`
`
`
` These highlights do not include all the information needed to use
`
`
`
`TRADJENTA safely and effectively. See full prescribing information for
`
` TRADJENTA.
`
`
` Tradjenta® (linagliptin) tablets
`
` Initial U.S. Approval: 2011
`----------------------------RECENT MAJOR CHANGES-------------------------
`
`
`
`
`
`
`
`Warnings and Precautions, Bullous Pemphigoid (5.5)
`12/2016
`
`----------------------------INDICATIONS AND USAGE--------------------------
`
`TRADJENTA is a dipeptidyl peptidase-4 (DPP-4) inhibitor indicated as an
` adjunct to diet and exercise to improve glycemic control in adults with type 2
`
`
` diabetes mellitus (1.1)
`
`Important limitations of use:
`
`Should not be used in patients with type 1 diabetes or for the treatment
`
`
`
`
`
`•
`of diabetic ketoacidosis (1.2)
`
`
`Has not been studied in patients with a history of pancreatitis (1.2)
`
`
`
`
`•
`----------------------DOSAGE AND ADMINISTRATION----------------------
`The recommended dose of TRADJENTA is 5 mg once daily. (2.1)
`
`
`
`
`
`•
`TRADJENTA can be taken with or without food. (2.1)
`
`
`
`•
`---------------------DOSAGE FORMS AND STRENGTHS---------------------
`
`Tablets: 5 mg (3)
`
`-------------------------------CONTRAINDICATIONS-----------------------------
`History of hypersensitivity reaction to linagliptin, such as anaphylaxis,
`
`
`
`angioedema, exfoliative skin conditions, urticaria, or bronchial hyperreactivity
`
`
`
`(4)
`
`
`
`
`
`
`
`
`
`•
`
`
`•
`
`
`•
`
`•
`
`
`•
`
`
`•
`
`
`
`
`
`
`
`
`
`
`
`
`•
`
`
`•
`
`
`•
`
`Severe and disabling arthralgia has been reported in patients taking
`
`
`
`
`
` DPP-4 inhibitors. Consider as a possible cause for severe joint pain and
`
`
`
`
` discontinue drug if appropriate. (5.4)
`
`
`
`
` There have been postmarketing reports of bullous pemphigoid requiring
`
`
`
`
` hospitalization in patients taking DPP-4 inhibitors. Tell patients to report
` development of blisters or erosions. If bullous pemphigoid is suspected,
`
`
`
`
` discontinue TRADJENTA (5.5).
`
`
` There have been no clinical studies establishing conclusive evidence of
`
`
`macrovascular risk reduction with TRADJENTA or any other
`
`
`antidiabetic drug (5.6)
`------------------------------ADVERSE REACTIONS------------------------------
` Adverse reactions reported in ≥5% of patients treated with
`
`
`
`
`•
`TRADJENTA and more commonly than in patients treated with placebo
`
`
`
`
`included nasopharyngitis (6.1)
`
`
`
`Hypoglycemia was more commonly reported in patients treated with the
`
`
`combination of TRADJENTA and sulfonylurea compared with those
`
`treated with the combination of placebo and sulfonylurea (6.1)
`
`
`To report SUSPECTED ADVERSE REACTIONS, contact Boehringer
`
`
`Ingelheim Pharmaceuticals, Inc. at 1-800-542-6257 or 1-800-459-9906
`
`
`
`TTY, or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.
`
`------------------------------DRUG INTERACTIONS------------------------------
`
`
`
`Strong P-glycoprotein/CYP3A4 inducer: The efficacy of TRADJENTA may
`
`
`be reduced when administered in combination (e.g., with rifampin). Use of
`
`
`alternative treatments is strongly recommended. (7.1)
`-----------------------USE IN SPECIFIC POPULATIONS-----------------------
`
`
`Pregnancy: There are no adequate and well-controlled studies in
`
`•
`
`
`
`pregnant women. TRADJENTA tablets should be used during
`
`pregnancy only if clearly needed. (8.1)
`
`
`Nursing mothers: Caution should be exercised when TRADJENTA is
`
`
`administered to a nursing woman (8.3)
`
`
`Pediatric patients: Safety and effectiveness of TRADJENTA in patients
`
`
`below the age of 18 have not been established (8.4)
`
`
`
`
`Renal or hepatic impairment: No dose adjustment recommended (8.6,
`
`8.7)
`
`-----------------------WARNINGS AND PRECAUTIONS-----------------------
`There have been postmarketing reports of acute pancreatitis, including
`
`•
`fatal pancreatitis. If pancreatitis is suspected, promptly discontinue
`
`
`
`TRADJENTA. (5.1)
`
`• When used with an insulin secretagogue (e.g., sulfonylurea) or insulin,
`
`
`
`
`consider lowering the dose of the insulin secretagogue or insulin to
`
`
`
`
`reduce the risk of hypoglycemia (5.2)
`
`
`There have been postmarketing reports of serious hypersensitivity
`
`reactions in patients treated with TRADJENTA including anaphylaxis,
`
`
`
`
`angioedema, and exfoliative skin conditions. In such cases, promptly
`
`
`discontinue TRADJENTA, assess for other potential causes, institute
`
`
`
`
`appropriate monitoring and treatment, and initiate alternative treatment
`
`
`for diabetes. (5.3)
`
`
`_______________________________________________________________________________________________________________________________________
`
`
`
`
`
`
`
`See 17 for PATIENT COUNSELING INFORMATION and Medication
`
`Guide.
`
`
`
`
`
`
`
`
`
`
`
`
`
`Revised: 12/2016
`
`
`FULL PRESCRIBING INFORMATION: CONTENTS*
`
`1
`
`
`
`
`
`INDICATIONS AND USAGE
`
`
`1.1 Monotherapy and Combination Therapy
`
`
`1.2
`Important Limitations of Use
`
`
`2 DOSAGE AND ADMINISTRATION
`
`
`2.1 Recommended Dosing
`
`
`
`2.2 Concomitant Use with an Insulin Secretagogue (e.g., Sulfonylurea)
`
`
`
`or with Insulin
`
`3 DOSAGE FORMS AND STRENGTHS
`
`
`4 CONTRAINDICATIONS
`
`
`5 WARNINGS AND PRECAUTIONS
`
`
`5.1 Pancreatitis
`
`
`
`
`5.2 Use with Medications Known to Cause Hypoglycemia
`
`
`5.3 Hypersensitivity Reactions
`
`
`
`5.4 Severe and Disabling Arthralgia
`
`
`5.5 Bullous Pemphigoid
`
`
`5.6 Macrovascular Outcomes
`
`
`6 ADVERSE REACTIONS
`
`
`6.1 Clinical Trials Experience
`
`
`
`6.2 Postmarketing Experience
`
`7 DRUG INTERACTIONS
`
`
`Inducers of P-glycoprotein or CYP3A4 Enzymes
`
`7.1
`
`
`
`
`
`
`Reference ID: 4032562
`
`
`8 USE IN SPECIFIC POPULATIONS
`
`
`8.1 Pregnancy
`
`
`8.3 Nursing Mothers
`
`
`8.4 Pediatric Use
`
`
`8.5 Geriatric Use
`
`
`8.6 Renal Impairment
`
`
`8.7 Hepatic Impairment
`
`
`10 OVERDOSAGE
`
`
`11 DESCRIPTION
`
`
`12 CLINICAL PHARMACOLOGY
`
`
`12.1 Mechanism of Action
`
`
`12.2 Pharmacodynamics
`
`
`12.3 Pharmacokinetics
`
`
`13 NONCLINICAL TOXICOLOGY
`
`
`
`13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
`
`
`14 CLINICAL STUDIES
`
`
`14.1 Monotherapy
`
`
`14.2 Combination Therapy
`
`
`
`14.3 Renal Impairment
`
`16 HOW SUPPLIED/STORAGE AND HANDLING
`
`
`17 PATIENT COUNSELING INFORMATION
`
`
`
`
`
`*Sections or subsections omitted from the full prescribing information are not
`listed.
`
`
`
`
` 1
`
`
`
`
`
` FULL PRESCRIBING INFORMATION
`
` INDICATIONS AND USAGE
` 1
`
`
` 1.1 Monotherapy and Combination Therapy
`
` TRADJENTA tablets are indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus [see Clinical Studies (14.1)].
`
`
`
`
`
`1.2 Important Limitations of Use
`
`
`
`
`
`
`TRADJENTA 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.
`
` TRADJENTA 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 TRADJENTA [see Warnings and Precautions (5.1)].
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
` DOSAGE AND ADMINISTRATION
` 2
`
`
` 2.1 Recommended Dosing
` The recommended dose of TRADJENTA is 5 mg once daily.
`
` TRADJENTA tablets can be taken with or without food.
`
`2.2 Concomitant Use with an Insulin Secretagogue (e.g., Sulfonylurea) or with Insulin
`
`
`
`
`
`When TRADJENTA is used in combination with an insulin secretagogue (e.g., sulfonylurea) or with insulin, a lower dose of the insulin secretagogue or insulin may be
`
`
`
`
`
`required to reduce the risk of hypoglycemia [see Warnings and Precautions (5.2)].
`
`
`
`
`DOSAGE FORMS AND STRENGTHS
`3
`
`
`TRADJENTA (linagliptin) 5 mg tablets are light red, round, biconvex, bevel-edged, film-coated tablets with “D5” debossed on one side and the Boehringer Ingelheim
`
`
`
`
`logo debossed on the other side.
`
`
`
`CONTRAINDICATIONS
`4
`
`
`TRADJENTA is contraindicated in patients with a history of a hypersensitivity reaction to linagliptin, such as anaphylaxis, angioedema, exfoliative skin conditions,
`
`
`
`
`
`
`urticaria, or bronchial hyperreactivity [see Warnings and Precautions (5.3) and Adverse Reactions (6.1)].
`
`
`
`
`
`
`WARNINGS AND PRECAUTIONS
`5
`
`
`5.1 Pancreatitis
`
`
`There have been postmarketing reports of acute pancreatitis, including fatal pancreatitis, in patients taking TRADJENTA. Take careful notice of potential signs and
`
`
`
`
`symptoms of pancreatitis. If pancreatitis is suspected, promptly discontinue TRADJENTA 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 TRADJENTA.
`
`
`
`
`5.2 Use with Medications Known to Cause Hypoglycemia
`
`
`
`Insulin secretagogues and insulin are known to cause hypoglycemia. The use of TRADJENTA 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)]. The use of TRADJENTA in combination with
`
`
`
`
`
`insulin in subjects with severe renal impairment was associated with a higher rate of hypoglycemia [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 TRADJENTA.
`
`
`
`
`
`
`5.3 Hypersensitivity Reactions
`
`
`There have been postmarketing reports of serious hypersensitivity reactions in patients treated with TRADJENTA. These reactions include anaphylaxis, angioedema,
`
`
`
`
`
`and exfoliative skin conditions. Onset of these reactions occurred within the first 3 months after initiation of treatment with TRADJENTA, with some reports occurring
`
`
`
`
`after the first dose. If a serious hypersensitivity reaction is suspected, discontinue TRADJENTA, 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 TRADJENTA.
`
`
`
`
`
`
`5.4 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.
`
`
`5.5 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
`
`
`
`
`TRADJENTA. If bullous pemphigoid is suspected, TRADJENTA should be discontinued and referral to a dermatologist should be considered for diagnosis and
`
`
`
`
`
`
`
`appropriate treatment.
`
`
`5.6 Macrovascular Outcomes
`
`
`There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with TRADJENTA tablets or any other antidiabetic drug.
`
`
`
`ADVERSE REACTIONS
`6
`
`
`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.
`
`
`
`
`
`
`Reference ID: 4032562
`
`
`
` 2
`
`
`
` The safety evaluation of TRADJENTA 5 mg once daily in patients with type 2 diabetes is based on 14 placebo-controlled trials, 1 active-controlled study, and one study
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
` in patients with severe renal impairment. In the 14 placebo-controlled studies, a total of 3625 patients were randomized and treated with TRADJENTA 5 mg daily and
` 2176 with placebo. The mean exposure in patients treated with TRADJENTA across studies was 29.6 weeks. The maximum follow-up was 78 weeks.
`
`
`
`
`
`
`TRADJENTA 5 mg once daily was studied as monotherapy in three placebo-controlled trials of 18 and 24 weeks’ duration and in five additional placebo-controlled
`
`
`
`
`
`
`
`
`studies lasting ≤18 weeks. The use of TRADJENTA in combination with other antihyperglycemic agents was studied in six placebo-controlled trials: two with
`
`
`
`
`
`
`
`
`
`
`metformin (12 and 24 weeks’ treatment duration); one with a sulfonylurea (18 weeks’ treatment duration); one with metformin and sulfonylurea (24 weeks’ treatment
`
`
`
`
`
`
`duration); one with pioglitazone (24 weeks’ treatment duration); and one with insulin (primary endpoint at 24 weeks).
`
`
`
`
`
`
`
`In a pooled dataset of 14 placebo-controlled clinical trials, adverse reactions that occurred in ≥2% of patients receiving TRADJENTA (n = 3625) and more commonly
`
`
`
`
`
`
`
`
`than in patients given placebo (n = 2176), are shown in Table 1. The overall incidence of adverse events with TRADJENTA were similar to placebo.
`
`
`
`
`
`
`
`
`
` Table 1 Adverse Reactions Reported in ≥2% of Patients Treated with TRADJENTA and Greater than Placebo in Placebo-Controlled Clinical Studies of
`
`
`
`
`
`
` TRADJENTA Monotherapy or Combination Therapy
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
` Number (%) of Patients
`
`
`
`
` Nasopharyngitis
`
` Diarrhea
`
` Cough
`
`
`
`
`
`
`
`
`
` TRADJENTA 5 mg
`
` n = 3625
`
` 254 (7.0)
`
` 119 (3.3)
` 76 (2.1)
`
`
`
` Placebo
`
` n = 2176
`
` 132 (6.1)
` 65 (3.0)
`
`
` 30 (1.4)
`
`
`
`Rates for other adverse reactions for TRADJENTA 5 mg vs placebo when TRADJENTA was used in combination with specific anti-diabetic agents were: urinary tract
`
`
`
`
`
`
`
`
`
`
`
`
`
`infection (3.1% vs 0%) and hypertriglyceridemia (2.4% vs 0%) when TRADJENTA was used as add-on to sulfonylurea; hyperlipidemia (2.7% vs 0.8%) and weight
`
`
`
`
`
`
`
`
`increased (2.3% vs 0.8%) when TRADJENTA was used as add-on to pioglitazone; and constipation (2.1% vs 1%) when TRADJENTA was used as add-on to basal
`
`
`
`
`
`
`
`
`
`
`insulin therapy.
`
`
`
`Following 104 weeks’ treatment in a controlled study comparing TRADJENTA with glimepiride in which all patients were also receiving metformin, adverse reactions
`
`
`
`
`
`
`
`reported in ≥5% of patients treated with TRADJENTA (n = 776) and more frequently than in patients treated with a sulfonylurea (n = 775) were back pain (9.1% vs
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`8.4%), arthralgia (8.1% vs 6.1%), upper respiratory tract infection (8.0% vs 7.6%), headache (6.4% vs 5.2%), cough (6.1% vs 4.9%), and pain in extremity (5.3% vs
`
`
`
`
`
`
`
`
`3.9%).
`
`
`Other adverse reactions reported in clinical studies with treatment of TRADJENTA 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
`
`
`
`
`
`
`
`TRADJENTA 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.
`
`
`
`
`Hypoglycemia
`
`In the placebo-controlled studies, 199 (6.6%) of the total 2994 patients treated with TRADJENTA 5 mg reported hypoglycemia compared to 56 patients (3.6%) of 1546
`
`
`
`
`
`
`placebo-treated patients. The incidence of hypoglycemia was similar to placebo when TRADJENTA was administered as monotherapy or in combination with
`
`
`
`
`
`metformin, or with pioglitazone. When TRADJENTA was administered in combination with metformin and a sulfonylurea, 181 of 792 (22.9%) patients reported
`
`
`
`
`hypoglycemia compared with 39 of 263 (14.8%) patients administered placebo in combination with metformin and a 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.
`
`
`
`In the study of patients receiving TRADJENTA as add-on therapy to a stable dose of insulin for up to 52 weeks (n=1261), no significant difference in the incidence of
`
`
`
`
`
`
`
`
`investigator reported hypoglycemia, defined as all symptomatic or asymptomatic episodes with a self-measured blood glucose ≤70 mg/dL, was noted between the
`
`
`
`
`
`
`
`
`TRADJENTA- (31.4%) and placebo- (32.9%) treated groups. During the same time period, severe hypoglycemic events, defined as requiring the assistance of another
`
`
`
`
`
`
`
`
`
`person to actively administer carbohydrate, glucagon or other resuscitative actions, were reported in 11 (1.7%) of TRADJENTA treated patients and 7 (1.1%) of
`
`
`
`
`
`
`
`
`
`
`placebo treated patients. Events that were considered life-threatening or required hospitalization were reported in 3 (0.5%) patients on TRADJENTA and 1 (0.2%) on
`
`
`
`
`
`
`
`
`placebo.
`
`
`Use in Renal Impairment
`
`TRADJENTA was compared to placebo as add-on to pre-existing antidiabetic therapy over 52 weeks in 133 patients with severe renal impairment (estimated GFR <30
`
`
`
`
`
`mL/min). For the initial 12 weeks of the study, background antidiabetic therapy was kept stable and included insulin, sulfonylurea, glinides, and pioglitazone. For the
`
`
`
`remainder of the trial, dose adjustments in antidiabetic background therapy were allowed.
`
`
`
`
`
`In general, the incidence of adverse events including severe hypoglycemia was similar to those reported in other TRADJENTA trials. The observed incidence of
`
`
`
`
`
`hypoglycemia was higher (TRADJENTA, 63% compared to placebo, 49%) due to an increase in asymptomatic hypoglycemic events especially during the first 12
`
`
`
`
`
`
`
`
`
`
`weeks when background glycemic therapies were kept stable. Ten TRADJENTA-treated patients (15%) and 11 placebo-treated patients (17%) reported at least one
`
`
`
`
`
`
`episode of confirmed symptomatic hypoglycemia (accompanying finger stick glucose ≤54 mg/dL). During the same time period, severe hypoglycemic events, defined
`
`
`
`as an event requiring the assistance of another person to actively administer carbohydrate, glucagon or other resuscitative actions, were reported in 3 (4.4%)
`
`
`
`
`
`TRADJENTA-treated patients and 3 (4.6%) placebo-treated patients. Events that were considered life-threatening or required hospitalization were reported in 2 (2.9%)
`
`
`
`
`
`
`patients on TRADJENTA and 1 (1.5%) patient on placebo.
`
`
`
`
`
`Renal function as measured by mean eGFR and creatinine clearance did not change over 52 weeks’ treatment compared to placebo.
`
`
`
`
`
`
`
`
`Laboratory Tests
`
`Changes in laboratory findings were similar in patients treated with TRADJENTA 5 mg compared to patients treated with placebo. Changes in laboratory values that
`
`
`
`
`occurred more frequently in the TRADJENTA group and ≥1% more than in the placebo group were increases in uric acid (1.3% in the placebo group, 2.7% in the
`
`
`
`
`
`
`
`
`
`TRADJENTA group).
`
`
`No clinically meaningful changes in vital signs were observed in patients treated with TRADJENTA.
`
`
`
`
`
`
`
`
`
` 3
`
`Reference ID: 4032562
`
`
`
`
`
`
`6.2 Postmarketing Experience
`
`
`
`
`
`Additional adverse reactions have been identified during postapproval use of TRADJENTA. 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.
`
`
`
`
`
`Acute pancreatitis, including fatal pancreatitis [see Indications and Usage (1.2) and Warnings and Precautions (5.1)]
`
`
`•
`
`Hypersensitivity reactions including anaphylaxis, angioedema, and exfoliative skin conditions [see Warnings and Precautions (5.3)]
`
`
`
`
`
`•
`
`
`Severe and disabling arthralgia [see Warnings and Precautions (5.4)]
`
`
`
`•
`
`
`Bullous pemphigoid [see Warnings and Precautions (5.5)]
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`•
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`Rash
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`•
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`• Mouth ulceration, stomatitis
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`DRUG INTERACTIONS
`7
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`7.1 Inducers of P-glycoprotein or CYP3A4 Enzymes
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`Rifampin decreased linagliptin exposure, suggesting that the efficacy of TRADJENTA may be reduced when administered in combination with a strong P-gp or
`CYP3A4 inducer. Therefore, use of alternative treatments is strongly recommended when linagliptin is to be administered with a strong P-gp or CYP3A4 inducer [see
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`Clinical Pharmacology (12.3)].
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`USE IN SPECIFIC POPULATIONS
`8
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`8.1 Pregnancy
`Pregnancy Category B
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`Reproduction studies have been performed in rats and rabbits. There are, however, no adequate and well-controlled studies in pregnant women. Because animal
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`reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.
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`Linagliptin administered during the period of organogenesis was not teratogenic at doses up to 30 mg/kg in the rat and 150 mg/kg in the rabbit, or approximately 49 and
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`1943 times the clinical dose based on AUC exposure. Doses of linagliptin causing maternal toxicity in the rat and the rabbit also caused developmental delays in
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`skeletal ossification and slightly increased embryofetal loss in the rat (1000 times the clinical dose) and increased fetal resorptions and visceral and skeletal variations in
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`the rabbit (1943 times the clinical dose).
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`Linagliptin administered to female rats from gestation day 6 to lactation day 21 resulted in decreased body weight and delays in physical and behavioral development in
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`male and female offspring at maternally toxic doses (exposures >1000 times the clinical dose). No functional, behavioral, or reproductive toxicity was observed in
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`offspring of rats exposed to 49 times the clinical dose.
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`Linagliptin crossed the placenta into the fetus following oral dosing in pregnant rats and rabbits.
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`8.3 Nursing Mothers
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`Available animal data have shown excretion of linagliptin in milk at a milk-to-plasma ratio of 4:1. It is not known whether this drug is excreted in human milk.
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`Because many drugs are excreted in human milk, caution should be exercised when TRADJENTA is administered to a nursing woman.
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`8.4 Pediatric Use
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`Safety and effectiveness of TRADJENTA in pediatric patients under 18 years of age have not been established.
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`8.5 Geriatric Use
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`There were 4040 type 2 diabetes patients treated with linagliptin 5 mg from 15 clinical trials of TRADJENTA; 1085 (27%) were 65 years and over, while 131 (3%)
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`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
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`years and over. No overall differences in safety or effectiveness were observed between patients 65 years and over and younger patients. Therefore, no dose
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`adjustment is recommended in the elderly population. While clinical studies of linagliptin have not identified differences in response between the elderly and younger
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`patients, greater sensitivity of some older individuals cannot be ruled out.
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`8.6 Renal Impairment
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`No dose adjustment is recommended for patients with renal impairment [see Clinical Pharmacology (12.3)].
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`8.7 Hepatic Impairment
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`No dose adjustment is recommended for patients with hepatic impairment [see Clinical Pharmacology (12.3)].
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`OVERDOSAGE
`10
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`In the event of an overdose with TRADJENTA, contact the Poison Control Center. Employ the usual supportive measures (e.g., remove unabsorbed material from the
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`gastrointestinal tract, employ clinical monitoring, and institute supportive treatment) as dictated by the patient’s clinical status. Removal of linagliptin by hemodialysis
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`or peritoneal dialysis is unlikely.
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`During controlled clinical trials in healthy subjects, with single doses of up to 600 mg of TRADJENTA (equivalent to 120 times the recommended daily dose) there
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`were no dose-related clinical adverse drug reactions. There is no experience with doses above 600 mg in humans.
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`DESCRIPTION
`11
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`TRADJENTA (linagliptin) tablets contain, as the active ingredient, an orally-active inhibitor of the dipeptidyl peptidase-4 (DPP-4) enzyme.
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`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
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`quinazolinyl)methyl]
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`The empirical formula is C25H28N8O2 and the molecular weight is 472.54 g/mol. The structural formula is:
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`Reference ID: 4032562
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` 4
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`N
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`O
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`N
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`N
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`N
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`O
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`N
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`N
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`N
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`NH2
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` 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
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` (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).
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`Each film-coated tablet of TRADJENTA contains 5 mg of linagliptin free base and the following inactive ingredients: mannitol, pregelatinized starch, corn starch,
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`copovidone, and magnesium stearate. In addition, the film coating contains the following inactive ingredients: hypromellose, titanium dioxide, talc, polyethylene glycol,
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`and red ferric oxide.
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`CLINICAL PHARMACOLOGY
`12
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`12.1 Mechanism of Action
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`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
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`(GIP). Thus, linagliptin increases the concentrations of active incretin hormones, stimulating the release of insulin in a glucose-dependent manner and decreasing the
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`levels of glucagon in the circulation. Both incretin hormones are involved in the physiological regulation of glucose homeostasis. Incretin hormones are secreted at a
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`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
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`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
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`in hepatic glucose output.
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`12.2 Pharmacodynamics
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`Linagliptin binds to DPP-4 in a reversible manner and thus increases the concentrations of incretin hormones. Linagliptin glucose dependently increases insulin
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`secretion and lowers glucagon secretion, thus resulting in better regulation of glucose homeostasis. Linagliptin binds selectively to DPP-4, and selectively inhibits DPP
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`4 but not DPP-8 or DPP-9 activity in vitro at concentrations approximating therapeutic exposures.
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`Cardiac Electrophysiology
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`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
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`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
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`dose. At the 100-mg dose, peak linagliptin plasma concentrations were approximately 38-fold higher than the peak concentrations following a 5-mg dose.
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`12.3 Pharmacokinetics
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`The pharmacokinetics of linagliptin has been characterized in healthy subjects and patients with type 2 diabetes. After oral administration of a single 5-mg dose to
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`healthy subjects, peak plasma concentrations of linagliptin occurred at approximately 1.5 hours post dose (Tmax); the mean plasma area under the curve (AUC) was 139
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`nmol*h/L and maximum concentration (Cmax) was 8.9 nmol/L.
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`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
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`DPP-4. The prolonged elimination phase does not contribute to the accumulation of the drug. The effective half-life for accumulation of linagliptin, as determined
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`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
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`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. The intra-subject and inter-subject
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`coefficients of variation for linagliptin AUC were small (12.6% and 28.5%, respectively). Plasma AUC of linagliptin increased in a less than dose-proportional manner
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`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.
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`Absorption
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`The absolute bioavailability of linagliptin is approximately 30%. High-fat meal reduced Cmax by 15% and increased AUC by 4%; this effect is not clinically relevant.
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`TRADJENTA may be administered with or without food.
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`Distribution
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`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
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`that linagliptin extensively distributes to the tissues. Plasma protein binding of linagliptin is concentration-dependent, decreasing from about 99% at
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`1 nmol/L to 75%-89% at ≥30 nmol/L, reflecting saturation of binding to DPP-4 with increasing concentration of linagliptin. At high concentrations, where DPP-4 is
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`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
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`or hepatic impairment.
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`Metabolism
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`Following oral administration, the majority (about 90%) of linagliptin is excreted unchanged, indicating that metabolism represents a minor elimination pathway. A
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`small fraction of absorbed linagliptin is metabolized to a pharmacologically inactive metabolite, which shows a steady-state exposure of 13.3% relative to linagliptin.
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`Excretion
`Following administration of an oral [14C]-linagliptin dose to healthy subjects, approximately 85% of the administered radioactivity was eliminated via the enterohepatic
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`system (80%) or urine (5%) within 4 days of dosing. Renal clearance at steady state was approximately 70 mL/min.
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`Specific Populations
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`Renal Impairment
`An open-label pharmacokinetic study evaluated the pharmacokinetics of linagliptin 5 mg in male and female patients with varying degrees of chronic renal impairment.
`The study included 6 healthy subjects with normal renal function (creatinine clearance [CrCl] ≥80 mL/min), 6 patients with mild renal impairment (CrCl 50 to <80
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`mL/min), 6 patients with moderate renal impairment (CrCl 30 to <50 mL/min), 10 patients with type 2 diabetes mellitus and severe renal impairment (CrCl <30
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`mL/min), and 11 patients with type 2 diabetes mellitus and normal renal function. Creatinine clearance was measured by 24-hour urinary creatinine clearance
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`measurements or estimated from serum creatinine based on the Cockcroft-Gault formula.
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`Under steady-state conditions, linagliptin exposure in patients with mild renal impairment was comparable to healthy subjects.
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` 5
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`Reference ID: 4032562
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`In patients with moderate renal impairment under steady-state conditions, mean exposure of linagliptin in