Dulaglutide OK for Primary and Secondary CV Risk Reduction in US

Megan Brooks

February 24, 2020

The US Food and Drug Administration (FDA) has additionally approved dulaglutide (Trulicity, Lilly) for reducing the risk of major adverse cardiovascular events (MACE) in adults with type 2 diabetes with and without established cardiovascular disease (CVD) or multiple CV risk factors, the company has announced.

Dulaglutide is a once-weekly injectable glucagon-like peptide-1 (GLP-1) receptor agonist first approved in the United States in 2014 for the treatment of type 2 diabetes.  

It's now the first and only type 2 diabetes medicine approved to reduce the risk of CV events for both primary and secondary prevention populations.

The European Medicines Agency approved a similar indication for dulaglutide last fall.

The new US indication is based on results of the CV outcomes trial for dulaglutide, known as REWIND, which was the longest-running CV outcomes trial in the GLP-1 agonist class.

Chair of the REWIND study, Hertzel Gerstein, MD, professor of medicine at McMaster University and Hamilton Health Sciences, Ontario, Canada, said in a Lilly statement that the trial included a "broad population of people living with type 2 diabetes, reflective of those in the general population. We therefore assessed the effect of Trulicity in people with established CVD as well as those with multiple CV risk factors."

"Globally, over 415 million people have type 2 diabetes, which is itself a CV risk factor. However, only about one third have established CVD, which is why this new indication, and the supporting evidence, is important for the millions of people in the United States living with diabetes," he added.

Other GLP-1 agonists have been granted approvals for additional reduction of CV events in patients with type 2 diabetes, but only for secondary prevention.

Most recently the FDA expanded the indication for once-weekly semaglutide (Ozempic, Novo Nordisk) to include reducing the risk for MACE, including CV death, nonfatal myocardial infarction (MI), or nonfatal stroke, in adults with type 2 diabetes who have established CVD.

Additional Approval Based on REWIND Trial

The REWIND trial included primarily people with type 2 diabetes without established CVD. The full study results were presented at the 2019 American Diabetes Association Scientific Sessions, as reported by Medscape Medical News

REWIND showed a significant reduction in risk of MACE — a composite endpoint of nonfatal MI, nonfatal stroke, or CV death — which occurred in 12.0% of patients in the dulaglutide group versus 13.4% of patients in the placebo group, for a risk reduction of 0.88 (95% CI, 0.79 - 0.99; = .026), which was consistent across subgroups.

All three components of the MACE primary endpoint showed a reduction with dulaglutide compared to placebo, including CV death (HR, 0.91; 95% CI, 0.78 - 1.06) and nonfatal MI (HR, 0.96; 95% CI, 0.79 - 1.16), with the strongest and only significant effect seen in nonfatal stroke (HR, 0.76; 95% CI, 0.61 - 0.95).

No difference was seen between groups in hospital admissions for heart failure.

Dulaglutide was also found to modestly reduce weight by around 1.5 kg (= .0001) and systolic blood pressure by 1.7 mmHg (= .0001).

The safety profile of dulaglutide in REWIND was consistent with other members of the GLP-1 agonist class, with gastrointestinal events being the most common adverse event leading to discontinuation.

Sherry Martin, MD, Lilly's vice president, medical affairs, noted in the company statement: "For the first time, healthcare providers can prescribe a diabetes medicine proven to significantly reduce the risk of experiencing a CV event for people with type 2 diabetes with and without established CVD."

"Trulicity can help people achieve their A1C goals and protect them from experiencing a CV event with a once-weekly, easy-to-use treatment option," added Martin.

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