Trulicity
Trulicity: instructions for use and reviews
- 1. Release form and composition
- 2. Pharmacological properties
- 3. Indications for use
- 4. Contraindications
- 5. Method of application and dosage
- 6. Side effects
- 7. Overdose
- 8. Special instructions
- 9. Application during pregnancy and lactation
- 10. Use in childhood
- 11. In case of impaired renal function
- 12. For violations of liver function
- 13. Use in the elderly
- 14. Drug interactions
- 15. Analogs
- 16. Terms and conditions of storage
- 17. Terms of dispensing from pharmacies
- 18. Reviews
- 19. Price in pharmacies
Latin name: Trulicity
ATX code: A10BX14
Active ingredient: dulaglutide (Dulaglutide)
Producer: Eli Lilly & Company (USA); Eli Lilly Italy S.p. A. (Eli Lilly Italia S. p. A) (Italy)
Description and photo update: 2018-27-11
Prices in pharmacies: from 9969 rubles.
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Trulicity is a parenteral hypoglycemic agent.
Release form and composition
The drug is released in the form of a solution for subcutaneous (s / c) administration: a clear, colorless liquid (0.5 ml in a syringe, sealed on one side, and equipped with an injection needle with a protective cap on the other; in a cardboard box 4 syringe pens, in each of which 1 syringe is built in, and instructions for the use of Trulicity).
0.5 ml of solution contains:
- active substance: dulaglutide - 0.75 or 1.5 mg;
- additional components: mannitol, sodium citrate dihydrate, polysorbate 80 (vegetable), anhydrous citric acid, water for injection.
Pharmacological properties
Pharmacodynamics
Dulaglutide is a long-acting glucagon-like peptide 1 (GLP-1) receptor agonist. The molecule of the substance consists of two identical chains connected by disulfide bonds, each of which includes an analogue of the modified human GLP-1, covalently linked through a small polypeptide chain to a fragment of the heavy chain (Fc) of the modified human immunoglobulin G4 (IgG4). The part of the dulaglutide molecule, which is an analogue of GLP-1, is, on average, 90% similar to native (natural) human GLP-1. The half-life (T 1/2) of native human GLP-1 as a result of cleavage by dipeptidyl peptidase-4 (DPP-4) and renal clearance is 1.5–2 minutes.
Dulaglutide, in contrast to native GLP-1, is resistant to the action of DPP-4 and has a large size, which slows down absorption and reduces renal clearance. Similar structural features of the active substance provide a soluble form, and its T 1/2 due to this reaches 4.7 days, which makes it possible to inject Trulicity subcutaneously once a week. In addition, the design of the dulaglutide molecule makes it possible to reduce the immune response mediated by the Fcγ receptor and reduce the immunogenic potential.
The hypoglycemic activity of the substance is associated with several mechanisms of GLP-1 action. Against the background of an increased concentration of glucose, dulaglutide in the β-cells of the pancreas leads to an increase in the level of intracellular cyclic adenosine monophosphate (cAMP), which causes an increase in insulin production. In type 2 diabetes mellitus (non-insulin dependent), the substance inhibits the excess production of glucagon, which leads to a decrease in the release of glucose from the liver, and also slows down gastric emptying.
Starting from the first administration, in type 2 diabetes mellitus, Trulicity improves glycemic control as a result of a sustained decrease in fasting glucose, before meals and after meals, which persists for a week until the next dose.
In patients with type 2 diabetes mellitus, according to the results of a pharmacodynamic study of dulaglutide, the drug contributed to the restoration of phase I of insulin secretion to the level observed in healthy individuals taking placebo, and improved phase II of insulin secretion in response to an intravenous bolus of glucose solution. Also, during the study, it was found that with a single administration of the drug at a dose of 1.5 mg, the maximum production of insulin by β-cells of the pancreas increased and the function of β-cells was activated in patients with non-insulin-dependent diabetes, compared with the placebo group.
The pharmacokinetic and corresponding pharmacodynamic profile of the active ingredient allows Trulicity to be used once a week.
The efficacy and safety of dulaglutide was studied in the process of 6 randomized controlled trials of phase III, in which 5171 patients with type 2 diabetes mellitus participated (including those over 65 years old - 958 and over 75 years old - 93 people). The studies involved 3136 persons who received treatment with dulaglutide, while 1719 of them received the drug once a week at a dose of 1.5 mg and 1417 at a dose of 0.75 mg at the same frequency of use. All studies reported clinically significant improvement in glycemic control as measured by glycated hemoglobin (HbA1C).
The use of dulaglutide as a monotherapy versus metformin was studied in a 52-week active controlled clinical study. When Truliciti was administered once a week at doses of 1.5 mg / 0.75 mg, its efficacy was superior to that of metformin, used at a daily dose of 1500–2000 mg, in reducing HbA1c. 26 weeks after the start of therapy, the vast majority of the subjects achieved the target HbA1c <7.0 and <6.5% with dulaglutide than with metformin. The frequency of reported cases of symptomatic hypoglycemia (episodes / patient / year) when using once a week dulaglutide in doses of 1.5 mg / 0.75 mg and using metformin was 0.62; 0.15 and 0.09, respectively.
The efficacy and safety of the drug was evaluated in both placebo-controlled and actively-controlled clinical studies (sitagliptin at a dose of 100 mg / day) for 104 weeks when all drugs were used in combination with metformin. With the use of Trulicity for 52 weeks, 1 time per week at a dose of 1.5 mg / 0.75 mg, a more significant decrease in HbA1c was noted than with sitagliptin. At the same time, a much larger number of patients using dulaglutide achieved target HbA1c levels <7 and <6.5%. These effects persisted throughout the study period. With the introduction of dulaglutide at a dose of 1.5 mg / 0.75 mg and taking sitagliptin, the frequency of confirmed symptomatic hypoglycemia was 0.19; 0.18 and 0.17, respectively.
The efficacy and safety of the drug was also evaluated in a study with active control for 26 weeks in comparison with the introduction of liraglutide - 1.8 mg / day, both drugs were used in combination with metformin. Treatment with dulaglutide at a dose of 1.5 mg once a week led to a similar decrease in HbA1c and the number of patients reaching the target HbA1c level <7 and <6.5% compared with treatment with liraglutide. When Trulicity was used at a dose of 1.5 mg, the frequency of documented symptomatic hypoglycemia was 0.12, and with liraglutide therapy - 0.29.
In all the studies described above, there were no cases of severe hypoglycemia during treatment with dulaglutide.
Comparison of dulaglutide with insulin glargine was conducted in studies lasting 78 weeks with active control. Both agents have been used in combination with metformin and sulfonylurea derivatives. After 52 weeks of dulaglutide treatment with a weekly dose of 1.5 mg, there was a significantly greater decrease in HbA1c compared with insulin glargine, and with the introduction of dulaglutide once a week at a dose of 0.75 mg, the decrease in HbA1c was comparable to that with insulin glargine. At 52 and 78 weeks in the dulaglutide (dose 1.5 mg) group, when compared with the insulin glargine group, the majority of patients achieved the target HbA1c value of <7.0% or <6.5%. The incidence of confirmed symptomatic hypoglycemia for Trulicity at doses of 1.5 mg / 0.75 mg and insulin glargine was 1.67; 1.67 and 3.02, respectively. During therapy with dulaglutide (dose 1,5 mg) and insulin glargine therapy, an equal number of cases of severe hypoglycemia (two each) were reported.
When conducting placebo-controlled observations and actively-controlled clinical trials, the active substance was compared with exenatide (the first two weeks at a dose of 0.005 mg twice a day, then at a dose of 0.01 mg twice a day), when both drugs were combined with pioglitazone and metformin. Patients who received dulaglutide once a week at a dose of 1.5 mg / 0.75 mg had a more pronounced HbA1c compared to the placebo and exenatide group. A significantly larger number of patients achieved the target HbA1c level <7.0% or <6.5%. The frequency of confirmed symptomatic hypoglycemia with the introduction of Trulicity once a week in doses of 1.5 mg / 0.75 mg and 2 times a day of Exenatide was 0.19, respectively; 0.14 and 0.75. Severe hypoglycemia was not observed in the dulaglutide group,and in the exenatide group there were 2 cases of complications.
In the course of a clinical study of Trulicity therapy in combination with insulin, with metformin or without metformin, patients who received insulin 1 or 2 times a day before enrollment in the study abandoned the previous regimen and were randomized to groups using dulaglutide 1 time per week or insulin glargine once a day. Both groups also received prandial insulin lispro, given 3 times daily, with or without metformin. 26 weeks after the start of the study, the effect of dulaglutide in doses of 1.5 mg / 0.75 mg once a week was greater than the effect of insulin glargine in reducing HbA1c. This ratio was maintained until the end of the study, the majority of patients treated with dulaglutide achieved the target HbA1c level <7.0% or <6.5% after 26 weeks and after 52 weeks - <7.0%.when compared with the insulin glargine group.
The frequency of documented symptomatic hypoglycemia with the introduction of dulaglutide once a week at doses of 1.5 mg / 0.75 mg and with the use of insulin glargine once a day was 31.06; 35.66 and 40.95, respectively. There were 10 cases of severe hypoglycemia during therapy with dulaglutide at a dose of 1.5 mg and 7 cases at a dose of 0.75 mg, as well as 15 cases during therapy with insulin glargine.
The use of Trulicity provided a significantly greater decrease in fasting blood glucose concentration compared to the baseline level, the main effect of the drug was observed after 2 weeks. Improvements in fasting glucose were noted throughout the longest study period of 104 weeks. Dulaglutide treatment also resulted in a significant decrease in mean postprandial glycemia (postprandial blood glucose concentration) when compared to baseline (change from baseline to primary time point ranged from −1.95 to −4.23 mmol / L).
With the introduction of Trulicity at a dose of 1.5 mg, a stable decrease in body weight was noted throughout the study (from the baseline to the final time point, the change in the mean value was from -0.35 to -2.9 kg). During therapy with dulaglutide at a dose of 0.75 mg, the change in body weight ranged from 0.86 to −2.63 kg. Its decrease was observed in patients receiving dulaglutide, regardless of the presence of the side effect in the form of nausea. At the same time, weight loss was quantitatively higher in the group of patients with complaints of nausea.
Pharmacokinetics
In type 2 diabetes mellitus, after SC administration of Truliciti, the maximum concentration of dulaglutide (C max) in plasma was observed after 48 hours. The area under the concentration-time curve (AUC) and the average C max after multiple s / c injections of the agent at a dose of 1.5 mg averaged 114 ng / ml and 14,000 ng × h / ml, respectively. The steady-state concentration of dulaglutide in the blood (C ss) was achieved after 2–4 weeks of therapy at a dose of 1.5 mg once a week. After the introduction of dulaglutide under the skin in the thigh, abdomen or shoulder in a single dose of 1.5 mg, the concentrations were comparable. With a single subcutaneous injection of Trulicity at a dose of 1.5 mg / 0.75 mg, its average absolute bioavailability was 47% and 65%, respectively.
The average volume of distribution (V d) of the agent in an equilibrium state after its SC administration at doses of 1.5 mg / 0.75 mg in type 2 diabetes mellitus was approximately 19.2 and 17.4 liters, respectively.
It is assumed that the cleavage of dulaglutide into amino acids occurs using the main pathways of protein catabolism.
The average clearance of the substance used in doses of 1.5 mg / 0.75 mg in steady state was equal to 0.073 l / h and 0.107 l / h, respectively, and T 1/2 was 4.5 and 4.7 days, respectively.
Pharmacokinetic analysis showed a statistically significant inverse relationship between body weight or BMI and the use of dulaglutide, however, body weight or BMI did not have a significant effect on glycemic control.
The pharmacokinetic parameters of dulaglutide do not significantly depend on gender and race.
Indications for use
Trulicity is recommended for use in adult patients with type 2 diabetes mellitus to improve glycemic control:
- As a monotherapy drug, if the use of diet and exercise cannot provide the necessary glycemic control in patients who are not shown to use metformin due to the presence of intolerance or contraindications.
- As part of combination therapy in combination with other antidiabetic agents (including insulin), if the use of the latter together with diet and exercise cannot provide the necessary glycemic control.
Contraindications
Absolute:
- chronic heart failure (CHF);
- diabetic ketoacidosis;
- type 1 diabetes mellitus;
- severe lesions of the gastrointestinal tract (GIT), including severe gastric paresis - due to the lack of experience with the use of Trulicity in such patients;
- severe renal impairment;
- acute pancreatitis;
- age up to 18 years;
- pregnancy and lactation;
- hypersensitivity to any of the components of the product.
Relative (use Trulicity with extreme caution):
- concomitant use of oral medications that require rapid absorption from the gastrointestinal tract;
- age over 75 years.
Trulicity, instructions for use: method and dosage
Trulicity is injected subcutaneously into the thigh, abdomen or shoulder area once a week at any time of the day. The drug cannot be administered intravenously or intramuscularly. Injections are carried out regardless of the diet.
When using the drug for monotherapy, the recommended dose is 0.75 mg.
When carrying out combined treatment, Trulicity should be used at a dose of 1.5 mg, and in patients aged 75 years and older - at an initial dose of 0.75 mg.
When Trulicity is added to current treatment with metformin and / or pioglitazone, the latter can be continued at the same dose. When adding the drug to the ongoing therapy with prandial insulin or sulfonylurea derivatives, it is necessary to consider the possibility of reducing the dose of prandial insulin or sulfonylurea derivatives due to the aggravation of the risk of hypoglycemia. Additional glycemic control is not required to change the dose of dulaglutide, and for the dose of prandial insulin or a sulfonylurea derivative it may be necessary.
If the administration of one dose of Trulicity was missed, it must be administered as soon as possible, provided that at least 72 hours (3 days) remain until the next scheduled dose is used. If less than 72 hours remain before the next dose, you should skip 1 injection and use the next dose according to the usual treatment schedule. In any case, you can resume the usual dulaglutide regimen once a week. If necessary, the day of the week on which the drug is regularly used can be changed if at least 72 hours have passed since the previous administration.
The Trulicity single-use syringe is a single-use, pre-filled, ready-to-use solution delivery device. Each pen contains one weekly dose of the drug - 0.75 mg / 0.5 ml or 1.5 mg / 0.5 mg. Each device is designed to deliver only 1 dose. Since Trulicity is used once a week, it is recommended to make notes on the calendar to remind you about the next administration.
After pressing the green button on the pen, the needle is automatically inserted into the skin and the solution is injected, and after the injection is completed, the needle is removed.
Before carrying out the procedure, you should remove the syringe pen from the refrigerator, inspect it, check the labeling and the expiration date. If the solution becomes cloudy, changes in color or visible particles appear in it, or if the pen is damaged, the agent cannot be used in this device.
Before using Trulicity, you must wash your hands and choose an injection site. The drug should be injected into the thigh or abdomen, if another person is injecting the patient, he can inject the solution into the shoulder area. Injection sites should be changed (alternated) every week; if the same area is used, different injection points should be selected.
To carry out the injection, you need to make sure that the syringe pen is blocked, then remove and discard the gray cap that covers its base. You do not need to put it back on, as this can damage the needle, and you should also not touch the needle. Then it is required to strongly press the transparent base of the syringe pen to the skin surface at the injection site, and unlock it by turning the locking ring. After pressing the green button for the administration of the drug, you need to hold it until you hear a loud click. The transparent base should continue to be pressed firmly against the skin until a second click is heard. It will sound about 5-10 seconds later as the needle begins to retract. After that, the pen should be removed from the skin. Confirmation that the injection is completethere will be a gray part of the mechanism, which can be seen only after the end of the procedure.
It should be remembered that glass parts are included in the design of the pen, so it must be used with caution. Once the device has been dropped onto a hard surface, it cannot be used.
The syringe should be stored in the refrigerator without freezing. If the solution in the device has been frozen, it must not be used.
Side effects
- Gastrointestinal tract: very often - nausea, abdominal pain, diarrhea, vomiting *; often - dyspepsia, loss of appetite, flatulence, constipation, bloating, belching, gastroesophageal reflux disease; rarely - acute pancreatitis;
- metabolism and nutritional disorders: very often - hypoglycemia ** (in combination with prandial insulin and metformin * or metformin and glimepiride); often - hypoglycemia ** (as a monotherapy drug or in combination with metformin and pioglitazone);
- instrumental and laboratory data: often - atrioventricular (AV) block of the 1st degree, sinus tachycardia;
- general disorders and disorders at the injection site: often - weakness; infrequently - reactions at the injection site.
* Only for the administration of Trulicity at a dose of 1.5 mg, for a dose of 0.75 mg, the frequency of adverse reactions corresponds to a lower category.
** Documented symptomatic hypoglycemia and blood glucose level ≤3.9 mmol / L.
In clinical trials, the most common adverse effects were gastrointestinal disorders (including nausea, vomiting, diarrhea), usually mild to moderate severity. Most often, these reactions were observed during the first two weeks of drug treatment, and during the next four weeks the frequency of their development rapidly decreased. In the course of clinical and pharmacological studies, which lasted up to 6 weeks, in which patients with type 2 diabetes mellitus took part, most adverse reactions from the gastrointestinal tract were recorded during the first 2-3 days after the first dose, with the following doses their frequency declined.
Overdose
Symptoms of a Trulicity overdose include hypoglycemia and adverse gastrointestinal effects.
With the development of such reactions, it is necessary to begin symptomatic treatment corresponding to the manifested clinical signs.
special instructions
Trulicity should not be used in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis.
GLP-1 receptor agonists can lead to the development of negative effects from the digestive tract. This fact must be taken into account when prescribing Trulicity to patients with impaired renal function, since undesirable phenomena such as vomiting, nausea and / or diarrhea can cause dehydration, which in turn impairs renal function.
Treatment with GLP-1 receptor agonists is associated with the threat of acute pancreatitis. If characteristic symptoms of acute pancreatitis (including persistent severe pain in the abdomen) appear during therapy with dulaglutide, it is necessary to stop using the drug and immediately consult a doctor. In the case of diagnosed confirmation of the presence of pancreatitis, Trulicity therapy cannot be resumed. An increase in the activity of pancreatic enzymes in the absence of other signs of acute pancreatitis in itself is not a prognostic factor for this disease.
The drug in a dose of 1.5 mg contains less than 1 mmol of sodium (23 mg), i.e. it actually does not contain sodium.
There is no evidence of the effect of Trulicity on human fertility. In animal studies following the use of dulaglutide, no direct effects on mating or fertility have been observed.
Influence on the ability to drive vehicles and complex mechanisms
The drug does not affect or may have a slight effect on the ability to drive vehicles and control other complex equipment. When prescribing Trulicity in combination with insulin or sulfonylurea derivatives, it is recommended to drive transport and other complex and potentially dangerous mechanisms with extreme caution to prevent the onset of hypoglycemia.
Application during pregnancy and lactation
Data on the use of dulaglutide by pregnant women are lacking or very limited. When conducting studies on animals, the reproductive toxicity of the drug was revealed, and therefore, during pregnancy, the use of Trulicity is contraindicated.
Since it is not known whether dulaglutide passes into breast milk, a risk to the health of newborns / infants cannot be excluded during therapy. During lactation, the use of Trulicity is contraindicated.
Pediatric use
For patients under 18 years of age, the use of a hypoglycemic agent is contraindicated, since there is no information confirming the effectiveness and safety of its administration to children and adolescents.
With impaired renal function
In the presence of severe renal impairment [estimated GFR (glomerular filtration rate) <30 ml / min / 1.73 m²] or end-stage renal disease, the use of Trulicity is contraindicated due to very limited experience with its use in this population.
Patients with mild / moderate functional renal impairment do not need to change the dose of Trulicity.
For violations of liver function
In patients with impaired liver activity, there is no need to adjust the dose of this hypoglycemic drug.
Use in the elderly
Patients over the age of 65 do not need to change the recommended dose of dulaglutide. However, due to the fact that the experience of treating people over 75 years of age with the drug is extremely limited, for this age category, its initial dose should not exceed 0.75 mg once a week.
Drug interactions
Dulaglutide, causing a decrease in the rate of gastric emptying, may affect the speed of absorption of oral drugs used concomitantly with it. Trulicity should be used with caution in patients receiving oral medications who require rapid gastrointestinal absorption. Delayed gastric emptying may result in a slight increase in sustained-release drug exposure as a result of the increased release period.
Interaction reactions observed when Trulicity is combined with other medicinal substances / preparations:
- paracetamol: after the first administration of dulaglutide at doses of 1 or 3 mg, the C max of paracetamol decreased by 36 and 50%, respectively, and the median T max was noted later (after 3 and 4 hours, respectively). After combined use with dulaglutide at a dose not exceeding 3 mg, in a steady state, there was no statistically significant difference in the values of AUC (0-12), T max and C max of paracetamol (no dose change is required);
- atorvastatin: the C max and AUC (0 – ∞) of this substance and its main metabolite o-hydroxyatorvastatin decreased to 70 and 21%, respectively, and the average T 1/2 of atorvastatin and o-hydroxyatorvastatin after dulaglutide increased by 17 and 41%, respectively; such changes are not clinically significant;
- warfarin: the concentration of S- and R-warfarin, and C max of R-warfarin remained unchanged, and C max of S-warfarin decreased by 22%; AUC for INR (International Normalized Ratio) increased by 2%, which is presumably not clinically significant, there was no effect on the maximum INR value (INR max); the response period for INR max increased by 6 hours, which was combined with a T max delay of approximately 4 and 6 hours for S- and R-warfarin, respectively; this combination does not require dose adjustment of warfarin;
- digoxin: the total exposure (AUC t) and T max of this substance in the equilibrium state remained unchanged after combined use with two consecutive doses of dulaglutide; C max decreased by 22%; no change in digoxin dose is required;
- antihypertensive drugs: there were no clinically significant changes in the AUC or C max of lisinopril while using multiple doses of dulaglutide; on the 3rd and 24th days of the study, there was a statistically significant delay in T max of lisinopril by about 1 hour; with the introduction of a single dose of dulaglutide simultaneously with metoprolol, the AUC and C max of the latter increased by 19 and 32%, respectively; C max metoprolol able to reach 1 hour later, but this change is not applied to the statistically significant (correction doses of these agents are not needed);
- metformin (conventional release): when combined with multiple doses of dulaglutide, the metformin AUC t increased to 15%, C max decreased to 12%, T max remained unchanged; such effects are associated with a delay in gastric emptying caused by dulaglutide, and are within the range of variability of the pharmacokinetics of metformin, as a result of which they are not determined as clinically significant (dose adjustment is not performed);
- oral contraceptives (norgestimate 0.18 mg / ethinyl estradiol 0.025 mg): there was no effect on the total exposure of norelgestromin and ethinyl estradiol, the latter also showed a statistically significant decrease in C max by 26% and 13%, and a delay in T max by 2 and 0, 3 hours, respectively (dose adjustment of these substances is not required);
- sitagliptin: no change in the concentration of this substance was observed when combined with a single dose of dulaglutide; when combined with two consecutive doses of dulaglutide, a decrease in AUC 0-t and C max of sitagliptin was noted by 7.4 and 23.1%, respectively; T max - increased by 0.5 hours, compared with monotherapy with this agent; within 24 hours sitagliptin can bring up to 80% inhibition of DPP-4; C max and exposure to dulaglutide increased on average by 27% and 38%, respectively, and the median T max increased to approximately 24 hours, dulaglutide demonstrates a high degree of protection against DPP-4 inactivation.
Analogs
Trulicity's analogues are: Byetta, Victoza, Byeta Long, Saxenda, Lixumia, etc.
Terms and conditions of storage
Store in its original packaging, protected from light, at a temperature of 2-8 ° C. Do not freeze! Keep out of the reach of children.
Shelf life is 2 years. The drug purchased from a pharmacy can be stored at a temperature not exceeding 30 ° C for no more than 14 days.
Terms of dispensing from pharmacies
Dispensed by prescription.
Reviews about Trulicity
According to the few reviews on medical websites about Trulicity, it is an effective glucose-normalizing agent. The drug, preventing surges in blood sugar, provides proper glycemic control when administered 1 dose once a week, which is very convenient for patients. Also, thanks to the action of the antidiabetic agent, many patients were able to lose weight by an average of 2–6 kg.
The disadvantages of Trulicity include the presence of adverse reactions (mainly nausea and vomiting), as well as its high cost.
Price for Trulicity in pharmacies
The price of Trulicity (solution for subcutaneous administration) for a package containing 4 syringe pens of 0.5 ml each can be: dosage of 1.5 mg - 10900-11200 rubles; dosage 0.75 mg –11340–11740 rubles.
Trulicity: prices in online pharmacies
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Drug name Price Pharmacy |
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Trulicity 1.5 mg / 0.5 ml solution for subcutaneous administration of 0.5 ml 4 pcs. 9969 RUB Buy |
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Trulicity 0.75 mg / 0.5 ml solution for subcutaneous administration of 0.5 ml 4 pcs. 10485 RUB Buy |
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Trulicity p / c input 1.5 mg syringe pen 0.5 ml No. 4 11250 RUB Buy |
Anna Kozlova Medical journalist About the author
Education: Rostov State Medical University, specialty "General Medicine".
Information about the drug is generalized, provided for informational purposes only and does not replace the official instructions. Self-medication is hazardous to health!
