Anaphylactic Reaction to Dulaglutide: A Glucagon Like Peptide- 1 Receptor Agonist

Abstract

Introduction: The development of Glucagon like peptide-1 (GLP-1) receptors agonists represents an important advancement in the management of type 2 diabetes. The long-acting GLP-1 receptor agonists improve glycemic control, promote weight loss. Anaphylaxis to GLP-1 receptor agonists and mainly Dulaglutide is a rare but serious side effect. We report a patient with Type 2 DM who was recently started on Dulaglutide and started to experience systemic hypersensitivity reactions that required discontinuing the medication and inpatient hospitalization. Case: A 53-Year-old Caucasian female with past medical history of type 2 DM on Metformin presented to the ED with sudden onset of sporadic itchy rash on the lip and chin associated with lip swelling within one hour of her first injection of Dulaglutide. She denied difficulty breathing, rash or pruritus on any other part of the body. She denied any food allergies. The patient used two tablets of Oral Diphenhydramine 25 mg with minimal improvement in her symptoms which warrant her to come to the ED. On arrival, she was Afebrile with a HR 97 beats/minute, a BP of 105/58 mm of Hg and a RR of 17 breaths/minute. The rash was blotchy, non- tender, more evident on the upper lip as compared to the lower lip. Lab results showed WBC count of 11 k/uL with basophils of 2% and HbA1c 8.6%. She was treated for her allergic reaction with Intramuscular injection of Epinephrine 0.3mg, Intravenous Dexamethasone 6mg and Intravenous Diphenhydramine 25mg. She was then transferred to the observation unit for monitoring. Her home metformin 500mg two times a day was continued. After 48 hours, the patient’s symptoms were improved and she was discharged home. She was advised to follow up with her PCP and endocrinologist and stop Dulaglutide. Discussion: GLP-1 receptor agonists are commonly used currently in the management of DM due to their beneficial effect in controlling blood glucose as compared to other diabetic medications. Rarely, a potentially life-threatening reaction, such as anaphylactic reactions have been documented with GLP-1 receptor agonist. Systemic allergic reaction to GLP-1 Agonist Exenatide has been reported in the literature. Our patient had anaphylactic reaction after using Dulaglutide. The mechanism of action of anaphylaxis in GLP-1 receptor agonists is thought to be related to IgE mediated and the immune response was demonstrated by basophil activation.