GLP-1 agonist dulaglutide (Trulicity) is a new injectable type 2 diabetes medicine funded by PHARMAC under Special Authority.1 Self-administered once weekly as a subcutaneous injection, it comes in a single-use disposable pen. Dulaglutide will be available as a second-line therapy once it has Medsafe approval, which is expected later this year.1
GLP-1, an incretin hormone released by the gut in response to food, is known to have the following actions:
- enhances glucose-dependent insulin secretion by pancreatic beta cells
- suppresses secretion of glucagon by pancreatic alpha cells
- signals satiety to the brain.2
By exhibiting these GLP-1 actions, dulaglutide reduces fasting blood glucose levels, postprandial blood glucose levels and appetite. Due to its appetite suppressant action, it promotes weight loss but there is variability in this effect and to achieve this it must be combined with healthy eating and healthy activity.3 Other medicines within this class are being independently used as weight-loss medications including liraglutide (Saxenda), which is registered for use in New Zealand but not funded.
Dulaglutide is not independently associated with hypoglycaemia, but it can increase the risk of this when used with medications that cause hypoglycaemia, such as insulin and sulfonylureas. Dulaglutide can also cause nausea, and occasionally vomiting: however, this side effect normally settles within the first few weeks.4 A description of common adverse effects and contraindications associated with dulaglutide can be found here.5
The SGLT2 inhibitor empagliflozin was also made available under Special Authority earlier this year, with the same funding criteria as dulaglutide. The choice of second-line agent is determined by cardiovascular and renal status, and Māori or Pacific ethnicity. The Special Authority criteria promote improved access for Māori and Pacific peoples, to address inequities in diabetes prescribing and health outcomes. Guidance is available online from the New Zealand Society for the Study of Diabetes (NZSSD).6
The funding of both empagliflozin and dulaglutide by PHARMAC has increased the availability of funded second-line agents for people with type 2 diabetes whose HbA1c level is greater than 53mmol/mol. Metformin remains the first-line pharmacological agent.
PHARMAC will fund either empagliflozin (Jardiance) or dulaglutide (Trulicity); however, some patients may benefit from using both agents in combination.1,7 If this is the case, consider inviting your patient to self-fund empagliflozin (the least expensive of the two agents) while receiving funded dulaglutide.