Empagliflozin and metformin hydrochloride
- Postmarketing cases of metformin-associated lactic acidosis have resulted in death, hypothermia, hypotension, and resistant bradyarrhythmias.
- The onset of metformin-associated lactic acidosis is often subtle,accompanied only by nonspecific symptoms such as malaise, myalgias, respiratory distress, somnolence, and abdominal pain.
- Metformin-associated lactic acidosis was characterized by elevated blood lactate levels(>5 mmol/Liter), anion gap acidosis (without evidence of ketonuria or ketonemia), an increased lactate / pyruvate ratio; and metformin plasma levels generally >5 mcg/mL.
- Risk factors for metformin-associated lactic acidosis include renal impairment, concomitant use of certain drugs (e.g., carbonic anhydrase inhibitors such as topiramate), age 65 years old or greater, having a radiological study with contrast, surgery and other procedures, hypoxic states (e.g., acute congestive heart failure), excessive alcohol intake, and hepatic impairment.
- If metformin-associated lactic acidosis is suspected, immediately discontinue Empagliflozin and metformin hydrochloride and institute general supportive measures in a hospital setting.
- Prompt hemodialysis is recommended.
- Empagliflozin is indicated to reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease.
- However, the effectiveness of Empagliflozin and metformin hydrochloride on reducing the risk of cardiovascular death in adults with type 2 diabetes mellitus and cardiovascular disease has not been established.
- DOSAGE FORMS AND STRENGTHS
- Tablets:
- 5 mg empagliflozin/500 mg metformin hydrochloride
- 5 mg empagliflozin/1000 mg metformin hydrochloride
- 12.5 mg empagliflozin/500 mg metformin hydrochloride
- 12.5 mg empagliflozin/1000 mg metformin hydrochloride.
- Moderate to severe renal impairment (eGFR less than 45 mL/min/1.73 m2), end stage renal disease, or dialysis.
Acute or chronic metabolic acidosis, including diabetic ketoacidosis.
Diabetic ketoacidosis should be treated with insulin.
History of serious hypersensitivity reaction to empagliflozin or metformin.
- Moderate to severe renal impairment (eGFR less than 45 mL/min/1.73 m2), end stage renal disease, or dialysis.
- Acute or chronic metabolic acidosis, including diabetic ketoacidosis.
- Diabetic ketoacidosis should be treated with insulin.
- History of serious hypersensitivity reaction to empagliflozin or metformin.
- There have been postmarketing cases of metformin-associated lactic acidosis, including fatal cases.
- These cases had a subtle onset and were accompanied by nonspecific symptoms such as malaise, myalgias, abdominal pain, respiratory distress, or increased somnolence; however, hypothermia, hypotension, and resistant bradyarrhythmias have occurred with severe acidosis.
- Metformin-associated lactic acidosis was characterized by elevated blood lactate concentrations (>5 mmol/Liter), anion gap acidosis (without evidence of ketonuria or ketonemia), and an increased lactate:pyruvate ratio; metformin plasma levels generally >5 mcg/mL.
- Metformin decreases liver uptake of lactate increasing lactate blood levels which may increase the risk of lactic acidosis, especially in patients at risk.
- If metformin-associated lactic acidosis is suspected, general supportive measures should be instituted promptly in a hospital setting, along with immediate discontinuation of Empagliflozin and metformin hydrochloride.
- In Empagliflozin and metformin hydrochloride-treated patients with a diagnosis or strong suspicion of lactic acidosis, prompt hemodialysis is recommended to correct the acidosis and remove accumulated metformin (metformin hydrochloride is dialyzable, with a clearance of up to 170 mL/minute under good hemodynamic conditions).
- Hemodialysis has often resulted in reversal of symptoms and recovery.
- Educate patients and their families about the symptoms of lactic acidosis and if these symptoms occur instruct them to discontinue Empagliflozin and metformin hydrochloride and report these symptoms to their healthcare provider.
- For each of the known and possible risk factors for metformin-associated lactic acidosis, recommendations to reduce the risk of and manage metformin-associated lactic acidosis are provided below:
- Renal Impairment: :*The postmarketing metformin-associated lactic acidosis cases primarily occurred in patients with significant renal impairment.
- The risk of metformin accumulation and metformin-associated lactic acidosis increases with the severity of renal impairment because metformin is substantially excreted by the kidney.
- Before initiating Empagliflozin and metformin hydrochloride, obtain an estimated glomerular filtration rate (eGFR).
Empagliflozin and metformin hydrochloride is contraindicated in patients with an eGFR below 45 mL/min/1.73 m2.
Obtain an eGFR at least annually in all patients taking Empagliflozin and metformin hydrochloride. In patients at increased risk for the development of renal impairment (e.g., the elderly), renal function should be assessed more frequently.
- Before initiating Empagliflozin and metformin hydrochloride, obtain an estimated glomerular filtration rate (eGFR).
- Empagliflozin and metformin hydrochloride is contraindicated in patients with an eGFR below 45 mL/min/1.73 m2.
- Obtain an eGFR at least annually in all patients taking Empagliflozin and metformin hydrochloride. In patients at increased risk for the development of renal impairment (e.g., the elderly), renal function should be assessed more frequently.
- Drug Interactions:
- The concomitant use of Empagliflozin and metformin hydrochloride with specific drugs may increase the risk of metformin-associated lactic acidosis: those that impair renal function, result in significant hemodynamic change, interfere with acid-base balance or increase metformin accumulation.
- Therefore, consider more frequent monitoring of patients.
- Age 65 or Greater:
- The risk of metformin-associated lactic acidosis increases with the patients age because elderly patients have a greater likelihood of having hepatic, renal, or cardiac impairment than younger patients.
- Assess renal function more frequently in elderly patients.
- Radiological Studies with Contrast:
- Administration of intravascular iodinated contrast agents in metformin-treated patients has led to an acute decrease in renal function and the occurrence of lactic acidosis.
- Stop Empagliflozin and metformin hydrochloride at the time of, or prior to, an iodinated contrast imaging procedure in patients with an eGFR between 45 and 60 mL/min/1.73 m2; in patients with a history of hepatic impairment, alcoholism, or heart failure; or in patients who will be administered intra-arterial iodinated contrast.
- Re-evaluate eGFR 48 hours after the imaging procedure, and restart Empagliflozin and metformin hydrochloride if renal function is stable.
- Surgery and Other Procedures:
- Withholding of food and fluids during surgical or other procedures may increase the risk for volume depletion, hypotension and renal impairment.
- Empagliflozin and metformin hydrochloride should be temporarily discontinued while patients have restricted food and fluid intake.
- Hypoxic States:
- Several of the postmarketing cases of metformin-associated lactic acidosis occurred in the setting of acute congestive heart failure (particularly when accompanied by hypoperfusion and hypoxemia).
- Cardiovascular collapse (shock), acute myocardial infarction, sepsis, and other conditions associated with hypoxemia have been associated with lactic acidosis and may also cause pre renal azotemia.
- When such events occur, discontinue Empagliflozin and metformin hydrochloride.
- Excessive Alcohol Intake:
- Alcohol potentiates the effect of metformin on lactate metabolism and this may increase the risk of metformin-associated lactic acidosis.
- Warn patients against excessive alcohol intake while receiving Empagliflozin and metformin hydrochloride.
- Hepatic Impairment:
- Patients with hepatic impairment have developed cases of metformin-associated lactic acidosis.
- This may be due to impaired lactate clearance resulting in higher lactate blood levels.
- Therefore, avoid use of Empagliflozin and metformin hydrochloride in patients with clinical or laboratory evidence of hepatic disease.

# Hypotension
- Empagliflozin causes intravascular volume contraction.
- Symptomatic hypotension may occur after initiating empagliflozin particularly in patients with renal impairment, the elderly, in patients with low systolic blood pressure, and in patients on diuretics.
- Before initiating Empagliflozin and metformin hydrochloride, assess for volume contraction and correct volume status if indicated.
- Monitor for signs and symptoms of hypotension after initiating therapy and increase monitoring in clinical situations where volume contraction is expected.

# Ketoacidosis
- 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 sodiu- glucose co-transporter-2 (SGLT2) inhibitors, including empagliflozin.
- Fatal cases of ketoacidosis have been reported in patients taking empagliflozin.
- Empagliflozin and metformin hydrochloride is not indicated for the treatment of patients with type 1 diabetes mellitus.
- Patients treated with Empagliflozin and metformin hydrochloride 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 Empagliflozin and metformin hydrochloride may be present even if blood glucose levels are less than 250 mg/dL.
- If ketoacidosis is suspected, Empagliflozin and metformin hydrochloride should be discontinued, 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, and particularly in patients with type 1 diabetes, the presence of ketoacidosis was not immediately recognized and institution of treatment was delayed because 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 Empagliflozin and metformin hydrochloride, 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 Empagliflozin and metformin hydrochloride consider monitoring for ketoacidosis and temporarily discontinuing Empagliflozin and metformin hydrochloride in clinical situations known to predispose to ketoacidosis (e.g., prolonged fasting due to acute illness or surgery).

# Acute Kidney Injury and Impairment in Renal Function
- Empagliflozin causes intravascular volume contraction.
- There have been postmarketing reports of acute kidney injury, some requiring hospitalization and dialysis, in patients receiving SGLT2 inhibitors, including empagliflozin; some reports involved patients younger than 65 years of age.
- Before initiating Empagliflozin and metformin hydrochloride, 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 Empagliflozin and metformin hydrochloride in any setting of reduced oral intake (such as acute illness or fasting) or fluid losses (such as gastrointestinal illness or excessive heat exposure); monitor patients for signs and symptoms of acute kidney injury.
- If acute kidney injury occurs, discontinue Empagliflozin and metformin hydrochloride promptly and institute treatment.
- Empagliflozin increases serum creatinine and decreases eGFR.
- Patients with hypovolemia may be more susceptible to these changes.
- Renal function abnormalities can occur after initiating Empagliflozin and metformin hydrochloride.
- Renal function should be evaluated prior to initiation of Empagliflozin and metformin hydrochloride and monitored periodically thereafter.
- More frequent renal function monitoring is recommended in patients with an eGFR below 60 mL/min/1.73 m2.
- Use of Empagliflozin and metformin hydrochloride is contraindicated in patients with an eGFR less than 45 mL/min/1.73 m2.

# Urosepsis and Pyelonephritis
- There have been postmarketing reports of serious urinary tract infections including urosepsis and pyelonephritis requiring hospitalization in patients receiving SGLT2 inhibitors, including empagliflozin.
- Treatment with SGLT2 inhibitors increases the risk for urinary tract infections.
- Evaluate patients for signs and symptoms of urinary tract infections and treat promptly, if indicated.

# Hypoglycemia with Concomitant Use with Insulin and Insulin Secretagogues
- Empagliflozin:
- Insulin and insulin secretagogues are known to cause hypoglycemia.
- The risk of hypoglycemia is increased when empagliflozin is used in combination with insulin secretagogues (e.g., sulfonylurea) or insulin.
- Therefore, a lower dose of the insulin secretagogue or insulin may be required to reduce the risk of hypoglycemia when used in combination with Empagliflozin and metformin hydrochloride.
- Metformin:
- Hypoglycemia does not occur in patients receiving metformin alone under usual circumstances of use, but could occur when caloric intake is deficient, when strenuous exercise is not compensated by caloric supplementation, or during concomitant use with other glucose-lowering agents (such as SUs and insulin) or ethanol.
- Elderly, debilitated, or malnourished patients, and those with adrenal or pituitary insufficiency or alcohol intoxication are particularly susceptible to hypoglycemic effects.
- Hypoglycemia may be difficult to recognize in the elderly, and in people who are taking -adrenergic blocking drugs.
- Monitor for a need to lower the dose of Empagliflozin and metformin hydrochloride to minimize the risk of hypoglycemia in these patients.

# Genital Mycotic Infections
- Empagliflozin increases the risk for genital mycotic infections.
- Patients with a history of chronic or recurrent genital mycotic infections were more likely to develop mycotic genital infections.
- Monitor and treat as appropriate.

# Vitamin B12 Levels
- In controlled, 29-week clinical trials of metformin, a decrease to subnormal levels of previously normal serum vitamin B12 levels, without clinical manifestations, was observed in approximately 7% of metformin-treated patients.
- Such decrease, possibly due to interference with B12 absorption from the B12-intrinsic factor complex, is, however, very rarely associated with anemia or neurologic manifestations due to the short duration (<1 year) of the clinical trials.
- This risk may be more relevant to patients receiving long-term treatment with metformin, and adverse hematologic and neurologic reactions have been reported postmarketing.
- The decrease in vitamin B12 levels appears to be rapidly reversible with discontinuation of metformin or vitamin B12 supplementation.
- Measurement of hematologic parameters on an annual basis is advised in patients on Empagliflozin and metformin hydrochloride and any apparent abnormalities should be appropriately investigated and managed.
- Certain individuals (those with inadequate vitamin B12 or calcium intake or absorption) appear to be predisposed to developing subnormal vitamin B12 levels.
- In these patients, routine serum vitamin B12 measurement at 2- to 3-year intervals may be useful.

# Increased Low-Density Lipoprotein Cholesterol (LDL-C)
- Increases in LDL-C can occur with empagliflozin.
- Monitor and treat as appropriate.

# Macrovascular Outcomes
- There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Empagliflozin and metformin hydrochloride.
- Lactic Acidosis
- Hypotension
- Ketoacidosis
- Acute Kidney Injury and Impairment in Renal Function
- Urosepsis and Pyelonephritis
- Hypoglycemia with Concomitant Use with Insulin and Insulin Secretagogues
- Genital Mycotic Infections
- Vitamin B12 Deficiency
- Increased Low-Density Lipoprotein Cholesterol (LDL-C).
- 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 concomitantly administered empagliflozin (daily dose 10 mg and 25 mg) and metformin hydrochloride (mean daily dose of approximately 1800 mg) has been evaluated in 3456 patients with type 2 diabetes mellitus treated for 16 to 24 weeks, of which 926 patients received placebo, 1271 patients received a daily dose of empagliflozin 10 mg, and 1259 patients received a daily dose of empagliflozin 25 mg.
- Discontinuation of therapy due to adverse events across treatment groups was 3.0%, 2.8%, and 2.9% for placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively.
- Empagliflozin Add-On Combination Therapy with Metformin:
- In a 24-week placebo-controlled trial of empagliflozin 10 mg and 25 mg administered once daily added to metformin, there were no adverse reactions reported regardless of investigator assessment of causality in 5% of patients and more commonly than in patients given placebo.
- Empagliflozin Add-On Combination Therapy with Metformin and Sulfonylurea:
- In a 24-week placebo-controlled trial of empagliflozin 10 mg and 25 mg administered once daily added to metformin and sulfonylurea, adverse reactions reported regardless of investigator assessment of causality in 5% of patients and more commonly than in patients given placebo are presented in Table 1.
- Empagliflozin:
- The data in Table 2 are derived from a pool of four 24-week placebo-controlled trials and 18-week data from a placebo-controlled trial with basal insulin.
- Empagliflozin was used as monotherapy in one trial and as add-on therapy in four trials.
- These data reflect exposure of 1976 patients to empagliflozin with a mean exposure duration of approximately 23 weeks.
- Patients received placebo (N=995), empagliflozin 10 mg (N=999), or empagliflozin 25 mg (N=977) once daily.
- The mean age of the population was 56 years and 3% were older than 75 years of age.
- More than half (55%) of the population was male; 46% were White, 50% were Asian, and 3% were Black or African American.
- At baseline, 57% of the population had diabetes more than 5 years and had a mean hemoglobin A1c (HbA1c) of 8%.
- Established microvascular complications of diabetes at baseline included diabetic nephropathy (7%), retinopathy (8%), or neuropathy (16%).
- Baseline renal function was normal or mildly impaired in 91% of patients and moderately impaired in 9% of patients (mean eGFR 86.8 mL/min/1.73 m2).
- Table 2 shows common adverse reactions (excluding hypoglycemia) associated with the use of empagliflozin.
- The adverse reactions were not present at baseline, occurred more commonly on empagliflozin than on placebo and occurred in greater than or equal to 2% of patients treated with empagliflozin 10 mg or empagliflozin 25 mg.
- Volume Depletion:
- Empagliflozin causes an osmotic diuresis, which may lead to intravascular volume contraction and adverse reactions related to volume depletion.
- In the pool of five placebo-controlled clinical trials, adverse reactions related to volume depletion (e.g., blood pressure (ambulatory) decreased, blood pressure systolic decreased, dehydration, hypotension, hypovolemia, orthostatic hypotension, and syncope) were reported by 0.3%, 0.5%, and 0.3% of patients treated with placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively.
- Empagliflozin may increase the risk of hypotension in patients at risk for volume contraction.
- Increased Urination:
- In the pool of five placebo-controlled clinical trials, adverse reactions of increased urination (e.g., polyuria, pollakiuria, and nocturia) occurred more frequently on empagliflozin than on placebo (see Table 3).
- Specifically, nocturia was reported by 0.4%, 0.3%, and 0.8% of patients treated with placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively.
- Acute Impairment in Renal Function:
- Treatment with empagliflozin was associated with increases in serum creatinine and decreases in eGFR.
- Patients with moderate renal impairment at baseline had larger mean changes.
- In a long-term cardiovascular outcome trial, the acute impairment in renal function was observed to reverse after treatment discontinuation suggesting acute hemodynamic changes play a role in the renal function changes observed with empagliflozin.
- Hypoglycemia:
- The incidence of hypoglycemia increased when empagliflozin was administered with insulin or sulfonylurea.
- Genital Mycotic Infections:
- In the pool of five placebo-controlled clinical trials, the incidence of genital mycotic infections (e.g., vaginal mycotic infection, vaginal infection, genital infection fungal, vulvovaginal candidiasis, and vulvitis) was increased in patients treated with empagliflozin compared to placebo, occurring in 0.9%, 4.1%, and 3.7% of patients randomized to placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively.
- Discontinuation from study due to genital infection occurred in 0% of placebo-treated patients and 0.2% of patients treated with either empagliflozin 10 or 25 mg.
- Genital mycotic infections occurred more frequently in female than male patients.
- Phimosis occurred more frequently in male patients treated with empagliflozin 10 mg (less than 0.1%) and empagliflozin 25 mg (0.1%) than placebo (0%).
- Urinary Tract Infections:
- In the pool of five placebo-controlled clinical trials, the incidence of urinary tract infections (e.g., urinary tract infection, asymptomatic bacteriuria, and cystitis) was increased in patients treated with empagliflozin compared to placebo.
- Patients with a history of chronic or recurrent urinary tract infections were more likely to experience a urinary tract infection.
- The rate of treatment discontinuation due to urinary tract infections was 0.1%, 0.2%, and 0.1% for placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively.
- Urinary tract infections occurred more frequently in female patients.
- The incidence of urinary tract infections in female patients randomized to placebo, empagliflozin 10 mg, and empagliflozin 25 mg was 16.6%, 18.4%, and 17.0%, respectively.
- The incidence of urinary tract infections in male patients randomized to placebo, empagliflozin 10 mg, and empagliflozin 25 mg was 3.2%, 3.6%, and 4.1%, respectively.
- Metformin:
- The most common (>5%) established adverse reactions due to initiation of metformin therapy are diarrhea, nausea/ vomiting, flatulence, abdominal discomfort, indigestion, asthenia, and headache.
- Long-term treatment with metformin has been associated with a decrease in vitamin B12 absorption which may very rarely result in clinically significant vitamin B12 deficiency (e.g., megaloblastic anemia).

# Laboratory Tests
- Empagliflozin:
- Increase in Low-Density Lipoprotein Cholesterol (LDL-C): Dose-related increases in low-density lipoprotein cholesterol (LDL-C) were observed in patients treated with empagliflozin.
- LDL-C increased by 2.3%, 4.6%, and 6.5% in patients treated with placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively.
- The range of mean baseline LDL-C levels was 90.3 to 90.6 mg/dL across treatment groups.
- Increase in Hematocrit:
- In a pool of four placebo-controlled studies, median hematocrit decreased by 1.3% in placebo and increased by 2.8% in empagliflozin 10 mg and 2.8% in empagliflozin 25 mg treated patients.
- At the end of treatment, 0.6%, 2.7%, and 3.5% of patients with hematocrits initially within the reference range had values above the upper limit of the reference range with placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively.
- Metformin:
- In controlled clinical trials of metformin of 29 weeks duration, a decrease to subnormal levels of previously normal serum Vitamin B12 levels, without clinical manifestations, was observed in approximately 7% of patients.
- Such decrease, possibly due to interference with B12 absorption from the B12-intrinsic factor complex, is, however, very rarely associated with anemia and appears to be rapidly reversible with discontinuation of metformin or Vitamin B12 supplementation.
- 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.
Ketoacidosis
Urosepsis and pyelonephritis.
- Ketoacidosis
- Urosepsis and pyelonephritis.
- Diuretics:
Coadministration of empagliflozin with diuretics resulted in increased urine volume and frequency of voids, which might enhance the potential for volume depletion.
- Coadministration of empagliflozin with diuretics resulted in increased urine volume and frequency of voids, which might enhance the potential for volume depletion.
- Insulin or Insulin Secretagogues:
Coadministration of empagliflozin with insulin or insulin secretagogues increases the risk for hypoglycemia.
- Coadministration of empagliflozin with insulin or insulin secretagogues increases the risk for hypoglycemia.
- Positive Urine Glucose Test:
Monitoring glycemic control with urine glucose tests is not recommended in patients taking SGLT2 inhibitors as SGLT2 inhibitors increase urinary glucose excretion and will lead to positive urine glucose tests.
Use alternative methods to monitor glycemic control.
- Monitoring glycemic control with urine glucose tests is not recommended in patients taking SGLT2 inhibitors as SGLT2 inhibitors increase urinary glucose excretion and will lead to positive urine glucose tests.
- Use alternative methods to monitor glycemic control.
- Interference with 1,5-anhydroglucitol (1,5-AG) Assay :
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 SGLT2 inhibitors.
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 SGLT2 inhibitors.
- Use alternative methods to monitor glycemic control.

# Drug Interactions with Metformin Hydrochloride
- Drugs that Reduce Metformin Clearance:
Concomitant use of drugs that interfere with common renal tubular transport systems involved in the renal elimination of metformin (e.g., organic cationic transporter-2  / multidrug and toxin extrusion  inhibitors such as ranolazine, vandetanib, dolutegravir, and cimetidine) could increase systemic exposure to metformin and may increase the risk for lactic acidosis. Consider the benefits and risks of concomitant use.
- Concomitant use of drugs that interfere with common renal tubular transport systems involved in the renal elimination of metformin (e.g., organic cationic transporter-2  / multidrug and toxin extrusion  inhibitors such as ranolazine, vandetanib, dolutegravir, and cimetidine) could increase systemic exposure to metformin and may increase the risk for lactic acidosis. Consider the benefits and risks of concomitant use.
- Carbonic Anhydrase Inhibitors :
Topiramate or other carbonic anhydrase inhibitors (e.g., zonisamide, acetazolamide or dichlorphenamide) frequently causes a decrease in serum bicarbonate and induce non-anion gap, hyperchloremic metabolic acidosis.
Concomitant use of these drugs with Empagliflozin and metformin hydrochloride may increase the risk of lactic acidosis.
Consider more frequent monitoring of these patients.
- Topiramate or other carbonic anhydrase inhibitors (e.g., zonisamide, acetazolamide or dichlorphenamide) frequently causes a decrease in serum bicarbonate and induce non-anion gap, hyperchloremic metabolic acidosis.
- Concomitant use of these drugs with Empagliflozin and metformin hydrochloride may increase the risk of lactic acidosis.
- Consider more frequent monitoring of these patients.
- Drugs Affecting Glycemic Control:
Certain drugs tend to produce hyperglycemia and may lead to loss of glycemic control.
These drugs include the thiazides and other diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blocking drugs, and isoniazid.
When such drugs are administered to a patient receiving Empagliflozin and metformin hydrochloride, the patient should be closely observed to maintain adequate glycemic control.
When such drugs are withdrawn from a patient receiving Empagliflozin and metformin hydrochloride, the patient should be observed closely for hypoglycemia.
- Certain drugs tend to produce hyperglycemia and may lead to loss of glycemic control.
- These drugs include the thiazides and other diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blocking drugs, and isoniazid.
- When such drugs are administered to a patient receiving Empagliflozin and metformin hydrochloride, the patient should be closely observed to maintain adequate glycemic control.
- When such drugs are withdrawn from a patient receiving Empagliflozin and metformin hydrochloride, the patient should be observed closely for hypoglycemia.
- Alcohol:
Alcohol is known to potentiate the effect of metformin on lactate metabolism.
Warn patients against excessive alcohol intake while receiving Empagliflozin and metformin hydrochloride.
- Alcohol is known to potentiate the effect of metformin on lactate metabolism.
- Warn patients against excessive alcohol intake while receiving Empagliflozin and metformin hydrochloride.
- Based on animal data showing adverse renal effects, Empagliflozin and metformin hydrochloride is not recommended during the second and third trimesters of pregnancy.
- Limited available data with Empagliflozin and metformin hydrochloride or empagliflozin in pregnant women are not sufficient to determine a drug-associated risk for major birth defects and miscarriage.
- Published studies with metformin use during pregnancy have not reported a clear association with metformin and major birth defect or miscarriage risk.
- There are risks to the mother and fetus associated with poorly controlled diabetes in pregnancy.
- In animal studies, adverse renal changes were observed in rats when empagliflozin was administered during a period of renal development corresponding to the late second and third trimesters of human pregnancy.
- Doses approximately 13-times the maximum clinical dose caused renal pelvic and tubule dilatations that were reversible.
- Empagliflozin was not teratogenic in rats and rabbits up to 300 mg/kg/day, which approximates 48-times and 128-times, respectively, the maximum clinical dose of 25 mg when administered during organogenesis.
- No adverse developmental effects were observed when metformin was administered to pregnant Sprague Dawley rats and rabbits during the period of organogenesis at doses up to 2- and 6-times, respectively, a 2000 mg clinical dose, based on body surface area.
- The estimated background risk of major birth defects is 6-10% in women with pre-gestational diabetes with a HbA1c >7 and has been reported to be as high as 20-25% in women with HbA1c >10.
- The estimated background risk of miscarriage for the indicated population is unknown.
- In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.
- Clinical Considerations:
- Disease-associated maternal and/or embryo/fetal risk:
Poorly controlled diabetes in pregnancy increases the maternal risk for diabetic ketoacidosis, pre-eclampsia, spontaneous abortions, preterm delivery, stillbirth, and delivery complications.
Poorly controlled diabetes increases the fetal risk for major birth defects, still birth, and macrosomia related morbidity.
- Poorly controlled diabetes in pregnancy increases the maternal risk for diabetic ketoacidosis, pre-eclampsia, spontaneous abortions, preterm delivery, stillbirth, and delivery complications.
- Poorly controlled diabetes increases the fetal risk for major birth defects, still birth, and macrosomia related morbidity.
- Data:
- Human Data:
Published data from post-marketing studies have not reported a clear association with metformin and major birth defects, miscarriage, or adverse maternal or fetal outcomes when metformin was used during pregnancy.
However, these studies cannot definitely establish the absence of any metformin-associated risk because of methodological limitations, including small sample size and inconsistent comparator groups.
- Published data from post-marketing studies have not reported a clear association with metformin and major birth defects, miscarriage, or adverse maternal or fetal outcomes when metformin was used during pregnancy.
- However, these studies cannot definitely establish the absence of any metformin-associated risk because of methodological limitations, including small sample size and inconsistent comparator groups.
- Animal Data:
- Empagliflozin:
- Empagliflozin dosed directly to juvenile rats from postnatal day (PND) 21 until PND 90 at doses of 1, 10, 30 and 100 mg/kg/day caused increased kidney weights and renal tubular and pelvic dilatation at 100 mg/kg/day, which approximates 13-times the maximum clinical dose of 25 mg, based on AUC.
- These findings were not observed after a 13 week drug-free recovery period.
- 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.
- In embryo-fetal development studies in rats and rabbits, empagliflozin was administered for intervals coinciding with the first trimester period of organogenesis in humans.
- Doses up to 300 mg/kg/day, which approximates 48-times (rats) and 128-times (rabbits) the maximum clinical dose of 25 mg (based on AUC), did not result in adverse developmental effects.
- In rats, at higher doses of empagliflozin causing maternal toxicity, malformations of limb bones increased in fetuses at 700 mg/kg/day or 154-times the 25 mg maximum clinical dose.
- In the rabbit, higher doses of empagliflozin resulted in maternal and fetal toxicity at 700 mg/kg/day, or 139-times the 25 mg maximum clinical dose.
- In pre- and postnatal development studies in pregnant rats, empagliflozin was administered from gestation day 6 through to lactation day 20 (weaning) at up to 100 mg/kg/day (approximately 16-times the 25 mg maximum clinical dose) without maternal toxicity.
- Reduced body weight was observed in the offspring at greater than or equal to 30 mg/kg/day (approximately 4-times the 25 mg maximum clinical dose).
- Metformin hydrochloride:
Metformin hydrochloride did not cause adverse developmental effects when administered to pregnant Sprague Dawley rats and rabbits at up to 600 mg/kg/day during the period of organogenesis.
This represents an exposure of approximately 2- and 6-times a clinical dose of 2000 mg, based on body surface area (mg/m2) for rats and rabbits, respectively.
- Metformin hydrochloride did not cause adverse developmental effects when administered to pregnant Sprague Dawley rats and rabbits at up to 600 mg/kg/day during the period of organogenesis.
- This represents an exposure of approximately 2- and 6-times a clinical dose of 2000 mg, based on body surface area (mg/m2) for rats and rabbits, respectively.
- Empagliflozin and Metformin hydrochloride:
No adverse developmental effects were observed when empagliflozin and metformin hydrochloride were coadministered to pregnant rats during the period of organogenesis at exposures of approximately 35- and 14-times the clinical AUC exposure of empagliflozin associated with the 10 mg and 25 mg doses, respectively, and 4-times the clinical AUC exposure of metformin associated with the 2000 mg dose.
- No adverse developmental effects were observed when empagliflozin and metformin hydrochloride were coadministered to pregnant rats during the period of organogenesis at exposures of approximately 35- and 14-times the clinical AUC exposure of empagliflozin associated with the 10 mg and 25 mg doses, respectively, and 4-times the clinical AUC exposure of metformin associated with the 2000 mg dose.
- Limited published studies report that metformin is present in human milk.
- However, there is insufficient information on the effects of metformin on the breastfed infant and no available information on the effects of metformin on milk production.
- Empagliflozin is 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 Empagliflozin and metformin hydrochloride is not recommended while breastfeeding.
- Published clinical lactation studies report that metformin is present in human milk which resulted in infant doses approximately 0.11% to 1% of the maternal weight-adjusted dosage and a milk/plasma ratio ranging between 0.13 and 1.
- However, the studies were not designed to definitely establish the risk of use of metformin during lactation because of small sample size and limited adverse event data collected in infants.
- Empagliflozin was present at a low level in rat fetal tissues after a single oral dose to the dams at gestation day 18.
- In rat milk, the mean milk to plasma ratio ranged from 0.634 -5, and was greater than one from 2 to 24 hours post-dose.
- The mean maximal milk to plasma ratio of 5 occurred at 8 hours post-dose, suggesting accumulation of empagliflozin in the milk.
- Juvenile rats directly exposed to empagliflozin showed a risk to the developing kidney (renal pelvic and tubular dilatations) during maturation.
- Empagliflozin:
- No empagliflozin dosage change is recommended based on age.
- In studies assessing the efficacy of empagliflozin in improving glycemic control in patients with type 2 diabetes, a total of 2721 (32%) patients treated with empagliflozin were 65 years of age and older, and 491 (6%) were 75 years of age and older.
- Empagliflozin is expected to have diminished glycemic efficacy in elderly patients with renal impairment.
- The risk of volume depletion-related adverse reactions increased in patients who were 75 years of age and older to 2.1%, 2.3%, and 4.4% for placebo, empagliflozin 10 mg, and empagliflozin 25 mg.
- The risk of urinary tract infections increased in patients who were 75 years of age and older to 10.5%, 15.7%, and 15.1% in patients randomized to placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively.
- Metformin hydrochloride :
- Controlled clinical studies of metformin hydrochloride did not include sufficient numbers of elderly patients to determine whether they respond differently from younger patients, although other reported clinical experience has not identified differences in responses between the elderly and young patients.
- In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy and the higher risk of lactic acidosis.
- Assess renal function more frequently in elderly patients.
- In patients with volume depletion not previously treated with empagliflozin, correct this condition before initiating Empagliflozin and metformin hydrochloride.
- Individualize the starting dose of Empagliflozin and metformin hydrochloride based on the patients current regimen:
- In patients on metformin hydrochloride, switch to Empagliflozin and metformin hydrochloride containing empagliflozin 5 mg with a similar total daily dose of metformin hydrochloride;
 In patients on empagliflozin, switch to Empagliflozin and metformin hydrochloride containing metformin hydrochloride 500 mg with a similar total daily dose of empagliflozin;
 In patients already treated with empagliflozin and metformin hydrochloride, switch to Empagliflozin and metformin hydrochloride containing the same total daily doses of each component.
- Take Empagliflozin and metformin hydrochloride twice daily with meals; with gradual dose escalation to reduce the gastrointestinal side effects due to metformin.
- Adjust dosing based on effectiveness and tolerability while not exceeding the maximum recommended daily dose of metformin hydrochloride 2000 mg and empagliflozin 25 mg.

# Recommended Dosage in Patients with Renal Impairment
- Assess renal function prior to initiation of Empagliflozin and metformin hydrochloride and periodically, thereafter.
- Empagliflozin and metformin hydrochloride is contraindicated in patients with an eGFR less than 45 mL/min/1.73 m2.

# Discontinuation for Iodinated Contrast Imaging Procedures
- Discontinue Empagliflozin and metformin hydrochloride at the time of, or prior to, an iodinated contrast imaging procedure in patients with an eGFR between 45 and 60 mL/min/1.73 m2; in patients with a history of liver disease, alcoholism or heart failure; or in patients who will be administered intra-arterial iodinated contrast.
- Re-evaluate eGFR 48 hours after the imaging procedure; restart Empagliflozin and metformin hydrochloride if renal function is stable.
- Employ the usual supportive measures (e.g., remove unabsorbed material from the gastrointestinal tract, employ clinical monitoring, and institute supportive treatment) as dictated by the patients clinical status.
- Removal of empagliflozin by hemodialysis has not been studied.
- However, metformin is dialyzable with a clearance of up to 170 mL/min under good hemodynamic conditions.
- Therefore, hemodialysis may be useful partly for removal of accumulated metformin from patients in whom Empagliflozin and metformin hydrochloride overdosage is suspected.
- Metformin hydrochloride :
- Overdose of metformin hydrochloride has occurred, including ingestion of amounts greater than 50 grams. Hypoglycemia was reported in approximately 10% of cases, but no causal association with metformin has been established.
- Lactic acidosis has been reported in approximately 32% of metformin overdose cases.
- Empagliflozin and metformin hydrochloride combines 2 antihyperglycemic agents with complementary mechanisms of action to improve glycemic control in patients with type 2 diabetes: empagliflozin, a sodium-glucose co-transporter 2 (SGLT2) inhibitor, and metformin, a member of the biguanide class.
- Empagliflozin:
- Sodium-glucose co-transporter 2 (SGLT2) is the predominant transporter responsible for reabsorption of glucose from the glomerular filtrate back into the circulation.
- Empagliflozin is an inhibitor of SGLT2.
- By inhibiting SGLT2, empagliflozin reduces renal reabsorption of filtered glucose and lowers the renal threshold for glucose, and thereby increases urinary glucose excretion.
- Metformin :
- Metformin is an antihyperglycemic agent which improves glucose tolerance in patients with type 2 diabetes mellitus, lowering both basal and postprandial plasma glucose.
- It is not chemically or pharmacologically related to any other classes of oral antihyperglycemic agents.
- Metformin decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization.
- Unlike SUs, metformin does not produce hypoglycemia in either patients with type 2 diabetes mellitus or normal subjects (except in special circumstances) and does not cause hyperinsulinemia.
- With metformin therapy, insulin secretion remains unchanged while fasting insulin levels and day-long plasma insulin response may actually decrease.
- Empagliflozin :
- Empagliflozin is an orally-active inhibitor of the sodium-glucose co-transporter 2 (SGLT2).
- The chemical name of empagliflozin is D-Glucitol,1,5-anhydro-1-C-oxy]phenyl]methyl]phenyl]-, (1S).
- Its molecular formula is C23H27ClO7 and the molecular weight is 450.91.
- Empagliflozin is a white to yellowish, non-hygroscopic powder.
- It is very slightly soluble in water, sparingly soluble in methanol, slightly soluble in ethanol and acetonitrile; soluble in 50% acetonitrile/water; and practically insoluble in toluene.
- Metformin hydrochloride:
- Metformin hydrochloride is a white to off-white crystalline compound with a molecular formula of C4H11N5HCl and a molecular weight of 165.63.
- Metformin hydrochloride is freely soluble in water and is practically insoluble in acetone, ether, and chloroform.
- The pKa of metformin is 12.4.
- The pH of a 1% aqueous solution of metformin hydrochloride is 6.68.
- SYNJARDY:
- Empagliflozin and metformin hydrochloride tablets for oral administration are available in four dosage strengths containing 5 mg empagliflozin and 500 mg metformin hydrochloride, 5 mg empagliflozin and 1000 mg metformin hydrochloride, 12.5 mg empagliflozin and 500 mg metformin hydrochloride, or 12.5 mg empagliflozin and 1000 mg metformin hydrochloride.
- Each film-coated tablet of Empagliflozin and metformin hydrochloride contains the following inactive ingredients: copovidone, corn starch, colloidal silicon dioxide, magnesium stearate. Film-coating: hypromellose, titanium dioxide, talc, polyethylene glycol 400, and yellow ferric oxide (5 mg/500 mg, 5 mg/1000 mg) or red ferric oxide and black ferrosoferric oxide (12.5 mg/500 mg, 12.5 mg/1000 mg).
- Urinary Glucose Excretion :
- In patients with type 2 diabetes, urinary glucose excretion increased immediately following a dose of empagliflozin and was maintained at the end of a 4-week treatment period averaging at approximately 64 grams per day with 10 mg empagliflozin and 78 grams per day with 25 mg empagliflozin once daily.
- Urinary Volume:
- In a 5-day study, mean 24-hour urine volume increase from baseline was 341 mL on Day 1 and 135 mL on Day 5 of empagliflozin 25 mg once daily treatment.
- Cardiac Electrophysiology :
- In a randomized, placebo-controlled, active-comparator, crossover study, 30 healthy subjects were administered a single oral dose of empagliflozin 25 mg, empagliflozin 200 mg (8 times the maximum dose), moxifloxacin, and placebo.
- No increase in QTc was observed with either 25 mg or 200 mg empagliflozin.
- The results of a bioequivalence study in healthy subjects demonstrated that Empagliflozin and metformin hydrochloride (empagliflozin/metformin hydrochloride) 5 mg/500 mg, 5 mg/1000 mg, 12.5 mg/500 mg, and 12.5 mg/1000 mg combination tablets are bioequivalent to coadministration of corresponding doses of empagliflozin and metformin hydrochloride as individual tablets.
- Administration of 12.5 mg empagliflozin/1000 mg metformin hydrochloride under fed conditions resulted in a 9% decrease in AUC and a 28% decrease in Cmax for empagliflozin, when compared to fasted conditions.
- For metformin, AUC decreased by 12% and Cmax decreased by 26% compared to fasting conditions.
- The observed effect of food on empagliflozin and metformin is not considered to be clinically relevant.
- Empagliflozin:
- Absorption :
- The pharmacokinetics of empagliflozin has been characterized in healthy volunteers and patients with type 2 diabetes and no clinically relevant differences were noted between the two populations.
- After oral administration, peak plasma concentrations of empagliflozin were reached at 1.5 hours post-dose.
- Thereafter, plasma concentrations declined in a biphasic manner with a rapid distribution phase and a relatively slow terminal phase.
- The steady state mean plasma AUC and Cmax were 1870 nmolh/L and 259 nmol/L, respectively, with 10 mg empagliflozin once daily treatment, and 4740 nmolh/L and 687 nmol/L, respectively, with 25 mg empagliflozin once daily treatment.
- Systemic exposure of empagliflozin increased in a dose-proportional manner in the therapeutic dose range.
- The single-dose and steady-state pharmacokinetic parameters of empagliflozin were similar, suggesting linear pharmacokinetics with respect to time.
- Administration of 25 mg empagliflozin after intake of a high-fat and high-calorie meal resulted in slightly lower exposure; AUC decreased by approximately 16% and Cmax decreased by approximately 37%, compared to fasted condition.
- The observed effect of food on empagliflozin pharmacokinetics was not considered clinically relevant and empagliflozin may be administered with or without food.
- Distribution :
- The apparent steady-state volume of distribution was estimated to be 73.8 L based on a population pharmacokinetic analysis.
- Following administration of an oral -empagliflozin solution to healthy subjects, the red blood cell partitioning was approximately 36.8% and plasma protein binding was 86.2%.
- Metabolism :
- No major metabolites of empagliflozin were detected in human plasma and the most abundant metabolites were three glucuronide conjugates (2-O-, 3-O-, and 6-O-glucuronide).
- Systemic exposure of each metabolite was less than 10% of total drug-related material.
- In vitro studies suggested that the primary route of metabolism of empagliflozin in humans is glucuronidation by the uridine 5'-diphospho-glucuronosyltransferases UGT2B7, UGT1A3, UGT1A8, and UGT1A9.
- Elimination :
- The apparent terminal elimination half-life of empagliflozin was estimated to be 12.4 h and apparent oral clearance was 10.6 L/h based on the population pharmacokinetic analysis.
- Following once-daily dosing, up to 22% accumulation, with respect to plasma AUC, was observed at steady-state, which was consistent with empagliflozin half-life.
- Following administration of an oral -empagliflozin solution to healthy subjects, approximately 95.6% of the drug-related radioactivity was eliminated in feces (41.2%) or urine (54.4%).
- The majority of drug-related radioactivity recovered in feces was unchanged parent drug and approximately half of drug-related radioactivity excreted in urine was unchanged parent drug.
- Metformin:
- Absorption:
- The absolute bioavailability of a metformin hydrochloride 500-mg tablet given under fasting conditions is approximately 50% to 60%.
- Studies using single oral doses of metformin hydrochloride tablets 500 mg to 1500 mg, and 850 mg to 2550 mg, indicate that there is a lack of dose proportionality with increasing doses, which is due to decreased absorption rather than an alteration in elimination.
- Food decreases the extent of and slightly delays the absorption of metformin, as shown by approximately a 40% lower Cmax, a 25% lower AUC, and a 35 minute prolongation of time to peak plasma concentration (Tmax) following administration of a single 850 mg tablet of metformin with food, compared to the same tablet strength administered fasting.
- The clinical relevance of these decreases is unknown.
- Distribution:
- The apparent volume of distribution (V/F) of metformin following single oral doses of immediate-release metformin hydrochloride tablets 850 mg averaged 654358 L.
- Metformin is negligibly bound to plasma proteins, in contrast to SUs, which are more than 90% protein bound.
- Metformin partitions into erythrocytes, most likely as a function of time.
- At usual clinical doses and dosing schedules of metformin tablets, steady-state plasma concentrations of metformin are reached within 24 to 48 hours and are generally <1 mcg/mL.
- During controlled clinical trials of metformin, maximum metformin plasma levels did not exceed 5 mcg/mL, even at maximum doses.
- Metabolism:
- Intravenous single-dose studies in normal subjects demonstrate that metformin is excreted unchanged in the urine and does not undergo hepatic metabolism (no metabolites have been identified in humans) nor biliary excretion.
- Elimination:
Renal clearance is approximately 3.5 times greater than creatinine clearance, which indicates that tubular secretion is the major route of metformin elimination.
- Renal clearance is approximately 3.5 times greater than creatinine clearance, which indicates that tubular secretion is the major route of metformin elimination.
- Following oral administration, approximately 90% of the absorbed drug is eliminated via the renal route within the first 24 hours, with a plasma elimination half-life of approximately 6.2 hours.
- In blood, the elimination half-life is approximately 17.6 hours, suggesting that the erythrocyte mass may be a compartment of distribution.
- Specific Populations:
- Renal Impairment:
- SYNJARDY:
- Studies characterizing the pharmacokinetics of empagliflozin and metformin after administration of Empagliflozin and metformin hydrochloride in renally impaired patients have not been performed.
- Empagliflozin:
- In patients with mild (eGFR: 60 to less than 90 mL/min/1.73 m2), moderate (eGFR: 30 to less than 60 mL/min/1.73 m2), and severe (eGFR: less than 30 mL/min/1.73 m2) renal impairment and subjects with kidney failure/end stage renal disease (ESRD) patients, AUC of empagliflozin increased by approximately 18%, 20%, 66%, and 48%, respectively, compared to subjects with normal renal function.
- Peak plasma levels of empagliflozin were similar in subjects with moderate renal impairment and kidney failure/ESRD compared to patients with normal renal function.
- Peak plasma levels of empagliflozin were roughly 20% higher in subjects with mild and severe renal impairment as compared to subjects with normal renal function.
- Population pharmacokinetic analysis showed that the apparent oral clearance of empagliflozin decreased with a decrease in eGFR leading to an increase in drug exposure.
- However, the fraction of empagliflozin that was excreted unchanged in urine, and urinary glucose excretion, declined with decrease in eGFR.
- Metformin hydrochloride:
- In patients with decreased renal function (based on measured eGFR), the plasma and blood half-life of metformin is prolonged and the renal clearance is decreased in proportion to the decrease in eGFR.
- Hepatic Impairment:
- SYNJARDY:
- Studies characterizing the pharmacokinetics of empagliflozin and metformin after administration of Empagliflozin and metformin hydrochloride in hepatically impaired patients have not been performed.
- Empagliflozin:
- In subjects with mild, moderate, and severe hepatic impairment according to the Child-Pugh classification, AUC of empagliflozin increased by approximately 23%, 47%, and 75%, and Cmax increased by approximately 4%, 23%, and 48%, respectively, compared to subjects with normal hepatic function.
- Metformin hydrochloride:
- No pharmacokinetic studies of metformin hydrochloride have been conducted in patients with hepatic impairment.
- Effects of Age, Body Mass Index, Gender, and Race:
- Empagliflozin:
- Based on the population PK analysis, age, body mass index (BMI), gender and race (Asians versus primarily Whites) do not have a clinically meaningful effect on pharmacokinetics of empagliflozin.
- Metformin hydrochloride:
- Metformin pharmacokinetic parameters did not differ significantly between normal subjects and patients with type 2 diabetes mellitus when analyzed according to gender.
- Similarly, in controlled clinical studies in patients with type 2 diabetes mellitus, the antihyperglycemic effect of metformin was comparable in males and females.
- No studies of metformin pharmacokinetic parameters according to race have been performed.
- In controlled clinical studies of metformin in patients with type 2 diabetes mellitus, the antihyperglycemic effect was comparable in Caucasians (n=249), Blacks (n=51), and Hispanics (n=24).
- Geriatric:
- SYNJARDY:
- Studies characterizing the pharmacokinetics of empagliflozin and metformin after administration of Empagliflozin and metformin hydrochloride in geriatric patients have not been performed.
- Empagliflozin:
- Age did not have a clinically meaningful impact on the pharmacokinetics of empagliflozin based on a population pharmacokinetic analysis.
- Metformin hydrochloride:
- Limited data from controlled pharmacokinetic studies of metformin hydrochloride in healthy elderly subjects suggest that total plasma clearance of metformin is decreased, the half-life is prolonged, and Cmax is increased, compared with healthy young subjects.
- From these data, it appears that the change in metformin pharmacokinetics with aging is primarily accounted for by a change in renal function.
- Pediatric:
- Studies characterizing the pharmacokinetics of empagliflozin or metformin after administration of Empagliflozin and metformin hydrochloride in pediatric patients have not been performed.
- Pharmacokinetic drug interaction studies with Empagliflozin and metformin hydrochloride have not been performed; however, such studies have been conducted with the individual components empagliflozin and metformin.
- Empagliflozin :
- In vitro Assessment of Drug Interactions:
- Empagliflozin does not inhibit, inactivate, or induce CYP450 isoforms.
- In vitro data suggest that the primary route of metabolism of empagliflozin in humans is glucuronidation by the uridine 5'-diphospho-glucuronosyltransferases UGT1A3, UGT1A8, UGT1A9, and UGT2B7.
- Empagliflozin does not inhibit UGT1A1, UGT1A3, UGT1A8, UGT1A9, or UGT2B7.
- Therefore, no effect of empagliflozin is anticipated on concomitantly administered drugs that are substrates of the major CYP450 isoforms or UGT1A1, UGT1A3, UGT1A8, UGT1A9, or UGT2B7.
- The effect of UGT induction (e.g., induction by rifampicin or any other UGT enzyme inducer) on empagliflozin exposure has not been evaluated.
- Empagliflozin is a substrate for P-glycoprotein (P-gp) and breast cancer resistance protein (BCRP), but it does not inhibit these efflux transporters at therapeutic doses.
- Based on in vitro studies, empagliflozin is considered unlikely to cause interactions with drugs that are P-gp substrates.
- Empagliflozin is a substrate of the human uptake transporters OAT3, OATP1B1, and OATP1B3, but not OAT1 and OCT2.
- Empagliflozin does not inhibit any of these human uptake transporters at clinically relevant plasma concentrations and, therefore, no effect of empagliflozin is anticipated on concomitantly administered drugs that are substrates of these uptake transporters.
- In vivo Assessment of Drug Interactions:
- No dose adjustment of empagliflozin is recommended when coadministered with commonly prescribed medicinal products based on results of the described pharmacokinetic studies.
- Empagliflozin pharmacokinetics were similar with and without coadministration of metformin hydrochloride,glimepiride, pioglitazone, sitagliptin, linagliptin, warfarin, verapamil, ramipril, and simvastatin in healthy volunteers and with or without coadministration of hydrochlorothiazide and torsemide in patients with type 2 diabetes.
- The observed increases in overall exposure (AUC) of empagliflozin following coadministration with gemfibrozil, rifampicin, or probenecid are not clinically relevant.
- In subjects with normal renal function, coadministration of empagliflozin with probenecid resulted in a 30% decrease in the fraction of empagliflozin excreted in urine without any effect on 24-hour urinary glucose excretion.
- The relevance of this observation to patients with renal impairment is unknown.
- Empagliflozin and metformin hydrochloride:
- No animal studies have been conducted with the combination of empagliflozin and metformin hydrochloride to evaluate carcinogenesis, mutagenesis, or impairment of fertility.
- General toxicity studies in rats up to 13 weeks were performed with the combined components.
- These studies indicated that no additive toxicity is caused by the combination of empagliflozin and metformin.
- Empagliflozin:
- Carcinogenesis :
- Carcinogenesis was evaluated in 2-year studies conducted in CD-1 mice and Wistar rats.
- Empagliflozin did not increase the incidence of tumors in female rats dosed at 100, 300, or 700 mg/kg/day (up to 72 times the exposure from the maximum clinical dose of 25 mg).
- In male rats, hemangiomas of the mesenteric lymph node were increased significantly at 700 mg/kg/day or approximately 42 times the exposure from a 25 mg clinical dose.
- Empagliflozin did not increase the incidence of tumors in female mice dosed at 100, 300, or 1000 mg/kg/day (up to 62 times the exposure from a 25 mg clinical dose).
- Renal tubule adenomas and carcinomas were observed in male mice at 1000 mg/kg/day, which is approximately 45 times the exposure of the maximum clinical dose of 25 mg.
- These tumors may be associated with a metabolic pathway predominantly present in the male mouse kidney.
- Mutagenesis:
- Empagliflozin was not mutagenic or clastogenic with or without metabolic activation in the in vitro Ames bacterial mutagenicity assay, the in vitro L5178Y tk+/- mouse lymphoma cell assay, and an in vivo micronucleus assay in rats.
- Impairment of Fertility:
- Empagliflozin had no effects on mating, fertility or early embryonic development in treated male or female rats up to the high dose of 700 mg/kg/day (approximately 155 times the 25 mg clinical dose in males and females, respectively).
- Metformin hydrochloride:
- Carcinogenesis:
- Long-term carcinogenicity studies have been performed in rats (dosing duration of 104 weeks) and mice (dosing duration of 91 weeks) at doses up to and including 900 mg/kg/day and 1500 mg/kg/day, respectively.
- These doses are both approximately 4 times the maximum recommended human daily dose of 2000 mg/kg/day based on body surface area comparisons.
- No evidence of carcinogenicity with metformin was found in either male or female mice.
- Similarly, there was no tumorigenic potential observed with metformin in male rats.
- There was, however, an increased incidence of benign stromal uterine polyps in female rats treated with 900 mg/kg/day.
- Mutagenesis:
- There was no evidence of a mutagenic potential of metformin in the following in vitro tests: Ames test (Salmonella typhimurium), gene mutation test (mouse lymphoma cells), or chromosomal aberrations test (human lymphocytes).
- Results in the in vivo mouse micronucleus test were also negative.
- Impairment of Fertility:
- Fertility of male or female rats was unaffected by metformin when administered at doses as high as 600 mg/kg/day, which is approximately 2 times the MRHD based on body surface area comparisons.
- In patients with type 2 diabetes, treatment with empagliflozin and metformin produced clinically and statistically significant improvements in HbA1c compared to placebo.
- Reductions in HbA1c were observed across subgroups including age, gender, race, and baseline body mass index (BMI).
- Empagliflozin Add-On Combination Therapy with Metformin :
- A total of 637 patients with type 2 diabetes participated in a double-blind, placebo-controlled study to evaluate the efficacy and safety of empagliflozin in combination with metformin.
- Patients with type 2 diabetes inadequately controlled on at least 1500 mg of metformin hydrochloride per day entered an open-label 2-week placebo run-in.
- At the end of the run-in period, patients who remained inadequately controlled and had an HbA1c between 7 and 10% were randomized to placebo, empagliflozin 10 mg, or empagliflozin 25 mg.
- At Week 24, treatment with empagliflozin 10 mg or 25 mg daily provided statistically significant reductions in HbA1c (p-value <0.0001), FPG, and body weight compared with placebo (see Table 7).
a Modified intent to treat population. Last observation on study (LOCF) was used to impute missing data at Week 24. At Week 24, 9.7%, 14.1%, and 24.6% was imputed for patients randomized to empagliflozin 10 mg, empagliflozin 25 mg, and placebo, respectively.
b ANCOVA p-value <0.0001 (HbA1c: ANCOVA model includes baseline HbA1c, treatment, renal function, and region. Body weight and FPG: same model used as for HbA1c but additionally including baseline body weight/baseline FPG, respectively.)
c FPG (mg/dL); for empagliflozin 10 mg, n=216, for empagliflozin 25 mg, n=213, and for placebo, n=207.
- At Week 24, the systolic blood pressure was statistically significantly reduced compared to placebo by -4.1 mmHg (placebo-corrected, p-value <0.0001) for empagliflozin 10 mg and -4.8 mmHg (placebo-corrected, p-value <0.0001) for empagliflozin 25 mg.
- Empagliflozin Initial Combination Therapy with Metformin:
- A total of 1364 patients with type 2 diabetes participated in a double-blind, randomized, active-controlled study to evaluate the efficacy and safety of empagliflozin in combination with metformin as initial therapy compared to the corresponding individual components.
- Treatment-naive patients with inadequately controlled type 2 diabetes entered an open-label placebo run-in for 2 weeks.
- At the end of the run-in period, patients who remained inadequately controlled and had an HbA1c between 7 and 10.5% were randomized to one of 8 active-treatment arms: empagliflozin 10 mg or 25 mg; metformin hydrochloride 1000 mg, or 2000 mg; empagliflozin 10 mg in combination with 1000 mg or 2000 mg metformin hydrochloride; or empagliflozin 25 mg in combination with 1000 mg or 2000 mg metformin hydrochloride.
- At Week 24, initial therapy of empagliflozin in combination with metformin provided statistically significant reductions in HbA1c (p-value <0.01) compared to the individual components.
- Empagliflozin Add-On Combination Therapy with Metformin and Sulfonylurea:
- A total of 666 patients with type 2 diabetes participated in a double-blind, placebo-controlled study to evaluate the efficacy and safety of empagliflozin in combination with metformin plus a sulfonylurea.
- Patients with inadequately controlled type 2 diabetes on at least 1500 mg per day of metformin hydrochloride and on a sulfonylurea, entered a 2-week open-label placebo run-in.
- At the end of the run-in, patients who remained inadequately controlled and had an HbA1c between 7% and 10% were randomized to placebo, empagliflozin 10 mg, or empagliflozin 25 mg.
- Treatment with empagliflozin 10 mg or 25 mg daily provided statistically significant reductions in HbA1c (p-value <0.0001), FPG, and body weight compared with placebo.
- Active-Controlled Study vs Glimepiride in Combination with Metformin
- The efficacy of empagliflozin was evaluated in a double-blind, glimepiride-controlled, study in 1545 patients with type 2 diabetes with insufficient glycemic control despite metformin therapy.
- Patients with inadequate glycemic control and an HbA1c between 7% and 10% after a 2-week run-in period were randomized to glimepiride or empagliflozin 25 mg.
- At Week 52, empagliflozin 25 mg and glimepiride lowered HbA1c and FPG.
- The difference in observed effect size between empagliflozin 25 mg and glimepiride excluded the pre-specified non-inferiority margin of 0.3%.
- The mean daily dose of glimepiride was 2.7 mg and the maximal approved dose in the United States is 8 mg per day.
- At Week 52, the adjusted mean change from baseline in systolic blood pressure was -3.6 mmHg, compared to 2.2 mmHg for glimepiride.
- The differences between treatment groups for systolic blood pressure was statistically significant (p-value <0.0001).
- At Week 104, the adjusted mean change from baseline in HbA1c was -0.75% for empagliflozin 25 mg and -0.66% for glimepiride.
- The adjusted mean treatment difference was -0.09% with a 97.5% confidence interval of (-0.32%, 0.15%), excluding the pre-specified non-inferiority margin of 0.3%.
- The mean daily dose of glimepiride was 2.7 mg and the maximal approved dose in the United States is 8 mg per day.
- The Week 104 analysis included data with and without concomitant glycemic rescue medication, as well as off-treatment data.
- Missing data for patients not providing any information at the visit were imputed based on the observed off-treatment data.
- In this multiple imputation analysis, 13.9% of the data were imputed for empagliflozin 25 mg and 12.9% for glimepiride.
- At Week 104, empagliflozin 25 mg daily resulted in a statistically significant difference in change from baseline for body weight compared to glimepiride (-3.1 kg for empagliflozin 25 mg vs. +1.3 kg for glimepiride; ANCOVA-LOCF, p-value <0.0001).

# Empagliflozin Cardiovascular Outcome Study in Patients with Type 2 Diabetes Mellitus and Atherosclerotic Cardiovascular Disease
- Empagliflozin is indicated to reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease.
- However, the effectiveness of Empagliflozin and metformin hydrochloride on reducing the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease has not been established.
- The effect of empagliflozin on cardiovascular risk in adult patients with type 2 diabetes and established, stable, atherosclerotic cardiovascular disease is presented below.
- The EMPA-REG OUTCOME study, a multicenter, multi-national, randomized, double-blind parallel group trial compared the risk of experiencing a major adverse cardiovascular event (MACE) between empagliflozin and placebo when these were added to and used concomitantly with standard of care treatments for diabetes and atherosclerotic cardiovascular disease.
- Coadministered antidiabetic medications were to be kept stable for the first 12 weeks of the trial.
- Thereafter, antidiabetic and atherosclerotic therapies could be adjusted, at the discretion of investigators, to ensure participants were treated according to the standard care for these diseases.
- A total of 7020 patients were treated (empagliflozin 10 mg = 2345; empagliflozin 25 mg = 2342; placebo = 2333) and followed for a median of 3.1 years.  Approximately 72% of the study population was Caucasian, 22% was Asian, and 5% was Black.
- The mean age was 63 years and approximately 72% were male.
- All patients in the study had inadequately controlled type 2 diabetes mellitus at baseline (HbA1c greater than or equal to 7%).
- The mean HbA1c at baseline was 8.1% and 57% of participants had had diabetes for more than 10 years.
- Approximately 31%, 22% and 20% reported a past history of neuropathy, retinopathy and nephropathy to investigators respectively and the mean eGFR was 74 mL/min/1.73 m2.
- At baseline, patients were treated with one (~30%) or more (~70%) antidiabetic medications including metformin (74%), insulin (48%), and sulfonylurea (43%).
- All patients had established atherosclerotic cardiovascular disease at baseline including one (82%) or more (18%) of the following; a documented history of coronary artery disease (76%), stroke (23%) or peripheral artery disease (21%).
- At baseline, the mean systolic blood pressure was 136 mmHg, the mean diastolic blood pressure was 76 mmHg, the mean LDL was 86 mg/dL, the mean HDL was 44 mg/dL, and the mean urinary albumin to creatinine ratio (UACR) was 175 mg/g.
- At baseline, approximately 81% of patients were treated with renin-angiotensin system inhibitors, 65% with beta-blockers, 43% with diuretics, 77% with statins, and 86% with antiplatelet agents (mostly aspirin).
- The primary endpoint in EMPA-REG OUTCOME was the time to first occurrence of a Major Adverse Cardiac Event (MACE).
- A major adverse cardiac event was defined as occurrence of either a cardiovascular death or a nonfatal myocardial infarction (MI) or a nonfatal stroke.
- The statistical analysis plan had pre-specified that the 10 and 25 mg doses would be combined.
- A Cox proportional hazards model was used to test for non-inferiority against the pre-specified risk margin of 1.3 for the hazard ratio of MACE and superiority on MACE if non-inferiority was demonstrated.
- Type-1 error was controlled across multiples tests using a hierarchical testing strategy.
- Empagliflozin significantly reduced the time to first occurrence of primary composite endpoint of cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke (HR: 0.86; 95% CI 0.74, 0.99).
- The treatment effect was due to a significant reduction in the risk of cardiovascular death in subjects randomized to empagliflozin (HR: 0.62; 95% CI 0.49, 0.77), with no change in the risk of non-fatal myocardial infarction or non-fatal stroke.
- Results for the 10 mg and 25 mg empagliflozin doses were consistent with results for the combined dose groups.
- The efficacy of empagliflozin on cardiovascular death was generally consistent across major demographic and disease subgroups.
- Vital status was obtained for 99.2% of subjects in the trial.
- A total of 463 deaths were recorded during the EMPA-REG OUTCOME trial.
- Most of these deaths were categorized as cardiovascular deaths.
- The non-cardiovascular deaths were only a small proportion of deaths, and were balanced between the treatment groups (2.1% in patients treated with empagliflozin, and 2.4% of patients treated with placebo).
- Store in a safe place out of reach of children.
- Instruct patients to read the Medication Guide before starting Empagliflozin and metformin hydrochloride therapy and to reread it each time the prescription is renewed.
- Instruct patients to inform their doctor or pharmacist if they develop any unusual symptom, or if any known symptom persists or worsens.
- Inform patients of the potential risks and benefits of Empagliflozin and metformin hydrochloride and of alternative modes of therapy.
- Also inform patients about the importance of adherence to dietary instructions, regular physical activity, periodic blood glucose monitoring and HbA1c testing, recognition and management of hypoglycemia and hyperglycemia, and assessment for diabetes complications.
- Advise patients to seek medical advice promptly during periods of stress such as fever, trauma, infection, or surgery, as medication requirements may change.
- Lactic Acidosis:
- Inform patients of the risks of lactic acidosis due to the metformin component, its symptoms, and conditions that predispose to its development.
- Advise patients to discontinue Empagliflozin and metformin hydrochloride immediately and to notify their doctor promptly if unexplained hyperventilation, malaise, myalgia, unusual somnolence, slow or irregular heart beat, sensation of feeling cold (especially in the extremities), or other nonspecific symptoms occur.
- GI symptoms are common during initiation of metformin treatment and may occur during initiation of Empagliflozin and metformin hydrochloride therapy; however, advise patients to consult their doctor if they develop unexplained symptoms.
- Although GI symptoms that occur after stabilization are unlikely to be drug related, such an occurrence of symptoms should be evaluated to determine if it may be due to metformin-induced lactic acidosis or other serious disease.
- Hypotension:
- Inform patients that hypotension may occur with Empagliflozin and metformin hydrochloride 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.
- Ketoacidosis:
- Inform patients that ketoacidosis is a serious life-threatening condition.
- Cases of ketoacidosis have been reported during use of empagliflozin.
- 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 Empagliflozin and metformin hydrochloride and seek medical advice immediately.
- Acute Kidney Injury:
- Inform patients that acute kidney injury has been reported during use of empagliflozin.
- Advise patients to seek medical advice immediately if they have reduced oral intake (such as due to acute illness or fasting) or increased fluid losses (such as due to vomiting, diarrhea, or excessive heat exposure), as it may be appropriate to temporarily discontinue Empagliflozin and metformin hydrochloride use in those settings.
- Serious Urinary Tract Infections:
- Inform patients of the potential for urinary tract infections, which may be serious.
- Provide them with information on the symptoms of urinary tract infections.
- Advise them to seek medical advice if such symptoms occur.
- Genital Mycotic Infections in Females (e.g., Vulvovaginitis):
- 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.
- Genital Mycotic Infections in Males (e.g., Balanitis or Balanoposthitis):
- Inform male patients that yeast infection of penis (e.g., balanitis or balanoposthitis) may occur, especially in uncircumcised males and patients with chronic and recurrent infections.
- 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.
- Monitoring of Renal Function:
- Inform patients about the importance of regular testing of renal function when receiving treatment with Empagliflozin and metformin hydrochloride.
- Instruct patients to inform their doctor that they are taking Empagliflozin and metformin hydrochloride prior to any surgical or radiological procedure, as temporary discontinuation of Empagliflozin and metformin hydrochloride may be required until renal function has been confirmed to be normal.
- Hypoglycemia:
- Inform patients that the risk of hypoglycemia is increased when Empagliflozin and metformin hydrochloride is used in combination with an insulin secretagogue (e.g., sulfonylurea), and that a lower dose of the insulin secretagogue may be required to reduce the risk of hypoglycemia.
- Laboratory Tests:
- Inform patients that elevated glucose in urinalysis is expected when taking Empagliflozin and metformin hydrochloride.
- Pregnancy:
- Advise pregnant women, and females of reproductive potential of the potential risk to a fetus with treatment with Empagliflozin and metformin hydrochloride.
- Instruct females of reproductive potential to report pregnancies to their physicians as soon as possible.
- Lactation:
- Advise women that breastfeeding is not recommended during treatment with Empagliflozin and metformin hydrochloride.
- Females and Males of Reproductive Potential:
- Inform females that treatment with metformin may result in ovulation in some premenopausal anovulatory women which may lead to unintended pregnancy.
- Missed Dose:
- Instruct patients to take Empagliflozin and metformin hydrochloride only as prescribed.
- If a dose is missed, it should be taken as soon as the patient remembers.
- Advise patients not to double their next dose.
- Blood Glucose and A1C Monitoring:
- Inform patients that response to all diabetic therapies should be monitored by periodic measurements of blood glucose and HbA1c levels, with a goal of decreasing these levels toward the normal range.
- Hemoglobin A1c monitoring is especially useful for evaluating long-term glycemic control.
- Inform patients that the most common adverse reactions associated with the use of Empagliflozin and metformin hydrochloride are hypoglycemia, urinary tract infection, and nasopharyngitis.