FDA Label for Jentadueto Xr
View Indications, Usage & Precautions
- WARNING: LACTIC ACIDOSIS
- 1.1 INDICATION
- 1.2 IMPORTANT LIMITATIONS OF USE
- 2.1 RECOMMENDED DOSING
- 2.2 RECOMMENDED DOSING IN RENAL IMPAIRMENT
- 2.3 DISCONTINUATION FOR IODINATED CONTRAST IMAGING PROCEDURES
- 3 DOSAGE FORMS AND STRENGTHS
- 4 CONTRAINDICATIONS
- 5.1 LACTIC ACIDOSIS
- 5.2 PANCREATITIS
- 5.3 HEART FAILURE
- 5.4 USE WITH MEDICATIONS KNOWN TO CAUSE HYPOGLYCEMIA
- 5.5 HYPERSENSITIVITY REACTIONS
- 5.6 VITAMIN B12 LEVELS
- 5.7 SEVERE AND DISABLING ARTHRALGIA
- 5.8 BULLOUS PEMPHIGOID
- 5.9 MACROVASCULAR OUTCOMES
- 6.1 CLINICAL TRIALS EXPERIENCE
- 6.2 POSTMARKETING EXPERIENCE
- 7.1 DRUG INTERACTIONS WITH METFORMIN
- 7.2 DRUG INTERACTIONS WITH LINAGLIPTIN
- 7.3 INSULIN SECRETAGOGUES OR INSULIN
- 7.4 DRUGS AFFECTING GLYCEMIC CONTROL
- 8.1 PREGNANCY
- 8.2 LACTATION
- 8.3 FEMALES AND MALES OF REPRODUCTIVE POTENTIAL
- 8.4 PEDIATRIC USE
- 8.5 GERIATRIC USE
- 8.6 RENAL IMPAIRMENT
- 8.7 HEPATIC IMPAIRMENT
- 10 OVERDOSAGE
- 11 DESCRIPTION
- 12.1 MECHANISM OF ACTION
- 12.2 PHARMACODYNAMICS
- 12.3 PHARMACOKINETICS
- 13.1 CARCINOGENESIS, MUTAGENESIS, IMPAIRMENT OF FERTILITY
- 14 CLINICAL STUDIES
- 14.1 INITIAL COMBINATION THERAPY WITH LINAGLIPTIN AND METFORMIN
- 14.2 INITIAL COMBINATION THERAPY WITH LINAGLIPTIN AND METFORMIN VS LINAGLIPTIN IN TREATMENT-NAïVE PATIENTS
- 14.3 ADD-ON COMBINATION THERAPY WITH METFORMIN
- 14.4 ACTIVE-CONTROLLED STUDY VS GLIMEPIRIDE IN COMBINATION WITH METFORMIN
- 14.5 ADD-ON COMBINATION THERAPY WITH METFORMIN AND A SULFONYLUREA
- 16 HOW SUPPLIED/STORAGE AND HANDLING
- 17 PATIENT COUNSELING INFORMATION
- SPL MEDGUIDE
- PACKAGE LABEL.PRINCIPAL DISPLAY PANEL
Jentadueto Xr Product Label
The following document was submitted to the FDA by the labeler of this product Boehringer Ingelheim Pharmaceuticals, Inc.. The document includes published materials associated whith this product with the essential scientific information about this product as well as other prescribing information. Product labels may durg indications and usage, generic names, contraindications, active ingredients, strength dosage, routes of administration, appearance, warnings, inactive ingredients, etc.
Warning: Lactic Acidosis
Postmarketing cases of metformin-associated lactic acidosis have resulted in death, hypothermia, hypotension, and resistant bradyarrhythmias. The onset of metformin-associated lactic acidosis is often subtle, accompanied only by nonspecific symptoms such as malaise, myalgias, respiratory distress, somnolence, and abdominal pain. Metformin-associated lactic acidosis was characterized by elevated blood lactate levels (>5 mmol/Liter), anion gap acidosis (without evidence of ketonuria or ketonemia), an increased lactate/pyruvate ratio; and metformin plasma levels generally >5 mcg/mL [see Warnings and Precautions (5.1)].
Risk factors for metformin-associated lactic acidosis include renal impairment, concomitant use of certain drugs (e.g., carbonic anhydrase inhibitors such as topiramate), age 65 years old or greater, having a radiological study with contrast, surgery and other procedures, hypoxic states (e.g., acute congestive heart failure), excessive alcohol intake, and hepatic impairment.
Steps to reduce the risk of and manage metformin-associated lactic acidosis in these high risk groups are provided in the full prescribing information [see Dosage and Administration (2.2), Contraindications (4), Warnings and Precautions (5.1), Drug Interactions (7.1), and Use in Specific Populations (8.6, 8.7)].
If metformin-associated lactic acidosis is suspected, immediately discontinue JENTADUETO XR and institute general supportive measures in a hospital setting. Prompt hemodialysis is recommended [see Warnings and Precautions (5.1)].
1.1 Indication
JENTADUETO XR is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus when treatment with both linagliptin and metformin is appropriate [see Dosage and Administration (2.1) and Clinical Studies (14.1)].
1.2 Important Limitations Of Use
JENTADUETO XR should not be used in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings.
JENTADUETO XR has not been studied in patients with a history of pancreatitis. It is unknown whether patients with a history of pancreatitis are at an increased risk for the development of pancreatitis while using JENTADUETO XR [see Warnings and Precautions (5.2)].
2.1 Recommended Dosing
The dosage of JENTADUETO XR should be individualized on the basis of both effectiveness and tolerability, while not exceeding the maximum recommended total daily dose of linagliptin 5 mg and metformin hydrochloride 2000 mg. JENTADUETO XR should be given once daily with a meal. For available dosage forms and strengths [see Dosage Forms and Strengths (3)].
Recommended starting dose:
- In patients currently not treated with metformin, initiate JENTADUETO XR treatment with 5 mg linagliptin/1000 mg metformin hydrochloride extended-release once daily with a meal.
- In patients already treated with metformin, start JENTADUETO XR with 5 mg of linagliptin total daily dose and a similar total daily dose of metformin once daily with a meal.
- In patients already treated with linagliptin and metformin or JENTADUETO, switch to JENTADUETO XR containing 5 mg of linagliptin total daily dose and a similar total daily dose of metformin once daily with a meal.
JENTADUETO XR should be swallowed whole. The tablets must not be split, crushed, dissolved, or chewed before swallowing. There have been reports of incompletely dissolved tablets being eliminated in the feces for other tablets containing metformin extended-release. If a patient reports seeing tablets in feces, the healthcare provider should assess adequacy of glycemic control.
JENTADUETO XR 5 mg linagliptin/1000 mg metformin hydrochloride extended-release tablet should be taken as a single tablet once daily. Patients using 2.5 mg linagliptin/1000 mg metformin extended-release tablets should take two tablets together once daily.
No studies have been performed specifically examining the safety and efficacy of JENTADUETO XR in patients previously treated with other oral antihyperglycemic agents and switched to JENTADUETO XR. Any change in therapy of type 2 diabetes mellitus should be undertaken with care and appropriate monitoring as changes in glycemic control can occur.
2.2 Recommended Dosing In Renal Impairment
Assess renal function prior to initiation of JENTADUETO XR and periodically thereafter.
JENTADUETO XR is contraindicated in patients with an estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73 m2.
Initiation of JENTADUETO XR in patients with an eGFR between 30-45 mL/min/1.73 m2 is not recommended.
In patients taking JENTADUETO XR whose eGFR later falls below 45 mL/min/1.73 m2, assess benefit risk of continuing therapy.
Discontinue JENTADUETO XR if the patient’s eGFR later falls below 30 mL/min/1.73 m2 [see Contraindications (4) and Warnings and Precautions (5.1)].
2.3 Discontinuation For Iodinated Contrast Imaging Procedures
Discontinue JENTADUETO XR at the time of, or prior to, an iodinated contrast imaging procedure in patients with an eGFR between 30 and 60 mL/min/1.73 m2; in patients with a history of liver disease, alcoholism or heart failure; or in patients who will be administered intra-arterial iodinated contrast. Re-evaluate eGFR 48 hours after the imaging procedure; restart JENTADUETO XR if renal function is stable [see Warnings and Precautions (5.1)].
3 Dosage Forms And Strengths
JENTADUETO XR is a combination of linagliptin and extended-release metformin hydrochloride. JENTADUETO XR tablets are available in the following dosage forms and strengths:
- 5 mg/1000 mg are white, oval-shaped coated tablets with one side printed in black ink with the Boehringer Ingelheim logo and “D5” on the top line and “1000M” on the bottom line.
- 2.5 mg /1000 mg are yellow, oval-shaped coated tablets with one side printed in black ink with the Boehringer Ingelheim logo and “D2” on the top line and “1000M” on the bottom line.
4 Contraindications
JENTADUETO XR is contraindicated in patients with:
- Severe renal impairment (eGFR below 30 mL/min/1.73 m2) [see Warnings and Precautions (5.1)]
- Acute or chronic metabolic acidosis, including diabetic ketoacidosis. Diabetic ketoacidosis should be treated with insulin [see Warnings and Precautions (5.1)]
- A history of hypersensitivity reaction to linagliptin, such as anaphylaxis, angioedema, exfoliative skin conditions, urticaria, or bronchial hyperreactivity [see Warnings and Precautions (5.5) and Adverse Reactions (6.1)]
- Hypersensitivity to metformin
5.1 Lactic Acidosis
Metformin
There have been postmarketing cases of metformin-associated lactic
acidosis, including fatal cases. These cases had a subtle onset and
were accompanied by nonspecific symptoms such as malaise, myalgias,
abdominal pain, respiratory distress, or increased somnolence; however,
hypothermia, hypotension and resistant bradyarrhythmias have occurred
with severe acidosis. Metformin-associated lactic acidosis was characterized
by elevated blood lactate concentrations (>5 mmol/Liter), anion gap
acidosis (without evidence of ketonuria or ketonemia), and an increased
lactate pyruvate ratio; metformin plasma levels generally >5 mcg/mL.
Metformin decreases liver uptake of lactate increasing lactate blood
levels which may increase risk of lactic acidosis, especially in patients
at risk.
If metformin-associated lactic acidosis is suspected, general supportive measures should be instituted promptly in a hospital setting, along with immediate discontinuation of JENTADUETO XR. In JENTADUETO XR-treated patients with a diagnosis or strong suspicion of lactic acidosis, prompt hemodialysis is recommended to correct the acidosis and remove accumulated metformin (metformin hydrochloride is dialyzable, with clearance of up to 170 mL/min under good hemodynamic conditions). Hemodialysis has often resulted in reversal of symptoms and recovery.
Educate patients and their families about the symptoms of lactic acidosis and if these symptoms occur instruct them to discontinue JENTADUETO XR and report these symptoms to their healthcare provider.
For each of the known and possible risk factors for metformin-associated lactic acidosis, recommendations to reduce the risk of and manage metformin-associated lactic acidosis are provided below:
Renal Impairment: The postmarketing metformin-associated lactic acidosis cases primarily occurred in patients with significant renal impairment. The risk of metformin accumulation and metformin-associated lactic acidosis increases with the severity of renal impairment because metformin is substantially excreted by the kidney. Clinical recommendations based upon the patient’s renal function include [see Dosage and Administration (2.2), Clinical Pharmacology (12.3)]:
- Before initiating JENTADUETO XR, obtain an estimated glomerular filtration rate (eGFR).
- JENTADUETO XR is contraindicated in patients with an eGFR less than 30 mL/min/1.73 m2 [see Contraindications (4)].
- Initiation of JENTADUETO XR is not recommended in patients with eGFR between 30 – 45 mL/min/1.73 m2.
- Obtain an eGFR at least annually in all patients taking JENTADUETO XR. In patients at increased risk for the development of renal impairment (e.g., the elderly), renal function should be assessed more frequently.
- In patients taking JENTADUETO XR whose eGFR later falls below 45 mL/min/1.73 m2, assess the benefit and risk of continuing therapy.
Drug Interactions: The concomitant use of JENTADUETO XR with specific drugs may increase the risk of metformin-associated lactic acidosis: those that impair renal function, result in significant hemodynamic change, interfere with acid-base balance or increase metformin accumulation (e.g., cationic drugs) [see Drug Interactions (7.1)]. Therefore, consider more frequent monitoring of patients.
Age 65 or Greater: The risk of metformin-associated lactic acidosis increases with the patient’s age because elderly patients have a greater likelihood of having hepatic, renal, or cardiac impairment than younger patients. Assess renal function more frequently in elderly patients [see Use in Specific Populations (8.5)].
Radiological Studies with Contrast: Administration of intravascular iodinated contrast agents in metformin-treated patients has led to an acute decrease in renal function and the occurrence of lactic acidosis. Stop JENTADUETO XR at the time of, or prior to, an iodinated contrast imaging procedure in patients with an eGFR between 30 and 60 mL/min/1.73 m2; in patients with a history of hepatic impairment, alcoholism, or heart failure; or in patients who will be administered intra-arterial iodinated contrast. Re-evaluate eGFR 48 hours after the imaging procedure, and restart JENTADUETO XR if renal function is stable.
Surgery and Other Procedures: Withholding of food and fluids during surgical or other procedures may increase the risk for volume depletion, hypotension and renal impairment. JENTADUETO XR should be temporarily discontinued while patients have restricted food and fluid intake.
Hypoxic States: Several of the postmarketing cases of metformin-associated lactic acidosis occurred in the setting of acute congestive heart failure (particularly when accompanied by hypoperfusion and hypoxemia). Cardiovascular collapse (shock), acute myocardial infarction, sepsis, and other conditions associated with hypoxemia have been associated with lactic acidosis and may also cause prerenal azotemia. When such events occur, discontinue JENTADUETO XR.
Excessive Alcohol Intake: Alcohol potentiates the effect of metformin on lactate metabolism and this may increase the risk of metformin-associated lactic acidosis. Warn patients against excessive alcohol intake while receiving JENTADUETO XR.
Hepatic Impairment: Patients with hepatic impairment have developed cases of metformin-associated lactic acidosis. This may be due to impaired lactate clearance resulting in higher lactate blood levels. Therefore, avoid use of JENTADUETO XR in patients with clinical or laboratory evidence of hepatic disease.
5.2 Pancreatitis
There have been postmarketing reports of acute pancreatitis, including fatal pancreatitis, in patients taking linagliptin. Take careful notice of potential signs and symptoms of pancreatitis. If pancreatitis is suspected, promptly discontinue JENTADUETO XR and initiate appropriate management. It is unknown whether patients with a history of pancreatitis are at increased risk for the development of pancreatitis while using JENTADUETO XR.
5.3 Heart Failure
An association between DPP-4 inhibitor treatment and heart failure has been observed in cardiovascular outcomes trials for two other members of the DPP-4 inhibitor class. These trials evaluated patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease.
Consider the risks and benefits of JENTADUETO XR prior to initiating treatment in patients at risk for heart failure, such as those with a prior history of heart failure and a history of renal impairment, and observe these patients for signs and symptoms of heart failure during therapy. Advise patients of the characteristic symptoms of heart failure and to immediately report such symptoms. If heart failure develops, evaluate and manage according to current standards of care and consider discontinuation of JENTADUETO XR.
5.4 Use With Medications Known To Cause Hypoglycemia
Linagliptin
Insulin secretagogues and insulin are known to cause
hypoglycemia. The use of linagliptin in combination with an insulin
secretagogue (e.g., sulfonylurea) was associated with a higher rate
of hypoglycemia compared with placebo in a clinical trial [see
Adverse Reactions (6.1)].
Therefore, a lower dose of the insulin secretagogue or insulin may
be required to reduce the risk of hypoglycemia when used in combination
with JENTADUETO XR [see Drug Interactions (7.3)].
Metformin
Hypoglycemia
does not occur in patients receiving metformin alone under usual circumstances
of use, but could occur when caloric intake is deficient, when strenuous
exercise is not compensated by caloric supplementation, or during
concomitant use with other glucose-lowering agents (such as SUs and
insulin) or ethanol. Elderly, debilitated, or malnourished patients,
and those with adrenal or pituitary insufficiency or alcohol intoxication
are particularly susceptible to hypoglycemic effects. Hypoglycemia
may be difficult to recognize in the elderly, and in people who are
taking β-adrenergic blocking drugs.
5.5 Hypersensitivity Reactions
There have been postmarketing reports of serious hypersensitivity reactions in patients treated with linagliptin (one of the components of JENTADUETO XR). These reactions include anaphylaxis, angioedema, and exfoliative skin conditions. Onset of these reactions occurred within the first 3 months after initiation of treatment with linagliptin, with some reports occurring after the first dose. If a serious hypersensitivity reaction is suspected, discontinue JENTADUETO XR, assess for other potential causes for the event, and institute alternative treatment for diabetes.
Angioedema has also been reported with other dipeptidyl peptidase-4 (DPP-4) inhibitors. Use caution in a patient with a history of angioedema to another DPP-4 inhibitor because it is unknown whether such patients will be predisposed to angioedema with JENTADUETO XR.
5.6 Vitamin B12 Levels
In controlled, 29-week clinical trials of metformin a decrease to subnormal levels of previously normal serum vitamin B12 levels, without clinical manifestations, was observed in approximately 7% of metformin-treated patients. Such decrease, possibly due to interference with B12 absorption from the B12-intrinsic factor complex, is, however, very rarely associated with anemia or neurologic manifestations due to the short duration (<1 year) of the clinical trials. This risk may be more relevant to patients receiving long-term treatment with metformin, and adverse hematologic and neurologic reactions have been reported postmarketing. The decrease in vitamin B12 levels appears to be rapidly reversible with discontinuation of metformin or vitamin B12 supplementation. Measurement of hematologic parameters on an annual basis is advised in patients on JENTADUETO XR and any apparent abnormalities should be appropriately investigated and managed. Certain individuals (those with inadequate vitamin B12 or calcium intake or absorption) appear to be predisposed to developing subnormal vitamin B12 levels. In these patients, routine serum vitamin B12 measurement at 2- to 3-year intervals may be useful.
5.7 Severe And Disabling Arthralgia
There have been postmarketing reports of severe and disabling arthralgia in patients taking DPP-4 inhibitors. The time to onset of symptoms following initiation of drug therapy varied from one day to years. Patients experienced relief of symptoms upon discontinuation of the medication. A subset of patients experienced a recurrence of symptoms when restarting the same drug or a different DPP-4 inhibitor. Consider DPP-4 inhibitors as a possible cause for severe joint pain and discontinue drug if appropriate.
5.8 Bullous Pemphigoid
Postmarketing cases of bullous pemphigoid requiring hospitalization have been reported with DPP-4 inhibitor use. In reported cases, patients typically recovered with topical or systemic immunosuppressive treatment and discontinuation of the DPP-4 inhibitor. Tell patients to report development of blisters or erosions while receiving JENTADUETO XR. If bullous pemphigoid is suspected, JENTADUETO XR should be discontinued and referral to a dermatologist should be considered for diagnosis and appropriate treatment.
5.9 Macrovascular Outcomes
There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with linagliptin or metformin.
6.1 Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
Linagliptin/Metformin
The safety of concomitantly administered linagliptin (daily dose
5 mg) and metformin (mean daily dose of approximately 1800 mg) has
been evaluated in 2816 patients with type 2 diabetes mellitus treated
for ≥12 weeks in clinical trials.
Three placebo-controlled studies with linagliptin + metformin were conducted: 2 studies were 24 weeks in duration, 1 study was 12 weeks in duration. In the 3 placebo-controlled clinical studies, adverse reactions which occurred in ≥5% of patients receiving linagliptin + metformin (n=875) and were more common than in patients given placebo + metformin (n=539) included nasopharyngitis (5.7% vs 4.3%).
In a 24-week factorial design study, adverse reactions reported in ≥5% of patients receiving linagliptin + metformin and were more common than in patients given placebo are shown in Table 1.
Placebo n=72 | Linagliptin Monotherapy n=142 | Metformin Monotherapy n=291 | Combination
of Linagliptin with Metformin n=286 | |
n (%) | n (%) | n (%) | n (%) | |
Nasopharyngitis | 1 (1.4) | 8 (5.6) | 8 (2.7) | 18 (6.3) |
Diarrhea | 2 (2.8) | 5 (3.5) | 11 (3.8) | 18 (6.3) |
Other adverse reactions reported in clinical studies with treatment of linagliptin + metformin were hypersensitivity (e.g., urticaria, angioedema, or bronchial hyperreactivity), cough, decreased appetite, nausea, vomiting, pruritus, and pancreatitis.
Linagliptin
Adverse reactions reported in ≥2% of patients treated
with linagliptin 5 mg and more commonly than in patients treated with
placebo included: nasopharyngitis (7.0% vs 6.1%), diarrhea (3.3%
vs 3.0%), and cough (2.1% vs 1.4%).
Rates for other adverse reactions for linagliptin 5 mg vs placebo when linagliptin was used in combination with specific anti-diabetic agents were: urinary tract infection (3.1% vs 0%) and hypertriglyceridemia (2.4% vs 0%) when linagliptin was used as add-on to sulfonylurea; hyperlipidemia (2.7% vs 0.8%) and weight increased (2.3% vs 0.8%) when linagliptin was used as add-on to pioglitazone; and constipation (2.1% vs 1%) when linagliptin was used as add-on to basal insulin therapy.
Other adverse reactions reported in clinical studies with treatment of linagliptin monotherapy were hypersensitivity (e.g., urticaria, angioedema, localized skin exfoliation, or bronchial hyperreactivity) and myalgia. In the clinical trial program, pancreatitis was reported in 15.2 cases per 10,000 patient year exposure while being treated with linagliptin compared with 3.7 cases per 10,000 patient year exposure while being treated with comparator (placebo and active comparator, sulfonylurea). Three additional cases of pancreatitis were reported following the last administered dose of linagliptin.
Metformin
The most common adverse reactions due to initiation of metformin
are diarrhea, nausea/vomiting, flatulence, asthenia, indigestion,
abdominal discomfort, and headache.
In a 24-week clinical trial in which extended-release metformin or placebo was added to glyburide therapy, the most common (>5% and greater than placebo) adverse reactions in the combined treatment group were hypoglycemia (13.7% vs 4.9%), diarrhea (12.5% vs 5.6%), and nausea (6.7% vs 4.2%).
Hypoglycemia
Linagliptin/Metformin
In a 24-week
factorial design study, hypoglycemia was reported in 4 (1.4%) of 286
subjects treated with linagliptin + metformin, 6 (2.1%) of 291 subjects
treated with metformin, and 1 (1.4%) of 72 subjects treated with placebo.
When linagliptin was administered in combination with metformin and
a sulfonylurea, 181 (22.9%) of 792 patients reported hypoglycemia
compared with 39 (14.8%) of 263 patients administered placebo in combination
with metformin and sulfonylurea. Adverse reactions of hypoglycemia
were based on all reports of hypoglycemia. A concurrent glucose measurement
was not required or was normal in some patients. Therefore, it is
not possible to conclusively determine that all these reports reflect
true hypoglycemia.
Laboratory Tests
Linagliptin
Increase in Uric Acid: Changes in laboratory
values that occurred more frequently in the linagliptin group and
≥1% more than in the placebo group were increases in uric acid (1.3%
in the placebo group, 2.7% in the linagliptin group).
Increase in Lipase: In a placebo-controlled clinical trial with linagliptin in type 2 diabetes mellitus patients with micro- or macroalbuminuria, a mean increase of 30% in lipase concentrations from baseline to 24 weeks was observed in the linagliptin arm compared to a mean decrease of 2% in the placebo arm. Lipase levels above 3 times upper limit of normal were seen in 8.2% compared to 1.7% patients in the linagliptin and placebo arms, respectively.
Metformin
Decrease in Vitamin B12 Absorption: Long-term treatment with metformin
has been associated with a decrease in vitamin B12 absorption which may very rarely result in clinically significant
vitamin B12 deficiency (e.g., megaloblastic
anemia) [see Warnings and Precautions (5.6)].
6.2 Postmarketing Experience
The following adverse reactions have been identified during postapproval use. Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Linagliptin
- Acute pancreatitis, including fatal pancreatitis [see Indications and Usage (1.2) and Warnings and Precautions (5.2)]
- Hypersensitivity reactions including anaphylaxis, angioedema, and exfoliative skin conditions [see Warnings and Precautions (5.5)]
- Severe and disabling arthralgia [see Warnings and Precautions (5.7)]
- Bullous pemphigoid [see Warnings and Precautions (5.8)]
- Rash
- Mouth ulceration, stomatitis
- Cholestatic, hepatocellular, and mixed hepatocellular liver injury
Metformin
7.1 Drug Interactions With Metformin
Carbonic Anhydrase Inhibitors
Topiramate or other carbonic anhydrase inhibitors (e.g.,
zonisamide, acetazolamide or dichlorphenamide) frequently cause a
decrease in serum bicarbonate and induce non-anion gap, hyperchloremic
metabolic acidosis. Concomitant use of these drugs with JENTADUETO
XR, may increase the risk of lactic acidosis. Consider more frequent
monitoring of these patients [see Warnings and Precautions
(5.1) and Clinical Pharmacology (12.3)].
Drugs that Reduce Metformin Clearance
Concomitant use of drugs that interfere with common renal
tubular transport systems involved in the renal elimination of metformin
(e.g., organic cationic transporter-2 [OCT2] / multidrug and toxin
extrusion [MATE] inhibitors such as ranolazine, vandetanib, dolutegravir,
and cimetidine) could increase systemic exposure to metformin and
may increase the risk for lactic acidosis [see Clinical Pharmacology
(12.3)]. Consider the benefits
and risks of concomitant use.
Alcohol
Alcohol
is known to potentiate the effect of metformin on lactate metabolism.
Warn patients against excessive alcohol intake while receiving JENTADUETO
XR.
7.2 Drug Interactions With Linagliptin
Inducers of P-glycoprotein and CYP3A4
Enzymes
Rifampin decreased linagliptin exposure,
suggesting that the efficacy of linagliptin may be reduced when administered
in combination with a strong P-gp inducer or CYP 3A4 inducer. As JENTADUETO
XR is a fixed-dose combination of linagliptin and metformin, use of
alternative treatments (not containing linagliptin) is strongly recommended
when concomitant treatment with a strong P-gp or CYP 3A4 inducer is
necessary [see Clinical Pharmacology (12.3)].
7.3 Insulin Secretagogues Or Insulin
Coadministration of JENTADUETO XR with an insulin secretagogue (e.g., sulfonylurea) or insulin may require lower doses of the insulin secretagogue or insulin to reduce the risk of hypoglycemia.
7.4 Drugs Affecting Glycemic Control
Certain drugs tend to produce hyperglycemia and may lead to loss of glycemic control. These drugs include the thiazides and other diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blocking drugs, and isoniazid. When such drugs are administered to a patient receiving JENTADUETO XR, the patient should be closely observed to maintain adequate glycemic control [see Clinical Pharmacology (12.3)]. When such drugs are withdrawn from a patient receiving JENTADUETO XR, the patient should be observed closely for hypoglycemia.
8.1 Pregnancy
Risk Summary
The limited data with JENTADUETO XR and linagliptin
use in pregnant women are not sufficient to inform a JENTADUETO XR-associated
or linagliptin-associated risk for major birth defects and miscarriage.
Published studies with metformin use during pregnancy have not reported
a clear association with metformin and major birth defect or miscarriage
risk [see Data]. There are risks to the mother and fetus associated with poorly
controlled diabetes in pregnancy [see Clinical Considerations].
In animal reproduction studies, no adverse developmental effects were observed when the combination of linagliptin and metformin was administered to pregnant rats during the period of organogenesis at doses similar to the maximum recommended clinical dose, based on exposure [see Data].
The estimated background risk of major birth defects is 6-10% in women with pre-gestational diabetes with a HbA1c>7 and has been reported to be as high as 20-25% in women with HbA1c>10. The estimated background risk of miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively.
Clinical Considerations
Disease-associated maternal
and/or embryo/fetal risk
Poorly controlled diabetes
in pregnancy increases the maternal risk for diabetic ketoacidosis,
pre-eclampsia, and delivery complications. Poorly controlled diabetes
increases the fetal risk for major birth defects, still birth, and
macrosomia related morbidity.
Data
Human Data
Published
data from post-marketing studies have not reported a clear association
with metformin and major birth defects, miscarriage, or adverse maternal
or fetal outcomes when metformin was used during pregnancy. However,
these studies cannot definitely establish the absence of any metformin-associated
risk because of methodological limitations, including small sample
size and inconsistent comparator groups.
Animal Data
Linagliptin
and metformin, the components of JENTADUETO XR, were coadministered
to pregnant Wistar Han rats during the period of organogenesis. No
adverse developmental outcome was observed at doses similar to the
maximum recommended clinical dose, based on exposure. At higher doses
associated with maternal toxicity, the metformin component of the
combination was associated with an increased incidence of fetal rib
and scapula malformations at ≥ 9-times a 2000 mg clinical dose, based
on exposure.
Linagliptin
No adverse developmental outcome
was observed when linagliptin was administered to pregnant Wistar
Han rats and Himalayan rabbits during the period of organogenesis
at doses up to 240 mg/kg and 150 mg/kg, respectively. These doses
represent approximately 943 times (rats) and 1943 times (rabbits)
the 5 mg clinical dose, based on exposure. No adverse functional,
behavioral, or reproductive outcome was observed in offspring following
administration of linagliptin to Wistar Han rats from gestation day
6 to lactation day 21 at a dose 49 times the 5 mg clinical dose, based
on exposure.
Metformin Hydrochloride:
Metformin hydrochloride
did not cause adverse developmental effects when administered to pregnant
rabbits up to 600 mg/kg/day during the period of organogenesis. This
represents an exposure of approximately 6-times a clinical dose of
2000 mg, based on body surface area.
8.2 Lactation
Risk Summary
There is no information regarding the presence
of JENTADUETO XR or linagliptin in human milk, the effects on the
breastfed infant, or the effects on milk production. However, linagliptin
is present in rat milk. Limited published studies report that metformin
is present in human milk [see Data]. However, there is insufficient information
to determine the effects of metformin on the breastfed infant and
no available information on the effects of metformin on milk production.
Therefore, the developmental and health benefits of breastfeeding
should be considered along with the mother’s clinical need for JENTADUETO
XR and any potential adverse effects on the breastfed child from JENTADUETO
XR or from the underlying maternal condition.
Data
Published clinical lactation studies report that metformin is present in human milk which resulted in infant doses approximately 0.11% to 1% of the maternal weight-adjusted dosage and a milk/plasma ratio ranging between 0.13 and 1. However, the studies were not designed to definitely establish the risk of use of metformin during lactation because of small sample size and limited adverse event data collected in infants.
8.3 Females And Males Of Reproductive Potential
Discuss the potential for unintended pregnancy with premenopausal women as therapy with metformin may result in ovulation in some anovulatory women.
8.4 Pediatric Use
Safety and effectiveness of JENTADUETO XR in pediatric patients under 18 years of age have not been established.
8.5 Geriatric Use
Linagliptin is minimally excreted by the kidney; however, metformin is substantially excreted by the kidney [see Warnings and Precautions (5.1) and Clinical Pharmacology (12.3)].
Linagliptin
There
were 4040 type 2 diabetes patients treated with linagliptin 5 mg from
15 clinical trials of linagliptin; 1085 (27%) patients were 65 years
and over, while 131 (3%) were 75 years and over. Of these patients,
2566 were enrolled in 12 double-blind placebo-controlled studies;
591 (23%) were 65 years and over, while 82 (3%) were 75 years and
over. No overall differences in safety or effectiveness were observed
between patients 65 years and over and younger patients. Therefore,
no dose adjustment is recommended in the elderly population. While
clinical studies of linagliptin have not identified differences in
response between the elderly and younger patients, greater sensitivity
of some older individuals cannot be ruled out.
Metformin
Controlled
clinical studies of metformin did not include sufficient numbers of
elderly patients to determine whether they respond differently from
younger patients, although other reported clinical experience has
not identified differences in responses between the elderly and young
patients. In general, dose selection for an elderly patient should
be cautious, usually starting at the low end of the dosing range,
reflecting the greater frequency of decreased hepatic, renal, or cardiac
function, and of concomitant disease or other drug therapy and the
higher risk of lactic acidosis. Assess renal function more frequently
in elderly patients [see Contraindications (4), Warnings and Precautions (5.1), and Clinical Pharmacology (12.3)].
8.6 Renal Impairment
Metformin is substantially excreted by the kidney, and the risk of metformin accumulation and lactic acidosis increases with the degree of renal impairment. JENTADUETO XR is contraindicated in severe renal impairment: patients with an estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73 m2 [see Dosage and Administration (2.2), Contraindications (4), Warnings and Precautions (5.1) and Clinical Pharmacology (12.3)].
If JENTADUETO XR is discontinued due to evidence of renal impairment, linagliptin may be continued as a single entity tablet at the same total daily dose of 5 mg. No dose adjustment of linagliptin is recommended in patients with renal impairment.
8.7 Hepatic Impairment
Use of metformin in patients with hepatic impairment has been associated with some cases of lactic acidosis. JENTADUETO XR is not recommended in patients with hepatic impairment [see Warnings and Precautions (5.1)].
10 Overdosage
In the event of an overdose with JENTADUETO XR, contact the Poison Control Center. Employ the usual supportive measures (e.g., remove unabsorbed material from the gastrointestinal tract, employ clinical monitoring, and institute supportive treatment) as dictated by the patient’s clinical status. Removal of linagliptin by hemodialysis or peritoneal dialysis is unlikely. However, metformin is dialyzable with a clearance of up to 170 mL/min under good hemodynamic conditions. Therefore, hemodialysis may be useful partly for removal of accumulated metformin from patients in whom JENTADUETO XR overdosage is suspected.
Linagliptin
During
controlled clinical trials in healthy subjects, with single doses
of up to 600 mg of linagliptin (equivalent to 120 times the recommended
daily dose), there were no dose-related clinical adverse drug reactions.
There is no experience with doses above 600 mg in humans.
Metformin
Overdose of metformin has occurred, including ingestion of amounts
greater than 50 grams. Hypoglycemia was reported in approximately
10% of cases, but no causal association with metformin has been established.
Lactic acidosis has been reported in approximately 32% of metformin
overdose cases [see Boxed Warning and Warnings and Precautions
(5.1)].
11 Description
JENTADUETO XR tablets contain 2 oral antihyperglycemic drugs used in the management of type 2 diabetes mellitus: linagliptin and metformin hydrochloride.
Linagliptin
Linagliptin
is an orally-active inhibitor of the dipeptidyl peptidase-4 (DPP-4)
enzyme.
Linagliptin is described chemically as 1H-Purine-2,6-dione, 8-[(3R)-3-amino-1-piperidinyl]-7-(2-butyn-1-yl)-3,7-dihydro-3-methyl-1-[(4-methyl-2-quinazolinyl)methyl]-
The empirical formula is C25H28N8O2 and the molecular weight is 472.54 g/mol. The structural formula is:
Linagliptin is a white to yellowish, not or only slightly hygroscopic solid substance. It is very slightly soluble in water (0.9 mg/mL). Linagliptin is soluble in methanol (ca. 60 mg/mL), sparingly soluble in ethanol (ca. 10 mg/mL), very slightly soluble in isopropanol (<1 mg/mL), and very slightly soluble in acetone (ca. 1 mg/mL).
Metformin Hydrochloride
Metformin hydrochloride (N,N-dimethylimidodicarbonimidic
diamide hydrochloride) is not chemically or pharmacologically related
to any other classes of oral antihyperglycemic agents. Metformin hydrochloride
is a white to off-white crystalline compound with a molecular formula
of C4H11N5•HCl and a molecular weight of 165.63 g/mol. Metformin
hydrochloride is freely soluble in water and is practically insoluble
in acetone, ether, and chloroform. The pKa of metformin is 12.4. The
pH of a 1% aqueous solution of metformin hydrochloride is 6.68. The
structural formula is:
JENTADUETO XR consists of an extended-release metformin core tablet that is coated with the immediate-release drug substance linagliptin. JENTADUETO XR is available for oral administration as tablets containing 5 mg linagliptin and 1000 mg metformin hydrochloride extended-release (JENTADUETO XR 5 mg/1000 mg) or 2.5 mg linagliptin and 1000 mg metformin hydrochloride extended-release (JENTADUETO XR 2.5 mg/1000 mg). Each coated tablet of JENTADUETO XR contains the following inactive ingredients: Tablet core: polyethylene oxide, hypromellose, and magnesium stearate. Coating: hydroxypropyl cellulose, hypromellose, talc, titanium dioxide, arginine, polyethylene glycol, ferric oxide yellow (2.5 mg/1000 mg), carnauba wax, ferrosoferric oxide, propylene glycol, and isopropyl alcohol.
12.1 Mechanism Of Action
JENTADUETO XR
JENTADUETO XR combines 2 antihyperglycemic agents with complementary
mechanisms of action to improve glycemic control in patients with
type 2 diabetes mellitus: linagliptin, a dipeptidyl peptidase-4 (DPP-4)
inhibitor, and metformin, a member of the biguanide class.
Linagliptin
Linagliptin is an inhibitor of DPP-4, an enzyme that
degrades the incretin hormones glucagon-like peptide-1 (GLP-1) and
glucose-dependent insulinotropic polypeptide (GIP). Thus, linagliptin
increases the concentrations of active incretin hormones, stimulating
the release of insulin in a glucose-dependent manner and decreasing
the levels of glucagon in the circulation. Both incretin hormones
are involved in the physiological regulation of glucose homeostasis.
Incretin hormones are secreted at a low basal level throughout the
day and levels rise immediately after meal intake. GLP-1 and GIP increase
insulin biosynthesis and secretion from pancreatic beta cells in the
presence of normal and elevated blood glucose levels. Furthermore,
GLP-1 also reduces glucagon secretion from pancreatic alpha cells,
resulting in a reduction in hepatic glucose output.
Metformin
Metformin
is an antihyperglycemic agent which improves glucose tolerance in
patients with type 2 diabetes mellitus, lowering both basal and postprandial
plasma glucose. Its pharmacologic mechanisms of action are different
from other classes of oral antihyperglycemic agents. Metformin decreases
hepatic glucose production, decreases intestinal absorption of glucose,
and improves insulin sensitivity by increasing peripheral glucose
uptake and utilization. Unlike SUs, metformin does not produce hypoglycemia
in either patients with type 2 diabetes mellitus or normal subjects
(except in special circumstances) [see Warnings and Precautions
(5.4)] and does not cause
hyperinsulinemia. With metformin therapy, insulin secretion remains
unchanged while fasting insulin levels and day-long plasma insulin
response may actually decrease.
12.2 Pharmacodynamics
Linagliptin
Linagliptin
binds to DPP-4 in a reversible manner and increases the concentrations
of incretin hormones. Linagliptin glucose-dependently increases insulin
secretion and lowers glucagon secretion, thus resulting in a better
regulation of the glucose homeostasis. Linagliptin binds selectively
to DPP-4 and selectively inhibits DPP-4, but not DPP-8 or DPP-9 activity in vitro at concentrations approximating therapeutic exposures.
Cardiac Electrophysiology
In a randomized, placebo-controlled, active-comparator,
4-way crossover study, 36 healthy subjects were administered a single
oral dose of linagliptin 5 mg, linagliptin 100 mg (20 times the recommended
dose), moxifloxacin, and placebo. No increase in QTc was observed
with either the recommended dose of 5 mg or the 100-mg dose. At the
100-mg dose, peak linagliptin plasma concentrations were approximately
38-fold higher than the peak concentrations following a 5-mg dose.
12.3 Pharmacokinetics
JENTADUETO XR
Administration of JENTADUETO XR with a high-fat meal resulted in
up to 7-22% decrease in overall exposure (AUC0-72) of linagliptin; this effect is not clinically relevant. For metformin
extended-release, high-fat meals increased systemic exposure (AUC0-tz) by approximately 54-71% relative to fasting, while
Cmax is increased up to 11%. Meals prolonged
Tmax by approximately 3 hours.
Absorption
Linagliptin
The absolute bioavailability of
linagliptin is approximately 30%. Following oral administration, plasma
concentrations of linagliptin decline in at least a biphasic manner
with a long terminal half-life (>100 hours), related to the saturable
binding of linagliptin to DPP-4. However, the prolonged elimination
does not contribute to the accumulation of the drug. The effective
half-life for accumulation of linagliptin, as determined from oral
administration of multiple doses of linagliptin 5 mg, is approximately
12 hours. After once-daily dosing, steady state plasma concentrations
of linagliptin 5 mg are reached by the third dose, and Cmax and AUC increased by a factor of 1.3 at steady-state
compared with the first dose. Plasma AUC of linagliptin increased
in a less than dose-proportional manner in the dose range of 1 to
10 mg. The pharmacokinetics of linagliptin is similar in healthy subjects
and in patients with type 2 diabetes.
Metformin
Following a single oral dose of 1000 mg (2 x 500 mg tablets) metformin
extended-release after a meal, the time to reach maximum plasma metformin
concentration (Tmax) is achieved at approximately
7 to 8 hours. In both single- and multiple-dose studies in healthy
subjects, once daily 1000 mg (2 x 500 mg tablets) dosing provides
equivalent systemic exposure, as measured by AUC, and up to 35% higher
Cmax of metformin relative to the immediate-release
given as 500 mg twice daily.
Single oral doses of metformin extended-release from 500 mg to 2500 mg resulted in less than proportional increase in both AUC and Cmax. Low-fat and high-fat meals increased the systemic exposure (as measured by AUC) from metformin extended-release tablets by about 38% and 73%, respectively, relative to fasting. Both meals prolonged metformin Tmax by approximately 3 hours but Cmax was not affected.
Distribution
Linagliptin
The mean apparent volume of distribution at steady state
following a single intravenous dose of linagliptin 5 mg to healthy
subjects is approximately 1110 L, indicating that linagliptin extensively
distributes to the tissues. Plasma protein binding of linagliptin
is concentration-dependent decreasing from about 99% at 1 nmol/L to
75% to 89% at ≥30 nmol/L, reflecting saturation of binding to DPP-4
with increasing concentration of linagliptin. At high concentrations,
where DPP-4 is fully saturated, 70% to 80% of linagliptin remains
bound to plasma proteins and 20% to 30% is unbound in plasma. Plasma
binding is not altered in patients with renal or hepatic impairment.
Metformin
The apparent volume of distribution (V/F) of metformin
following single oral doses of immediate-release metformin hydrochloride
tablets 850 mg averaged 654±358 L. Metformin is negligibly bound to
plasma proteins, in contrast to SUs, which are more than 90% protein
bound. Metformin partitions into erythrocytes, most likely as a function
of time. At usual clinical doses and dosing schedules of metformin
tablets, steady-state plasma concentrations of metformin are reached
within 24 to 48 hours and are generally <1 mcg/mL. During controlled
clinical trials of metformin, maximum metformin plasma levels did
not exceed 5 mcg/mL, even at maximum doses.
Metabolism
Linagliptin
Following oral administration,
the majority (about 90%) of linagliptin is excreted unchanged, indicating
that metabolism represents a minor elimination pathway. A small fraction
of absorbed linagliptin is metabolized to a pharmacologically inactive
metabolite, which shows a steady-state exposure of 13.3% relative
to linagliptin.
Metformin
Intravenous single-dose studies
in normal subjects demonstrate that metformin is excreted unchanged
in the urine and does not undergo hepatic metabolism (no metabolites
have been identified in humans) nor biliary excretion.
Excretion
Linagliptin
Following administration
of an oral [14C] linagliptin dose to healthy
subjects, approximately 85% of the administered radioactivity was
eliminated via the enterohepatic system (80%) or urine (5%) within
4 days of dosing. Renal clearance at steady state was approximately
70 mL/min.
Metformin
Renal clearance is approximately
3.5 times greater than creatinine clearance, which indicates that
tubular secretion is the major route of metformin elimination. Following
oral administration, approximately 90% of the absorbed drug is eliminated
via the renal route within the first 24 hours, with a plasma elimination
half-life of approximately 6.2 hours. In blood, the elimination half-life
is approximately 17.6 hours, suggesting that the erythrocyte mass
may be a compartment of distribution.
Specific Populations
Renal Impairment
JENTADUETO
XR: Studies characterizing the pharmacokinetics of linagliptin
and metformin after administration of JENTADUETO XR in renally impaired
patients have not been performed [see Contraindications (4) and Warnings and Precautions (5.1)].
Linagliptin: Under steady-state conditions, linagliptin exposure in patients with mild renal impairment was comparable to healthy subjects. In patients with moderate renal impairment under steady-state conditions, mean exposure of linagliptin increased (AUCτ,ss by 71% and Cmax by 46%) compared with healthy subjects. This increase was not associated with a prolonged accumulation half-life, terminal half-life, or an increased accumulation factor. Renal excretion of linagliptin was below 5% of the administered dose and was not affected by decreased renal function.
Metformin: In patients with decreased renal function, the plasma and blood half-life of metformin is prolonged and the renal clearance is decreased [see Contraindications (4) and Warnings and Precautions (5.1)].
Hepatic Impairment
JENTADUETO XR: Studies characterizing
the pharmacokinetics of linagliptin and metformin after administration
of JENTADUETO XR in hepatically impaired patients have not been performed [see Warnings and Precautions (5.1)].
Linagliptin: In patients with mild hepatic impairment (Child-Pugh class A) steady-state exposure (AUCτ,ss) of linagliptin was approximately 25% lower and Cmax,ss was approximately 36% lower than in healthy subjects. In patients with moderate hepatic impairment (Child-Pugh class B), AUCss of linagliptin was about 14% lower and Cmax,ss was approximately 8% lower than in healthy subjects. Patients with severe hepatic impairment (Child-Pugh class C) had comparable exposure of linagliptin in terms of AUC0-24 and approximately 23% lower Cmax compared with healthy subjects. Reductions in the pharmacokinetic parameters seen in patients with hepatic impairment did not result in reductions in DPP-4 inhibition.
Metformin hydrochloride: No pharmacokinetic studies of metformin have been conducted in patients with hepatic impairment.
Body Mass Index (BMI)/Weight
Linagliptin: BMI/Weight had no clinically
meaningful effect on the pharmacokinetics of linagliptin based on
a population pharmacokinetic analysis.
Gender
Linagliptin: Gender had no clinically meaningful
effect on the pharmacokinetics of linagliptin based on a population
pharmacokinetic analysis.
Metformin hydrochloride: Metformin pharmacokinetic parameters did not differ significantly between normal subjects and patients with type 2 diabetes mellitus when analyzed according to gender. Similarly, in controlled clinical studies in patients with type 2 diabetes mellitus, the antihyperglycemic effect of metformin was comparable in males and females.
Geriatric
JENTADUETO XR: Studies characterizing
the pharmacokinetics of linagliptin and metformin after administration
of JENTADUETO XR in geriatric patients have not been performed [see Warnings and Precautions (5.1) and Use in Specific Populations (8.5)].
Linagliptin: Age did not have a clinically meaningful impact on the pharmacokinetics of linagliptin based on a population pharmacokinetic analysis.
Metformin hydrochloride: Limited data from controlled pharmacokinetic studies of metformin in healthy elderly subjects suggest that total plasma clearance of metformin is decreased, the half-life is prolonged, and Cmax is increased, compared with healthy young subjects. From these data, it appears that the change in metformin pharmacokinetics with aging is primarily accounted for by a change in renal function.
Pediatric
Studies characterizing
the pharmacokinetics of linagliptin and metformin after administration
of JENTADUETO XR in pediatric patients have not yet been performed.
Race
Linagliptin: Race had no clinically meaningful
effect on the pharmacokinetics of linagliptin based on available pharmacokinetic
data, including subjects of White, Hispanic, Black, and Asian racial
groups.
Metformin hydrochloride: No studies of metformin pharmacokinetic parameters according to race have been performed. In controlled clinical studies of metformin in patients with type 2 diabetes mellitus, the antihyperglycemic effect was comparable in Caucasians (n=249), Blacks (n=51), and Hispanics (n=24).
Drug Interactions
Pharmacokinetic drug interaction studies with JENTADUETO XR have not been performed; however, such studies have been conducted with the individual components of JENTADUETO XR (linagliptin and metformin hydrochloride).
Linagliptin
In vitro Assessment of
Drug Interactions
Linagliptin is a weak to moderate
inhibitor of CYP isozyme CYP3A4, but does not inhibit other CYP isozymes
and is not an inducer of CYP isozymes, including CYP1A2, 2A6, 2B6,
2C8, 2C9, 2C19, 2D6, 2E1, and 4A11.
Linagliptin is a P-glycoprotein (P-gp) substrate, and inhibits P-gp mediated transport of digoxin at high concentrations. Based on these results and in vivo drug interaction studies, linagliptin is considered unlikely to cause interactions with other P-gp substrates at therapeutic concentrations.
In vivo Assessment of
Drug Interactions
Strong inducers of CYP3A4 or
P-gp (e.g., rifampin) decrease exposure to linagliptin to subtherapeutic
and likely ineffective concentrations. For patients requiring use
of such drugs, an alternative to linagliptin is strongly recommended.
In vivo studies indicated evidence of a low propensity
for causing drug interactions with substrates of CYP3A4, CYP2C9, CYP2C8,
P-gp, and OCT. No dose adjustment of linagliptin is recommended based
on results of the described pharmacokinetic studies.
*Multiple dose (steady state) unless otherwise noted # Single dose †AUC = AUC(0 to 24 hours) for single-dose treatments and AUC = AUC(TAU) for multiple-dose treatments QD = once daily BID = twice daily TID = three times daily | ||||
Coadministered Drug | Dosing of Coadministered Drug* | Dosing of Linagliptin* | Geometric Mean Ratio (ratio with/without coadministered drug) No effect=1.0 | |
AUC† | Cmax | |||
No dosing adjustments required for linagliptin when given with the following coadministered drugs: | ||||
Metformin | 850 mg TID | 10 mg QD | 1.20 | 1.03 |
Glyburide | 1.75 mg# | 5 mg QD | 1.02 | 1.01 |
Pioglitazone | 45 mg QD | 10 mg QD | 1.13 | 1.07 |
Ritonavir | 200 mg BID | 5 mg# | 2.01 | 2.96 |
The efficacy of JENTADUETO XR may be reduced when administered in combination with strong inducers of CYP3A4 or P-gp (e.g., rifampin). Use of alternative treatments is strongly recommended [see Drug Interactions (7.2)]. | ||||
Rifampin | 600 mg QD | 5 mg QD | 0.60 | 0.56 |
* Multiple dose (steady state) unless otherwise noted # Single dose †AUC = AUC(INF) for single-dose treatments and AUC = AUC(TAU) for multiple-dose treatments **AUC=AUC(0-168) and Cmax=Emax for pharmacodynamic end points INR = International Normalized Ratio PT = Prothrombin Time QD = once daily TID = three times daily | |||||
Coadministered Drug | Dosing of Coadministered Drug* | Dosing of Linagliptin* | Geometric Mean Ratio (ratio with/without coadministered drug) No effect=1.0 | ||
AUC† | Cmax | ||||
No dosing adjustments required for the following coadministered drugs: | |||||
Metformin | 850 mg TID | 10 mg QD | metformin | 1.01 | 0.89 |
Glyburide | 1.75 mg# | 5 mg QD | glyburide | 0.86 | 0.86 |
Pioglitazone | 45 mg QD | 10 mg QD | pioglitazone metabolite M-III metabolite M-IV | 0.94 0.98 1.04 | 0.86 0.96 1.05 |
Digoxin | 0.25 mg QD | 5 mg QD | digoxin | 1.02 | 0.94 |
Simvastatin | 40 mg QD | 10 mg QD | simvastatin simvastatin acid | 1.34 1.33 | 1.10 1.21 |
Warfarin | 10 mg# | 5 mg QD | R-warfarin S-warfarin INR PT | 0.99 1.03 0.93** 1.03** | 1.00 1.01 1.04** 1.15** |
Ethinylestradiol and levonorgestrel | ethinylestradiol 0.03 mg and levonorgestrel 0.150 mg QD | 5 mg QD | ethinylestradiol levonorgestrel | 1.01 1.09 | 1.08 1.13 |
Metformin hydrochloride
* All metformin and coadministered drugs were given
as single doses † AUC = AUC(INF) ≠ metformin hydrochloride extended-release tablets 500 mg ‡ Ratio of arithmetic means **At steady state with topiramate 100 mg every 12 hours and metformin 500 mg every 12 hours; AUC = AUC0-12h | |||||
Coadministered Drug | Dosing of Coadministered Drug* | Dosing of Metformin* | Geometric Mean Ratio (ratio with/without coadministered drug) No effect=1.0 | ||
AUC† | Cmax | ||||
No dosing adjustments required for the following coadministered drugs: | |||||
Glyburide | 5 mg | 500 mg ≠ | metformin | 0.98‡ | 0.99‡ |
Furosemide | 40 mg | 850 mg | metformin | 1.09‡ | 1.22‡ |
Nifedipine | 10 mg | 850 mg | metformin | 1.16 | 1.21 |
Propranolol | 40 mg | 850 mg | metformin | 0.90 | 0.94 |
Ibuprofen | 400 mg | 850 mg | metformin | 1.05‡ | 1.07‡ |
Drugs that are eliminated by renal tubular secretion may reduce metformin elimination: [see Warnings and Precautions (5.1) and Drug Interactions (7.1)]. | |||||
Cimetidine | 400 mg | 850 mg | metformin | 1.40 | 1.61 |
Carbonic anhydrase inhibitors may cause metabolic acidosis: [see Warnings and Precautions (5.1) and Drug Interactions (7.1)]. | |||||
Topiramate** | 100 mg | 500 mg | metformin | 1.25 | 1.17 |
* All metformin and coadministered drugs were given
as single doses † AUC = AUC(INF) unless otherwise noted ‡ Ratio of arithmetic means, p-value of difference <0.05 § AUC(0-24 hr) reported ¶ Ratio of arithmetic means | |||||
Coadministered Drug | Dosing of Coadministered Drug* | Dosing of Metformin* | Geometric Mean Ratio (ratio with/without metformin) No effect=1.0 | ||
AUC† | Cmax | ||||
No dosing adjustments required for the following coadministered drugs: | |||||
Glyburide | 5 mg | 500 mg§ | glyburide | 0.78‡ | 0.63‡ |
Furosemide | 40 mg | 850 mg | furosemide | 0.87‡ | 0.69‡ |
Nifedipine | 10 mg | 850 mg | nifedipine | 1.10§ | 1.08 |
Propranolol | 40 mg | 850 mg | propranolol | 1.01§ | 0.94 |
Ibuprofen | 400 mg | 850 mg | ibuprofen | 0.97¶ | 1.01¶ |
Cimetidine | 400 mg | 850 mg | cimetidine | 0.95§ | 1.01 |
13.1 Carcinogenesis, Mutagenesis, Impairment Of Fertility
JENTADUETO XR
No animal studies have been conducted with the combined
products in JENTADUETO XR to evaluate carcinogenesis, mutagenesis,
or impairment of fertility. General toxicity studies in rats up to
13 weeks were performed with linagliptin/metformin coadministered.
The following data are based on the findings in studies with linagliptin and metformin individually.
Linagliptin
Linagliptin did not increase the incidence of tumors
in male and female rats in a 2-year study at doses of 6, 18, and 60
mg/kg. The highest dose of 60 mg/kg is approximately 418 times the
clinical dose of 5 mg/day based on AUC exposure. Linagliptin did not
increase the incidence of tumors in mice in a 2-year study at doses
up to 80 mg/kg (males) and 25 mg/kg (females), or approximately 35
and 270 times the clinical dose based on AUC exposure. Higher doses
of linagliptin in female mice (80 mg/kg) increased the incidence of
lymphoma at approximately 215 times the clinical dose based on AUC
exposure.
Linagliptin was not mutagenic or clastogenic with or without metabolic activation in the Ames bacterial mutagenicity assay, a chromosomal aberration test in human lymphocytes, and an in vivo micronucleus assay.
In fertility studies in rats, linagliptin had no adverse effects on early embryonic development, mating, fertility, or bearing live young up to the highest dose of 240 mg/kg (approximately 943 times the clinical dose based on AUC exposure).
Metformin Hydrochloride
Long-term carcinogenicity
studies have been performed in Sprague Dawley rats at doses of 150,
300, and 450 mg/kg/day in males and 150, 450, 900, and 1200 mg/kg/day
in females. These doses are both approximately 2, 4, and 8 times
in males, and 3, 7, 12, and 16 times in females of the maximum recommended
human daily dose of 2000 mg/kg/day based on body surface area comparisons.
No evidence of carcinogenicity with metformin was found in either
male or female rats. A carcinogenicity study was also performed in
Tg.AC transgenic mice at doses of up to 2000 mg/kg/day applied dermally.
No evidence of carcinogenicity was observed in male or female mice.
Genotoxicity assessments in the Ames test, gene mutation test (mouse lymphoma cells), chromosomal aberrations test (human lymphocytes) and in vivo mouse micronucleus tests were negative.
Fertility of male or female rats was unaffected by metformin when administered at doses as high as 600 mg/kg/day, which is approximately 2 times the MRHD based on body surface area comparisons.
14 Clinical Studies
The safety and efficacy of JENTADUETO XR have been established based on adequate and well-controlled studies of linagliptin and metformin coadministered in patients with type 2 diabetes mellitus inadequately controlled on diet and exercise and in combination with sulfonylurea.
14.1 Initial Combination Therapy With Linagliptin And Metformin
A total of 791 patients with type 2 diabetes mellitus and inadequate glycemic control on diet and exercise participated in the 24-week, randomized, double-blind, portion of this placebo-controlled factorial study designed to assess the efficacy of linagliptin as initial therapy with metformin. Patients on an antihyperglycemic agent (52%) underwent a drug washout period of 4 weeks’ duration. After the washout period and after completing a 2-week single-blind placebo run-in period, patients with inadequate glycemic control (A1C ≥7.0% to ≤10.5%) were randomized. Patients with inadequate glycemic control (A1C ≥7.5% to <11.0%) not on antihyperglycemic agents at study entry (48%) immediately entered the 2-week single-blind placebo run-in period and then were randomized. Randomization was stratified by baseline A1C (<8.5% vs ≥8.5%) and use of a prior oral antidiabetic drug (none vs monotherapy). Patients were randomized in a 1:2:2:2:2:2 ratio to either placebo or one of 5 active-treatment arms. Approximately equal numbers of patients were randomized to receive initial therapy with 5 mg of linagliptin once daily, 500 mg or 1000 mg of metformin twice daily, or 2.5 mg of linagliptin twice daily in combination with 500 mg or 1000 mg of metformin twice daily. Patients who failed to meet specific glycemic goals during the study were treated with sulfonylurea, thiazolidinedione, or insulin rescue therapy.
Initial therapy with the combination of linagliptin and metformin provided significant improvements in A1C, and fasting plasma glucose (FPG) compared to placebo, to metformin alone, and to linagliptin alone (Table 6, Figure 1). The adjusted mean treatment difference in A1C from baseline to week 24 (LOCF) was -0.5% (95% CI -0.7, -0.3; p<0.0001) for linagliptin 2.5 mg/metformin 1000 mg twice daily compared to metformin 1000 mg twice daily; -1.1% (95% CI -1.4, -0.9; p<0.0001) for linagliptin 2.5 mg/metformin 1000 mg twice daily compared to linagliptin 5 mg once daily; -0.6% (95% CI -0.8, -0.4; p<0.0001) for linagliptin 2.5 mg/metformin 500 mg twice daily compared to metformin 500 mg twice daily; and -0.8% (95% CI -1.0, -0.6; p<0.0001) for linagliptin 2.5 mg/metformin 500 mg twice daily compared to linagliptin 5 mg once daily.
Lipid effects were generally neutral. No meaningful change in body weight was noted in any of the 6 treatment groups.
*Total daily dose of linagliptin is equal to 5 mg **Full analysis population using last observation on study ***Metformin 500 mg twice daily, n=140; Linagliptin 2.5 mg twice daily + Metformin 500 mg twice daily, n=136; Metformin 1000 mg twice daily, n=137; Linagliptin 2.5 mg twice daily + Metformin 1000 mg twice daily, n=138 ****HbA1c: ANCOVA model included treatment and number of prior OADs as class-effects, as well as baseline HbA1c as continuous covariates. FPG: ANCOVA model included treatment and number of prior OADs as class-effects, as well as baseline HbA1c and baseline FPG as continuous covariates. | ||||||
Placebo | Linagliptin 5 mg Once Daily* | Metformin 500 mg Twice Daily | Linagliptin 2.5 mg Twice Daily* + Metformin 500 mg Twice Daily | Metformin 1000 mg Twice Daily | Linagliptin 2.5 mg Twice Daily* + Metformin 1000 mg Twice Daily | |
A1C (%) | ||||||
Number of patients | n=65 | n=135 | n=141 | n=137 | n=138 | n=140 |
Baseline (mean) | 8.7 | 8.7 | 8.7 | 8.7 | 8.5 | 8.7 |
Change from baseline (adjusted mean****) | 0.1 | -0.5 | -0.6 | -1.2 | -1.1 | -1.6 |
Difference from placebo (adjusted mean) (95% CI) | -- | -0.6 (-0.9, -0.3) | -0.8 (-1.0, -0.5) | -1.3 (-1.6, -1.1) | -1.2 (-1.5, -0.9) | -1.7 (-2.0, -1.4) |
Patients [n (%)] achieving A1C <7%*** | 7 (10.8) | 14 (10.4) | 26 (18.6) | 41 (30.1) | 42 (30.7) | 74 (53.6) |
Patients (%) receiving rescue medication | 29.2 | 11.1 | 13.5 | 7.3 | 8.0 | 4.3 |
FPG (mg/dL) | ||||||
Number of patients | n=61 | n=134 | n=136 | n=135 | n=132 | n=136 |
Baseline (mean) | 203 | 195 | 191 | 199 | 191 | 196 |
Change from baseline (adjusted mean****) | 10 | -9 | -16 | -33 | -32 | -49 |
Difference from placebo (adjusted mean) (95% CI) | -- | -19 (-31, -6) | -26 (-38, -14) | -43 (-56, -31) | -42 (-55, -30) | -60 (-72, -47) |
Figure 1 Adjusted Mean Change from Baseline for A1C (%) over 24 Weeks with Linagliptin and Metformin, Alone and in Combination in Patients with Type 2 Diabetes Mellitus Inadequately Controlled with Diet and Exercise - FAS completers.
14.2 Initial Combination Therapy With Linagliptin And Metformin Vs Linagliptin In Treatment-Naïve Patients
A total of 316 patients with type 2 diabetes diagnosed within the previous 12 months and treatment-naïve (no antidiabetic therapy for 12 weeks prior to randomization) and inadequate glycemic control (A1C ≥8.5% to ≤12.0%) participated in a 24-week, randomized, double-blind, study designed to assess the efficacy of linagliptin in combination with metformin vs linagliptin. Patients were randomized (1:1), after a 2-week run-in period, to either linagliptin 5 mg plus metformin (1500 to 2000 mg per day, n=159) or linagliptin 5 mg plus placebo, (n=157) administered once daily. Patients in the linagliptin and metformin treatment group were up-titrated to a maximum tolerated dose of metformin (1000 to 2000 mg per day) over a three-week period.
Initial therapy with the combination of linagliptin and metformin provided statistically significant improvements in A1C compared to linagliptin (Table 7). The mean difference between groups in A1C change from baseline was -0.8% with 2-sided 95% confidence interval (-1.23%, -0.45%).
†p<0.0001 compared to
linagliptin, ††p=0.0054 compared to linagliptin *Full analysis set population **A1C: MMRM model included treatment, continuous baseline A1C, baseline A1C by visit interaction, visit by treatment interaction, baseline renal impairment by treatment interaction and baseline renal impairment by treatment by visit interaction. FPG: MMRM model included treatment, continuous baseline A1C, continuous baseline FPG, baseline FPG by visit interaction, visit by treatment interaction, baseline renal impairment by treatment interaction and baseline renal impairment by treatment by visit interaction. | ||
Linagliptin 5 mg + Metformin | Linagliptin 5 mg + Placebo | |
A1C (%)* | ||
Number of patients | n=153 | n=150 |
Baseline (mean) | 9.8 | 9.9 |
Change from baseline (adjusted mean) | -2.9 | -2 |
Difference from linagliptin (adjusted mean**) (95% CI) | -0.84† (-1.23, -0.45) | -- |
Patients [n (%)] achieving A1C <7%* | 82 (53.6) | 45 (30) |
FPG (mg/dL)* | ||
Number of patients | n=153 | n=150 |
Baseline (mean) | 196 | 198 |
Change from baseline (adjusted mean) | -54 | -35 |
Difference from linagliptin (adjusted mean**) (95% CI) | -18†† (-31, -5.5) | -- |
The adjusted mean changes for A1C (%) from baseline over time for linagliptin and metformin as compared to linagliptin alone were maintained throughout the 24 week treatment period. Using the completers analysis the respective adjusted means for A1C (%) changes from baseline for linagliptin and metformin as compared to linagliptin alone were -1.9 and -1.3 at week 6, -2.6 and -1.8 at week 12, -2.7 and -1.9 at week 18, and -2.7 and -1.9 at week 24.
Changes in body weight from baseline were not clinically significant in either treatment group.
14.3 Add-On Combination Therapy With Metformin
A total of 701 patients with type 2 diabetes participated in a 24-week, randomized, double-blind, placebo-controlled study designed to assess the efficacy of linagliptin in combination with metformin. Patients already on metformin (n=491) at a dose of at least 1500 mg per day were randomized after completing a 2-week, open-label, placebo run-in period. Patients on metformin and another antihyperglycemic agent (n=207) were randomized after a run-in period of approximately 6 weeks on metformin (at a dose of at least 1500 mg per day) in monotherapy. Patients were randomized to the addition of either linagliptin 5 mg or placebo, administered once daily. Patients who failed to meet specific glycemic goals during the studies were treated with glimepiride rescue.
In combination with metformin, linagliptin provided statistically significant improvements in A1C, FPG, and 2-hour PPG compared with placebo (Table 8). Rescue glycemic therapy was used in 7.8% of patients treated with linagliptin 5 mg and in 18.9% of patients treated with placebo. A similar decrease in body weight was observed for both treatment groups.
* Full analysis population using last observation
on study **Linagliptin 5 mg + Metformin, n=485; Placebo + Metformin, n=163 ***HbA1c: ANCOVA model included treatment and number of prior oral OADs as class-effects, as well as baseline HbA1c as continuous covariates. FPG: ANCOVA model included treatment and number of prior OADs as class-effects, as well as baseline HbA1c and baseline FPG as continuous covariates. PPG: ANCOVA model included treatment and number of prior OADs as class-effects, as well as baseline HbA1c and baseline postprandial glucose after two hours as covariate. | ||
Linagliptin 5 mg + Metformin | Placebo + Metformin | |
A1C (%) | ||
Number of patients | n=513 | n=175 |
Baseline (mean) | 8.1 | 8.0 |
Change from baseline (adjusted mean***) | -0.5 | 0.15 |
Difference from placebo + metformin (adjusted mean) (95% CI) | -0.6 (-0.8, -0.5) | -- |
Patients [n (%)] achieving A1C <7%** | 127 (26.2) | 15 (9.2) |
FPG (mg/dL) | ||
Number of patients | n=495 | n=159 |
Baseline (mean) | 169 | 164 |
Change from baseline (adjusted mean***) | -11 | 11 |
Difference from placebo + metformin (adjusted mean) (95% CI) | -21 (-27, -15) | -- |
2-hour PPG (mg/dL) | ||
Number of patients | n=78 | n=21 |
Baseline (mean) | 270 | 274 |
Change from baseline (adjusted mean***) | -49 | 18 |
Difference from placebo + metformin (adjusted mean) (95% CI) | -67 (-95, -40) | -- |
14.4 Active-Controlled Study Vs Glimepiride In Combination With Metformin
The efficacy of linagliptin was evaluated in a 104-week double-blind, glimepiride-controlled non-inferiority study in type 2 diabetic patients with insufficient glycemic control despite metformin therapy. Patients being treated with metformin only entered a run-in period of 2 weeks’ duration, whereas patients pretreated with metformin and one additional antihyperglycemic agent entered a run-in treatment period of 6 weeks’ duration with metformin monotherapy (dose of ≥1500 mg per day) and washout of the other agent. After an additional 2-week placebo run-in period, those with inadequate glycemic control (A1C 6.5% to 10%) were randomized 1:1 to the addition of linagliptin 5 mg once daily or glimepiride. Randomization was stratified by baseline HbA1c (<8.5% vs ≥8.5%), and the previous use of antidiabetic drugs (metformin alone vs metformin plus one other OAD). Patients receiving glimepiride were given an initial dose of 1 mg/day and then electively titrated over the next 12 weeks to a maximum dose of 4 mg/day as needed to optimize glycemic control. Thereafter, the glimepiride dose was to be kept constant, except for down-titration to prevent hypoglycemia.
After 52 weeks and 104 weeks, linagliptin and glimepiride both had reductions from baseline in A1C (52 weeks: -0.4% for linagliptin, -0.6% for glimepiride; 104 weeks: -0.2% for linagliptin, -0.4% for glimepiride) from a baseline mean of 7.7% (Table 9). The mean difference between groups in A1C change from baseline was 0.2% with 2-sided 97.5% confidence interval (0.1%, 0.3%) for the intent-to-treat population using last observation carried forward. These results were consistent with the completers analysis.
*p<0.0001 vs glimepiride; †p=0.0012 vs glimepiride **Full analysis population using last observation on study ***HbA1c: ANCOVA model included treatment and number of prior OADs as class-effects, as well as baseline HbA1c as continuous covariates. FPG: ANCOVA model included treatment and number of prior OADs as class-effects, as well as baseline HbA1c and baseline FPG as continuous covariates. | ||||
Week 52 | Week 104 | |||
Linagliptin 5 mg + Metformin | Glimepiride + Metformin (mean glimepiride dose 3 mg) | Linagliptin 5 mg + Metformin | Glimepiride + Metformin (mean glimepiride dose 3 mg) | |
A1C (%) | ||||
Number of patients | n=764 | n=755 | n=764 | n=755 |
Baseline (mean) | 7.7 | 7.7 | 7.7 | 7.7 |
Change from baseline (adjusted mean***) | -0.4 | -0.6 | -0.2 | -0.4 |
Difference from glimepiride (adjusted mean) (97.5% CI) | 0.2 (0.1, 0.3) | -- | 0.2 (0.1, 0.3) | -- |
FPG (mg/dL) | ||||
Number of patients | n=733 | n=725 | n=733 | n=725 |
Baseline (mean) | 164 | 166 | 164 | 166 |
Change from baseline (adjusted mean***) | -8* | -15 | -2† | -9 |
Patients treated with linagliptin had a mean baseline body weight of 86 kg and were observed to have an adjusted mean decrease in body weight of 1.1 kg at 52 weeks and 1.4 kg at 104 weeks. Patients on glimepiride had a mean baseline body weight of 87 kg and were observed to have an adjusted mean increase from baseline in body weight of 1.4 kg at 52 weeks and 1.3 kg at 104 weeks (treatment difference p<0.0001 for both timepoints).
14.5 Add-On Combination Therapy With Metformin And A Sulfonylurea
A total of 1058 patients with type 2 diabetes mellitus participated in a 24-week, randomized, double-blind, placebo-controlled study designed to assess the efficacy of linagliptin in combination with a sulfonylurea and metformin. The most common sulfonylureas used by patients in the study were glimepiride (31%), glibenclamide (26%), and gliclazide (26% [not available in the United States]). Patients on a sulfonylurea and metformin were randomized to receive linagliptin 5 mg or placebo, each administered once daily. Patients who failed to meet specific glycemic goals during the study were treated with pioglitazone rescue. Glycemic end points measured included A1C and FPG.
In combination with a sulfonylurea and metformin, linagliptin provided statistically significant improvements in A1C and FPG compared with placebo (Table 10). In the entire study population (patients on linagliptin in combination with a sulfonylurea and metformin), a mean reduction from baseline relative to placebo in A1C of -0.6% and in FPG of -13 mg/dL was seen. Rescue therapy was used in 5.4% of patients treated with linagliptin 5 mg and in 13% of patients treated with placebo. Change from baseline in body weight did not differ significantly between the groups.
SU=sulfonylurea *Full analysis population using last observation on study **Linagliptin 5 mg + Metformin + SU, n=742; Placebo + Metformin + SU, n=247 ***HbA1c: ANCOVA model included treatment as class-effects and baseline HbA1c as continuous covariates. FPG: ANCOVA model included treatment as class-effects, as well as baseline HbA1c and baseline FPG as continuous covariates. | ||
Linagliptin 5 mg + Metformin + SU | Placebo + Metformin + SU | |
A1C (%) | ||
Number of patients | n=778 | n=262 |
Baseline (mean) | 8.2 | 8.1 |
Change from baseline (adjusted mean***) | -0.7 | -0.1 |
Difference from placebo (adjusted mean) (95% CI) | -0.6 (-0.7, -0.5) | -- |
Patients [n (%)] achieving A1C <7%** | 217 (29.2) | 20 (8.1) |
FPG (mg/dL) | ||
Number of patients | n=739 | n=248 |
Baseline (mean) | 159 | 163 |
Change from baseline (adjusted mean***) | -5 | 8 |
Difference from placebo (adjusted mean) (95% CI) | -13 (-18, -7) | -- |
16 How Supplied/Storage And Handling
JENTADUETO XR (linagliptin and metformin hydrochloride extended-release) tablets 5 mg/1000 mg, white, oval-shaped coated tablets with one side printed in black ink with the Boehringer Ingelheim logo and “D5” on the top line and “1000M” on the bottom line, are supplied as follows:
Bottles of 30 (NDC 0597-0275-33)
Bottles of 90 (NDC 0597-0275-81)
JENTADUETO XR (linagliptin and metformin hydrochloride extended-release) tablets 2.5 mg/1000 mg, yellow, oval-shaped coated tablets with one side printed in black ink with the Boehringer Ingelheim logo and “D2” on the top line and “1000M” on the bottom line, are supplied as follows:
Bottles of 60 (NDC 0597-0270-73)
Bottles of 180 (NDC 0597-0270-94)
Storage
Store at 25°C (77°F); excursions permitted to 15°-30°C (59°-86°F) [see USP Controlled Room Temperature]. Protect from exposure to
high humidity. Store in a safe place out of reach of children.
17 Patient Counseling Information
Advise the patient to read the FDA-approved patient labeling (Medication Guide)
Medication Guide
Instruct patients
to read the Medication Guide before starting JENTADUETO XR therapy
and to reread each time the prescription is renewed. Instruct patients
to inform their doctor if they develop any bothersome or unusual symptoms,
or if any symptom persists or worsens.
Inform patients of the potential risks and benefits of JENTADUETO XR and of alternative modes of therapy. Also inform patients about the importance of adherence to dietary instructions, regular physical activity, periodic blood glucose monitoring and A1C testing, recognition and management of hypoglycemia and hyperglycemia, and assessment for diabetes complications. Advise patients to seek medical advice promptly during periods of stress such as fever, trauma, infection, or surgery, as medication requirements may change.
Lactic Acidosis
Inform patients of the risks of lactic acidosis due to
the metformin component, its symptoms, and conditions that predispose
to its development [see Warnings and Precautions (5.1)]. Advise patients to discontinue
JENTADUETO XR immediately and to notify their doctor promptly if unexplained
hyperventilation, malaise, myalgia, unusual somnolence, slow or irregular
heartbeat, sensation of feeling cold (especially in the extremities),
or other nonspecific symptoms occur. GI symptoms are common during
initiation of metformin treatment and may occur during initiation
of JENTADUETO XR therapy; however, advise patients to consult their
doctor if they develop unexplained symptoms. Although GI symptoms
that occur after stabilization are unlikely to be drug related, such
an occurrence of symptoms should be evaluated to determine if it may
be due to metformin-induced lactic acidosis or other serious disease.
Pancreatitis
Inform patients that acute pancreatitis has been reported
during postmarketing use of linagliptin. Inform patients that persistent
severe abdominal pain, sometimes radiating to the back, which may
or may not be accompanied by vomiting, is the hallmark symptom of
acute pancreatitis. Instruct patients to discontinue JENTADUETO XR
promptly and contact their physician if persistent severe abdominal
pain occurs [see Warnings and Precautions (5.2)].
Heart Failure
Inform patients of the signs and symptoms of heart failure. Before
initiating JENTADUETO XR, patients should be asked about a history
of heart failure or other risk factors for heart failure including
moderate to severe renal impairment. Instruct patients to contact
their healthcare provider as soon as possible if they experience symptoms
of heart failure, including increasing shortness of breath, rapid
increase in weight or swelling of the feet [see Warnings and
Precautions (5.3)].
Monitoring of Renal
Function
Inform patients about the importance
of regular testing of renal function and hematological parameters
when receiving treatment with JENTADUETO XR.
Instruct patients to inform their doctor that they are taking JENTADUETO XR prior to any surgical or radiological procedure, as temporary discontinuation of JENTADUETO XR may be required until renal function has been confirmed to be normal [see Warnings and Precautions (5.1)].
Hypoglycemia
Inform patients that the risk of hypoglycemia is increased
when JENTADUETO XR is used in combination with an insulin secretagogue
(e.g., sulfonylurea), and that a lower dose of the insulin secretagogue
may be required to reduce the risk of hypoglycemia [see Warnings
and Precautions (5.4)].
Hypersensitivity
Reactions
Inform patients that serious allergic
reactions, such as anaphylaxis, angioedema, and exfoliative skin conditions,
have been reported during postmarketing use of linagliptin (one of
the components of JENTADUETO XR). If symptoms of allergic reactions
(such as rash, skin flaking or peeling, urticaria, swelling of the
skin, or swelling of the face, lips, tongue, and throat that may cause
difficulty in breathing or swallowing) occur, patients must stop taking
JENTADUETO XR and seek medical advice promptly [see Warnings
and Precautions (5.5)].
Missed Dose
Instruct patients to take JENTADUETO XR only as prescribed.
If a dose is missed, advise patients not to double their next dose.
Alcohol Intake
Warn patients against excessive alcohol intake, either
acute or chronic, while receiving JENTADUETO XR [see Warnings
and Precautions (5.1)].
Administration Instructions
Inform patients taking JENTADUETO XR that the tablets
must be swallowed whole and never split, crushed, dissolved, or chewed
and that incompletely dissolved JENTADUETO XR tablets may be eliminated
in the feces. Patients should be told that, if they see tablets in
feces, they should report this finding to their healthcare provider [see Dosage and Administration (2.1)].
Blood Glucose and A1C Monitoring
Inform patients
that response to all diabetic therapies should be monitored by periodic
measurements of blood glucose and A1C levels, with a goal of decreasing
these levels toward the normal range. A1C monitoring is especially
useful for evaluating long-term glycemic control.
Renal Function and Other Hematologic
Parameters Monitoring
Inform patients that
initial and periodic monitoring of hematologic parameters (e.g., hemoglobin/hematocrit
and red blood cell indices) and renal function (e.g., eGFR) should
be performed, at least on an annual basis [see Warnings and
Precautions (5.1, 5.6)].
Severe and Disabling Arthralgia
Inform patients that severe and disabling joint pain
may occur with this class of drugs. The time to onset of symptoms
can range from one day to years. Instruct patients to seek medical
advice if severe joint pain occurs [see Warnings and Precautions
(5.7)].
Bullous Pemphigoid
Inform patients that bullous pemphigoid may occur with
this class of drugs. Instruct patients to seek medical advice if blisters
or erosions occur [see Warnings and Precautions (5.8)].
Pregnancy
Inform female patients that treatment with metformin may result
in an unintended pregnancy in some premenopausal anovulatory females
due to its effect on ovulation [see Use in Specific Populations
(8.3)].
Distributed by:
Boehringer Ingelheim
Pharmaceuticals, Inc.
Ridgefield, CT 06877 USA
Marketed by:
Boehringer
Ingelheim Pharmaceuticals, Inc.
Ridgefield, CT 06877 USA
and
Eli Lilly and Company
Indianapolis, IN
46285 USA
Licensed
from:
Boehringer Ingelheim International GmbH, Ingelheim,
Germany
JENTADUETO is a registered trademark of and used under license from Boehringer Ingelheim International GmbH.
Copyright © 2017 Boehringer Ingelheim International
GmbH
ALL RIGHTS RESERVED
IT6354FH142017
Spl Medguide
MEDICATION GUIDE JENTADUETO® XR (JEN ta doo e' toe XR) (linagliptin and metformin hydrochloride extended-release) Tablets | ||||
Read this Medication Guide carefully before you start taking JENTADUETO XR and each time you get a refill. There may be new information. This information does not take the place of talking to your doctor about your medical condition or your treatment. If you have any questions about JENTADUETO XR, ask your doctor or pharmacist. | ||||
What is the most important
information I should know about JENTADUETO XR? Serious side effects can happen in people taking JENTADUETO XR, including: 1.Lactic acidosis. Metformin, one of the medicines in JENTADUETO XR, can cause a rare but serious condition called lactic acidosis (a buildup of an acid in the blood) that can cause death. Lactic acidosis is a medical emergency and must be treated in the hospital. Call your doctor right away if you have any of the following symptoms, which could be signs of lactic acidosis:
Most people who have had lactic acidosis with metformin have other things that, combined with metformin, led to the lactic acidosis. Tell your doctor if you have any of the following, because you have a higher chance of getting lactic acidosis with JENTADUETO XR if you: The best way to keep from having a problem with lactic acidosis from metformin is to tell your doctor if you have any of the problems in the list above. Your doctor may decide to stop your JENTADUETO XR for a while if you have any of these things. JENTADUETO XR can have other serious side effects. See “What are the possible side effects of JENTADUETO XR?” 2.Inflammation of the pancreas (pancreatitis) which may be severe and lead to death. Certain medical problems make you more likely to get pancreatitis. Before you start taking JENTADUETO XR: Tell your doctor if you have ever had: | ||||
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Stop taking JENTADUETO
XR and call your doctor right away if you have pain in your stomach
area (abdomen) that is severe and will not go away. The pain may be
felt going from your abdomen through to your back. The pain may happen
with or without vomiting. These may be symptoms of pancreatitis. 3.Heart failure. Heart failure means that your heart does not pump blood well enough. Before you start taking JENTADUETO XR, tell your doctor if you have ever had heart failure or have problems with your kidneys. Contact your doctor right away if you have any of the following symptoms:
These may be symptoms of heart failure. | ||||
What is JENTADUETO
XR?
| ||||
Who should
not take JENTADUETO XR? Do not take JENTADUETO XR if you:
| ||||
What should
I tell my doctor before using JENTADUETO XR? Before you take JENTADUETO XR, tell your doctor about all of your medical conditions, including if you:
Especially tell your doctor if you take: Know the medicines you take. Keep a list of them and show it to your doctor and pharmacist when you get a new medicine. | ||||
How should
I take JENTADUETO XR?
| ||||
What are the possible
side effects of JENTADUETO XR? JENTADUETO XR may cause serious side effects, including:
| ||||
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|
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If you have these
symptoms, stop taking JENTADUETO XR and call your doctor or go to
the nearest hospital emergency room right away.
These are not all the possible side effects of JENTADUETO XR. For more information, ask your doctor or pharmacist. Tell your doctor if you have any side effects that bother you or that do not go away. | ||||
How should
I store JENTADUETO XR?
| ||||
General information
about the safe and effective use of JENTADUETO XR Medicines are sometimes prescribed for purposes other than those listed in Medication Guides. Do not use JENTADUETO XR for a condition for which it was not prescribed. Do not give JENTADUETO XR to other people, even if they have the same symptoms you have. It may harm them. This Medication Guide summarizes the most important information about JENTADUETO XR. If you would like more information, talk with your doctor. You can ask your pharmacist or doctor for information about JENTADUETO XR that is written for health professionals. | ||||
What are the
ingredients in JENTADUETO XR? Active Ingredients: linagliptin and metformin hydrochloride Inactive Ingredients: polyethylene oxide, hypromellose, and magnesium stearate. The coating contains the following inactive ingredients: hydroxypropyl cellulose, hypromellose, talc, titanium dioxide, arginine, polyethylene glycol, ferric oxide yellow (2.5 mg/1000 mg), carnauba wax, ferrosoferric oxide, propylene glycol, and isopropyl alcohol. | ||||
What is type
2 diabetes? Type 2 diabetes is a condition in which your body does not make enough insulin, and/or the insulin that your body produces does not work as well as it should. Your body can also make too much sugar. When this happens, sugar (glucose) builds up in the blood. This can lead to serious medical problems. The main goal of treating diabetes is to lower your blood sugar to a normal level. High blood sugar can be lowered by diet and exercise, and by certain medicines when necessary. Talk to your doctor about how to prevent, recognize, and take care of low blood sugar (hypoglycemia), high blood sugar (hyperglycemia), and other problems you have because of your diabetes. | ||||
Distributed by:
Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT 06877 USA. Marketed by: Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT 06877 USA and Eli Lilly and Company. Indianapolis, IN 46285 USA. Licensed from: Boehringer Ingelheim International GmbH, Ingelheim, Germany. JENTADUETO is a registered trademark of and used under license from Boehringer Ingelheim International GmbH. *The brands listed are trademarks of their respective owners and are not trademarks of Boehringer Ingelheim Pharmaceuticals, Inc. The makers of these brands are not affiliated with and do not endorse Boehringer Ingelheim Pharmaceuticals, Inc., or its products. For more information, go to www.jentadueto.com (or scan the code below to go to www.jentadueto.com) or call Boehringer Ingelheim Pharmaceuticals, Inc. at 1-800-542-6257, or (TTY) 1-800-459-9906. Copyright © 2017 Boehringer Ingelheim International GmbH. ALL RIGHTS RESERVED IT6354FH142017 |
This Medication Guide has been approved by the U. S. Food and Drug Administration. Revised: August 2017
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Jentadueto
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XR 2.5/1000 mg Carton
NDC: 0597-0270-12
Jentadueto
XR 5/1000 mg Label
NDC: 0597-0275-33
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NDC: 0597-0275-81
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NDC: 0597-0275-88
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