Trulicity (dulaglutide) is a once-weekly injectable medication used to manage type 2 diabetes in the UK. Choosing the best location to inject Trulicity is essential for ensuring effective drug absorption, minimising discomfort, and preventing injection-related complications. The medication can be administered subcutaneously in three approved sites: the abdomen, thigh, or upper arm. Understanding the advantages of each location, along with proper injection technique and systematic site rotation, helps patients achieve optimal glycaemic control whilst reducing the risk of adverse effects such as lipohypertrophy and injection site reactions.

Approved Injection Sites for Trulicity in the UK

Trulicity (dulaglutide) is a once-weekly glucagon-like peptide-1 (GLP-1) receptor agonist used in the UK for the treatment of type 2 diabetes mellitus. According to the UK Summary of Product Characteristics (SmPC) and Patient Information Leaflet (PIL), there are three specific anatomical sites recommended for subcutaneous administration of this medication.

The recommended injection sites are:

• Abdomen – anywhere on the stomach area except within 5 cm of the navel

• Thigh – the front or outer areas of the upper leg

• Upper arm – the back of the upper arm, in the fatty tissue

These sites provide appropriate subcutaneous tissue for the medication to be absorbed effectively into the bloodstream. Each site contains sufficient fatty tissue to accommodate the injection volume (0.5 mL per dose, regardless of strength: 0.75 mg, 1.5 mg, 3.0 mg, or 4.5 mg) whilst minimising discomfort.

It is important to use only these recommended sites for subcutaneous injection. The medication should never be administered intravenously or intramuscularly. According to NICE guidance on diabetes management, proper injection technique is fundamental to achieving optimal glycaemic control and reducing the risk of injection-related complications. Patients should receive appropriate training from their diabetes specialist nurse or GP practice nurse before commencing treatment, ensuring they understand the correct anatomical landmarks for each injection site.

How to Choose the Best Location to Inject Trulicity

Selecting the optimal injection site for Trulicity depends on several individual factors, including body composition, personal comfort, manual dexterity, and any pre-existing skin conditions. All three recommended sites are suitable as per the SmPC/PIL, with patient preference and practical considerations often guiding the choice.

The abdomen is frequently the preferred site for many patients due to its accessibility and the relative ease of self-administration. The stomach area typically has adequate subcutaneous tissue, and most individuals can comfortably reach this site without assistance. However, patients should avoid injecting too close to the navel, any surgical scars, or areas with inflammation, bruising or lipodystrophy, as these may affect absorption or cause discomfort.

The thigh offers an excellent alternative, particularly for patients who prefer not to inject into their abdomen or who have limited abdominal subcutaneous tissue. The outer or front portion of the upper thigh is easily accessible when seated and provides a stable surface for injection. This site may be especially suitable for patients with previous abdominal surgery or those who find the abdomen uncomfortable.

The upper arm can be used but often requires assistance from another person, as reaching the correct area on the back of one's own arm can be challenging. This site may be most appropriate for patients receiving support from carers or family members.

Patients with very low body fat should discuss site selection with their healthcare provider, as they may need to pinch the skin more carefully to ensure subcutaneous rather than intramuscular injection. Those with lipodystrophy or significant scarring at any site should avoid those areas and rotate between the remaining options.

Rotating Injection Sites: Why It Matters

Systematic rotation of injection sites is a critical aspect of safe, long-term Trulicity administration. Repeatedly injecting into the same location can lead to several complications that may compromise both treatment efficacy and patient wellbeing.

Lipohypertrophy is the most common consequence of inadequate site rotation. This condition involves the abnormal accumulation of fatty tissue at frequently used injection sites, creating lumps or thickened areas under the skin. These areas not only appear unsightly but can impair medication absorption, leading to unpredictable glycaemic control. While most research on absorption effects has been conducted with insulin, similar principles are thought to apply to GLP-1 receptor agonists like Trulicity.

Conversely, lipoatrophy – the loss of subcutaneous fat – can also occur with repeated injections in the same area, though this is less common with modern formulations. Both lipohypertrophy and lipoatrophy fall under the umbrella term of lipodystrophy, a recognised complication of subcutaneous diabetes medications.

Additional benefits of site rotation include:

• Reduced risk of injection site reactions such as erythema, bruising, or tenderness

• Decreased likelihood of developing scar tissue that may impede absorption

• Improved patient comfort and treatment adherence

• More consistent drug delivery

According to Forum for Injection Technique (FIT UK) recommendations, patients should maintain a systematic rotation pattern, rotating both within and between injection regions. Injections should be spaced apart sufficiently (approximately 1-2 cm) to avoid reusing the exact same spot. Patients should keep a record of injection sites, either mentally or in a diabetes diary, to ensure proper rotation. Regular examination of injection sites can help detect early signs of lipohypertrophy.

Step-by-Step Guide to Injecting Trulicity Safely

Proper injection technique is essential for ensuring optimal drug delivery, minimising discomfort, and reducing the risk of complications. Trulicity is supplied in a single-dose pen that simplifies the injection process, but careful attention to technique remains important.

1. Preparation (before injection):
2. Remove the pen from the refrigerator 30 minutes before use to allow it to reach room temperature naturally (do not warm using external heat sources)
3. Wash your hands thoroughly with soap and water
4. Inspect the pen – check the expiry date and ensure the medication is clear and colourless; do not use if cloudy or discoloured
5. Select and prepare the injection site – choose an approved area and clean with an alcohol wipe if recommended by your healthcare provider (though this is not always necessary for clean, intact skin)
6. Allow the skin to dry completely if using alcohol wipes

1. Injection technique:
2. Remove the base cap from the pen by pulling it straight off (do not replace the cap after removal)
3. Position the pen – place the clear base flat against your skin at a 90-degree angle (do not inject through clothing)
4. Create a skin fold if necessary – patients with minimal subcutaneous tissue should gently pinch the skin to ensure subcutaneous delivery
5. Unlock the pen by turning the lock ring
6. Press and hold the green injection button – you will hear a click, and the grey plunger will move
7. Keep the pen pressed against the skin until you hear a second click, which indicates the injection is complete
8. Remove the pen and check that the grey plunger is visible in the indicator window, confirming complete dose delivery

Post-injection care:

• Do not rub the injection site, as this may affect absorption

• Dispose of the used pen in a sharps container immediately (obtain from your GP or pharmacy according to local arrangements)

• Record the injection site and date in your diabetes diary

• Monitor for any unusual reactions over the following hours

Patients experiencing difficulty with the injection technique should contact their diabetes specialist nurse for additional training and support. Remember that each Trulicity pen is for single use only.

Common Injection Site Problems and How to Avoid Them

Despite proper technique, some patients may experience injection site reactions or complications. Understanding these issues and their prevention strategies can improve treatment tolerance and adherence.

Injection site reactions are reported local adverse effects of Trulicity. According to the UK SmPC, these may include:

• Mild erythema (redness)

• Localised swelling or induration

• Pruritus (itching)

• Tenderness or discomfort

Most injection site reactions are mild, transient, and resolve within a few days without intervention. To minimise these reactions, ensure the medication has reached room temperature before injection, rotate sites systematically, and avoid injecting into areas with existing inflammation or skin conditions.

Bruising can occur if a small blood vessel is inadvertently punctured during injection. Whilst generally harmless, frequent bruising may indicate poor technique or the use of anticoagulant medications. Patients taking aspirin, warfarin, or direct oral anticoagulants should inform their healthcare provider, though these medications are not contraindications to Trulicity use. Applying gentle pressure (without rubbing) immediately after injection may reduce bruising risk.

Lipohypertrophy has been discussed previously but warrants emphasis as a preventable complication. Regular self-examination of injection sites can help detect early changes. Patients should palpate their injection areas monthly, feeling for any lumps, bumps, or thickened tissue. If lipohypertrophy develops, those areas must be avoided until the tissue returns to normal, which may take several months.

When to seek medical advice:

• Persistent injection site reactions lasting more than one week

• Signs of infection (increasing warmth, spreading redness, purulent discharge, fever)

• Severe pain or swelling at the injection site

• Signs of severe allergic reaction (widespread rash, difficulty breathing, facial swelling) – seek urgent medical attention or call 999

• Unexplained lumps or significant changes in subcutaneous tissue

Patients experiencing recurrent or troublesome injection site problems should consult their GP or diabetes specialist nurse, who may recommend alternative injection sites, review technique, or consider whether the reactions represent a hypersensitivity to the medication. In rare cases, persistent local reactions may necessitate switching to an alternative GLP-1 receptor agonist, though this decision should be made in consultation with a diabetes specialist and in accordance with NICE guidelines for type 2 diabetes management.

Patients are encouraged to report any suspected side effects to the MHRA Yellow Card Scheme at yellowcard.mhra.gov.uk.

Frequently Asked Questions