Dapagliflozin / saxagliptin

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# Overview
Dapagliflozin / saxagliptin is a sodium-glucose cotransporter 2 (SGLT-2) inhibitor and a dipeptidyl peptidase-4 (DPP-4) inhibitor combination product that is FDA approved for the improved glycemic control of adults with type 2 diabetes mellitus (T2DM) who have inadequate control with dapagliflozin or who are already treated with dapagliflozin and saxagliptin.   Common adverse reactions include upper respiratory tract infection, urinary tract infection, and dyslipidemia.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Dapagliflozin / saxagliptin (dapagliflozin and saxagliptin) is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (T2DM) who have inadequate control with dapagliflozin or who are already treated with dapagliflozin and saxagliptin.
- In patients with volume depletion, correct this condition prior to initiation of Dapagliflozin / saxagliptin.
- The recommended dose of Dapagliflozin / saxagliptin is a 10 mg dapagliflozin/5 mg saxagliptin tablet taken orally once daily in the morning with or without food.
- Do not split or cut Dapagliflozin / saxagliptin tablets.
- Assessment of renal function is recommended prior to initiation of Dapagliflozin / saxagliptin therapy and periodically thereafter.
- Do not initiate Dapagliflozin / saxagliptin in patients with an estimated glomerular filtration rate (eGFR) below 60 mL/min/1.73 m2.
- Discontinue Dapagliflozin / saxagliptin if eGFR falls persistently below 60 mL/min/1.73 m2.
- Dapagliflozin / saxagliptin is contraindicated in patients with an eGFR less than 45 mL/min/1.73 m2.
- Do not coadminister Dapagliflozin / saxagliptin with strong cytochrome P450 3A4/5 inhibitors (e.g., ketoconazole, atazanavir, clarithromycin, indinavir, itraconazole, nefazodone, nelfinavir, ritonavir, saquinavir, and telithromycin).

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Dapagliflozin / saxagliptin Off-Label Guideline-Supported Use and Dosage (Adult) in the drug label.

### NonGuideline-Supported Use
There is limited information regarding Dapagliflozin / saxagliptin Off-Label Non-Guideline-Supported Use and Dosage (Adult) in the drug label.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding Dapagliflozin / saxagliptin FDA-Labeled Indications and Dosage (Pediatric) in the drug label.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Dapagliflozin / saxagliptin Off-Label Guideline-Supported Use and Dosage (Pediatric) in the drug label.

### NonGuideline-Supported Use
There is limited information regarding Dapagliflozin / saxagliptin Off-Label Non-Guideline-Supported Use and Dosage (Pediatric) in the drug label.

# Contraindications
- Dapagliflozin / saxagliptin is contraindicated in patients with:
- History of a serious hypersensitivity reaction to dapagliflozin or to saxagliptin, including anaphylaxis, angioedema or exfoliative skin conditions.
- Moderate to severe renal impairment (eGFR less than 45 mL/min/1.73 m2), end-stage renal disease (ESRD), or patients on dialysis.

# Warnings
- There have been postmarketing reports of acute pancreatitis in patients taking saxagliptin. 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 compared to 9 of 8173 (0.1%) receiving placebo. Pre-existing risk factors for pancreatitis were identified in 88% (15/17) of those patients receiving saxagliptin and in 100% (9/9) of those patients receiving placebo.
- After initiation of Dapagliflozin / saxagliptin, observe patients for signs and symptoms of pancreatitis. If pancreatitis is suspected, promptly discontinue Dapagliflozin / saxagliptin 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 Dapagliflozin / saxagliptin.
- In a cardiovascular outcomes trial enrolling participants with established ASCVD or multiple risk factors for ASCVD (SAVOR trial), more patients randomized to saxagliptin (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 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 Dapagliflozin / saxagliptin prior to initiating treatment in patients at a higher risk of 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 Dapagliflozin / saxagliptin.
- Dapagliflozin causes intravascular volume contraction. Symptomatic hypotension can occur after initiating Dapagliflozin / saxagliptin particularly in patients with impaired renal function (eGFR <60 mL/min/1.73 m2), elderly patients, or patients on loop diuretics. Before initiating Dapagliflozin / saxagliptin volume status should be assessed and corrected. Do not initiate Dapagliflozin / saxagliptin in patients with an eGFR <60 mL/min/1.73 m2. Monitor for signs and symptoms of hypotension after initiating therapy.
- Reports of ketoacidosis, a serious life-threatening condition requiring urgent hospitalization have been identified in postmarketing surveillance in patients with type 1 and type 2 diabetes mellitus receiving sodium-glucose cotransporter-2 (SGLT-2) inhibitors, including dapagliflozin. Fatal cases of ketoacidosis have been reported in patients taking dapagliflozin. Dapagliflozin / saxagliptin is not indicated for the treatment of patients with type 1 diabetes mellitus.
- Patients treated with Dapagliflozin / saxagliptin who present with signs and symptoms consistent with severe metabolic acidosis should be assessed for ketoacidosis regardless of presenting blood glucose levels as ketoacidosis associated with Dapagliflozin / saxagliptin may be present even if blood glucose levels are less than 250 mg/dL. If ketoacidosis is suspected, Dapagliflozin / saxagliptin should be discontinued, the patient should be evaluated and prompt treatment should be instituted. Treatment of ketoacidosis may require insulin, fluid and carbohydrate replacement.
- In many of the postmarketing reports for dapagliflozin, and particularly in patients with type 1 diabetes, the presence of ketoacidosis was not immediately recognized and the institution of treatment was delayed because the presenting blood glucose levels were below those typically expected for diabetic ketoacidosis (often less than 250 mg/dL). Signs and symptoms at presentation were consistent with dehydration and severe metabolic acidosis and included nausea, vomiting, abdominal pain, generalized malaise, and shortness of breath. In some but not all cases, factors predisposing to ketoacidosis such as insulin dose reduction, acute febrile illness, reduced caloric intake due to illness or surgery, pancreatic disorders suggesting insulin deficiency (e.g., type 1 diabetes, history of pancreatitis or pancreatic surgery), and alcohol abuse were identified.
- Before initiating Dapagliflozin / saxagliptin, consider factors in the patient history that may predispose to ketoacidosis including pancreatic insulin deficiency from any cause, caloric restriction and alcohol abuse. In patients treated with Dapagliflozin / saxagliptin consider monitoring for ketoacidosis and temporarily discontinuing Dapagliflozin / saxagliptin in clinical situations known to predispose to ketoacidosis (e.g., prolonged fasting due to acute illness or surgery).
- Dapagliflozin causes intravascular volume contraction, and can cause renal impairment. There have been postmarketing reports of acute kidney injury, some requiring hospitalization and dialysis, in patients receiving dapagliflozin; some reports involved patients younger than 65 years of age.
- Before initiating Dapagliflozin / saxagliptin, consider factors that may predispose patients to acute kidney injury including hypovolemia, chronic renal insufficiency, congestive heart failure, and concomitant medications (diuretics, ACE inhibitors, ARBs, NSAIDs). Consider temporarily discontinuing Dapagliflozin / saxagliptin in any setting of reduced oral intake (such as acute illness or fasting) or fluid losses (gastrointestinal illness or excessive heat exposure); monitor patients for signs and symptoms of acute kidney injury. If acute kidney injury occurs, discontinue Dapagliflozin / saxagliptin promptly and institute treatment.
- Dapagliflozin increases serum creatinine and decreases eGFR. Elderly patients and patients with impaired renal function may be more susceptible to these changes. Adverse reactions related to renal function can occur after initiating Dapagliflozin / saxagliptin. Discontinue Dapagliflozin / saxagliptin in patients if eGFR falls persistently below 60 mL/min/1.73 m2. Dapagliflozin / saxagliptin is contraindicated in patients with an eGFR less than 45 mL/min/1.73 m2.
- There have been postmarketing reports of serious urinary tract infections including urosepsis and pyelonephritis requiring hospitalization in patients receiving SGLT-2 inhibitors, including dapagliflozin. Treatment with SGLT-2 inhibitors increases the risk for urinary tract infections. Evaluate patients for signs and symptoms of urinary tract infections and treat promptly, if indicated.
- Insulin and insulin secretagogues, such as sulfonylureas, are known to cause hypoglycemia. Both saxagliptin and dapagliflozin can individually increase the risk of hypoglycemia when combined with insulin or an insulin secretagogue. Therefore, a lower dose of insulin or insulin secretagogue may be required to reduce the risk of hypoglycemia when these agents are used in combination with Dapagliflozin / saxagliptin.
- There have been postmarketing reports of serious hypersensitivity reactions in patients treated with saxagliptin. 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, with some reports occurring after the first dose. If a serious hypersensitivity reaction is suspected, discontinue Dapagliflozin / saxagliptin, treat per standard of care, and monitor until signs and symptoms are resolved. Assess for other potential causes for the event. Institute alternative treatment for diabetes.
- Use caution in a patient with a history of angioedema to another dipeptidyl peptidase-4 (DPP-4) inhibitor because it is unknown whether such patients will be predisposed to angioedema with saxagliptin.
- Dapagliflozin increases the risks of genital mycotic infections. Patients with a history of genital mycotic infections were more likely to develop genital mycotic infections. Monitor and treat appropriately.
- Increases in LDLC can occur with dapagliflozin. Monitor LDL-C and treat per standard of care after initiating Dapagliflozin / saxagliptin.
- Across 22 clinical studies for dapagliflozin, newly diagnosed cases of bladder cancer were reported in 10/6045 patients (0.17%) treated with dapagliflozin and 1/3512 patient (0.03%) treated with placebo/comparator. After excluding patients in whom exposure to study drug was less than one year at the time of diagnosis of bladder cancer, there were 4 cases with dapagliflozin and no cases with placebo/comparator. Bladder cancer risk factors and hematuria (a potential indicator of pre-existing tumors) were balanced between treatment arms at baseline. There were too few cases to determine whether the emergence of these events is related to dapagliflozin.
- There are insufficient data to determine whether dapagliflozin has an effect on pre-existing bladder tumors. Consequently, Dapagliflozin / saxagliptin should not be used in patients with active bladder cancer. In patients with prior history of bladder cancer, the benefits of glycemic control versus unknown risks for cancer recurrence with Dapagliflozin / saxagliptin should be considered.
- There have been postmarketing reports of severe and disabling arthralgia in patients taking DPP-4 inhibitors. The time to onset of symptoms following initiation of drug therapy varied from one day to years. Patients experienced relief of symptoms upon discontinuation of the medication. A subset of patients experienced a recurrence of symptoms restarting the same drug or a different DPP-4 inhibitor. Consider DPP-4 inhibitors as a possible cause for severe joint pain and discontinue drug if appropriate.
- Postmarketing cases of bullous pemphigoid requiring hospitalization have been reported with DPP-4 inhibitor use. In reported cases, patients typically recovered with topical or systemic immunosuppressive treatment and discontinuation of the DPP-4 inhibitor. Tell patients to report development of blisters or erosions while receiving Dapagliflozin / saxagliptin. If bullous pemphigoid is suspected, Dapagliflozin / saxagliptin should be discontinued and referral to a dermatologist should be considered for diagnosis and appropriate treatment.
- There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Dapagliflozin / saxagliptin.

# Adverse Reactions

## Clinical Trials Experience
- Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.
- The safety of combined use of 10 mg dapagliflozin and 5 mg saxagliptin has been evaluated in 492 adult subjects with type 2 diabetes in a pooled safety analysis of three phase 3 active/placebo-controlled clinical trials with a median exposure of 51 weeks. The mean age of these subjects was 54 years, 0.8% were 75 years or older and 53.7% were female. The population was 80.9% White, 8.3% Black or African American, 3.7% Asian, and 6.6% Other race. At baseline the population had diabetes for an average of 7.5 years and a mean HbA1c of 8.4%. The mean eGFR at baseline was 94.4 mL/min/1.73 m2.
- The common adverse reactions were based on the pooled analyses of these studies as shown in Table 1.
- Additionally, adverse reactions reported in <5% and 2% from the dapagliflozin development program and 1% more frequently compared to placebo included increased urination, and discomfort with urination.

### Hypoglycemia
- Hypoglycemia was reported in 8 subjects (1.6%) treated with Dapagliflozin / saxagliptin. No episodes of major hypoglycemia (defined as a symptomatic episode requiring external assistance) were reported.

### Genital Mycotic Infections
- Genital mycotic infections were reported in 15 subjects (3%) treated with Dapagliflozin / saxagliptin. Reported adverse reactions by frequency included vulvovaginal mycotic infection, balanoposthitis, genital fungal infection, vaginal infection, and vulvovaginitis. The majority of subjects (84.2%) who experienced genital infection adverse reactions were females.

### Urinary Tract Infections
- Urinary tract infections were reported in 28 subjects (5.7%) treated with Dapagliflozin / saxagliptin. Reported adverse reactions by frequency included urinary tract infection, Escherichia urinary tract infection, prostatitis, and pyelonephritis. The majority of subjects (80.6%) who experienced urinary tract infection adverse reactions were females.

### Volume Depletion
- Events related to volume depletion (hypotension, dehydration, and hypovolemia) were reported in 2 subjects (0.4%) treated with Dapagliflozin / saxagliptin.

### Renal Impairment
- Adverse reactions related to decreased renal function were reported in 10 subjects (2.0%) treated with Dapagliflozin / saxagliptin. The reported adverse reactions included decreased glomerular filtration rate, renal impairment, increased blood creatinine, acute renal failure, and decreased urine output. None of the adverse reactions was reported as serious and all but one were mild to moderate in intensity. Three subjects discontinued due to decreased eGFR. Subjects with AEs of renal impairment had lower mean eGFR values at baseline of 64.4 ml/min/1.73 m2 compared to 94.4 ml/min/1.73 m2 in overall population treated with Dapagliflozin / saxagliptin.
Dapagliflozin
- Use of dapagliflozin was associated with increases in serum creatinine and decreases in eGFR (see Table 2). In patients with normal or mildly impaired renal function at baseline, serum creatinine and eGFR returned to baseline values at Week 24. Sustained decreases in eGFR were seen in patients with moderate renal impairment (eGFR 30 to less than 60 mL/min/1.73 m2). Elderly patients and patients with impaired renal function were more susceptible to these adverse reactions.

### Laboratory Findings
Decrease in Lymphocyte Counts (saxagliptin)
- A dose-related mean decrease in absolute lymphocyte count has been observed with saxagliptin. In a pool of 5 placebo-controlled studies, a mean decrease in absolute lymphocyte count of approximately 100 cells/microL relative to placebo. There was a dose-related mean decrease in absolute lymphocyte count observed with saxagliptin. The proportion of patients who were reported to have a lymphocyte count 750 cells/microL was 0.5%, 1.5%, and 0.4% in the saxagliptin 2.5 mg, 5 mg, and placebo groups, respectively. The decreases in lymphocyte count were not associated with clinically relevant adverse reactions.
- 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 on lymphocyte counts in patients with lymphocyte abnormalities (e.g., human immunodeficiency virus) is unknown.
Increase in Hematocrit (dapagliflozin)
- In a pool of 13 placebo-controlled studies with dapagliflozin, increases from baseline in mean hematocrit values were observed in dapagliflozin treated patients starting at Week 1 and continuing up to Week 16, when the maximum mean difference from baseline was observed. At Week 24, the mean changes from baseline in hematocrit were 0.33% in the placebo group and 2.30% in the dapagliflozin 10 mg group. By Week 24, hematocrit values >55% were reported in 0.4% of placebo-treated patients and 1.3% of dapagliflozin 10 mg-treated patients.
Increase in Serum Inorganic Phosphorus (dapagliflozin)
- In a pool of 13 placebo-controlled studies with dapagliflozin, increases from baseline in mean serum phosphorus levels were reported at Week 24 in dapagliflozin treated patients compared with placebo-treated patients (mean increase of 0.13 versus 0.04 mg/dL, respectively). Higher proportions of patients with marked laboratory abnormalities of hyperphosphatemia (5.6 mg/dL for age 17-65 years or 5.1 mg/dL for age 66 years) were reported on dapagliflozin at Week 24 (0.9% versus 1.7% for placebo and dapagliflozin 10 mg, respectively).
Increase in Low-Density Lipoprotein Cholesterol
- Patients treated with Dapagliflozin / saxagliptin demonstrated a mean percent increase from baseline LDL-cholesterol (ranging from 2.1 to 6.9%).
Elevations in creatine kinase
- In the pooled safety analysis, an imbalance in the number of subjects who experienced serum creatine kinase (CK) elevations >10x the upper limit of normal (a marker of muscle injury/necrosis) was observed in 5 subjects (1%) treated with Dapagliflozin / saxagliptin. The elevations were transient. Rhabdomyolysis was reported for one of those subjects for which no obvious cause was identified.

## Postmarketing Experience
- Additional adverse reactions have been identified during postapproval use of saxagliptin and dapagliflozin. Because the following 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.

### Saxagliptin
- Hypersensitivity reactions including anaphylaxis, angioedema, and exfoliative skin conditions
- Pancreatitis
- Severe and disabling arthralgia
- Bullous pemphigoid

### Dapagliflozin
- Ketoacidosis
- Acute Kidney Injury and Impairment in Renal Function
- Urosepsis and pyelonephritis
- Rash

# Drug Interactions
- Strong Inhibitors of CYP3A4/5 Enzymes
- Positive Urine Glucose Test
- Interference with 1,5-anhydroglucitol (1,5-AG) Assay
- 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). Do not coadminister Dapagliflozin / saxagliptin with strong cytochrome P450 3A4/5 inhibitors.
- Monitoring glycemic control with urine glucose tests is not recommended in patients taking SGLT-2 inhibitors as SGLT-2 inhibitors increase urinary glucose excretion and will lead to positive urine glucose tests. Use alternative methods to monitor glycemic control.
- Monitoring glycemic control with 1,5-AG assay is not recommended as measurements of 1,5-AG are unreliable in assessing glycemic control in patients taking SGLT-2 inhibitors. Use alternative methods to monitor glycemic control.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA):

### Risk Summary
- Based on animal data showing adverse renal effects, from dapagliflozin, Dapagliflozin / saxagliptin is not recommended during the second and third trimesters of pregnancy.
- The limited available data with Dapagliflozin / saxagliptin or its components (dapagliflozin and saxagliptin) in pregnant women are not sufficient to determine a drug associated risk for major birth defects or miscarriage. There are risks to the mother and fetus associated with poorly controlled diabetes in pregnancy.
- In animal studies, adverse renal pelvic and tubular dilatations, that were not fully reversible, were observed in juvenile rats when dapagliflozin (a component of Dapagliflozin / saxagliptin) was administered at an exposure 15-times the exposure at the 10 mg clinical dose during a period of renal development corresponding to the late second and third trimesters of human pregnancy.
- No adverse developmental effects were observed when saxagliptin was administered to pregnant rats and rabbits.
- 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.

### Clinical Considerations=
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.

### Data (Animal)
Dapagliflozin
- Dapagliflozin dosed directly to juvenile rats from postnatal day (PND) 21 until PND 90 at doses of 1, 15, or 75 mg/kg/day, increased kidney weights and increased the incidence of renal pelvic and tubular dilatations at all doses. Exposure at the lowest dose was 15-times the 10 mg clinical dose, based on AUC. These outcomes occurred with drug exposure during periods of renal development in rats that correspond to the late second and third trimester of human renal development. The renal pelvic and tubular dilatations observed in juvenile animals did not fully reverse within a 1-month recovery period.
- In a prenatal and postnatal development study, maternal rats were dosed from gestation day 6 through lactation day 21 at doses of 1, 15, or 75 mg/kg/day, and pups were indirectly exposed in utero and throughout lactation. Increased incidence or severity of renal pelvic dilatation was observed in adult offspring of treated dams at 75 mg/kg/day (maternal and pup dapagliflozin exposures were 1415-times and 137-times, respectively, the 10 mg clinical dose, based on AUC). Dose-related reductions in pup body weights were observed at exposures greater than or equal to 19-times the 10 mg clinical dose, based on AUC. No adverse effects on developmental endpoints were noted at 1 mg/kg/day, or approximately 19-times the 10 mg clinical dose, based on AUC.
- In embryo-fetal development studies, dapagliflozin 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 1441-times the clinical dose of 10 mg, based on AUC.
Saxagliptin
- 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.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Dapagliflozin / saxagliptin in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Dapagliflozin / saxagliptin during labor and delivery.

### Nursing Mothers
Risk Summary
- There is no information regarding the presence of Dapagliflozin / saxagliptin or its components (dapagliflozin and saxagliptin) in human milk, the effects on the breastfed infant, or the effects on milk production.
- Saxagliptin and dapagliflozin are present in the milk of lactating rats . Since human kidney maturation occurs in utero and during the first 2 years of life when lactational exposure may occur, there may be risk to the developing human kidney. Because of the potential for serious adverse reactions in a breastfed infant, advise women that use of Dapagliflozin / saxagliptin is not recommended while breastfeeding.

### Data
Dapagliflozin
- Dapagliflozin was present at a milk/plasma ratio of 0.49, indicating that dapagliflozin and its metabolites are transferred into milk at a concentration that is approximately 50% of that in maternal plasma. Juvenile rats directly exposed to dapagliflozin showed a risk to the developing kidney (renal pelvic and tubular dilatations) during maturation.
Saxagliptin
- Saxagliptin is secreted in the milk of lactating rats at approximately a 1:1 ratio with plasma drug concentrations.

### Pediatric Use
- Safety and effectiveness of Dapagliflozin / saxagliptin in patients under 18 years of age have not been established.

### Geriatic Use
- Because elderly patients are more likely to have decreased renal function, care should be taken when using Dapagliflozin / saxagliptin in the elderly based on renal function.
Dapagliflozin
- A total of 1424 (24%) of the 5936 dapagliflozin-treated patients were 65 years and older and 207 (3.5%) patients were 75 years and older in a pool of 21 double-blind, controlled, clinical safety and efficacy studies of dapagliflozin. After controlling for level of renal function (eGFR), in clinical studies with dapagliflozin, efficacy was similar for patients under age 65 years and those 65 years and older. In patients 65 years and older, a higher proportion of patients treated with dapagliflozin had adverse reactions related to volume depletion and renal impairment or failure compared to patients treated with placebo.
Saxagliptin
- In the seven double-blind, controlled clinical safety and efficacy trials of saxagliptin, a total of 4751 (42.0%) of the 11,301 patients randomized to saxagliptin 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.

### Gender
There is no FDA guidance on the use of Dapagliflozin / saxagliptin with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Dapagliflozin / saxagliptin with respect to specific racial populations.

### Renal Impairment
- Discontinue Dapagliflozin / saxagliptin in patients if eGFR falls persistently below 60 mL/min/1.73 m2. Dapagliflozin / saxagliptin is contraindicated in patients with moderate to severe renal impairment (eGFR less than 45 mL/min/1.73 m2), ESRD, or on dialysis.

### Hepatic Impairment
- Dapagliflozin / saxagliptin may be used in patients with hepatic impairment. However, the benefit-risk for the use of Dapagliflozin / saxagliptin in patients with severe hepatic impairment should be individually assessed since safety and efficacy have not been studied in this population.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Dapagliflozin / saxagliptin in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Dapagliflozin / saxagliptin in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Take with or without food.
- Swallow whole; do not split or cut tablets.

### Monitoring
- Improvements in glycemic control (HbA1c, blood glucose levels) indicate efficacy.
- HbA1c: Twice yearly in patients who are meeting treatment goals; every 3 months in patients whose therapy has changed and/or who are not meeting glycemic goals; more frequently as clinically warranted.
- Blood glucose (self-monitoring): As needed to assist in meeting goals of therapy.
- Renal function: Prior to initiation and periodically thereafter.
- LDL-C.
- Ketoacidosis: In symptomatic patients and in clinical situations that predispose to ketoacidosis (eg, prolonged fasting with acute illness or surgery).
- Signs or symptoms of pancreatitis.
- Signs or symptoms of heart failure.
- Volume status: Prior to initiating therapy, particularly in patients who are predisposed to volume depletion.
- Hypotension: During treatment.
- Signs and symptoms of acute kidney injury.
- Signs or symptoms of urinary tract infection.

# IV Compatibility
There is limited information regarding the compatibility of Dapagliflozin / saxagliptin and IV administrations.

# Overdosage
- There is no information available on overdose with Dapagliflozin / saxagliptin. In the event of an overdose, contact the Poison Control Center. Appropriate supportive treatment should be initiated as dictated by the patients clinical status. Saxagliptin and its major metabolite can be removed by hemodialysis (23% of dose over 4 hours). The removal of dapagliflozin by hemodialysis has not been studied.

# Pharmacology

## Mechanism of Action
- Dapagliflozin / saxagliptin combines two antihyperglycemic agents to improve glycemic control in patients with type 2 diabetes mellitus: dapagliflozin, a sodium-glucose cotransporter 2 (SGLT-2) inhibitor, and saxagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor.

### Dapagliflozin
- Sodium-glucose cotransporter 2 (SGLT-2), expressed in the proximal renal tubules, is responsible for the majority of the reabsorption of filtered glucose from the tubular lumen. Dapagliflozin is an inhibitor of SGLT-2. By inhibiting SGLT-2, dapagliflozin reduces reabsorption of filtered glucose and lowers the renal threshold for glucose, and thereby increases urinary glucose excretion.

### Saxagliptin
- 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 DPP-4 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 DPP-4 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.

## Structure

### Dapagliflozin

### Saxagliptin

## Pharmacodynamics

### =Dapagliflozin
- Increases in the amount of glucose excreted in the urine were observed in healthy subjects and in patients with type 2 diabetes mellitus following the administration of dapagliflozin. Dapagliflozin dose of 5 or 10 mg per day in patients with type 2 diabetes mellitus for 12 weeks resulted in excretion of approximately 70 grams of glucose in the urine per day at Week 12. A near maximum glucose excretion was observed at the dapagliflozin daily dose of 20 mg. This urinary glucose excretion with dapagliflozin also results in increases in urinary volume.
- In patients with type 2 diabetes mellitus, administration of saxagliptin inhibits DPP-4 enzyme activity for a 24-hour period. After an oral glucose load or a meal, this DPP-4 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.

### Cardiac Electrophysiology
Dapagliflozin
- Dapagliflozin was not associated with clinically meaningful prolongation of QTc interval at daily doses up to 150 mg (15 times the recommended maximum dose) in a study of healthy subjects. In addition, no clinically meaningful effect on QTc interval was observed following single doses of up to 500 mg (50 times the recommended maximum daily dose) of dapagliflozin in healthy subjects.
Saxagliptin
- In a randomized, double-blind, placebo-controlled, 4-way crossover, active comparator study using moxifloxacin in 40 healthy subjects, saxagliptin was not associated with clinically meaningful prolongation of the QTc interval or heart rate at daily doses up to 40 mg (8 times the recommended maximum daily dose).

## Pharmacokinetics
- Overall, the pharmacokinetics of dapagliflozin and saxagliptin were not affected in a clinically relevant manner when administered as Dapagliflozin / saxagliptin.
Saxagliptin
- 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 ngh/mL and 214 ngh/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.
Dapagliflozin
- Following oral administration of dapagliflozin, the maximum plasma concentration (Cmax) is usually attained within 2 hours under fasting state. The Cmax and AUC values increase dose proportionally with increase in dapagliflozin dose in the therapeutic dose range. The absolute oral bioavailability of dapagliflozin following the administration of a 10 mg dose is 78%. Administration of dapagliflozin with a high-fat meal decreases its Cmax by up to 50% and prolongs Tmax by approximately 1 hour, but does not alter AUC as compared with the fasted state.
Saxagliptin
- 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.
Dapagliflozin
- Dapagliflozin is approximately 91% protein bound. Protein binding is not altered in patients with renal or hepatic impairment.
Saxagliptin
- 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.
Dapagliflozin
- The metabolism of dapagliflozin is primarily mediated by UGT1A9; CYP-mediated metabolism is a minor clearance pathway in humans. Dapagliflozin is extensively metabolized, primarily to yield dapagliflozin 3-O-glucuronide, which is an inactive metabolite. Dapagliflozin 3-O-glucuronide accounted for 61% of a 50 mg -dapagliflozin dose and is the predominant drug-related component in human plasma.
Saxagliptin
- The metabolism of saxagliptin is primarily mediated by cytochrome P450 3A4/5 (CYP3A4/5). The major metabolite of saxagliptin is also a DPP-4 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.
Dapagliflozin
- Dapagliflozin and related metabolites are primarily eliminated via the renal pathway. Following a single 50 mg dose of -dapagliflozin, 75% and 21% total radioactivity is excreted in urine and feces, respectively. In urine, less than 2% of the dose is excreted as parent drug. In feces, approximately 15% of the dose is excreted as parent drug. The mean plasma terminal half-life (t1/2) for dapagliflozin is approximately 12.9 hours following a single oral dose of dapagliflozin 10 mg.
Saxagliptin
- Saxagliptin is eliminated by both renal and hepatic pathways. Following a single 50 mg dose of  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 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.
- Based on a population pharmacokinetic analysis, age, gender, race, and body weight do not have a clinically meaningful effect on the pharmacokinetics of saxagliptin and dapagliflozin.
Dapagliflozin
- At steady-state (20 mg once-daily dapagliflozin for 7 days), patients with type 2 diabetes with mild, moderate, or severe renal impairment (as determined by eGFR) had geometric mean systemic exposures of dapagliflozin that were 45%, 2.04-fold, and 3.03-fold higher, respectively, as compared to patients with type 2 diabetes with normal renal function. Higher systemic exposure of dapagliflozin in patients with type 2 diabetes mellitus with renal impairment did not result in a correspondingly higher 24-hour urinary glucose excretion. The steady-state 24-hour urinary glucose excretion in patients with type 2 diabetes and mild, moderate, and severe renal impairment was 42%, 80%, and 90% lower, respectively, than patients with type 2 diabetes with normal renal function. The impact of hemodialysis on dapagliflozin exposure is not known.
Saxagliptin
- 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 (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.
Dapagliflozin
- In subjects with mild and moderate hepatic impairment (Child-Pugh classes A and B), mean Cmax and AUC of dapagliflozin were up to 12% and 36% higher, respectively, as compared to healthy matched control subjects following single-dose administration of 10 mg dapagliflozin. These differences were not considered to be clinically meaningful. In patients with severe hepatic impairment (Child-Pugh class C), mean Cmax and AUC of dapagliflozin were up to 40% and 67% higher, respectively, as compared to healthy matched controls.
Saxagliptin
- 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.
- Pharmacokinetics of Dapagliflozin / saxagliptin in the pediatric population has not been studied. Studies characterizing the pharmacokinetics of dapagliflozin or saxagliptin after administration of Dapagliflozin / saxagliptin in pediatric patients have not been performed.
Saxagliptin and Dapagliflozin
- The lack of pharmacokinetic interaction between saxagliptin and dapagliflozin was demonstrated in a drug-drug interaction study between saxagliptin and dapagliflozin.
Dapagliflozin
- The metabolism of dapagliflozin is primarily via glucuronide conjugation mediated by UDP glucuronosyltransferase 1A9 (UGT1A9).
- In in vitro studies, dapagliflozin and dapagliflozin 3-O-glucuronide neither inhibited CYP 1A2, 2C9, 2C19, 2D6, or 3A4, nor induced CYP 1A2, 2B6, or 3A4. Dapagliflozin is a weak substrate of the P-glycoprotein (P-gp) active transporter, and dapagliflozin 3-O-glucuronide is a substrate for the OAT3 active transporter. Dapagliflozin or dapagliflozin 3-O-glucuronide did not meaningfully inhibit P-gp, OCT2, OAT1, or OAT3 active transporters. Overall, dapagliflozin is unlikely to affect the pharmacokinetics of concurrently administered medications that are P-gp, OCT2, OAT1, or OAT3 substrates.
- Table 3 shows the effect of coadministered drugs on the pharmacokinetics of dapagliflozin.
- Table 4 shows the effect of dapagliflozin on other coadministered drugs. Dapagliflozin did not meaningfully affect the pharmacokinetics of the coadministered drugs.
Saxagliptin
- 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.

## Nonclinical Toxicology
Dapagliflozin / saxagliptin
- No animal studies have been conducted with the combined products in Dapagliflozin / saxagliptin to evaluate carcinogenesis, mutagenesis, or impairment of fertility. The following data are based on the findings in the studies with dapagliflozin and saxagliptin individually.

### Carcinogenesis
Dapagliflozin
- Carcinogenicity was evaluated in 2-year studies conducted in CD-1 mice and Sprague-Dawley rats. Dapagliflozin did not increase the incidence of tumors in mice dosed orally at 5, 15, and 40 mg/kg/day in males and 2, 10, and 20 mg/kg/day in females (exposure less than or equal to 72-times (males) and 105-times (females) the 10 mg/day clinical dose, based on AUC). Dapagliflozin did not increase the incidence of tumors in rats (both males and females) dosed orally at 0.5, 2, and 10 mg/kg/day (exposure less than or equal to 131-times (males) and 186-times (females) the clinical dose of 10 mg/day, based on AUC).
Saxagliptin
- 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.

### Mutagenesis
Dapagliflozin
- Dapagliflozin was not mutagenic with or without metabolic activation in the Ames assay. Dapagliflozin was mutagenic in a series of in vitro clastogenicity assays at concentrations greater than or equal to 100 micrograms per mL, but not without metabolic activation. Dapagliflozin was not mutagenic or clastogenic in a series of in vivo studies evaluating micronuclei or DNA repair in rats at exposure multiples greater than 2100-times the clinical dose.
Saxagliptin
- 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.

### Impairment of Fertility
Dapagliflozin
- Dapagliflozin had no effects on the ability of rats to mate and sire, maintain a litter, or early embryonic development at exposure multiples less than or equal to 1708- and 998-times the maximum recommended human doses of 10 mg/day (based on AUC) in males and females, respectively.
Saxagliptin
- 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.
Saxagliptin
- 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.

# Clinical Studies
- 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 added to dapagliflozin 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 16 weeks of open-label metformin and 10 mg dapagliflozin treatment. Following the lead-in period, eligible patients were randomized to 5 mg saxagliptin (N=153) or placebo (N=162).
- The group treated with add-on saxagliptin had statistically significant greater reductions in HbA1c from baseline versus the group treated with placebo (see Table 7).
- 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.
- The cardiovascular risk of saxagliptin was evaluated in SAVOR (Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus - Thrombolysis in Myocardial Infarction), a multicenter, multinational, randomized, double-blind trial comparing saxagliptin (N=8280) to placebo (N=8212), 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.
- Subjects were at least 40 years of age, had HbA1c 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  inhibitors or angiotensin receptor blockers  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 (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 HbA1c level of 8.0%.
- 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 nonfatal myocardial infarction (MI) or a nonfatal ischemic stroke. 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 with an estimated HR: 1.0; 95.1% CI: (0.89, 1.12). The upper bound of this confidence interval, 1.12, excluded a risk margin larger than 1.3.
- 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 group than in the placebo group (4.6%). The risk of deaths from all-cause mortality was not statistically different between the treatment groups (HR: 1.11; 95.1% CI: 0.96, 1.27).

# How Supplied
- Dapagliflozin / saxagliptin (dapagliflozin and saxagliptin) tablets for oral use are available in packages as listed:

## Storage
- Store at 20C to 25C (68F to 77F); excursions permitted to 15C to 30C (59F to 86F).

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Inform patients that acute pancreatitis has been reported during postmarketing use of saxagliptin. Inform patients that persistent severe abdominal pain, sometimes radiating to the back, which may or may not be accompanied by vomiting, is the hallmark symptom of acute pancreatitis.
- Instruct patients to promptly discontinue Dapagliflozin / saxagliptin and contact their healthcare provider if persistent severe abdominal pain occurs.
- Inform patients of the signs and symptoms of heart failure. Instruct patients to contact their healthcare provider as soon as possible if they experience symptoms of heart failure, including increasing shortness of breath, rapid increase in weight or swelling of the feet.
- Inform patients that symptomatic hypotension may occur with Dapagliflozin / saxagliptin and advise them to contact their healthcare provider if they experience such symptoms. Inform patients that dehydration may increase the risk for hypotension, and to have adequate fluid intake.
- Inform patients that ketoacidosis is a serious life-threatening condition. Cases of ketoacidosis have been reported during use of dapagliflozin. Instruct patients to check ketones (when possible) if symptoms consistent with ketoacidosis occur even if blood glucose is not elevated. If symptoms of ketoacidosis (including nausea, vomiting, abdominal pain, tiredness and labored breathing) occur, instruct patients to discontinue Dapagliflozin / saxagliptin and seek medical advice immediately.
- Inform patients that acute kidney injury has been reported during use of dapagliflozin. Advise patients to seek medical advice immediately if they have reduced oral intake (due to acute illness or fasting) or increased fluid losses (due to vomiting, diarrhea, or excessive heat exposure), as it may be appropriate to temporarily discontinue Dapagliflozin / saxagliptin use in those settings.
- Inform patients of the potential for urinary tract infections, which may be serious. Inform them of the symptoms of urinary tract infections and advise them to seek medical advice if symptoms occur.
- Inform patients that serious hypersensitivity reactions (e.g., anaphylaxis, angioedema, urticaria, and exfoliative skin conditions) have been reported with dapagliflozin and saxagliptin, components of Dapagliflozin / saxagliptin. Symptoms of these allergic reactions include: 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.
- Advise patients to immediately report any signs or symptoms suggesting allergic reaction, angioedema or exfoliative skin conditions, and stop taking Dapagliflozin / saxagliptin and seek medical advice promptly.
- Inform female patients that vaginal yeast infections may occur and provide them with information on the signs and symptoms of vaginal yeast infections. Advise them of treatment options and when to seek medical advice.
- Inform male patients that yeast infections of the penis (e.g., balanitis or balanoposthitis) may occur, especially in patients with prior history. Provide them with information on the signs and symptoms of balanitis and balanoposthitis (rash or redness of the glans or foreskin of the penis). Advise them of treatment options and when to seek medical advice.
- Inform patients to promptly report any signs of macroscopic hematuria or other symptoms potentially related to bladder cancer.
- 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.
- Inform patients that bullous pemphigoid may occur with Dapagliflozin / saxagliptin. Instruct patients to seek medical advice if blisters or erosions occur.
- Advise pregnant patients of the potential risk to a fetus with treatment with Dapagliflozin / saxagliptin. Instruct patients to immediately inform their healthcare provider if pregnant or planning to become pregnant. Advise patients that use of Dapagliflozin / saxagliptin is not recommended while breastfeeding.
- Inform patients that due to its mechanism of action, patients taking Dapagliflozin / saxagliptin will test positive for glucose in their urine.
- Patients should be informed that if they miss a dose of Dapagliflozin / saxagliptin 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.

# Precautions with Alcohol
Alcohol-Dapagliflozin / saxagliptin interaction has not been established. Talk to your doctor regarding the effects of taking alcohol with this medication.

# Brand Names
- Qtern

# Look-Alike Drug Names
There is limited information regarding Dapagliflozin / saxagliptin Look-Alike Drug Names in the drug label.

# Drug Shortage Status
Drug Shortage

# Price