardized approach:
- Initial dose: 0.75 mg subcutaneously once weekly – this is the FDA-approved starting dose to minimize gastrointestinal adverse effects 1, 4, 7
- Titration schedule: increase to 1.5 mg once weekly after 4 weeks if additional glycemic control is needed and the 0.75 mg dose is tolerated 1, 4, 7
- Higher doses (3.0 mg and 4.5 mg) are investigational and not yet FDA-approved, though phase 2 trials show superior HbA1c reduction and weight loss with acceptable safety profiles 5
- Injection site: abdomen, thigh, or upper arm – pharmacokinetics are identical across injection sites, so no preference is required 8
- Timing: administer at any time of day, with or without meals – dulaglutide's long half-life (approximately 5 days) allows flexible timing 8, 7
Monitoring Schedule After Initiation
Follow this structured monitoring protocol:
- Week 4: assess gastrointestinal tolerance – nausea, vomiting, and diarrhea are the most common adverse effects, typically mild-to-moderate and transient 4, 7, 3
- Week 4: consider dose escalation to 1.5 mg if the 0.75 mg dose is tolerated and additional glycemic control is needed 1, 4, 7
- Weeks 12–16: evaluate treatment response – check HbA1c, fasting glucose, weight, and blood pressure to assess efficacy 1, 2
- Every 3 months thereafter: monitor HbA1c, weight, blood pressure, and cardiovascular risk factors until glycemic targets are achieved, then every 3–6 months 1, 2
- Monitor for hypoglycemia – dulaglutide has minimal intrinsic hypoglycemia risk when used as monotherapy, but risk increases when combined with sulfonylureas or insulin 1, 3
Special Populations and Dose Adjustments
Dulaglutide requires no dose adjustment in these populations:
- Chronic kidney disease (all stages, including eGFR <30 mL/min/1.73 m²) – no dose adjustment required, making dulaglutide a preferred agent for patients with renal impairment 1, 8, 3
- Elderly patients – age does not influence dulaglutide pharmacokinetics to any clinically relevant degree, so no dose adjustment is needed 8
- Body weight, sex, race, or ethnicity – these factors do not require dose adjustment 8
However, use caution in these scenarios:
- Advanced chronic kidney disease (eGFR <30 mL/min/1.73 m²) – while no dose adjustment is required, GLP-1 receptor agonists are preferred over insulin for glycemic management due to lower hypoglycemia risk 1
- Patients with poor oral intake or at high risk of dehydration – gastrointestinal adverse effects (nausea, vomiting, diarrhea) may increase dehydration risk, requiring closer monitoring 3
Patient Education Essentials Before Starting Dulaglutide
Provide these specific counseling points:
- Gastrointestinal side effects are common but transient – nausea occurs in approximately 14–20% of patients, diarrhea in 16–17%, and vomiting in 6–10%, but these effects are typically mild-to-moderate and decrease over time 4, 5, 3
- Hypoglycemia risk is low with dulaglutide alone – the glucose-dependent mechanism of GLP-1 receptor agonists results in minimal intrinsic hypoglycemia risk, but risk increases when combined with sulfonylureas or insulin 1, 3
- Weight loss is expected – dulaglutide consistently produces modest weight loss (2.8–3.9 kg with 1.5 mg dose), which is a therapeutic benefit 4, 5
- Injection technique – dulaglutide is administered as a once-weekly subcutaneous injection using a pre-filled pen device, which simplifies administration 4, 7
- Missed doses – if a dose is missed, administer as soon as possible if ≤3 days since the missed dose; if >3 days, skip and resume at the next scheduled dose 2
- Warning signs requiring immediate medical attention – severe abdominal pain (possible pancreatitis), right upper quadrant pain with fever (possible cholecystitis), or symptoms of hypoglycemia 2, 3
Common Pitfalls to Avoid
Do not make these errors when initiating dulaglutide:
- Do not delay GLP-1 receptor agonist initiation until multiple oral agents have failed – early use in appropriate candidates (established cardiovascular disease, chronic kidney disease, or obesity) leads to better outcomes 1, 2
- Do not discontinue metformin when starting dulaglutide unless contraindicated – metformin provides complementary glucose-lowering and should be continued 1, 6
- Do not fail to reduce or discontinue sulfonylureas – combining dulaglutide with sulfonylureas significantly increases hypoglycemia risk, requiring dose reduction or discontinuation 1, 2
- Do not prescribe dulaglutide to patients with personal or family history of medullary thyroid cancer or MEN 2 – this is an absolute contraindication 1, 2
- Do not assume dose adjustment is needed for renal impairment – dulaglutide requires no dose adjustment across all CKD stages, including end-stage renal disease 1, 8, 3
When NOT to Initiate Dulaglutide
Avoid dulaglutide in these specific scenarios:
- HbA1c >10% or blood glucose ≥300 mg/dL with symptoms of hyperglycemia – insulin should be initiated first in patients with severe hyperglycemia or evidence of catabolism 1
- Evidence of significant insulin deficiency – GLP-1 receptor agonists are preferred only when insulin deficiency is absent; patients with type 1 diabetes or latent autoimmune diabetes in adults (LADA) require insulin 1
- Active symptomatic gallbladder disease – GLP-1 receptor agonists increase the risk of cholelithiasis and cholecystitis by approximately 38% versus placebo 2
- Recent heart failure decompensation – avoid GLP-1 receptor agonists in patients with recent heart failure exacerbation, as they may increase risk 2