Saxagliptin (saxagliptin 5 mg) Dailymed
Generic: saxagliptin is used for the treatment of Diabetes Mellitus, Type 2
IMPRINT: SX2 M
SHAPE: round
COLOR: white
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saxagliptin 5 mg - sx2 m round white
saxagliptin 2.5 mg - sx1 m round yellow
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1 Indications And Usage
Saxagliptin tablets are a dipeptidyl peptidase-4 (DPP4) inhibitor indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. (1.1 ,14 )
Limitation of use:
• Not used for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis. (1.2 )1.1Monotherapy and Combination Therapy
Saxagliptin 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) ].
1.2Limitation of Use
Saxagliptin tablets are not indicated for the treatment of type 1 diabetes mellitus or diabetic ketoacidosis, as they would not be effective in these settings.
2 Dosage And Administration
• Recommended dosage is 2.5 mg or 5 mg once daily taken regardless of meals. (2.1 )• Patients eGFR < 45 mL/min/1.73 m2 (with moderate or severe renal impairment, or end-stage renal disease): Recommended dosage is 2.5 mg once daily regardless of meals. (2.2 )• Assess renal function before starting saxagliptin tablets and periodically thereafter. (2.2 )• 2.5 mg daily is recommended for patients also taking strong cytochrome P450 3A4/5 (CYP3A4/5) inhibitors (e.g., ketoconazole). (2.3 ,7.1 )2.1Recommended Dosage
The recommended dosage of saxagliptin tablets is 2.5 mg or 5 mg once daily taken regardless of meals. Saxagliptin tablets must not be split or cut.
2.2Dosage in Patients with Renal Impairment
No dosage adjustment for saxagliptin tablets is recommended for patients with eGFR ≥ 45 mL/min/1.73 m2.
The dosage of saxagliptin tablets is 2.5 mg once daily (regardless of meals) for patients with eGFR < 45 mL/min/1.73 m2 (which includes a subset of moderate or severe renal impairment, or with end-stage renal disease (ESRD) requiring hemodialysis) [see Clinical Pharmacology (12.3) and Clinical Studies (14.2) ]. Saxagliptin tablets should be administered following hemodialysis. Saxagliptin tablets have not been studied in patients undergoing peritoneal dialysis.
Because the dosage of saxagliptin tablets should be limited to 2.5 mg based upon renal function, assessment of renal function is recommended prior to initiation of saxagliptin tablets and periodically thereafter.
2.3Dosage Adjustment with Concomitant Use of Strong CYP3A4/5 Inhibitors
The dosage of saxagliptin tablets is 2.5 mg once daily when coadministered with strong cytochrome P450 3A4/5 (CYP3A4/5) inhibitors (e.g., ketoconazole, atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, ritonavir, saquinavir, and telithromycin) [see Drug Interactions (7.1) and Clinical Pharmacology (12.3) ].
2.4Concomitant Use with an Insulin Secretagogue (e.g., Sulfonylurea) or with Insulin
When saxagliptin tablets are 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 minimize the risk of hypoglycemia [see Warnings and Precautions (5.3) ].
3 Dosage Forms And Strengths
Saxagliptin Tablets are available containing 3.075 mg or 6.149 mg of saxagliptin hydrochloride dihydrate equivalent to 2.5 mg or 5 mg of saxagliptin.
• The 2.5 mg tablets are yellow, film-coated, round, unscored tablets imprinted with SX1 over M in black ink on one side of the tablet and blank on the other side.• The 5 mg tablets are white to off-white, film-coated, round, unscored tablets imprinted with SX2 over M in black ink on one side of the tablet and blank on the other side.
• Tablets: 5 mg and 2.5 mg. (3 )
4 Contraindications
Saxagliptin tablets are contraindicated in patients with a history of a serious hypersensitivity reaction to saxagliptin tablets, such as anaphylaxis, angioedema, or exfoliative skin conditions [see Warnings and Precautions (5.4) and Adverse Reactions (6.2) ].
• History of a serious hypersensitivity reaction (e.g., anaphylaxis, angioedema, exfoliative skin conditions) to saxagliptin tablets. (4 )
5 Warnings And Precautions
• Pancreatitis: If pancreatitis is suspected, promptly discontinue saxagliptin tablets. (5.1 )• Heart Failure: Consider the risks and benefits of saxagliptin tablets in patients who have known risk factors for heart failure. Monitor patients for signs and symptoms. (5.2 )• Hypoglycemia: In add-on to sulfonylurea, add-on to insulin, and add-on to metformin plus sulfonylurea trials, confirmed hypoglycemia was more common in patients treated with saxagliptin tablets compared to placebo. When used with an insulin secretagogue (e.g., sulfonylurea) or insulin, a lower dose of insulin secretagogue or insulin may be required to minimize the risk of hypoglycemia. (5.3 ,6.1 )• Hypersensitivity-Related Events (e.g., Urticaria, Facial Edema): More common in patients treated with saxagliptin tablets than in patients treated with placebo; and postmarketing reports of serious hypersensitivity reactions such as anaphylaxis, angioedema, and exfoliative skin conditions. Promptly discontinue saxagliptin tablets, assess for other potential causes, institute appropriate monitoring and treatment, and initiate alternative treatment for diabetes. (5.4 ,6.1 ,6.2 )• Arthralgia: Severe and disabling arthralgia has been reported in patients taking DPP4 inhibitors. Consider as a possible cause for severe joint pain and discontinue drug if appropriate. (5.5 )• Bullous Pemphigoid: There have been postmarketing reports of bullous pemphigoid requiring hospitalization in patients taking DPP4 inhibitors. Tell patients to report development of bulers or erosions. If bullous pemphigoid is suspected, discontinue saxagliptin tablets. (5.6 )• Macrovascular Outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with saxagliptin tablets. (5.7 )5.1Pancreatitis
There have been postmarketing reports of acute pancreatitis in patients taking saxagliptin tablets. In a cardiovascular outcomes trial enrolling participants with established atherosclerotic cardiovascular disease (ASCVD) or multiple risk factors for ASCVD (SAVOR trial), cases of definite acute pancreatitis were confirmed in 17 of 8240 (0.2%) patients receiving saxagliptin tablets compared to 9 of 8173 (0.1%) receiving placebo. Preexisting risk factors for pancreatitis were identified in 88% (15/17) of those patients receiving saxagliptin tablets and in 100% (9/9) of those patients receiving placebo.
After initiation of saxagliptin tablets, observe patients for signs and symptoms of pancreatitis. If pancreatitis is suspected, promptly discontinue saxagliptin tablets 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 saxagliptin tablets.
5.2Heart Failure
In a cardiovascular outcomes trial enrolling participants with established ASCVD or multiple risk factors for ASCVD (SAVOR trial), more patients randomized to saxagliptin tablets (289/8280, 3.5%) were hospitalized for heart failure compared to patients randomized to placebo (228/8212, 2.8%). In a time-to-first-event analysis the risk of hospitalization for heart failure was higher in the saxagliptin tablets group (estimated Hazard Ratio: 1.27; 95% CI: 1.07, 1.51). Subjects with a prior history of heart failure and subjects with renal impairment had a higher risk for hospitalization for heart failure, irrespective of treatment assignment.
Consider the risks and benefits of saxagliptin tablets prior to initiating treatment in patients at a higher risk for heart failure. Observe 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 saxagliptin tablets.
5.3Hypoglycemia with Concomitant Use of Sulfonylurea or Insulin
When saxagliptin tablets were used in combination with a sulfonylurea or with insulin, medications known to cause hypoglycemia, the incidence of confirmed hypoglycemia was increased over that of placebo used in combination with a sulfonylurea or with insulin [see Adverse Reactions (6.1) ]. Therefore, a lower dose of the insulin secretagogue or insulin may be required to minimize the risk of hypoglycemia when used in combination with saxagliptin tablets [see Dosage and Administration (2.4) ].
5.4Hypersensitivity Reactions
There have been postmarketing reports of serious hypersensitivity reactions in patients treated with saxagliptin tablets. These reactions include anaphylaxis, angioedema, and exfoliative skin conditions. Onset of these reactions occurred within the first 3 months after initiation of treatment with saxagliptin tablets, with some reports occurring after the first dose.
If a serious hypersensitivity reaction is suspected, discontinue saxagliptin tablets, assess for other potential causes for the event, and institute alternative treatment for diabetes [see Adverse Reactions (6.2) ].
Use caution in a patient with a history of angioedema to another dipeptidyl peptidase-4 (DPP4) inhibitor because it is unknown whether such patients will be predisposed to angioedema with saxagliptin tablets.
5.5Severe and Disabling Arthralgia
There have been postmarketing reports of severe and disabling arthralgia in patients taking DPP4 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 DPP4 inhibitor. Consider DPP4 inhibitors as a possible cause for severe joint pain and discontinue drug if appropriate.
5.6Bullous Pemphigoid
Postmarketing cases of bullous pemphigoid requiring hospitalization have been reported with DPP4 inhibitor use. In reported cases, patients typically recovered with topical or systemic immunosuppressive treatment and discontinuation of the DPP4 inhibitor. Tell patients to report development of bulers or erosions while receiving saxagliptin tablets. If bullous pemphigoid is suspected, saxagliptin tablets should be discontinued and referral to a dermatologist should be considered for diagnosis and appropriate treatment.
5.7Macrovascular Outcomes
There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with saxagliptin tablets.
6 Adverse Reactions
The following serious adverse reactions are described below or elsewhere in the prescribing information:
• Pancreatitis [see Warnings and Precautions (5.1) ]• Heart Failure [see Warnings and Precautions (5.2) ]• Hypoglycemia with Concomitant Use of Sulfonylurea or Insulin [see Warnings and Precautions (5.3)]• Hypersensitivity Reactions [see Warnings and Precautions (5.4) ]• Severe and Disabling Arthralgia [see Warnings and Precautions (5.5) ]• Bullous Pemphigoid [see Warnings and Precautions (5.6) ]
• Adverse reactions reported in ≥ 5% of patients treated with saxagliptin tablets and more commonly than in patients treated with placebo are upper respiratory tract infection, urinary tract infection, and headache. (6.1 )• Peripheral edema was reported more commonly in patients treated with the combination of saxagliptin tablets and a thiazolidinedione (TZD) than in patients treated with the combination of placebo and TZD. (6.1 )
To report SUSPECTED ADVERSE REACTIONS, contact Mylan at 1-877-446-3679 (1-877-4-INFO-RX) or FDA at 1-800-FDA-1088 orwww.fda.gov/medwatch.
6.1Clinical 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.
The data in Table 1 are derived from a pool of 5 placebo-controlled clinical trials [see Clinical Studies (14) ]. These data shown in the table reflect exposure of 882 patients to saxagliptin tablets and a mean duration of exposure to saxagliptin tablets of 21 weeks. The mean age of these patients was 55 years, 1.4% were 75 years or older and 48.4% were male. The population was 67.5% White, 4.6% Black or African American, 17.4% Asian, Other 10.5% and 9.8% were of Hispanic or Latino ethnicity. At baseline the population had diabetes for an average of 5.2 years and a mean HbA1c of 8.2%. Baseline estimated renal function was normal or mildly impaired (eGFR ≥ 60 mL/min/1.73 m2) in 91% of these patients.
Table 1 shows common adverse reactions, excluding hypoglycemia, associated with the use of saxagliptin tablets. These adverse reactions occurred more commonly on saxagliptin tablets than on placebo and occurred in at least 5% of patients treated with saxagliptin tablets.
Table 1: Adverse Reactions in Placebo-Controlled Trials The 5 placebo-controlled trials include two monotherapy trials and one add-on combination therapy trial with each of the following: metformin, thiazolidinedione, or glyburide. Table shows 24-week data regardless of glycemic rescue.  Reported in ≥ 5% of Patients Treated with Saxagliptin Tablets 5 mg and More Commonly than in Patients Treated with Placebo
% of Patients
Saxagliptin Tablets 5 mg
N = 882
Placebo
N = 799
Upper respiratory tract infection
7.7
7.6
Urinary tract infection
6.8
6.1
Headache
6.5
5.9
In patients treated with saxagliptin tablets 2.5 mg, headache (6.5%) was the only adverse reaction reported at a rate ≥ 5% and more commonly than in patients treated with placebo.
In the add-on to TZD trial, the incidence of peripheral edema was higher for saxagliptin tablets 5 mg versus placebo (8.1% and 4.3%, respectively). The incidence of peripheral edema for saxagliptin tablets 2.5 mg was 3.1%. None of the reported adverse reactions of peripheral edema resulted in study drug discontinuation. Rates of peripheral edema for saxagliptin tablets 2.5 mg and saxagliptin tablets 5 mg versus placebo were 3.6% and 2% versus 3% given as monotherapy, 2.1% and 2.1% versus 2.2% given as add-on therapy to metformin, and 2.4% and 1.2% versus 2.2% given as add-on therapy to glyburide.
The incidence rate of fractures was 1.0 and 0.6 per 100 patient-years, respectively, for saxagliptin tablets (pooled analysis of 2.5 mg, 5 mg, and 10 mg) and placebo. The 10 mg dosage is not an approved dosage. The incidence rate of fracture events in patients who received saxagliptin tablets did not increase over time. Causality has not been established and nonclinical studies have not demonstrated adverse effects of saxagliptin tablets on bone.
An event of thrombocytopenia, consistent with a diagnosis of idiopathic thrombocytopenic purpura, was observed in the clinical program. The relationship of this event to saxagliptin tablets is not known.
Discontinuation of therapy due to adverse reactions occurred in 2.2%, 3.3%, and 1.8% of subjects receiving saxagliptin tablets 2.5 mg, saxagliptin tablets 5 mg, and placebo, respectively. The most common adverse reactions (reported in at least 2 subjects treated with saxagliptin tablets 2.5 mg or at least 2 subjects treated with saxagliptin tablets 5 mg) associated with premature discontinuation of therapy included lymphopenia (0.1% and 0.5% versus 0%, respectively), rash (0.2% and 0.3% versus 0.3%), blood creatinine increased (0.3% and 0% versus 0%), and blood creatine phosphokinase increased (0.1% and 0.2% versus 0%).
In the add-on to insulin trial [see Clinical Studies (14.1) ], the incidence of adverse events, including serious adverse events and discontinuations due to adverse events, was similar between saxagliptin tablets and placebo, except for confirmed hypoglycemia [see Adverse Reactions (6.1) ].
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 add-on to glyburide study, the overall incidence of reported hypoglycemia was higher for saxagliptin tablets 2.5 mg and saxagliptin tablets 5 mg (13.3% and 14.6%) versus placebo (10.1%). The incidence of confirmed hypoglycemia in this study, defined as symptoms of hypoglycemia accompanied by a fingerstick glucose value of ≤ 50 mg/dL, was 2.4% and 0.8% for saxagliptin tablets 2.5 mg and saxagliptin tablets 5 mg and 0.7% for placebo [see Warnings and Precautions (5.3) ]. The incidence of reported hypoglycemia for saxagliptin tablets 2.5 mg and saxagliptin tablets 5 mg versus placebo given as monotherapy was 4% and 5.6% versus 4.1%, respectively, 7.8% and 5.8% versus 5% given as add-on therapy to metformin, and 4.1% and 2.7% versus 3.8% given as add-on therapy to TZD. The incidence of reported hypoglycemia was 3.4% in treatment-naive patients given saxagliptin tablets 5 mg plus metformin and 4% in patients given metformin alone.
In the active-controlled trial comparing add-on therapy with saxagliptin tablets 5 mg to glipizide in patients inadequately controlled on metformin alone, the incidence of reported hypoglycemia was 3% (19 events in 13 patients) with saxagliptin tablets 5 mg versus 36.3% (750 events in 156 patients) with glipizide. Confirmed symptomatic hypoglycemia (accompanying fingerstick blood glucose ≤ 50 mg/dL) was reported in none of the saxagliptin tablet-treated patients and in 35 glipizide-treated patients (8.1%) (p < 0.0001).
In the add-on to insulin trial, the overall incidence of reported hypoglycemia was 18.4% for saxagliptin tablets 5 mg and 19.9% for placebo. However, the incidence of confirmed symptomatic hypoglycemia (accompanying fingerstick blood glucose ≤ 50 mg/dL) was higher with saxagliptin tablets 5 mg (5.3%) versus placebo (3.3%).
In the add-on to metformin plus sulfonylurea trial, the overall incidence of reported hypoglycemia was 10.1% for saxagliptin tablets 5 mg and 6.3% for placebo. Confirmed hypoglycemia was reported in 1.6% of the saxagliptin tablet-treated patients and in none of the placebo-treated patients [see Warnings and Precautions (5.3) ].
Hypersensitivity-related events, such as urticaria and facial edema in the 5-study pooled analysis up to Week 24 were reported in 1.5%, 1.5%, and 0.4% of patients who received saxagliptin tablets 2.5 mg, saxagliptin tablets 5 mg, and placebo, respectively. None of these events in patients who received saxagliptin tablets required hospitalization or were reported as life-threatening by the investigators. One saxagliptin tablet-treated patient in this pooled analysis discontinued due to generalized urticaria and facial edema.
In the SAVOR trial, adverse reactions related to renal impairment, including laboratory changes (i.e., doubling of serum creatinine compared with baseline and serum creatinine > 6 mg/dL), were reported in 5.8% (483/8280) of saxagliptin tablet-treated subjects and 5.1% (422/8212) of placebo-treated subjects. The most frequently reported adverse reactions included renal impairment (2.1% vs. 1.9%), acute renal failure (1.4% vs. 1.2%), and renal failure (0.8% vs. 0.9%), in the saxagliptin tablets versus placebo groups, respectively. From baseline to the end of treatment, there was a mean decrease in eGFR of 2.5 mL/min/1.73 m2 for saxagliptin tablet-treated patients and a mean decrease of 2.4 mL/min/1.73 m2 for placebo-treated patients. More subjects randomized to saxagliptin tablets (421/5227, 8.1%) compared to subjects randomized to placebo (344/5073, 6.8%) had downward shifts in eGFR from > 50 mL/min/1.73 m2 (i.e., normal or mild renal impairment) to ≤ 50 mL/min/1.73 m2 (i.e., moderate or severe renal impairment). The proportions of subjects with renal adverse reactions increased with worsening baseline renal function and increased age, regardless of treatment assignment.
In the unblinded, controlled, clinical trial database for saxagliptin tablets to date, there have been 6 (0.12%) reports of tuberculosis among the 4959 saxagliptin tablet-treated patients (1.1 per 1000 patient-years) compared to no reports of tuberculosis among the 2868 comparator-treated patients. Two of these six cases were confirmed with laboratory testing. The remaining cases had limited information or had presumptive diagnoses of tuberculosis. None of the six cases occurred in the United States or in Western Europe. One case occurred in Canada in a patient originally from Indonesia who had recently visited Indonesia. The duration of treatment with saxagliptin tablets until report of tuberculosis ranged from 144 to 929 days. Post-treatment lymphocyte counts were consistently within the reference range for four cases. One patient had lymphopenia prior to initiation of saxagliptin tablets that remained stable throughout saxagliptin tablet treatment. The final patient had an isolated lymphocyte count below normal approximately four months prior to the report of tuberculosis. There have been no spontaneous reports of tuberculosis associated with saxagliptin tablet use. Causality has not been estimated and there are too few cases to date to determine whether tuberculosis is related to saxagliptin tablet use.
There has been one case of a potential opportunistic infection in the unblinded, controlled clinical trial database to date in a saxagliptin tablet-treated patient who developed suspected foodborne fatal salmonella sepsis after approximately 600 days of saxagliptin tablet therapy. There have been no spontaneous reports of opportunistic infections associated with saxagliptin tablet use.
No clinically meaningful changes in vital signs have been observed in patients treated with saxagliptin tablets.
Absolute Lymphocyte Counts
There was a dose-related mean decrease in absolute lymphocyte count observed with saxagliptin tablets. From a baseline mean absolute lymphocyte count of approximately 2200 cells/microL, mean decreases of approximately 100 and 120 cells/microL with saxagliptin tablets 5 mg and 10 mg, respectively, relative to placebo were observed at 24 weeks in a pooled analysis of five placebo-controlled clinical studies. Similar effects were observed when saxagliptin tablets 5 mg were given in initial combination with metformin compared to metformin alone. There was no difference observed for saxagliptin tablets 2.5 mg relative to placebo. The proportion of patients who were reported to have a lymphocyte count ≤ 750 cells/microL was 0.5%, 1.5%, 1.4%, and 0.4% in the saxagliptin tablets 2.5 mg, 5 mg, 10 mg, and placebo groups, respectively. In most patients, recurrence was not observed with repeated exposure to saxagliptin tablets although some patients had recurrent decreases upon rechallenge that led to discontinuation of saxagliptin tablets. The decreases in lymphocyte count were not associated with clinically relevant adverse reactions. The 10 mg dosage is not an approved dosage.
In the SAVOR trial mean decreases of approximately 84 cells/microL with saxagliptin tablets relative to placebo was observed. The proportion of patients who experienced a decrease in lymphocyte counts to a count of ≤ 750 cells/microL was 1.6% (136/8280) and 1.0% (78/8212) on saxagliptin tablets and placebo respectively.
The clinical significance of this decrease in lymphocyte count relative to placebo is not known. When clinically indicated, such as in settings of unusual or prolonged infection, lymphocyte count should be measured. The effect of saxagliptin tablets on lymphocyte counts in patients with lymphocyte abnormalities (e.g., human immunodeficiency virus) is unknown.
6.2Postmarketing Experience
Additional adverse reactions have been identified during post-approval use of saxagliptin tablets. 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.
• Hypersensitivity reactions including anaphylaxis, angioedema, and exfoliative skin conditions• Pancreatitis• Severe and disabling arthralgia• Bullous pemphigoid• Rhabdomyolysis
7 Drug Interactions
• Strong CYP3A4/5 Inhibitors (e.g., Ketoconazole): Coadministration with saxagliptin tablets significantly increases saxagliptin concentrations. Recommend limiting saxagliptin tablet dosage to 2.5 mg once daily. (2.3 ,7.1 )7.1Strong Inhibitors of CYP3A4/5 Enzymes
Ketoconazole significantly increased saxagliptin exposure. Similar significant increases in plasma concentrations of saxagliptin are anticipated with other strong CYP3A4/5 inhibitors (e.g., atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, ritonavir, saquinavir, and telithromycin). The dose of saxagliptin tablets should be limited to 2.5 mg when coadministered with a strong CYP3A4/5 inhibitor [see Dosage and Administration (2.3) and Clinical Pharmacology (12.3) ].
8 Use In Specific Populations
8.1 Pregnancy
Limited data with saxagliptin tablets in pregnant women are not sufficient to determine a drug-associated risk for major birth defects or miscarriages. There are risks to the mother and fetus associated with poorly controlled diabetes in pregnancy [see Clinical Considerations ].
No adverse developmental effects independent of maternal toxicity were observed when saxagliptin was administered to pregnant rats and rabbits during the period of organogenesis and in pregnant and lactating rats during the pre- and postnatal period [see Data ].
The estimated background risk of major birth defects is 6 to 10% in women with pre-gestational diabetes with an HbA1c greater than 7 and has been reported to be as high as 20 to 25% in women with an HbA1c greater than 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.
Disease-associated Maternal and/or Embryo/Fetal Risk
Poorly controlled diabetes in pregnancy increases the maternal risk for diabetic ketoacidosis, preeclampsia, spontaneous abortions, preterm delivery, still birth and delivery complications. Poorly controlled diabetes increases the fetal risk for major birth defects, stillbirth, and macrosomia related morbidity.
Animal Data
In embryo-fetal development studies, saxagliptin was administered to pregnant rats and rabbits during the period of organogenesis, corresponding to the first trimester of human pregnancy. No adverse developmental effects were observed in either species at exposures 1503- and 152-times the 5 mg clinical dose in rats and rabbits, respectively, based on AUC. Saxagliptin crosses the placenta into the fetus following dosing in pregnant rats.
In a prenatal and postnatal development study, no adverse developmental effects were observed in maternal rats administered saxagliptin from gestation day 6 through lactation day 21 at exposures up to 470-times the 5 mg clinical dose, based on AUC.
8.2 Lactation
There is no information regarding the presence of saxagliptin in human milk, the effects on the breastfed infant, or the effects on milk production.
Saxagliptin is present in the milk of lactating rats [see Data ]. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for saxagliptin tablets and any potential adverse effects on the breastfed infant from saxagliptin tablets or from the underlying maternal condition.
Saxagliptin is secreted in the milk of lactating rats at approximately a 1:1 ratio with plasma drug concentrations.
8.4 Pediatric Use
Safety and effectiveness of saxagliptin tablets in pediatric patients under 18 years of age have not been established. Additionally, studies characterizing the pharmacokinetics of saxagliptin tablets in pediatric patients have not been performed.
8.5 Geriatric Use
In the seven, double-blind, controlled clinical safety and efficacy trials of saxagliptin tablets, a total of 4751 (42.0%) of the 11301 patients randomized to saxagliptin tablets were 65 years and over, and 1210 (10.7%) were 75 years and over. No overall differences in safety or effectiveness were observed between subjects ≥ 65 years old and younger subjects. While this clinical experience has not identified differences in responses between the elderly and younger patients, greater sensitivity of some older individuals cannot be ruled out.
Saxagliptin and its active metabolite are eliminated in part by the kidney. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection in the elderly based on renal function [see Dosage and Administration (2.2) and Clinical Pharmacology (12.3) ].
8.6Renal Impairment
In a 12-week randomized placebo-controlled trial, saxagliptin tablets 2.5 mg were administered to 85 subjects with moderate (n = 48) or severe (n = 18) renal impairment or end-stage renal disease (ESRD) (n = 19) [see Clinical Studies (14) ]. The incidence of adverse events, including serious adverse events and discontinuations due to adverse events, was similar between saxagliptin tablets and placebo. The overall incidence of reported hypoglycemia was 20% among subjects treated with saxagliptin tablets 2.5 mg and 22% among subjects treated with placebo. Four saxagliptin tablet-treated subjects (4.7%) and three placebo-treated subjects (3.5%) reported at least one episode of confirmed symptomatic hypoglycemia (accompanying fingerstick glucose ≤ 50 mg/dL).
10 Overdosage
In a controlled clinical trial, once-daily, orally-administered saxagliptin tablets in healthy subjects at doses up to 400 mg daily for 2 weeks (80 times the MRHD) had no dose-related clinical adverse reactions and no clinically meaningful effect on QTc interval or heart rate.
In the event of an overdose, appropriate supportive treatment should be initiated as dictated by the patient’s clinical status. Saxagliptin and its active metabolite are removed by hemodialysis (23% of dose over 4 hours).
11 Description
Saxagliptin is an orally-active inhibitor of the DPP4 enzyme.
Saxagliptin hydrochloride dihydrate is described chemically as (1S,3S,5S)-2-[(2S)-Amino-(3-hydroxytricyclo [3.3.1.13,7]dec-1-yl)acetyl]-2-azabicyclo[3.1.0] hexane-3-carbonitrile hydrochloride dihydrate or (1S,3S,5S)-2-[(2S)-2-Amino-2-(3-hydroxyadamantan-1-yl)acetyl]-2-azabicyclo [3.1.0] hexane-3-carbonitrile hydrochloride dihydrate. The molecular formula is C18H25N3O2•HCl•2H2O and the molecular weight is 387.92. The structural formula is:
Saxagliptin hydrochloride dihydrate is a white to off-white, non-hygroscopic, crystalline powder. It is sparingly soluble in water at 24°C ± 3°C, slightly soluble in ethyl acetate, and soluble in methanol, ethanol, isopropyl alcohol, acetonitrile, acetone, and polyethylene glycol 400 (PEG 400).
Each film-coated tablet of saxagliptin for oral use contains either 3.075 mg saxagliptin hydrochloride dihydrate equivalent to 2.5 mg saxagliptin or 6.149 mg saxagliptin hydrochloride dihydrate equivalent to 5 mg saxagliptin and the following inactive ingredients: croscarmellose sodium, hydrochloric acid, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, polyvinyl alcohol, sodium hydroxide, talc and titanium dioxide. The 2.5 mg tablets also contain yellow iron oxide. The imprinting ink contains ammonium hydroxide, black iron oxide, propylene glycol and shellac glaze.
12 Clinical Pharmacology
12.1 Mechanism of Action
Increased concentrations of the incretin hormones such as glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) are released into the bloodstream from the small intestine in response to meals. These hormones cause insulin release from the pancreatic beta cells in a glucose-dependent manner but are inactivated by the DPP4 enzyme within minutes. GLP-1 also lowers glucagon secretion from pancreatic alpha cells, reducing hepatic glucose production. In patients with type 2 diabetes, concentrations of GLP-1 are reduced but the insulin response to GLP-1 is preserved. Saxagliptin is a competitive DPP4 inhibitor that slows the inactivation of the incretin hormones, thereby increasing their bloodstream concentrations and reducing fasting and postprandial glucose concentrations in a glucose-dependent manner in patients with type 2 diabetes mellitus.
12.2 Pharmacodynamics
In patients with type 2 diabetes mellitus, administration of saxagliptin tablets inhibits DPP4 enzyme activity for a 24-hour period. After an oral glucose load or a meal, this DPP4 inhibition resulted in a 2- to 3-fold increase in circulating levels of active GLP-1 and GIP, decreased glucagon concentrations, and increased glucose-dependent insulin secretion from pancreatic beta cells. The rise in insulin and decrease in glucagon were associated with lower fasting glucose concentrations and reduced glucose excursion following an oral glucose load or a meal.
In a randomized, double-blind, placebo-controlled, 4-way crossover, active comparator study using moxifloxacin in 40 healthy subjects, saxagliptin tablets were not associated with clinically meaningful prolongation of the QTc interval or heart rate at daily doses up to 40 mg (8 times the MRHD).
12.3 Pharmacokinetics
The pharmacokinetics of saxagliptin and its active metabolite, 5-hydroxy saxagliptin were similar in healthy subjects and in patients with type 2 diabetes mellitus. The Cmax and AUC values of saxagliptin and its active metabolite increased proportionally in the 2.5 to 400 mg dose range. Following a 5 mg single oral dose of saxagliptin to healthy subjects, the mean plasma AUC values for saxagliptin and its active metabolite were 78 ng•h/mL and 214 ng•h/mL, respectively. The corresponding plasma Cmax values were 24 ng/mL and 47 ng/mL, respectively. The average variability (%CV) for AUC and Cmax for both saxagliptin and its active metabolite was less than 25%.
No appreciable accumulation of either saxagliptin or its active metabolite was observed with repeated once-daily dosing at any dose level. No dose- and time-dependence were observed in the clearance of saxagliptin and its active metabolite over 14 days of once-daily dosing with saxagliptin at doses ranging from 2.5 to 400 mg.
The median time to maximum concentration (Tmax) following the 5 mg once daily dose was 2 hours for saxagliptin and 4 hours for its active metabolite. Administration with a high-fat meal resulted in an increase in Tmax of saxagliptin by approximately 20 minutes as compared to fasted conditions. There was a 27% increase in the AUC of saxagliptin when given with a meal as compared to fasted conditions. Saxagliptin tablets may be administered with or without food.
The in vitro protein binding of saxagliptin and its active metabolite in human serum is negligible. Therefore, changes in blood protein levels in various disease states (e.g., renal or hepatic impairment) are not expected to alter the disposition of saxagliptin.
The metabolism of saxagliptin is primarily mediated by cytochrome P450 3A4/5 (CYP3A4/5). The major metabolite of saxagliptin is also a DPP4 inhibitor, which is one-half as potent as saxagliptin. Therefore, strong CYP3A4/5 inhibitors and inducers will alter the pharmacokinetics of saxagliptin and its active metabolite [see Drug Interactions (7.1) ].
Saxagliptin is eliminated by both renal and hepatic pathways. Following a single 50 mg dose of 14C-saxagliptin, 24%, 36%, and 75% of the dose was excreted in the urine as saxagliptin, its active metabolite, and total radioactivity, respectively. The average renal clearance of saxagliptin (~ 230 mL/min) was greater than the average estimated glomerular filtration rate (~ 120 mL/min), suggesting some active renal excretion. A total of 22% of the administered radioactivity was recovered in feces representing the fraction of the saxagliptin dose excreted in bile and/or unabsorbed drug from the gastrointestinal tract. Following a single oral dose of saxagliptin tablets 5 mg to healthy subjects, the mean plasma terminal half-life (t1/2) for saxagliptin and its active metabolite was 2.5 and 3.1 hours, respectively.
Renal Impairment
A single-dose, open-label study was conducted to evaluate the pharmacokinetics of saxagliptin (10 mg dose) in subjects with varying degrees of chronic renal impairment compared to subjects with normal renal function. The 10 mg dosage is not an approved dosage. The degree of renal impairment did not affect Cmax of saxagliptin or its metabolite. In subjects with moderate renal impairment with (eGFR 30 to less than 45 mL/min/1.73 m2), severe renal impairment (eGFR 15 to less than 30 mL/min/1.73 m2) and ESRD patient on hemodialysis, the AUC values of saxagliptin or its active metabolite were > 2 fold higher than AUC values in subjects with normal renal function.
Hepatic Impairment
In subjects with hepatic impairment (Child-Pugh classes A, B, and C), mean Cmax and AUC of saxagliptin were up to 8% and 77% higher, respectively, compared to healthy matched controls following administration of a single 10 mg dose of saxagliptin. The 10 mg dosage is not an approved dosage. The corresponding Cmax and AUC of the active metabolite were up to 59% and 33% lower, respectively, compared to healthy matched controls. These differences are not considered to be clinically meaningful.
Body Mass Index
No dosage adjustment is recommended based on body mass index (BMI) which was not identified as a significant covariate on the apparent clearance of saxagliptin or its active metabolite in the population pharmacokinetic analysis.
Gender
No dosage adjustment is recommended based on gender. There were no differences observed in saxagliptin pharmacokinetics between males and females. Compared to males, females had approximately 25% higher exposure values for the active metabolite than males, but this difference is unlikely to be of clinical relevance. Gender was not identified as a significant covariate on the apparent clearance of saxagliptin and its active metabolite in the population pharmacokinetic analysis.
Geriatric
No dosage adjustment is recommended based on age alone. Elderly subjects (65-80 years) had 23% and 59% higher geometric mean Cmax and geometric mean AUC values, respectively, for saxagliptin than young subjects (18-40 years). Differences in active metabolite pharmacokinetics between elderly and young subjects generally reflected the differences observed in saxagliptin pharmacokinetics. The difference between the pharmacokinetics of saxagliptin and the active metabolite in young and elderly subjects is likely due to multiple factors including declining renal function and metabolic capacity with increasing age. Age was not identified as a significant covariate on the apparent clearance of saxagliptin and its active metabolite in the population pharmacokinetic analysis.
Race and Ethnicity
No dosage adjustment is recommended based on race. The population pharmacokinetic analysis compared the pharmacokinetics of saxagliptin and its active metabolite in 309 Caucasian subjects with 105 non-Caucasian subjects (consisting of six racial groups). No significant difference in the pharmacokinetics of saxagliptin and its active metabolite were detected between these two populations.
In Vitro Assessment of Drug Interactions
The metabolism of saxagliptin is primarily mediated by CYP3A4/5.
In in vitro studies, saxagliptin and its active metabolite did not inhibit CYP1A2, 2A6, 2B6, 2C9, 2C19, 2D6, 2E1, or 3A4, or induce CYP1A2, 2B6, 2C9, or 3A4. Therefore, saxagliptin is not expected to alter the metabolic clearance of coadministered drugs that are metabolized by these enzymes. Saxagliptin is a P-glycoprotein (P-gp) substrate but is not a significant inhibitor or inducer of P-gp.
In Vivo Assessment of Drug Interactions
Table 2: Effect of Coadministered Drugs on Systemic Exposures of Saxagliptin and its Active Metabolite, 5-hydroxy Saxagliptin ND = not determined; QD = once daily; q6h = every 6 hours; q12h = every 12 hours; BID = twice daily; LA = long acting
Coadministered Drug
Dosage of Coadministered DrugSingle dose unless otherwise noted. The 10 mg saxagliptin dose is not an approved dosage.
Dosage of Saxagliptin
Geometric Mean Ratio
(ratio with/without coadministered drug)
No Effect = 1.00
AUCAUC = AUC(INF) for drugs given as single dose and AUC = AUC(TAU) for drugs given in multiple doses
Cmax
No dosing adjustments required for the following:
Metformin
1000 mg
100 mg
saxagliptin
0.98
0.79
5-hydroxy saxagliptin
0.99
0.88
Glyburide
5 mg
10 mg
saxagliptin
0.98
1.08
5-hydroxy saxagliptin
ND
ND
Dapagliflozin
10 mg single dose
5 mg single dose
saxagliptin
↓ 1%
↓ 7%
5-hydroxy saxagliptin
↑ 9%
↑ 6%
PioglitazoneResults exclude one subject
45 mg QD for 10 days
10 mg QD for 5 days
saxagliptin
1.11
1.11
5-hydroxy saxagliptin
ND
ND
Digoxin
0.25 mg q6h first day followed by q12h second day followed by QD for 5 days
10 mg QD for 7 days
saxagliptin
1.05
0.99
5-hydroxy saxagliptin
1.06
1.02
Simvastatin
40 mg QD for 8 days
10 mg QD for 4 days
saxagliptin
1.12
1.21
5-hydroxy saxagliptin
1.02
1.08
Diltiazem
360 mg LA QD for 9 days
10 mg
saxagliptin
2.09
1.63
5-hydroxy saxagliptin
0.66
0.57
RifampinThe plasma dipeptidyl peptidase-4 (DPP4) activity inhibition over a 24-hour dose interval was not affected by rifampin
600 mg QD for 6 days
5 mg
saxagliptin
0.24
0.47
5-hydroxy saxagliptin
1.03
1.39
Omeprazole
40 mg QD for 5 days
10 mg
saxagliptin
1.13
0.98
5-hydroxy saxagliptin
ND
ND
Aluminum hydroxide + magnesium hydroxide + simethicone
aluminum hydroxide: 2400 mg
magnesium hydroxide: 2400 mg
simethicone: 240 mg
10 mg
saxagliptin
0.97
0.74
5-hydroxy saxagliptin
ND
ND
Famotidine
40 mg
10 mg
saxagliptin
1.03
1.14
5-hydroxy saxagliptin
ND
ND
Limit saxagliptin tablet dose to 2.5 mg once daily when coadministered with strong CYP3A4/5 inhibitors [see Drug Interactions (7.1) and Dosage and Administration (2.3) ]:
Ketoconazole
200 mg BID for 9 days
100 mg
saxagliptin
2.45
1.62
5-hydroxy saxagliptin
0.12
0.05
Ketoconazole
200 mg BID for 7 days
20 mg
saxagliptin
3.67
2.44
5-hydroxy saxagliptin
ND
ND
Â
Table 3: Effect of Saxagliptin on Systemic Exposures of Coadministered Drugs ND = not determined; QD = once daily; q6h = every 6 hours; q12h = every 12 hours; BID = twice daily; LA = long acting
Coadministered Drug
Dosage of Coadministered DrugSingle dose unless otherwise noted. The 10 mg and 100 mg saxagliptin doses are not approved dosages.
Dosage of Saxagliptin
Geometric Mean Ratio
(ratio with/without saxagliptin)
No Effect = 1.00
AUCAUC = AUC(INF) for drugs given as single dose and AUC = AUC(TAU) for drugs given in multiple doses
Cmax
No dosing adjustments required for the following:
Metformin
1000 mg
100 mg
metformin
1.20
1.09
Glyburide
5 mg
10 mg
glyburide
1.06
1.16
PioglitazoneResults include all subjects
45 mg QD for 10 days
10 mg QD for 5 days
pioglitazone
1.08
1.14
hydroxy-pioglitazone
ND
ND
Digoxin
0.25 mg q6h first day followed by q12h second day followed by QD for 5 days
10 mg QD for 7 days
digoxin
1.06
1.09
Simvastatin
40 mg QD for 8 days
10 mg QD for 4 days
simvastatin
1.04
0.88
simvastatin acid
1.16
1.00
Diltiazem
360 mg LA QD for 9 days
10 mg
diltiazem
1.10
1.16
Ketoconazole
200 mg BID for 9 days
100 mg
ketoconazole
0.87
0.84
Ethinyl estradiol and Norgestimate
ethinyl estradiol 0.035 mg and norgestimate 0.250 mg for 21 days
5 mg QD for 21 days
ethinyl estradiol
1.07
0.98
norelgestromin
1.10
1.09
norgestrel
1.13
1.17
13 Nonclinical Toxicology
13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility
Carcinogenicity was evaluated in 2-year studies conducted in CD-1 mice and Sprague-Dawley rats. Saxagliptin did not increase the incidence of tumors in mice dosed orally at 50, 250, and 600 mg/kg up to 870-times (males) and 1165-times (females) the 5 mg/day clinical dose, based on AUC. Saxagliptin did not increase the incidence of tumors in rats dosed orally at 25, 75, 150, and 300 mg/kg up to 355-times (males) and 2217-times (females) the 5 mg/day clinical dose, based on AUC.
Saxagliptin was not mutagenic or clastogenic in a battery of genotoxicity tests (Ames bacterial mutagenesis, human and rat lymphocyte cytogenetics, rat bone marrow micronucleus and DNA repair assays). The active metabolite of saxagliptin was not mutagenic in an Ames bacterial assay.
Saxagliptin administered to rats had no effect on fertility or the ability to maintain a litter at exposures up to 603-times and 776-times the 5 mg clinical dose in males and females, based on AUC.
13.2 Animal Toxicology and/or Pharmacology
Saxagliptin produced adverse skin changes in the extremities of cynomolgus monkeys (scabs and/or ulceration of tail, digits, scrotum, and/or nose). Skin lesions were reversible within exposure approximately 20-times the 5 mg clinical dose, but in some cases were irreversible and necrotizing at higher exposures. Adverse skin changes were not observed at exposures similar to (1- to 3-times) the 5 mg clinical dose. Clinical correlates to skin lesions in monkeys have not been observed in human clinical trials of saxagliptin.
14 Clinical Studies
14.1Glycemic Efficacy Trials
Saxagliptin tablets have been studied as monotherapy and in combination with metformin, glyburide, and thiazolidinedione (pioglitazone and rosiglitazone) therapy.
A total of 4148 patients with type 2 diabetes mellitus were randomized in six, double-blind, controlled clinical trials conducted to evaluate the safety and glycemic efficacy of saxagliptin tablets. A total of 3021 patients in these trials were treated with saxagliptin tablets. In these trials, the mean age was 54 years, and 71% of patients were Caucasian, 16% were Asian, 4% were black, and 9% were of other racial groups. An additional 423 patients, including 315 who received saxagliptin tablets, participated in a placebo-controlled, dose-ranging study of 6 to 12 weeks in duration.
In these six, double-blind trials, saxagliptin tablets were evaluated at doses of 2.5 mg and 5 mg once daily. Three of these trials also evaluated a saxagliptin tablet dose of 10 mg daily. The 10 mg daily dose of saxagliptin tablets did not provide greater efficacy than the 5 mg daily dose. The 10 mg dosage is not an approved dosage. Treatment with saxagliptin tablets 5 mg and 2.5 mg doses produced clinically relevant and statistically significant improvements in A1C, fasting plasma glucose (FPG), and 2-hour postprandial glucose (PPG) following a standard oral glucose tolerance test (OGTT), compared to control. Reductions in A1C were seen across subgroups including gender, age, race, and baseline BMI.
Saxagliptin tablets were not associated with significant changes from baseline in body weight or fasting serum lipids compared to placebo.
Saxagliptin tablets have also been evaluated in five additional trials in patients with type 2 diabetes: an active-controlled trial comparing add-on therapy with saxagliptin tablets to glipizide in 858 patients inadequately controlled on metformin alone, a trial comparing saxagliptin tablets to placebo in 455 patients inadequately controlled on insulin alone or on insulin in combination with metformin, a trial comparing saxagliptin tablets to placebo in 257 patients inadequately controlled on metformin plus a sulfonylurea, a trial comparing saxagliptin tablets to placebo in 315 patients inadequately controlled on dapagliflozin and metformin, and a trial comparing saxagliptin tablets to placebo in 170 patients with type 2 diabetes and moderate or severe renal impairment or ESRD.
A total of 766 patients with type 2 diabetes inadequately controlled on diet and exercise (A1C ≥ 7% to ≤ 10%) participated in two 24-week, double-blind, placebo-controlled trials evaluating the efficacy and safety of saxagliptin tablet monotherapy.
In the first trial, following a 2-week single-blind diet, exercise, and placebo lead-in period, 401 patients were randomized to 2.5 mg, 5 mg, or 10 mg of saxagliptin tablets or placebo. The 10 mg dosage is not an approved dosage. Patients who failed to meet specific glycemic goals during the study were treated with metformin rescue therapy, added on to placebo or saxagliptin tablets. Efficacy was evaluated at the last measurement prior to rescue therapy for patients needing rescue. Dose titration of saxagliptin tablets was not permitted.
Treatment with saxagliptin tablets 2.5 mg and 5 mg daily provided significant improvements in A1C, FPG, and PPG compared to placebo (Table 4). The percentage of patients who discontinued for lack of glycemic control or who were rescued for meeting prespecified glycemic criteria was 16% in the saxagliptin tablets 2.5 mg treatment group, 20% in the saxagliptin tablets 5 mg treatment group, and 26% in the placebo group.
Table 4: Glycemic Parameters at Week 24 in a Placebo-Controlled Study of Saxagliptin Tablet Monotherapy in Patients with Type 2 Diabetes Intent-to-treat population using last observation on study or last observation prior to metformin rescue therapy for patients needing rescue
Efficacy Parameter
Saxagliptin
Tablets
2.5 mg
N = 102
Saxagliptin
Tablets
5 mg
N = 106
Placebo
N = 95
Hemoglobin A1C (%)
N = 100
N = 103
N = 92
   Baseline (mean)
7.9
8.0
7.9
   Change from baseline (adjusted meanLeast squares mean adjusted for baseline value )
-0.4
-0.5
+0.2
   Difference from placebo (adjusted mean)
-0.6p-value < 0.0001 compared to placebo
-0.6
      95% Confidence Interval
(-0.9, -0.3)
(-0.9, -0.4)
   Percent of patients achieving A1C < 7%
35% (35/100)
38%p-value < 0.05 compared to placebo (39/103)
24% (22/92)
Fasting Plasma Glucose (mg/dL)
N = 101
N = 105
N = 92
   Baseline (mean)
178
171
172
   Change from baseline (adjusted mean)
-15
-9
+6
   Difference from placebo (adjusted mean)
-21
-15
      95% Confidence Interval
(-31, -10)
(-25, -4)
2-hour Postprandial Glucose (mg/dL)
N = 78
N = 84
N = 71
   Baseline (mean)
279
278
283
   Change from baseline (adjusted mean)
-45
-43
-6
   Difference from placebo (adjusted mean)
-39Significance was not tested for the 2-hour PPG for the 2.5 mg dose of saxagliptin tablets
-37
      95% Confidence Interval
(-61, -16)
(-59, -15)
A second 24-week monotherapy trial was conducted to assess a range of dosing regimens for saxagliptin tablets. Treatment-naive patients with inadequately controlled diabetes (A1C ≥ 7% to ≤ 10%) underwent a 2-week, single-blind diet, exercise, and placebo lead-in period. A total of 365 patients were randomized to 2.5 mg every morning, 5 mg every morning, 2.5 mg with possible titration to 5 mg every morning, or 5 mg every evening of saxagliptin tablets, or placebo. Patients who failed to meet specific glycemic goals during the study were treated with metformin rescue therapy added on to placebo or saxagliptin tablets; the number of patients randomized per treatment group ranged from 71 to 74.
Treatment with either saxagliptin tablets 5 mg every morning or 5 mg every evening provided significant improvements in A1C versus placebo (mean placebo-corrected reductions of -0.4% and -0.3%, respectively). Treatment with saxagliptin tablets 2.5 mg every morning also provided significant improvement in A1C versus placebo (mean placebo-corrected reduction of -0.4%).
Add-On Combination Therapy with Metformin
A total of 743 patients with type 2 diabetes participated in this 24-week, randomized, double-blind, placebo-controlled trial to evaluate the efficacy and safety of saxagliptin tablets in combination with metformin in patients with inadequate glycemic control (A1C ≥ 7% and ≤ 10%) on metformin alone. To qualify for enrollment, patients were required to be on a stable dose of metformin (1500-2550 mg daily) for at least 8 weeks.
Patients who met eligibility criteria were enrolled in a single-blind, 2-week, dietary and exercise placebo lead-in period during which patients received metformin at their pre-study dose, up to 2500 mg daily. Following the lead-in period, eligible patients were randomized to 2.5 mg, 5 mg, or 10 mg of saxagliptin tablets or placebo in addition to their current dose of open-label metformin. The 10 mg dosage is not an approved dosage. Patients who failed to meet specific glycemic goals during the study were treated with pioglitazone rescue therapy, added on to existing study medications. Dose titrations of saxagliptin tablets and metformin were not permitted.
Saxagliptin tablets 2.5 mg and 5 mg add-on to metformin provided significant improvements in A1C, FPG, and PPG compared with placebo add-on to metformin (Table 5). Mean changes from baseline for A1C over time and at endpoint are shown in Figure 1. The proportion of patients who discontinued for lack of glycemic control or who were rescued for meeting prespecified glycemic criteria was 15% in the saxagliptin tablets 2.5 mg add-on to metformin group, 13% in the saxagliptin tablets 5 mg add-on to metformin group, and 27% in the placebo add-on to metformin group.
Table 5: Glycemic Parameters at Week 24 in a Placebo-Controlled Study of Saxagliptin Tablets as Add-On Combination Therapy with Metformin Intent-to-treat population using last observation on study or last observation prior to pioglitazone rescue therapy for patients needing rescue
Efficacy Parameter
Saxagliptin Tablets
2.5 mg + Metformin
N = 192
Saxagliptin Tablets
5 mg + Metformin
N = 191
Placebo + Metformin
N = 179
Hemoglobin A1C (%)
N = 186
N = 186
N = 175
   Baseline (mean)
8.1
8.1
8.1
   Change from baseline (adjusted meanLeast squares mean adjusted for baseline value )
-0.6
-0.7
+0.1
   Difference from placebo (adjusted mean†)
-0.7p-value < 0.0001 compared to placebo + metformin
-0.8
      95% Confidence Interval
(-0.9, -0.5)
(-1.0, -0.6)
   Percent of patients achieving A1C < 7%
37%p-value < 0.05 compared to placebo + metformin (69/186)
44%(81/186)
17% (29/175)
Fasting Plasma Glucose (mg/dL)
N = 188
N = 187
N = 176
   Baseline (mean)
174
179
175
   Change from baseline (adjusted mean)
-14
-22
+1
   Difference from placebo (adjusted mean)
-16
-23
      95% Confidence Interval
(-23, -9)
(-30, -16)
2-hour Postprandial Glucose (mg/dL)
N = 155
N = 155
N = 135
   Baseline (mean)
294
296
295
   Change from baseline (adjusted mean)
-62
-58
-18
   Difference from placebo (adjusted mean)
-44
-40
      95% Confidence Interval
(-60, -27)
(-56, -24)
Â
Figure 1: Mean Change from Baseline in A1C in a Placebo-Controlled Trial of Saxagliptin Tablets as Add-On Combination Therapy with Metformin*
Week 24 (LOCF) includes intent-to-treat population using last observation on study prior to pioglitazone rescue therapy for patients needing rescue. Mean change from baseline is adjusted for baseline value.
Add-On Combination Therapy with a Thiazolidinedione
A total of 565 patients with type 2 diabetes participated in this 24-week, randomized, double-blind, placebo-controlled trial to evaluate the efficacy and safety of saxagliptin tablets in combination with a thiazolidinedione (TZD) in patients with inadequate glycemic control (A1C ≥ 7% to ≤ 10.5%) on TZD alone. To qualify for enrollment, patients were required to be on a stable dose of pioglitazone (30-45 mg once daily) or rosiglitazone (4 mg once daily or 8 mg either once daily or in two divided doses of 4 mg) for at least 12 weeks.
Patients who met eligibility criteria were enrolled in a single-blind, 2-week, dietary and exercise placebo lead-in period during which patients received TZD at their pre-study dose. Following the lead-in period, eligible patients were randomized to 2.5 mg or 5 mg of saxagliptin tablets or placebo in addition to their current dose of TZD. Patients who failed to meet specific glycemic goals during the study were treated with metformin rescue, added on to existing study medications. Dose titration of saxagliptin tablets or TZD was not permitted during the study. A change in TZD regimen from rosiglitazone to pioglitazone at specified, equivalent therapeutic doses was permitted at the investigator’s discretion if believed to be medically appropriate.
Saxagliptin tablets 2.5 mg and 5 mg add-on to TZD provided significant improvements in A1C, FPG, and PPG compared with placebo add-on to TZD (Table 6). The proportion of patients who discontinued for lack of glycemic control or who were rescued for meeting prespecified glycemic criteria was 10% in the saxagliptin tablets 2.5 mg add-on to TZD group, 6% for the saxagliptin tablets 5 mg add-on to TZD group, and 10% in the placebo add-on to TZD group.
Table 6: Glycemic Parameters at Week 24 in a Placebo-Controlled Study of Saxagliptin Tablets as Add-On Combination Therapy with a Thiazolidinedione Intent-to-treat population using last observation on study or last observation prior to metformin rescue therapy for patients needing rescue
Efficacy Parameter
Saxagliptin Tablets
2.5 mg + TZD
N = 195
Saxagliptin Tablets
5 mg + TZD
N = 186
Placebo + TZD
N = 184
Hemoglobin A1C (%)
N = 192
N = 183
N = 180
   Baseline (mean)
8.3
8.4
8.2
   Change from baseline (adjusted meanLeast squares mean adjusted for baseline value )
-0.7
-0.9
-0.3
   Difference from placebo (adjusted mean)
-0.4p-value < 0.05 compared to placebo + TZD
-0.6p-value < 0.0001 compared to placebo + TZD
      95% Confidence Interval
(-0.6, -0.2)
(-0.8, -0.4)
   Percent of patients achieving A1C < 7%
42%(81/192)
42%(77/184)
26% (46/180)
Fasting Plasma Glucose (mg/dL)
N = 193
N = 185
N = 181
   Baseline (mean)
163
160
162
   Change from baseline (adjusted mean)
-14
-17
-3
   Difference from placebo (adjusted mean)
-12
-15
      95% Confidence Interval
(-20, -3)
(-23, -6)
2-hour Postprandial Glucose (mg/dL)
N = 156
N = 134
N = 127
   Baseline (mean)
296
303
291
   Change from baseline (adjusted mean)
-55
-65
-15
   Difference from placebo (adjusted mean)
-40
-50
      95% Confidence Interval
(-56, -24)
(-66, -34)
Add-On Combination Therapy with Glyburide
A total of 768 patients with type 2 diabetes participated in this 24-week, randomized, double-blind, placebo-controlled trial to evaluate the efficacy and safety of saxagliptin tablets in combination with a sulfonylurea (SU) in patients with inadequate glycemic control at enrollment (A1C ≥ 7.5% to ≤ 10%) on a submaximal dose of SU alone. To qualify for enrollment, patients were required to be on a submaximal dose of SU for 2 months or greater. In this study, saxagliptin tablets in combination with a fixed, intermediate dose of SU was compared to titration to a higher dose of SU.
Patients who met eligibility criteria were enrolled in a single-blind, 4-week, dietary and exercise lead-in period, and placed on glyburide 7.5 mg once daily. Following the lead-in period, eligible patients with A1C ≥ 7% to ≤ 10% were randomized to either 2.5 mg or 5 mg of saxagliptin tablets add-on to 7.5 mg glyburide or to placebo plus a 10 mg total daily dose of glyburide. Patients who received placebo were eligible to have glyburide up-titrated to a total daily dose of 15 mg. Up-titration of glyburide was not permitted in patients who received saxagliptin tablets 2.5 mg or 5 mg. Glyburide could be down-titrated in any treatment group once during the 24-week study period due to hypoglycemia as deemed necessary by the investigator. Approximately 92% of patients in the placebo plus glyburide group were up-titrated to a final total daily dose of 15 mg during the first 4 weeks of the study period. Patients who failed to meet specific glycemic goals during the study were treated with metformin rescue, added on to existing study medication. Dose titration of saxagliptin tablets was not permitted during the study.
In combination with glyburide, saxagliptin tablets 2.5 mg and 5 mg provided significant improvements in A1C, FPG, and PPG compared with the placebo plus up-titrated glyburide group (Table 7). The proportion of patients who discontinued for lack of glycemic control or who were rescued for meeting prespecified glycemic criteria was 18% in the saxagliptin tablets 2.5 mg add-on to glyburide group, 17% in the saxagliptin tablets 5 mg add-on to glyburide group, and 30% in the placebo plus up-titrated glyburide group.
Table 7: Glycemic Parameters at Week 24 in a Placebo-Controlled Study of Saxagliptin Tablets as Add-On Combination Therapy with Glyburide Intent-to-treat population using last observation on study or last observation prior to metformin rescue therapy for patients needing rescue
Efficacy Parameter
Saxagliptin Tablets
2.5 mg + Glyburide
7.5 mg
N = 248
Saxagliptin Tablets
5 mg + Glyburide
7.5 mg
N = 253
Placebo + Up-Titrated Glyburide
N = 267
Hemoglobin A1C (%)
N = 246
N = 250
N = 264
   Baseline (mean)
8.4
8.5
8.4
   Change from baseline (adjusted meanLeast squares mean adjusted for baseline value )
-0.5
-0.6
+0.1
   Difference from up-titrated glyburide (adjusted mean)
-0.6p-value < 0.0001 compared to placebo + up-titrated glyburide
-0.7
      95% Confidence Interval
(-0.8, -0.5)
(-0.9, -0.6)
   Percent of patients achieving A1C < 7%
22%p-value < 0.05 compared to placebo + up-titrated glyburide (55/246)
23%(57/250)
9% (24/264)
Fasting Plasma Glucose (mg/dL)
N = 247
N = 252
N = 265
   Baseline (mean)
170
175
174
   Change from baseline (adjusted mean)
-7
-10
+1
   Difference from up-titrated glyburide (adjusted mean)
-8
-10
      95% Confidence Interval
(-14, -1)
(-17, -4)
2-hour Postprandial Glucose (mg/dL)
N = 195
N = 202
N = 206
   Baseline (mean)
309
315
323
   Change from baseline (adjusted mean)
-31
-34
+8
   Difference from up-titrated glyburide (adjusted mean)
-38
-42
      95% Confidence Interval
(-50, -27)
(-53, -31)
Coadministration with Metformin in Treatment-Naive Patients
A total of 1306 treatment-naive patients with type 2 diabetes mellitus participated in this 24-week, randomized, double-blind, active-controlled trial to evaluate the efficacy and safety of saxagliptin tablets coadministered with metformin in patients with inadequate glycemic control (A1C ≥ 8% to ≤ 12%) on diet and exercise alone. Patients were required to be treatment-naive to be enrolled in this study.
Patients who met eligibility criteria were enrolled in a single-blind, 1-week, dietary and exercise placebo lead-in period. Patients were randomized to one of four treatment arms: saxagliptin tablets 5 mg + metformin 500 mg, saxagliptin 10 mg + metformin 500 mg, saxagliptin 10 mg + placebo, or metformin 500 mg + placebo. The 10 mg saxagliptin dosage is not an approved dosage. Saxagliptin tablets were dosed once daily. In the 3 treatment groups using metformin, the metformin dose was up-titrated weekly in 500 mg per day increments, as tolerated, to a maximum of 2000 mg per day based on FPG. Patients who failed to meet specific glycemic goals during the studies were treated with pioglitazone rescue as add-on therapy.
Coadministration of saxagliptin tablets 5 mg plus metformin provided significant improvements in A1C, FPG, and PPG compared with placebo plus metformin (Table 8).
Table 8: Glycemic Parameters at Week 24 in a Placebo-Controlled Trial of Saxagliptin Tablet Coadministration with Metformin in Treatment-Naive Patients Intent-to-treat population using last observation on study or last observation prior to pioglitazone rescue therapy for patients needing rescue
Efficacy Parameter
Saxagliptin Tablets
5 mg + Metformin
N = 320
Placebo + Metformin
N = 328
Hemoglobin A1C (%)
N = 306
N = 313
   Baseline (mean)
9.4
9.4
   Change from baseline (adjusted meanLeast squares mean adjusted for baseline value )
-2.5
-2.0
   Difference from placebo + metformin (adjusted mean)
-0.5p-value < 0.0001 compared to placebo + metformin
      95% Confidence Interval
(-0.7, -0.4)
   Percent of patients achieving A1C < 7%
60%p-value < 0.05 compared to placebo + metformin (185/307)
41% (129/314)
Fasting Plasma Glucose (mg/dL)
N = 315
N = 320
   Baseline (mean)
199
199
   Change from baseline (adjusted mean)
-60
-47
   Difference from placebo + metformin (adjusted mean)
-13
      95% Confidence Interval
(-19, -6)
2-hour Postprandial Glucose (mg/dL)
N = 146
N = 141
   Baseline (mean)
340
355
   Change from baseline (adjusted mean)
-138
-97
   Difference from placebo + metformin (adjusted mean)
-41
      95% Confidence Interval
(-57, -25)
Add-On Combination Therapy with Metformin versus Glipizide Add-On Combination Therapy with Metformin
In this 52-week, active-controlled trial, a total of 858 patients with type 2 diabetes and inadequate glycemic control (A1C > 6.5% and ≤ 10%) on metformin alone were randomized to double-blind add-on therapy with saxagliptin tablets or glipizide. Patients were required to be on a stable dose of metformin (at least 1500 mg daily) for at least 8 weeks prior to enrollment.
Patients who met eligibility criteria were enrolled in a single-blind, 2-week, dietary and exercise placebo lead-in period during which patients received metformin (1500-3000 mg based on their pre-study dose). Following the lead-in period, eligible patients were randomized to 5 mg of saxagliptin tablets or 5 mg of glipizide in addition to their current dose of open-label metformin. Patients in the glipizide plus metformin group underwent blinded titration of the glipizide dose during the first 18 weeks of the trial up to a maximum glipizide dose of 20 mg per day. Titration was based on a goal FPG ≤ 110 mg/dL or the highest tolerable glipizide dose. Fifty percent (50%) of the glipizide-treated patients were titrated to the 20-mg daily dose; 21% of the glipizide-treated patients had a final daily glipizide dose of 5 mg or less. The mean final daily dose of glipizide was 15 mg.
After 52 weeks of treatment, saxagliptin tablets and glipizide resulted in similar mean reductions from baseline in A1C when added to metformin therapy (Table 9). This conclusion may be limited to patients with baseline A1C comparable to those in the trial (91% of patients had baseline A1C < 9%).
From a baseline mean body weight of 89 kg, there was a statistically significant mean reduction of 1.1 kg in patients treated with saxagliptin tablets compared to a mean weight gain of 1.1 kg in patients treated with glipizide (p < 0.0001).
Table 9: Glycemic Parameters at Week 52 in an Active-Controlled Trial of Saxagliptin Tablets versus Glipizide in Combination with Metformin Intent-to-treat population using last observation on study
Efficacy Parameter
Saxagliptin Tablets
5 mg + Metformin
N = 428
Titrated Glipizide + Metformin
N = 430
Hemoglobin A1C (%)
N = 423
N = 423
   Baseline (mean)
7.7
7.6
   Change from baseline (adjusted meanLeast squares mean adjusted for baseline value )
-0.6
-0.7
   Difference from glipizide + metformin (adjusted mean)
0.1
      95% Confidence Interval
(-0.02, 0.2)Saxagliptin tablets + metformin is considered non-inferior to glipizide + metformin because the upper limit of this confidence interval is less than the prespecified non-inferiority margin of 0.35%
Fasting Plasma Glucose (mg/dL)
N = 420
N = 420
   Baseline (mean)
162
161
   Change from baseline (adjusted mean)
-9
-16
   Difference from glipizide + metformin (adjusted mean)
6
      95% Confidence Interval
(2, 11)Significance not tested
Add-On Combination Therapy with Insulin (with or without Metformin)
A total of 455 patients with type 2 diabetes participated in this 24-week, randomized, double-blind, placebo-controlled trial to evaluate the efficacy and safety of saxagliptin tablets in combination with insulin in patients with inadequate glycemic control (A1C ≥ 7.5% and ≤ 11%) on insulin alone (N = 141) or on insulin in combination with a stable dose of metformin (N = 314). Patients were required to be on a stable dose of insulin (≥ 30 units to ≤ 150 units daily) with ≤ 20% variation in total daily dose for ≥ 8 weeks prior to screening. Patients entered the trial on intermediate- or long-acting (basal) insulin or premixed insulin. Patients using short-acting insulins were excluded unless the short-acting insulin was administered as part of a premixed insulin.
Patients who met eligibility criteria were enrolled in a single-blind, four-week, dietary and exercise placebo lead-in period during which patients received insulin (and metformin if applicable) at their pretrial dose(s). Following the lead-in period, eligible patients were randomized to add-on therapy with either saxagliptin tablets 5 mg or placebo. Doses of the antidiabetic therapies were to remain stable but patients were rescued and allowed to adjust the insulin regimen if specific glycemic goals were not met or if the investigator learned that the patient had self-increased the insulin dose by > 20%. Data after rescue were excluded from the primary efficacy analyses.
Add-on therapy with saxagliptin tablets 5 mg provided significant improvements from baseline to Week 24 in A1C and PPG compared with add-on placebo (Table 10). Similar mean reductions in A1C versus placebo were observed for patients using saxagliptin tablets 5 mg add-on to insulin alone and saxagliptin tablets 5 mg add-on to insulin in combination with metformin (-0.4% and -0.4%, respectively). The percentage of patients who discontinued for lack of glycemic control or who were rescued was 23% in the saxagliptin tablets group and 32% in the placebo group.
The mean daily insulin dose at baseline was 53 units in patients treated with saxagliptin tablets 5 mg and 55 units in patients treated with placebo. The mean change from baseline in daily dose of insulin was 2 units for the saxagliptin tablets 5 mg group and 5 units for the placebo group.
Table 10: Glycemic Parameters at Week 24 in a Placebo-Controlled Trial of Saxagliptin Tablets as Add-On Combination Therapy with Insulin Intent-to-treat population using last observation on study or last observation prior to insulin rescue therapy for patients needing rescue
Efficacy Parameter
Saxagliptin Tablets
5 mg + Insulin
(+/- Metformin)
N = 304
Placebo + Insulin
(+/- Metformin)
N = 151
Hemoglobin A1C (%)
N = 300
N = 149
   Baseline (mean)
8.7
8.7
   Change from baseline (adjusted meanLeast squares mean adjusted for baseline value and metformin use at baseline )
-0.7
-0.3
   Difference from placebo (adjusted mean)
-0.4p-value < 0.0001 compared to placebo + insulin
      95% Confidence Interval
(-0.6, -0.2)
2-hour Postprandial Glucose (mg/dL)
N = 262
N = 129
   Baseline (mean)
251
255
   Change from baseline (adjusted mean)
-27
-4
   Difference from placebo (adjusted mean)
-23p-value < 0.05 compared to placebo + insulin
      95% Confidence Interval
(-37, -9)
The change in fasting plasma glucose from baseline to Week 24 was also tested, but was not statistically significant. The percent of patients achieving an A1C < 7% was 17% (52/300) with saxagliptin tablets in combination with insulin compared to 7% (10/149) with placebo. Significance was not tested.
Add-On Combination Therapy with Metformin Plus Sulfonylurea
A total of 257 patients with type 2 diabetes participated in this 24-week, randomized, double-blind, placebo-controlled trial to evaluate the efficacy and safety of saxagliptin tablets in combination with metformin plus a sulfonylurea in patients with inadequate glycemic control (A1C ≥ 7% and ≤ 10%). Patients were to be on a stable combined dose of metformin extended-release or immediate-release (at maximum tolerated dose, with minimum dose for enrollment being 1500 mg) and a sulfonylurea (at maximum tolerated dose, with minimum dose for enrollment being ≥ 50% of the maximum recommended dose) for ≥ 8 weeks prior to enrollment.
Patients who met eligibility criteria were entered in a 2-week enrollment period to allow assessment of inclusion/exclusion criteria. Following the 2-week enrollment period, eligible patients were randomized to either double-blind saxagliptin tablets (5 mg once daily) or double-blind matching placebo for 24 weeks. During the 24-week double-blind treatment period, patients were to receive metformin and a sulfonylurea at the same constant dose ascertained during enrollment. Sulfonylurea dose could be down titrated once in the case of a major hypoglycemic event or recurring minor hypoglycemic events. In the absence of hypoglycemia, titration (up or down) of study medication during the treatment period was prohibited.
Saxagliptin tablets in combination with metformin plus a sulfonylurea provided significant improvements in A1C and PPG compared with placebo in combination with metformin plus a sulfonylurea (Table 11). The percentage of patients who discontinued for lack of glycemic control was 6% in the saxagliptin tablets group and 5% in the placebo group.
Table 11: Glycemic Parameters at Week 24 in a Placebo-Controlled Trial of Saxagliptin Tablets as Add-On Combination Therapy with Metformin Plus Sulfonylurea Intent-to-treat population using last observation prior to discontinuation
Efficacy Parameter
Saxagliptin Tablets 5 mg + Metformin Plus Sulfonylurea
N = 129
Placebo + Metformin Plus Sulfonylurea
N = 128
Hemoglobin A1C (%)
N = 127
N =127
   Baseline (mean)
8.4
8.2
   Change from baseline (adjusted meanLeast squares mean adjusted for baseline value )
-0.7
-0.1
   Difference from placebo (adjusted mean)
-0.7p-value < 0.0001 compared to placebo + metformin plus sulfonylurea
      95% Confidence Interval
(-0.9, -0.5)
2-hour Postprandial Glucose (mg/dL)
N = 115
N = 113
   Baseline (mean)
268
262
   Change from baseline (adjusted mean)
-12
5
   Difference from placebo (adjusted mean)
-17p-value < 0.05 compared to placebo + metformin plus sulfonylurea
      95% Confidence Interval
(-32, -2)
The change in fasting plasma glucose from baseline to Week 24 was also tested, but was not statistically significant. The percent of patients achieving an A1C < 7% was 31% (39/127) with saxagliptin tablets in combination with metformin plus a sulfonylurea compared to 9% (12/127) with placebo. Significance was not tested.
Add-on Combination Therapy with Metformin Plus an SGLT2 Inhibitor
A total of 315 patients with type 2 diabetes participated in this 24-week randomized, double-blind, placebo-controlled trial to evaluate the efficacy and safety of saxagliptin tablets added to dapagliflozin (an SGLT2 inhibitor) and metformin in patients with a baseline of HbA1c ≥ 7% to ≤ 10.5%. The mean age of these subjects was 54.6 years, 1.6% were 75 years or older and 52.7% were female. The population was 87.9% White, 6.3% Black or African American, 4.1% Asian, and 1.6% Other race. At baseline the population had diabetes for an average of 7.7 years and a mean HbA1c of 7.9%. The mean eGFR at baseline was 93.4 mL/min/1.73 m2. Patients were required to be on a stable dose of metformin (≥ 1500 mg per day) for at least 8 weeks prior to enrollment. Eligible subjects who completed the screening period entered the lead in treatment period, which included open-label metformin and 10 mg dapagliflozin treatment. Following the lead-in period, eligible patients were randomized to saxagliptin tablets 5 mg (N = 153) or placebo (N = 162).
The group treated with add-on saxagliptin tablets had statistically significant greater reductions in HbA1c from baseline versus the group treated with placebo (see Table 12).
Table 12:Â HbA1c Change from Baseline at Week 24 in a Placebo-Controlled Trial of Saxagliptin Tablets as Add-on to Dapagliflozin and Metformin There were 6.5% (n = 10) of randomized subjects in the saxagliptin arm and 3.1% (n = 5) in the placebo arm for whom change from baseline HbA1c data was missing at week 24. Of the subjects who discontinued study medication early, 9.1% (1 of 11) in the saxagliptin arm and 16.7% (1 of 6) in the placebo arm had HbA1c measured at week 24.
Saxagliptin Tablets
5 mg
(N = 153)Number of randomized and treated patients.
Placebo
(N = 162)
In combination with Dapagliflozin and Metformin
Hemoglobin A1C (%)Analysis of Covariance including all post-baseline data regardless of rescue or treatment discontinuation. Model estimates calculated using multiple imputation to model washout of the treatment effect using placebo data for all subjects having missing week 24 data.
Baseline (mean)
8.0
7.9
Change from baseline (adjusted meanLeast squares mean adjusted for baseline value. )
-0.5
-0.2
   95% Confidence Interval
(-0.6, -0.4)
(-0.3, -0.1)
Difference from placebo (adjusted mean)
-0.4p-value < 0.0001
   95% Confidence Interval
(-0.5, -0.2)
The known proportion of patients achieving HbA1c < 7% at Week 24 was 35.3% in the saxagliptin treated group compared to 23.1% in the placebo treated group.
14.2Renal Impairment
A total of 170 patients participated in a 12-week, randomized, double-blind, placebo-controlled trial conducted to evaluate the efficacy and safety of saxagliptin tablets 2.5 mg once daily compared with placebo in patients with type 2 diabetes and moderate (n = 90) or severe (n = 41) renal impairment or ESRD (n = 39). In this trial, 98% of the patients were using background antidiabetic medications (75% were using insulin and 31% were using oral antidiabetic medications, mostly sulfonylureas).
After 12 weeks of treatment, saxagliptin tablets 2.5 mg provided significant improvement in A1C compared to placebo (Table 13). In the subgroup of patients with ESRD, saxagliptin tablets and placebo resulted in comparable reductions in A1C from baseline to Week 12. This finding is inconclusive because the trial was not adequately powered to show efficacy within specific subgroups of renal impairment.
After 12 weeks of treatment, the mean change in FPG was -12 mg/dL with saxagliptin tablets 2.5 mg and -13 mg/dL with placebo. Compared to placebo, the mean change in FPG with saxagliptin tablets was -12 mg/dL in the subgroup of patients with moderate renal impairment, -4 mg/dL in the subgroup of patients with severe renal impairment, and +44 mg/dL in the subgroup of patients with ESRD. These findings are inconclusive because the trial was not adequately powered to show efficacy within specific subgroups of renal impairment.
Table 13: A1C at Week 12 in a Placebo-Controlled Trial of Saxagliptin Tablets in Patients with Renal Impairment Intent-to-treat population using last observation on study
Efficacy Parameter
Saxagliptin Tablets
2.5 mg
N = 85
Placebo
N = 85
Hemoglobin A1C (%)
N = 81
N = 83
   Baseline (mean)
8.4
8.1
   Change from baseline (adjusted meanLeast squares mean adjusted for baseline value )
-0.9
-0.4
   Difference from placebo (adjusted mean)
-0.4p-value < 0.01 compared to placebo
      95% Confidence Interval
(-0.7, -0.1)
14.3Cardiovascular Safety Trial
The cardiovascular risk of saxagliptin tablets was evaluated in SAVOR, a multicenter, multinational, randomized, double-blind study comparing saxagliptin tablets (N = 8280) to placebo (N = 8212), both administered in combination with standard of care, in adult patients with type 2 diabetes at high risk for atherosclerotic cardiovascular disease. Of the randomized study subjects, 97.5% completed the trial, and the median duration of follow-up was approximately 2 years. The trial was event-driven, and patients were followed until a sufficient number of events were accrued.
Subjects were at least 40 years of age, had A1C ≥ 6.5%, and multiple risk factors (21% of randomized subjects) for cardiovascular disease (age ≥ 55 years for men and ≥ 60 years for women plus at least one additional risk factor of dyslipidemia, hypertension, or current cigarette smoking) or established (79% of the randomized subjects) cardiovascular disease defined as a history of ischemic heart disease, peripheral vascular disease, or ischemic stroke. Overall, the use of diabetes medications was balanced across treatment groups (metformin 69%, insulin 41%, sulfonylureas 40%, and TZDs 6%). The use of cardiovascular disease medications was also balanced (angiotensin-converting enzyme [ACE] inhibitors or angiotensin receptor blockers [ARBs] 79%, statins 78%, aspirin 75%, beta-blockers 62%, and non-aspirin antiplatelet medications 24%).
The majority of subjects were male (67%) and Caucasian (75%) with a mean age of 65 years. Approximately 16% of the population had moderate (estimated glomerular filtration rate [eGFR] ≥ 30 to ≤ 50 mL/min/1.73 m2) to severe (eGFR < 30 mL/min/1.73 m2) renal impairment, and 13% had a prior history of heart failure. Subjects had a median duration of type 2 diabetes mellitus of approximately 10 years, and a mean baseline A1C level of 8.0%. Approximately 5% of subjects were treated with diet and exercise only at baseline. Overall, the use of diabetes medications was balanced across treatment groups (metformin 69%, insulin 41%, sulfonylureas 40%, and TZDs 6%). The use of cardiovascular disease medications was also balanced (ACE inhibitors or ARBs 79%, statins 78%, aspirin 75%, beta-blockers 62%, and non-aspirin antiplatelet medications 24%).
The primary analysis in SAVOR was time to first occurrence of a Major Adverse Cardiac Event (MACE). A major adverse cardiac event in SAVOR was defined as a cardiovascular death or a non-fatal myocardial infarction (MI) or a non-fatal ischemic stroke. The study was designed as a non-inferiority trial with a pre-specified risk margin of 1.3 for the hazard ratio of MACE and was also powered for a superiority comparison if non-inferiority was demonstrated.
The results of SAVOR, including the contribution of each component to the primary composite endpoint, are shown in Table 14. The incidence rate of MACE was similar in both treatment arms: 3.8 MACE per 100 patient-years on placebo vs. 3.8 MACE per 100 patient-years on saxagliptin tablets. The estimated hazard ratio of MACE associated with saxagliptin tablets relative to placebo was 1.00 with a 95.1% confidence interval of (0.89, 1.12). The upper bound of this confidence interval, 1.12, excluded a risk margin larger than 1.3.
Table 14: Major Adverse Cardiovascular Events (MACE) by Treatment Group in the SAVOR Trial
Saxagliptin Tablets
Placebo
Hazard Ratio
Number of Subjects (%)
Rate per 100 PY
Number of Subjects (%)
Rate per 100 PY
(95.1% CI)
Composite of first event of CV death, non-fatal MI or non-fatal ischemic stroke (MACE)
N = 8280
Total PY = 16308.8
N = 8212
Total PY = 16156.0
613 (7.4)
3.8
609 (7.4)
3.8
1.00
(0.89, 1.12)
   CV death
245 (3.0)
1.5
234 (2.8)
1.4
   Non-fatal MI
233 (2.8)
1.4
260 (3.2)
1.6
   Non-fatal ischemic stroke
135 (1.6)
0.8
115 (1.4)
0.7
The Kaplan-Meier-based cumulative event probability is presented in Figure 2 for time to first occurrence of the primary MACE composite endpoint by treatment arm. The curves for both saxagliptin tablets and placebo arms are close together throughout the duration of the trial. The estimated cumulative event probability is approximately linear for both arms, indicating that the incidence of MACE for both arms was constant over the trial duration.
Figure 2: Cumulative Percent of Time to First MACE
Vital status was obtained for 99% of subjects in the trial. There were 798 deaths in the SAVOR trial. Numerically more patients (5.1%) died in the saxagliptin tablets group than in the placebo group (4.6%). The risk of deaths from all cause (Table 15) was not statistically different between the treatment groups (HR: 1.11; 95.1% CI: 0.96, 1.27).
Table 15: All-cause Mortality by Treatment Group in the SAVOR Study
Saxagliptin Tablets
Placebo
Hazard Ratio
Number of Subjects (%)
Rate per 100 PY
Number of Subjects (%)
Rate per 100 PY
(95.1% CI)
N = 8280
PY = 16645.3
N = 8212
PY = 16531.5
All-cause mortality
420 (5.1)
2.5
378 (4.6)
2.3
1.11
(0.96, 1.27)
   CV death
269 (3.2)
1.6
260 (3.2)
1.6
   Non-CV death
151 (1.8)
0.9
118 (1.4)
0.7
16 How Supplied/storage And Handling
How Supplied:Â Saxagliptin Tablets are available containing 3.075 mg or 6.149 mg of saxagliptin hydrochloride dihydrate equivalent to 2.5 mg or 5 mg of saxagliptin.
The 2.5 mg tablets are yellow, film-coated, round, unscored tablets imprinted with SX1 over M in black ink on one side of the tablet and blank on the other side. They are available as follows:
NDC 0378-4705-93bottles of 30 tablets
NDC 0378-4705-77bottles of 90 tablets
The 5 mg tablets are white to off-white, film-coated, round, unscored tablets imprinted with SX2 over M in black ink on one side of the tablet and blank on the other side. They are available as follows:
NDC 0378-4706-93bottles of 30 tablets
NDC 0378-4706-77bottles of 90 tablets
NDC 0378-4706-05bottles of 500 tablets
Storage and Handling: Store at 20° to 25°C (68° to 77°F). [See USP Controlled Room Temperature.]
Dispense in a tight, light-resistant container as defined in the USP using a child-resistant closure.
PHARMACIST: Dispense a Medication Guide with each prescription.
17 Patient Counseling Information
Advise the patient to read FDA-approved patient labeling (Medication Guide).
Medication Guide:Â Healthcare providers should instruct their patients to read the Medication Guide before starting saxagliptin tablet therapy and to reread it each time the prescription is renewed. Patients should be instructed to inform their healthcare provider if they develop any unusual symptom or if any existing symptom persists or worsens.
Patients should be informed of the potential risks and benefits of saxagliptin tablets and of alternative modes of therapy. Patients should also be informed 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 of diabetes complications. During periods of stress such as fever, trauma, infection, or surgery, medication requirements may change and patients should be advised to seek medical advice promptly.
Pancreatitis: Patients should be informed that acute pancreatitis has been reported during postmarketing use of saxagliptin tablets. Before initiating saxagliptin tablets, patients should be questioned about other risk factors for pancreatitis, such as a history of pancreatitis, alcoholism, gallstones, or hypertriglyceridemia. Patients should also be informed 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. Patients should be instructed to promptly discontinue saxagliptin tablets and contact their healthcare provider if persistent severe abdominal pain occurs [see Warnings and Precautions (5.1) ].
Heart Failure:Â Patients should be informed of the signs and symptoms of heart failure. Before initiating saxagliptin tablets, patients should be asked about a history of heart failure or other risk factors for heart failure including moderate to severe renal impairment. Patients should be instructed 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 (5.2) ].
Hypersensitivity Reactions:Â Patients should be informed that serious allergic (hypersensitivity) reactions, such as angioedema, anaphylaxis, and exfoliative skin conditions, have been reported during postmarketing use of saxagliptin tablets. If symptoms of these 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 saxagliptin tablets and seek medical advice promptly.
Severe and Disabling Arthralgia:Â 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 (5.5) ].
Bullous Pemphigoid:Â Inform patients that bullous pemphigoid may occur with this class of drugs. Instruct patients to seek medical advice if bulers or erosions occur [see Warnings and Precautions (5.6) ].
Missed Dose:Â Patients should be informed that if they miss a dose of saxagliptin tablets they should take the next dose as prescribed, unless otherwise instructed by their healthcare provider. Patients should be instructed not to take an extra dose the next day.
Administration Instructions: Patients should be informed that saxagliptin tablets must not be split or cut.
Laboratory Tests:Â Patients should be informed that response to all diabetic therapies should be monitored by periodic measurements of blood glucose and A1C, with a goal of decreasing these levels toward the normal range. A1C is especially useful for evaluating long-term glycemic control. Patients should be informed of the potential need to adjust their dose based on changes in renal function tests over time.
Medication Guide
Â
Saxagliptin Tablets, for oral use
(sax″ a glip′ tin)
What is the most important information I should know about saxagliptin tablets?
Â
Serious side effects can happen to people taking saxagliptin tablets, including:
1) Inflammation of the pancreas (pancreatitis) which may be severe and lead to death.
Â
Certain medical problems make you more likely to get pancreatitis.
Â
Before you start taking saxagliptin tablets:
Â
Tell your healthcare provider if you have ever had
• inflammation of your pancreas (pancreatitis)• a history of alcoholism
• stones in your gallbladder (gallstones)• high blood triglyceride levels
It is not known if having these medical problems will make you more likely to get pancreatitis with saxagliptin tablets.
Â
Stop taking saxagliptin tablets and contact your healthcare provider 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.
Â
2) Heart failure. Heart failure means your heart does not pump blood well enough.
Â
Before you start taking saxagliptin tablets:
Tell your healthcare provider if you
• have ever had heart failure or have problems with your kidneys.
Contact your healthcare provider right away if you have any of the following symptoms:
• increasing shortness of breath or trouble breathing, especially when you lie down• swelling or fluid retention, especially in the feet, ankles or legs
• an unusually fast increase in weight• unusual tiredness
These may be symptoms of heart failure.
What are saxagliptin tablets?
Â
• Saxagliptin tablets are a prescription medicine used with diet and exercise to control high blood sugar (hyperglycemia) in adults with type 2 diabetes.• Saxagliptin tablets lower blood sugar by helping the body increase the level of insulin after meals.• Saxagliptin tablets are unlikely by themselves to cause your blood sugar to be lowered to a dangerous level (hypoglycemia) because they do not work well when your blood sugar is low. However, hypoglycemia may still occur with saxagliptin tablets. Your risk for getting hypoglycemia is higher if you take saxagliptin tablets with some other diabetes medicines, such as a sulfonylurea or insulin.• Saxagliptin tablets are not for people with type 1 diabetes.• Saxagliptin tablets are not for people with diabetic ketoacidosis (increased ketones in your blood or urine).
It is not known if saxagliptin tablets are safe and effective in children younger than 18 years old.
Who should not take saxagliptin tablets?
Â
Do not take saxagliptin tablets if you:
• are allergic to any ingredients in saxagliptin tablets. See the end of this Medication Guide for a complete ul of ingredients in saxagliptin tablets.
Symptoms of a serious allergic reaction to saxagliptin tablets may include:
• swelling of your face, lips, throat, and other areas on your skin• raised, red areas on your skin (hives)
• difficulty with swallowing or breathing• skin rash, itching, flaking, or peeling
If you have these symptoms, stop taking saxagliptin tablets and contact your healthcare provider right away.
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Before taking saxagliptin tablets, tell your healthcare provider about all of your medical conditions, including if you:
• have kidney problems.• are pregnant or plan to become pregnant. It is not known if saxagliptin tablets will harm your unborn baby. If you are pregnant, talk with your healthcare provider about the best way to control your blood sugar while you are pregnant.• are breast-feeding or plan to breast-feed. Saxagliptin may be passed in your milk to your baby. Talk with your healthcare provider about the best way to feed your baby while you take saxagliptin tablets.
Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.
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Know the medicines you take. Keep a ul of your medicines and show it to your healthcare provider and pharmacist when you get a new medicine.
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Saxagliptin tablets may affect the way other medicines work, and other medicines may affect how saxagliptin tablets work. Contact your healthcare provider if you will be starting or stopping certain other types of medications, such as antibiotics, or medicines that treat fungus or HIV/AIDS, because your dose of saxagliptin tablets might need to be changed.
How should I take saxagliptin tablets?
• Take saxagliptin tablets by mouth one time each day exactly as directed by your healthcare provider. Do not change your dose without talking to your healthcare provider.• Saxagliptin tablets can be taken with or without food.• Do not split or cut saxagliptin tablets.• During periods of stress on the body, such as fever, trauma, infection, or surgery.Contact your healthcare provider right away as your medication needs may change.• Your healthcare provider should test your blood to measure how well your kidneys are working before and during your treatment with saxagliptin tablets. You may need a lower dose of saxagliptin tablets if your kidneys are not working well.• Follow your healthcare provider’s instructions for treating blood sugar that is too low (hypoglycemia). Talk to your healthcare provider if low blood sugar is a problem for you.• If you miss a dose of saxagliptin tablets, take it as soon as you remember. If it is almost time for your next dose, skip the missed dose. Just take the next dose at your regular time. Do not take two doses at the same time unless your healthcare provider tells you to do so. Talk to your healthcare provider if you have questions about a missed dose.• If you take too many saxagliptin tablets, call your healthcare provider or go to the nearest hospital emergency room right away.
What are the possible side effects of saxagliptin tablets?
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Saxagliptin tablets can cause serious side effects, including:
• See “What is the most important information I should know about saxagliptin tablets?â€â€¢ Allergic (hypersensitivity) reactions, such as:
• swelling of your face, lips, throat, and other areas on your skin• difficulty with swallowing or breathing• raised, red areas on your skin (hives)• skin rash, itching, flaking, or peeling If you have these symptoms, stop taking saxagliptin tablets and contact your healthcare provider right away.• Joint pain. Some people who take medicines called DPP4 inhibitors like saxagliptin tablets, may develop joint pain that can be severe. Call your healthcare provider if you have severe joint pain.• Skin reaction. Some people who take medicines called DPP4 inhibitors, like saxagliptin tablets, may develop a skin reaction called bullous pemphigoid that can require treatment in a hospital. Tell your healthcare provider right away if you develop bulers or the breakdown of the outer layer of your skin (erosion). Your healthcare provider may tell you to stop taking saxagliptin tablets.
Common side effects of saxagliptin tablets include:
• upper respiratory tract infection• urinary tract infection• headache
Low blood sugar (hypoglycemia) may become worse in people who also take another medication to treat diabetes, such as sulfonylureas or insulin. Tell your healthcare provider if you take other diabetes medicines. If you have symptoms of low blood sugar, you should check your blood sugar and treat if low, then call your healthcare provider. Symptoms of low blood sugar include:
• shaking• hunger
• sweating• headache
• rapid heartbeat• change in mood
• change in vision
Swelling or fluid retention in your hands, feet, or ankles (peripheral edema) may become worse in people who also take a thiazolidinedione to treat diabetes. If you do not know whether you are already on this type of medication, ask your healthcare provider.
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These are not all of the possible side effects of saxagliptin tablets.
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Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.
How should I store saxagliptin tablets?
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Store saxagliptin tablets between 20° to 25°C (68° to 77°F).
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Keep saxagliptin tablets and all medicines out of the reach of children.
General information about the use of saxagliptin tablets
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Medicines are sometimes prescribed for conditions that are not mentioned in Medication Guides. Do not use saxagliptin tablets for a condition for which they were not prescribed. Do not give saxagliptin tablets to other people, even if they have the same symptoms you have. They may harm them.
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You can ask your healthcare provider for additional information about saxagliptin tablets that is written for health professionals.
What are the ingredients of saxagliptin tablets?
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Active ingredient: saxagliptin
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Inactive ingredients: croscarmellose sodium, hydrochloric acid, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, polyvinyl alcohol, sodium hydroxide, talc and titanium dioxide. The 2.5 mg tablets also contain yellow iron oxide. The imprinting ink contains ammonium hydroxide, black iron oxide, propylene glycol and shellac glaze.
What is type 2 diabetes?
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Type 2 diabetes is a condition in which your body does not make enough insulin, and 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.
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The main goal of treating diabetes is to lower your blood sugar so that it is as close to normal as possible.
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High blood sugar can be lowered by diet and exercise, and by certain medicines when necessary.
Manufactured for: Mylan Pharmaceuticals Inc., Morgantown, WV 26505
Manufactured by: Mylan Laboratories Limited, Hyderabad — 500 096, India
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For more information, call Mylan at 1-877-446-3679 (1-877-4-INFO-RX).
This Medication Guide has been approved by the U.S. Food and Drug Administration.
Manufactured for: Mylan Pharmaceuticals Inc. Morgantown, WV 26505 U.S.A.
Manufactured by: Mylan Laboratories Limited Hyderabad — 500 096, India
75056462
Revised: 4/2023MXA:SAXA:R1mmh/MXA:MG:SAXA:R1m/MXA:MG:SAXA:R1mh
Principal Display Panel 2.5 Mg
NDC 0378-4705-93
SaxagliptinTablets2.5 mg
PHARMACIST: Dispense the accompanyingMedication Guide to each patient.
Rx only   30 Tablets
Each film-coated tablet contains3.075 mg of saxagliptin hydrochloridedihydrate equivalent to 2.5 mg ofsaxagliptin.
Usual Dosage: See accompanyingprescribing information.
Keep this and all medication out ofthe reach of children.
Store at 20° to 25°C (68° to 77°F). [SeeUSP Controlled Room Temperature.]
Manufactured for: Mylan Pharmaceuticals Inc. Morgantown, WV 26505 U.S.A.
Made in India
Mylan.com
RMXA4705H2
Dispense in a tight, light-resistantcontainer as defined in the USPusing a child-resistant closure.
Keep container tightly closed.
Code No.: MH/DRUGS/AD/089
Principal Display Panel 5 Mg
NDC 0378-4706-93
SaxagliptinTablets5 mg
PHARMACIST: Dispense the accompanyingMedication Guide to each patient.
Rx only   30 Tablets
Each film-coated tablet contains6.149 mg of saxagliptin hydrochloridedihydrate equivalent to 5 mg ofsaxagliptin.
Usual Dosage: See accompanyingprescribing information.
Keep this and all medication out ofthe reach of children.
Store at 20° to 25°C (68° to 77°F). [SeeUSP Controlled Room Temperature.]
Manufactured for: Mylan Pharmaceuticals Inc. Morgantown, WV 26505 U.S.A.
Made in India
Mylan.com
RMXA4706H2
Dispense in a tight, light-resistantcontainer as defined in the USPusing a child-resistant closure.
Keep container tightly closed.
Code No.: MH/DRUGS/AD/089
DISCLAIMER:
"This tool does not provide medical advice, and is for informational and educational purposes only, and is not a substitute for professional medical advice, treatment or diagnosis. Call your doctor to receive medical advice. If you think you may have a medical emergency, please dial 911."
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"This product uses publicly available data from the U.S. National Library of Medicine (NLM), National Institutes of Health, Department of Health and Human Services; NLM is not responsible for the product and does not endorse or recommend this or any other product."
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