I forgot to tell you about a new drug for diabetes that hit the market in the U.S. last fall. My preferred initial treatment approach to type 2 diabetes is diet and exercise in most cases, but in many cases that’s not enough.
If your blood sugar’s 400 mg/dl (22 mmol/l) and you’re fairly symptomatic from it, I’ll probably have to start you out on insulin while initiating dietary changes at the same time. Later we’ll try to get you off insulin, onto metformin, and perhaps off drugs entirely within a couple months. (Type 1 diabetics have to keep taking insulin shots, of course.)
Where this new drug fits into our armamentarium isn’t clear. Click here for links to professional association guidelines on diabetes drug prescribing.
In September, 2014, the Food and Drug Administration approved the fourth drug in the GLP-1 analogue class: dulaglutide. The granddaddy in the class is exenatide (Byetta). The new GLP-1 receptor agonist will be sold in the U.S. under the name of Trulicity. It’s a once-weekly injection.
This is only a summary and is liable to change. Get full information from your prescribing healthcare provider and pharmacist.
For adults with type 2 diabetes, in conjunction with diet and exercise. It’s not a first-line drug. It can be used by itself or in combination with metformin, pioglitazone, glimiperide (and presumably other sulfonylureas), and insulin lispro (e.g., Humalog, a rapid-acting insulin). The drug has not been tried with basal (long-acting) insulins.
Start with 0.75 mg subcutaneously every week. Can go up to 1.5 mg weekly if needed.
Hypoglycemia is rare, but possible, when GLP-1 analogues are used as the sole diabetes drug. When it happens, it’s rarely severe. But the risk increases substantially when dulaglutide is used along with insulin or insulin secretagogues such as sulfonylureas or meglitinides.
Common side effects are nausea, vomiting, diarrhea, abdominal pain, decreased appetite, dyspepsia, and fatigue.
It might cause thyroid tumors and pancreatitis.
Do Not Use If…
…you have a family or personal history of medullary thyroid cancer, or if you have Multiple Endocrine Neoplasia syndrome type 2 or pre-existing severe gastrointestinal disease. Those who are pregnant or nursing babies should probably not take it since we have no data on safety. Don’t use for diabetic ketoacidosis.
Use only with caution if you have a history of pancreatitis or known liver impairment.
Steve Parker, M.D.