PROGLINMET Vildagliptin / Metformin Hydrochloride 50mg / 850mg Film-Coated Tablet 30's
RXDRUG-DRP-4795-01
Discreet Packaging
FDA-registered Products
FDA-licensed Pharmacies
Indications/Uses
For patients with type 2 diabetes mellitus (T2DM): as an adjunct to diet and exercise to improve glycemic control in patients whose diabetes is not adequately controlled on metformin hydrochloride or vildagliptin alone or who are already treated with the combination of vildagliptin and metformin hydrochloride, as separate tablets; in combination with a sulfonylurea (SU) (i.e., triple combination therapy) as an adjunct to diet and exercise in patients inadequately controlled with metformin and a sulfonylurea; add-on to insulin as an adjunct to diet and exercise to improve glycemic control in patients when stable dose of insulin and metformin alone do not provide adequate glycemic control; initial therapy in patients with T2DM whose diabetes is not adequately controlled by diet and exercise alone.
Dosage/Direction for Use
The use of antihyperglycemic therapy in the management of type 2 diabetes should be individualized on the basis of effectiveness and tolerability. Do not exceed the maximum daily dose of vildagliptin (100 mg).
The recommended starting dose should be based on the patient's condition and/or current regimen of vildagliptin and/or metformin hydrochloride. Administer with meals to reduce the gastrointestinal side effects associated with metformin hydrochloride.
Starting dose for patients inadequately controlled on vildagliptin monotherapy: Based on the usual starting doses of metformin hydrochloride (500 mg twice daily or 850 mg once daily), initiate treatment at the 50 mg/500 mg tablet strength twice daily and gradually titrate after assessing adequacy of therapeutic response.
Starting dose for patients inadequately controlled on metformin hydrochloride monotherapy: Based on the patient's current dose of metformin hydrochloride, treatment may be initiated at either the 50 mg/500 mg, 50 mg/850 mg or 50 mg/1,000 mg tablet strength twice daily.
Starting dose for patients switching from combination therapy of vildagliptin plus metformin hydrochloride as separate tablets: Treatment may be initiated with either the 50 mg/500 mg, 50 mg/850 mg or 50 mg/1,000 mg tablet strength based on the dose of vildagliptin or metformin already being taken.
Starting dose for treatment of naive patients: In naive patients, treatment may be initiated at 50 mg/500 mg once daily and gradually titrated to a maximum dose of 50 mg/1,000 mg twice daily after assessing adequacy of therapeutic response.
Use in combination with SU or with insulin: The dose should provide vildagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken.
General target population: Adults 18 years of age and above.
Special Populations: Renal impairment: Do not use in patients with renal impairment, e.g., serum creatinine levels ≥1.5 mg/dL (>135 micromol/L) in males and ≥1.4 mg/dL (>110 micromol/L) in females (see Contraindications and Precautions).
Dosage adjustment may be required in renally impaired patients with creatinine clearance (this can be estimated from serum creatinine levels by using the Cockcroft-Gault formula) between 60 and 90 mL/min. Use is contraindicated in patients with creatinine clearance <60 mL/min (see Pharmacology under Actions, Contraindications, and Precautions).
Hepatic impairment: Use is not recommended in patients with clinical or laboratory evidence of hepatic impairment including patients with a pre-treatment ALT or AST >2.5X the upper limit of normal (see Precautions).
Pediatric patients: Safety and effectiveness in pediatric patients have not been established. Therefore, use is not recommended in children below 18 years of age.
Geriatric patients: As metformin is excreted via the kidneys, and elderly patients tend to exhibit decreased renal function, elderly patients should have their renal function monitored regularly. The dosage for elderly patients should be adjusted based on renal function (see Contraindications and Precautions).
Method of Administration: Oral use.
Administer with meals to reduce the gastrointestinal side effects associated with metformin hydrochloride.
If a dose is missed, it should be taken as soon as the patient remembers. A double dose should not be taken on the same day.
The recommended starting dose should be based on the patient's condition and/or current regimen of vildagliptin and/or metformin hydrochloride. Administer with meals to reduce the gastrointestinal side effects associated with metformin hydrochloride.
Starting dose for patients inadequately controlled on vildagliptin monotherapy: Based on the usual starting doses of metformin hydrochloride (500 mg twice daily or 850 mg once daily), initiate treatment at the 50 mg/500 mg tablet strength twice daily and gradually titrate after assessing adequacy of therapeutic response.
Starting dose for patients inadequately controlled on metformin hydrochloride monotherapy: Based on the patient's current dose of metformin hydrochloride, treatment may be initiated at either the 50 mg/500 mg, 50 mg/850 mg or 50 mg/1,000 mg tablet strength twice daily.
Starting dose for patients switching from combination therapy of vildagliptin plus metformin hydrochloride as separate tablets: Treatment may be initiated with either the 50 mg/500 mg, 50 mg/850 mg or 50 mg/1,000 mg tablet strength based on the dose of vildagliptin or metformin already being taken.
Starting dose for treatment of naive patients: In naive patients, treatment may be initiated at 50 mg/500 mg once daily and gradually titrated to a maximum dose of 50 mg/1,000 mg twice daily after assessing adequacy of therapeutic response.
Use in combination with SU or with insulin: The dose should provide vildagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken.
General target population: Adults 18 years of age and above.
Special Populations: Renal impairment: Do not use in patients with renal impairment, e.g., serum creatinine levels ≥1.5 mg/dL (>135 micromol/L) in males and ≥1.4 mg/dL (>110 micromol/L) in females (see Contraindications and Precautions).
Dosage adjustment may be required in renally impaired patients with creatinine clearance (this can be estimated from serum creatinine levels by using the Cockcroft-Gault formula) between 60 and 90 mL/min. Use is contraindicated in patients with creatinine clearance <60 mL/min (see Pharmacology under Actions, Contraindications, and Precautions).
Hepatic impairment: Use is not recommended in patients with clinical or laboratory evidence of hepatic impairment including patients with a pre-treatment ALT or AST >2.5X the upper limit of normal (see Precautions).
Pediatric patients: Safety and effectiveness in pediatric patients have not been established. Therefore, use is not recommended in children below 18 years of age.
Geriatric patients: As metformin is excreted via the kidneys, and elderly patients tend to exhibit decreased renal function, elderly patients should have their renal function monitored regularly. The dosage for elderly patients should be adjusted based on renal function (see Contraindications and Precautions).
Method of Administration: Oral use.
Administer with meals to reduce the gastrointestinal side effects associated with metformin hydrochloride.
If a dose is missed, it should be taken as soon as the patient remembers. A double dose should not be taken on the same day.
Overdosage
Signs and symptoms: Vildagliptin: In healthy subjects (seven to fourteen subjects per treatment group), vildagliptin was administered in once-daily doses of 25, 50, 100, 200, 400, and 600 mg for up to 10 consecutive days. Doses up to 200 mg were well tolerated. At 400 mg, there were three cases of muscle pain, and individual cases of mild and transient paresthesia, fever, edema and transient increase in lipase levels (2x ULN). At 600 mg, one subject experienced edema of the feet and hands, and an excessive increase in creatine phosphokinase (CPK) levels, accompanied by elevations of aspartate aminotransferase (AST), C-reactive protein, and myoglobin. Three additional subjects in this dose group presented with edema of both feet, accompanied by paresthesia in two cases. All symptoms and laboratory abnormalities resolved after study drug discontinuation. Vildagliptin is not dialyzable, however the major hydrolysis metabolite (LAY151) can be removed by hemodialysis.
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 hydrochloride has been established. Lactic acidosis has been reported in approximately 32% of metformin hydrochloride overdose cases. Metformin hydrochloride is dialyzable with a clearance of up to 170 mL/min under good hemodynamic conditions. Therefore, hemodialysis may be useful for removal of accumulated drug from patients in whom metformin hydrochloride overdosage is suspected.
In the event of overdosage, appropriate supportive treatment should be initiated according to patient's clinical signs and symptoms.
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 hydrochloride has been established. Lactic acidosis has been reported in approximately 32% of metformin hydrochloride overdose cases. Metformin hydrochloride is dialyzable with a clearance of up to 170 mL/min under good hemodynamic conditions. Therefore, hemodialysis may be useful for removal of accumulated drug from patients in whom metformin hydrochloride overdosage is suspected.
In the event of overdosage, appropriate supportive treatment should be initiated according to patient's clinical signs and symptoms.
Administration
Should be taken with food: Take w/ or immediately after meals to reduce GI discomfort.
Contraindications
Hypersensitivity: Known hypersensitivity to vildagliptin or metformin hydrochloride or to any of the excipients (see Excipients/Inactive Ingredients under Description).
Renal impairment: Use is contraindicated in patients with creatinine clearance <60 mL/min (see section Dosage & Administration and Precautions).
Congestive heart failure: Use is contraindicated in patients with congestive heart failure requiring pharmacologic treatment (see Precautions).
Metabolic acidosis: Use is contraindicated in patients with acute or chronic metabolic acidosis, including diabetic ketoacidosis, with or without coma. Diabetic ketoacidosis should be treated with insulin.
Renal impairment: Use is contraindicated in patients with creatinine clearance <60 mL/min (see section Dosage & Administration and Precautions).
Congestive heart failure: Use is contraindicated in patients with congestive heart failure requiring pharmacologic treatment (see Precautions).
Metabolic acidosis: Use is contraindicated in patients with acute or chronic metabolic acidosis, including diabetic ketoacidosis, with or without coma. Diabetic ketoacidosis should be treated with insulin.
Special Precautions
Vildagliptin/Metformin: Vildagliptin + metformin (ProglinMet) is not a substitute for insulin in insulin-requiring patients. It should not be used in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis.
Vildagliptin: Hepatic impairment: Vildagliptin is not recommended in patients with hepatic impairment, including patients with a pretreatment ALT or AST >2.5X the upper limit of normal.
Liver enzyme monitoring: Rare cases of hepatic dysfunction (including hepatitis) have been reported with vildagliptin. In these cases, the patients were generally asymptomatic without clinical sequelae and liver function tests (LFTs) returned to normal after discontinuation of treatment. LFTs should be performed prior to the initiation of treatment. Not recommended in patients with a pretreatment ALT or AST >2.5X the upper limit of normal. LFTs should be monitored at three-month intervals during the first year and periodically thereafter.
Patients who develop increased transaminase levels should be monitored with a second liver function evaluation to confirm the finding and be followed thereafter with frequent liver function tests until the abnormality(ies) return to normal. Should an increase in AST or ALT of 3X upper limit of normal or greater persist, withdrawal of therapy is recommended. Patients who develop jaundice or other signs suggestive of liver dysfunction should discontinue treatment and contact their physician immediately. Following withdrawal of treatment and LFT normalization, treatment should not be reinitiated. Vildagliptin + metformin (ProglinMet) is not recommended in patients with hepatic impairment.
Heart failure: A clinical trial of vildagliptin in patients with New York Heart Association (NYHA) functional class I-III showed that treatment with vildagliptin was not associated with a change in left-ventricular function or worsening of pre-existing congestive heart failure (CHF) versus placebo. Clinical experience in patients with NYHA functional class III treated with vildagliptin is still limited and results are inconclusive (see Pharmacology: Pharmacodynamics: Clinical Studies under Actions). There is no experience of vildagliptin use in clinical trials in patients with NYHA functional class IV and therefore use is not recommended in these patients.
Metformin Hydrochloride: Lactic acidosis: Lactic acidosis is a very rare but serious metabolic complication that can occur due to metformin accumulation. Reported cases of lactic acidosis in patients on metformin have occurred primarily in diabetic patients with significant renal failure. The incidence of lactic acidosis can and should be reduced by also assessing other associated risk factors, such as poorly controlled diabetes, ketosis, prolonged fasting, excessive alcohol intake, hepatic insufficiency and any conditions associated with hypoxia (see also Contraindications and Interactions).
Diagnosis of lactic acidosis: Lactic acidosis is characterized by acidotic dyspnea, abdominal pain and hypothermia followed by coma.
Diagnostic laboratory findings are decreased blood pH, plasma lactate levels above 5 mmol/L and an increased anion gap and lactate/pyruvate ratio. If metabolic acidosis is suspected, treatment with the medicinal product should be discontinued and the patient hospitalized immediately (see Overdosage).
Monitoring of renal function: Metformin hydrochloride is known to be substantially excreted by the kidney, and the risk of metformin hydrochloride accumulation and lactic acidosis increases with the degree of renal function impairment. Since advancing age is associated with reduced renal function, careful dose titration is needed in the elderly to establish the minimum dose for adequate glycemic effect, and renal function should be monitored regularly. Also, special caution should be exercised where renal function may become impaired, for example when initiating antihypertensive or diuretic therapy or when starting treatment with an NSAID. Renal function should be assessed before the initiation of treatment, then at least once a year in patients with normal renal function and at least two to four times a year in patients with creatinine clearance at the lower limit of normal clearance and in elderly patients. Additionally, patients in whom renal dysfunction is anticipated should have their renal function assessed more frequently. (See section Dosage & Administration and Contraindications).
Concomitant medications that may affect renal function or metformin hydrochloride disposition: Concomitant medications that may affect renal function, result in significant hemodynamic change or interfere with the disposition of metformin hydrochloride, such as cationic drugs that are eliminated by renal tubular secretion should be used with caution (see Interactions).
Administration of intravascular iodinated contrast materials: Treatment should be temporarily discontinued in patients undergoing radiologic studies involving intravascular administration of iodinated contrast materials, because use of such products may result in acute alteration of renal function and increase the risk of lactic acidosis. In patients undergoing such studies, vildagliptin + metformin (ProglinMet) should be temporarily discontinued at the time of or prior to the procedure, withheld for 48 hours subsequent to the procedure and reinstituted only after renal function has been re-evaluated and found to be normal.
Hypoxic states: Cardiovascular collapse (shock), acute congestive heart failure, acute myocardial infarction and other conditions characterized by hypoxemia have been associated with lactic acidosis and may also cause pre-renal azotemia. If such events occur, the medication should be promptly discontinued.
Surgical procedures: Use should be temporarily suspended for any surgical procedure (except minor procedures not associated with restricted intake of food and fluids) and should not be restarted until the patient's oral intake has resumed and renal function has been evaluated as normal.
Alcohol intake: Alcohol is known to potentiate the effect of metformin hydrochloride on lactate metabolism. Patients should be warned against excessive alcohol intake while receiving vildagliptin + metformin (ProglinMet).
Impaired hepatic function: Since impaired hepatic function has been associated with some cases of lactic acidosis, a risk associated with metformin hydrochloride, vildagliptin + metformin (ProglinMet) should generally be avoided in patients with clinical or laboratory evidence of hepatic disease.
Vitamin B12 levels: The metformin component of the product has been associated with a decrease in serum vitamin B12 levels without clinical manifestations, in approximately 7% of patients. Such decrease is very rarely associated with anemia and appears to be rapidly reversible with discontinuation of metformin hydrochloride and/or vitamin B12 supplementation. Measurement of hematological parameters on at least an annual basis is advised for patients receiving vildagliptin + metformin (ProglinMet) and any apparent abnormalities should be appropriately investigated and managed. Certain individuals (e.g., 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 measurements at minimally two-to-three-year intervals may be useful.
Change in clinical status of patients with previously controlled type 2 diabetes: A patient with type 2 diabetes previously well-controlled on vildagliptin + metformin (ProglinMet) who develops laboratory abnormalities or clinical illness (especially vague and poorly defined illness) should promptly be evaluated for ketoacidosis and/or lactic acidosis. If acidosis of either form occurs, vildagliptin + metformin (ProglinMet) must be stopped immediately and appropriate measures initiated.
Hypoglycemia: Hypoglycemia does not usually occur in patients receiving vildagliptin + metformin (ProglinMet) alone, but could occur when caloric intake is deficient, when strenuous exercise is not compensated by caloric supplementation, or ethanol use. Elderly, debilitated or malnourished patients and those with adrenal or pituitary insufficiency or alcohol intoxication are susceptible to hypoglycemic effects. Hypoglycemia may be difficult to recognize in the elderly and in people taking beta-adrenergic blocking drugs.
Loss of control of blood glucose: When a patient stabilized on any diabetic regimen is exposed to stress such as fever, trauma, infection, surgery, etc., a temporary loss of glycemic control may occur. At such times, it may be necessary to withhold vildagliptin + metformin (ProglinMet) and temporarily administer insulin. Vildagliptin + metformin (ProglinMet) may be reinstituted after the acute episode is resolved.
Vildagliptin: Hepatic impairment: Vildagliptin is not recommended in patients with hepatic impairment, including patients with a pretreatment ALT or AST >2.5X the upper limit of normal.
Liver enzyme monitoring: Rare cases of hepatic dysfunction (including hepatitis) have been reported with vildagliptin. In these cases, the patients were generally asymptomatic without clinical sequelae and liver function tests (LFTs) returned to normal after discontinuation of treatment. LFTs should be performed prior to the initiation of treatment. Not recommended in patients with a pretreatment ALT or AST >2.5X the upper limit of normal. LFTs should be monitored at three-month intervals during the first year and periodically thereafter.
Patients who develop increased transaminase levels should be monitored with a second liver function evaluation to confirm the finding and be followed thereafter with frequent liver function tests until the abnormality(ies) return to normal. Should an increase in AST or ALT of 3X upper limit of normal or greater persist, withdrawal of therapy is recommended. Patients who develop jaundice or other signs suggestive of liver dysfunction should discontinue treatment and contact their physician immediately. Following withdrawal of treatment and LFT normalization, treatment should not be reinitiated. Vildagliptin + metformin (ProglinMet) is not recommended in patients with hepatic impairment.
Heart failure: A clinical trial of vildagliptin in patients with New York Heart Association (NYHA) functional class I-III showed that treatment with vildagliptin was not associated with a change in left-ventricular function or worsening of pre-existing congestive heart failure (CHF) versus placebo. Clinical experience in patients with NYHA functional class III treated with vildagliptin is still limited and results are inconclusive (see Pharmacology: Pharmacodynamics: Clinical Studies under Actions). There is no experience of vildagliptin use in clinical trials in patients with NYHA functional class IV and therefore use is not recommended in these patients.
Metformin Hydrochloride: Lactic acidosis: Lactic acidosis is a very rare but serious metabolic complication that can occur due to metformin accumulation. Reported cases of lactic acidosis in patients on metformin have occurred primarily in diabetic patients with significant renal failure. The incidence of lactic acidosis can and should be reduced by also assessing other associated risk factors, such as poorly controlled diabetes, ketosis, prolonged fasting, excessive alcohol intake, hepatic insufficiency and any conditions associated with hypoxia (see also Contraindications and Interactions).
Diagnosis of lactic acidosis: Lactic acidosis is characterized by acidotic dyspnea, abdominal pain and hypothermia followed by coma.
Diagnostic laboratory findings are decreased blood pH, plasma lactate levels above 5 mmol/L and an increased anion gap and lactate/pyruvate ratio. If metabolic acidosis is suspected, treatment with the medicinal product should be discontinued and the patient hospitalized immediately (see Overdosage).
Monitoring of renal function: Metformin hydrochloride is known to be substantially excreted by the kidney, and the risk of metformin hydrochloride accumulation and lactic acidosis increases with the degree of renal function impairment. Since advancing age is associated with reduced renal function, careful dose titration is needed in the elderly to establish the minimum dose for adequate glycemic effect, and renal function should be monitored regularly. Also, special caution should be exercised where renal function may become impaired, for example when initiating antihypertensive or diuretic therapy or when starting treatment with an NSAID. Renal function should be assessed before the initiation of treatment, then at least once a year in patients with normal renal function and at least two to four times a year in patients with creatinine clearance at the lower limit of normal clearance and in elderly patients. Additionally, patients in whom renal dysfunction is anticipated should have their renal function assessed more frequently. (See section Dosage & Administration and Contraindications).
Concomitant medications that may affect renal function or metformin hydrochloride disposition: Concomitant medications that may affect renal function, result in significant hemodynamic change or interfere with the disposition of metformin hydrochloride, such as cationic drugs that are eliminated by renal tubular secretion should be used with caution (see Interactions).
Administration of intravascular iodinated contrast materials: Treatment should be temporarily discontinued in patients undergoing radiologic studies involving intravascular administration of iodinated contrast materials, because use of such products may result in acute alteration of renal function and increase the risk of lactic acidosis. In patients undergoing such studies, vildagliptin + metformin (ProglinMet) should be temporarily discontinued at the time of or prior to the procedure, withheld for 48 hours subsequent to the procedure and reinstituted only after renal function has been re-evaluated and found to be normal.
Hypoxic states: Cardiovascular collapse (shock), acute congestive heart failure, acute myocardial infarction and other conditions characterized by hypoxemia have been associated with lactic acidosis and may also cause pre-renal azotemia. If such events occur, the medication should be promptly discontinued.
Surgical procedures: Use should be temporarily suspended for any surgical procedure (except minor procedures not associated with restricted intake of food and fluids) and should not be restarted until the patient's oral intake has resumed and renal function has been evaluated as normal.
Alcohol intake: Alcohol is known to potentiate the effect of metformin hydrochloride on lactate metabolism. Patients should be warned against excessive alcohol intake while receiving vildagliptin + metformin (ProglinMet).
Impaired hepatic function: Since impaired hepatic function has been associated with some cases of lactic acidosis, a risk associated with metformin hydrochloride, vildagliptin + metformin (ProglinMet) should generally be avoided in patients with clinical or laboratory evidence of hepatic disease.
Vitamin B12 levels: The metformin component of the product has been associated with a decrease in serum vitamin B12 levels without clinical manifestations, in approximately 7% of patients. Such decrease is very rarely associated with anemia and appears to be rapidly reversible with discontinuation of metformin hydrochloride and/or vitamin B12 supplementation. Measurement of hematological parameters on at least an annual basis is advised for patients receiving vildagliptin + metformin (ProglinMet) and any apparent abnormalities should be appropriately investigated and managed. Certain individuals (e.g., 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 measurements at minimally two-to-three-year intervals may be useful.
Change in clinical status of patients with previously controlled type 2 diabetes: A patient with type 2 diabetes previously well-controlled on vildagliptin + metformin (ProglinMet) who develops laboratory abnormalities or clinical illness (especially vague and poorly defined illness) should promptly be evaluated for ketoacidosis and/or lactic acidosis. If acidosis of either form occurs, vildagliptin + metformin (ProglinMet) must be stopped immediately and appropriate measures initiated.
Hypoglycemia: Hypoglycemia does not usually occur in patients receiving vildagliptin + metformin (ProglinMet) alone, but could occur when caloric intake is deficient, when strenuous exercise is not compensated by caloric supplementation, or ethanol use. Elderly, debilitated or malnourished patients and those with adrenal or pituitary insufficiency or alcohol intoxication are susceptible to hypoglycemic effects. Hypoglycemia may be difficult to recognize in the elderly and in people taking beta-adrenergic blocking drugs.
Loss of control of blood glucose: When a patient stabilized on any diabetic regimen is exposed to stress such as fever, trauma, infection, surgery, etc., a temporary loss of glycemic control may occur. At such times, it may be necessary to withhold vildagliptin + metformin (ProglinMet) and temporarily administer insulin. Vildagliptin + metformin (ProglinMet) may be reinstituted after the acute episode is resolved.
Use In Pregnancy & Lactation
Pregnancy: Embryo-fetal development (teratology) studies have been conducted in rats and rabbits with the combination of vildagliptin and metformin hydrochloride in a 1:10 ratio and produced no evidence of teratogenicity in either species. There is insufficient experience with vildagliptin + metformin (ProglinMet) in pregnant women. Therefore, it should not be used during pregnancy unless the potential benefit justifies the potential risk to the fetus. Animal studies are not always predictive of human response.
Breast-feeding: No studies have been conducted with the combined components. Metformin is excreted into human breast milk. It is not known whether vildagliptin is excreted in human milk or not. It should not be administered to breast-feeding women.
Fertility: Fertility studies have been performed with vildagliptin in rats at doses producing exposures equivalent to up to 200 times the human dose and have revealed no evidence of impaired fertility or early embryonic development due to vildagliptin. Fertility of male or female rats was unaffected by metformin when administered at doses as high as 600 mg/kg/day, which is approximately three times the maximum recommended human daily dose based on body surface area comparisons. No studies on the effect of human fertility have been conducted for vildagliptin + metformin (ProglinMet).
Breast-feeding: No studies have been conducted with the combined components. Metformin is excreted into human breast milk. It is not known whether vildagliptin is excreted in human milk or not. It should not be administered to breast-feeding women.
Fertility: Fertility studies have been performed with vildagliptin in rats at doses producing exposures equivalent to up to 200 times the human dose and have revealed no evidence of impaired fertility or early embryonic development due to vildagliptin. Fertility of male or female rats was unaffected by metformin when administered at doses as high as 600 mg/kg/day, which is approximately three times the maximum recommended human daily dose based on body surface area comparisons. No studies on the effect of human fertility have been conducted for vildagliptin + metformin (ProglinMet).
Adverse Reactions
Summary of the safety profile: Vildagliptin/Metformin: The data presented here relate to the administration of vildagliptin and metformin as a free or fixed dose combination. Rare cases of angioedema have been reported on vildagliptin at a similar rate to controls. A greater proportion of cases were reported when vildagliptin was administered in combination with an angiotensin converting enzyme inhibitor (ACE-Inhibitor). The majority of events were mild in severity and resolved with ongoing vildagliptin treatment.
Rare cases of hepatic dysfunction (including hepatitis) have been reported with vildagliptin. In these cases, the patients were generally asymptomatic without clinical sequelae and liver function tests (LFTs) returned to normal after discontinuation of treatment. In data from controlled monotherapy and add-on therapy trials up to 24 weeks in duration, the incidence of ALT or AST elevations ≥ 3x ULN (classified as present on at least 2 consecutive measurements or at the final on-treatment visit) was 0.2%, 0.3% and 0.2% for vildagliptin 50 mg daily, vildagliptin 50 mg twice daily and all comparators, respectively. These elevations in transaminases were generally asymptomatic, non-progressive in nature and not associated with cholestasis or jaundice.
In clinical trials with the combination of vildagliptin + metformin, 0.4% of patients withdrew due to adverse reactions in the vildagliptin 50 mg once daily + metformin treatment group, and no withdrawal due to adverse reactions was reported in either the vildagliptin 50 mg twice daily + metformin or the placebo + metformin treatment groups.
In clinical trials, the incidence of hypoglycemia was uncommon in patients receiving vildagliptin 50 mg once daily in combination with metformin (0.9%), patients receiving vildagliptin 50 mg twice daily in combination with metformin (0.5%) and in patients receiving placebo and metformin (0.4%). No severe hypoglycemic events were reported in the vildagliptin arms.
Vildagliptin is weight neutral when administered in combination with metformin.
Gastrointestinal adverse reactions including diarrhea and nausea are known to occur very commonly during the introduction of metformin hydrochloride. In the vildagliptin monotherapy clinical program (n=2,264) where vildagliptin was administered 50 mg once daily, 50 mg twice daily, or 100 mg once daily, the rate of diarrhea was 1.2%, 3.5% and 0.8%, respectively and the rate of nausea was 1.7%, 3.7% and 1.7%, respectively as compared to 2.9% for both in the placebo group (n=347) and 26.2% and 10.3%, respectively, in the metformin hydrochloride group (n=252).
Overall, gastrointestinal symptoms were reported in 13.2% (50 mg once daily or twice daily) of patients treated with the combination of vildagliptin and metformin hydrochloride compared to 18.1% of patients treated with metformin hydrochloride alone.
Tabulated summary of adverse drug reactions from clinical trials: Adverse reactions reported in patients who received vildagliptin in double-blind studies as add-on to metformin and as monotherapy, are listed as follows, for each indication, by MedDRA system organ class, and absolute frequency. Within each system organ class, the adverse drug reactions are ranked by frequency, with the most frequent reactions first. Within each frequency grouping, adverse drug reactions are presented in order of decreasing seriousness. In addition, the corresponding frequency category for each adverse drug reaction is based on the following convention (CIOMS III): very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). (See Table 1.)
Rare cases of hepatic dysfunction (including hepatitis) have been reported with vildagliptin. In these cases, the patients were generally asymptomatic without clinical sequelae and liver function tests (LFTs) returned to normal after discontinuation of treatment. In data from controlled monotherapy and add-on therapy trials up to 24 weeks in duration, the incidence of ALT or AST elevations ≥ 3x ULN (classified as present on at least 2 consecutive measurements or at the final on-treatment visit) was 0.2%, 0.3% and 0.2% for vildagliptin 50 mg daily, vildagliptin 50 mg twice daily and all comparators, respectively. These elevations in transaminases were generally asymptomatic, non-progressive in nature and not associated with cholestasis or jaundice.
In clinical trials with the combination of vildagliptin + metformin, 0.4% of patients withdrew due to adverse reactions in the vildagliptin 50 mg once daily + metformin treatment group, and no withdrawal due to adverse reactions was reported in either the vildagliptin 50 mg twice daily + metformin or the placebo + metformin treatment groups.
In clinical trials, the incidence of hypoglycemia was uncommon in patients receiving vildagliptin 50 mg once daily in combination with metformin (0.9%), patients receiving vildagliptin 50 mg twice daily in combination with metformin (0.5%) and in patients receiving placebo and metformin (0.4%). No severe hypoglycemic events were reported in the vildagliptin arms.
Vildagliptin is weight neutral when administered in combination with metformin.
Gastrointestinal adverse reactions including diarrhea and nausea are known to occur very commonly during the introduction of metformin hydrochloride. In the vildagliptin monotherapy clinical program (n=2,264) where vildagliptin was administered 50 mg once daily, 50 mg twice daily, or 100 mg once daily, the rate of diarrhea was 1.2%, 3.5% and 0.8%, respectively and the rate of nausea was 1.7%, 3.7% and 1.7%, respectively as compared to 2.9% for both in the placebo group (n=347) and 26.2% and 10.3%, respectively, in the metformin hydrochloride group (n=252).
Overall, gastrointestinal symptoms were reported in 13.2% (50 mg once daily or twice daily) of patients treated with the combination of vildagliptin and metformin hydrochloride compared to 18.1% of patients treated with metformin hydrochloride alone.
Tabulated summary of adverse drug reactions from clinical trials: Adverse reactions reported in patients who received vildagliptin in double-blind studies as add-on to metformin and as monotherapy, are listed as follows, for each indication, by MedDRA system organ class, and absolute frequency. Within each system organ class, the adverse drug reactions are ranked by frequency, with the most frequent reactions first. Within each frequency grouping, adverse drug reactions are presented in order of decreasing seriousness. In addition, the corresponding frequency category for each adverse drug reaction is based on the following convention (CIOMS III): very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). (See Table 1.)
Long term clinical trials of up to more than 2 years did not show any additional safety signal or unforeseen risks when vildagliptin was added on to metformin. When vildagliptin was studied as initial combination therapy with metformin, no additional safety signal or unforeseen risk was observed.
Combination with insulin: In controlled clinical trials using vildagliptin 50 mg twice daily in combination with insulin, with or without concomitant metformin, the overall incidence of withdrawals due to adverse reactions was 0.3% in the vildagliptin treatment group and there were no withdrawals in the placebo group.
The incidence of hypoglycemia was similar in both treatment groups (14.0% in the vildagliptin group vs 16.4% in the placebo group). Two patients reported severe hypoglycemic events in the vildagliptin group, and 6 patients - in the placebo group. At the end of the study, effect on mean body weight was neutral (+0.6 kg change from baseline in the vildagliptin group and no weight change in the placebo group). (See Table 2.)
Combination with SU: There were no withdrawals reported due to adverse reactions in the vildagliptin + metformin + glimepiride treatment group versus 0.6% in the placebo + metformin + glimepiride treatment group.
The incidence of hypoglycemia was common in both treatment groups (5.1% for the vildagliptin + metformin + glimepiride vs. 1.9% for the placebo + metformin + glimepiride). One severe hypoglycemic event was reported in the vildagliptin group.
At the end of the study, effect on mean body weight was neutral (+0.6 kg in the vildagliptin group and -0.1 kg in the placebo group). (See Table 3.)
Vildagliptin: Adverse reactions for vildagliptin component from monotherapy double-blind studies are presented in Table 4. (See Table 4.)
None of the adverse reactions reported for them vildagliptin monotherapy were observed at clinically significant higher rates when vildagliptin was administered concomitantly with metformin.
The overall incidence of withdrawals from monotherapy trials due to adverse reactions was no greater for patients treated with vildagliptin at a dose of 50 mg once daily (0.2%) or vildagliptin at a dose of 50 mg twice daily (0.1%) than for placebo (0.6%) or comparators (0.5%).
In monotherapy studies, hypoglycemia was uncommon, reported in 0.5% (2 of 409) of patients treated with vildagliptin 50 mg once daily and 0.3% (4 of 1,373) of patients treated with vildagliptin 50 mg twice daily compared to 0.2% (2 of 1,082) of patients in the groups treated with an active comparator or placebo, with no serious or severe events reported. Vildagliptin is weight neutral when administered as monotherapy. Long-term clinical trials of up to 2 years did not show any additional safety signals or unforeseen risks with vildagliptin monotherapy.
Adverse drug reactions from spontaneous reports and literature cases - Post-marketing Experience (frequency not known): The following adverse drug reactions have been derived from post-marketing experience with vildagliptin + metformin (ProglinMet) via spontaneous case reports and literature cases.
Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency which is therefore categorized as not known.
Hepatitis, reversible upon drug discontinuation (see Precautions); Urticaria, pancreatitis, bullous and exfoliative skin lesions; Arthralgia, sometimes severe.
Metformin Hydrochloride: Known adverse reactions for metformin component are summarized in Table 5. (See Table 5.)
Gastrointestinal undesirable effects occur most frequently during initiation of therapy and resolve spontaneously in most cases.
Drug Interactions
Vildagliptin/Metformin: No clinically relevant pharmacokinetic interaction was observed when vildagliptin (100 mg once daily) was co-administered with metformin hydrochloride (1,000 mg once daily). Drug interactions for each component have been extensively studied. However, the concomitant use of the active substances in patients in clinical studies and in widespread clinical use has not resulted in any unexpected interactions.
The following statements reflect the information available on the individual active substances (vildagliptin and metformin).
Vildagliptin: Vildagliptin has a low potential for drug interactions. Since vildagliptin is not a cytochrome P (CYP) 450 enzyme substrate nor does it inhibit nor induce CYP 450 enzymes, it is not likely to interact with co-medications that are substrates, inhibitors or inducers of these enzymes.
Furthermore, vildagliptin does not affect metabolic clearance of co-medications metabolized by CYP 1A2, CYP 2C8, CYP 2C9, CYP 2C19, CYP 2D6, CYP 2E1, and CYP 3A4/5. Drug-drug interaction studies were conducted with commonly co-prescribed medications for patients with type 2 diabetes or medications with a narrow therapeutic window. As a result of these studies, no clinically relevant interactions with other oral antidiabetics (glibenclamide, pioglitazone, metformin hydrochloride), amlodipine, digoxin, ramipril, simvastatin, valsartan or warfarin were observed after co-administration with vildagliptin.
Metformin Hydrochloride: The following is known for metformin component: Furosemide: Furosemide increased Cmax and blood AUC of metformin with no change in renal clearance of metformin. Metformin decreased Cmax, blood AUC of furosemide, with no change in renal clearance of furosemide.
Nifedipine: Nifedipine increased absorption, Cmax and AUC of metformin, and increased excretion of metformin in urine. Metformin had minimal effects on nifedipine.
Glyburide: Glyburide produced no changes in metformin PK/PD parameters. Decreases in Cmax, blood AUC of glyburide were observed, but were highly variable. Therefore the clinical significance of this finding was unclear.
Cationic drugs: Cationic drugs (e.g., amiloride, digoxin, morphine, procainamide, quinidine, quinine, ranitidine, triamterene, trimethoprim, or vancomycin) that are eliminated by renal tubular secretion theoretically have the potential for interaction with metformin by competing for common renal tubular transport systems. Thus, with cimetidine increases in metformin plasma/blood concentration and AUC were observed to be 60% and 40%, respectively. Metformin had no effect on cimetidine PK. Although such interactions remain theoretical (except for cimetidine), careful monitoring of patients and doses of metformin and such medications are recommended.
Other: 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. Close monitoring of glycemic control and metformin dose adjustments are recommended when such drugs are administered or withdrawn for these patients.
There is an increased risk of lactic acidosis in acute alcohol intoxication (particularly in the case of fasting, malnutrition or hepatic insufficiency) due to the metformin active substance. Avoid consumption of alcohol and medicinal products containing alcohol (see Precautions).
The following statements reflect the information available on the individual active substances (vildagliptin and metformin).
Vildagliptin: Vildagliptin has a low potential for drug interactions. Since vildagliptin is not a cytochrome P (CYP) 450 enzyme substrate nor does it inhibit nor induce CYP 450 enzymes, it is not likely to interact with co-medications that are substrates, inhibitors or inducers of these enzymes.
Furthermore, vildagliptin does not affect metabolic clearance of co-medications metabolized by CYP 1A2, CYP 2C8, CYP 2C9, CYP 2C19, CYP 2D6, CYP 2E1, and CYP 3A4/5. Drug-drug interaction studies were conducted with commonly co-prescribed medications for patients with type 2 diabetes or medications with a narrow therapeutic window. As a result of these studies, no clinically relevant interactions with other oral antidiabetics (glibenclamide, pioglitazone, metformin hydrochloride), amlodipine, digoxin, ramipril, simvastatin, valsartan or warfarin were observed after co-administration with vildagliptin.
Metformin Hydrochloride: The following is known for metformin component: Furosemide: Furosemide increased Cmax and blood AUC of metformin with no change in renal clearance of metformin. Metformin decreased Cmax, blood AUC of furosemide, with no change in renal clearance of furosemide.
Nifedipine: Nifedipine increased absorption, Cmax and AUC of metformin, and increased excretion of metformin in urine. Metformin had minimal effects on nifedipine.
Glyburide: Glyburide produced no changes in metformin PK/PD parameters. Decreases in Cmax, blood AUC of glyburide were observed, but were highly variable. Therefore the clinical significance of this finding was unclear.
Cationic drugs: Cationic drugs (e.g., amiloride, digoxin, morphine, procainamide, quinidine, quinine, ranitidine, triamterene, trimethoprim, or vancomycin) that are eliminated by renal tubular secretion theoretically have the potential for interaction with metformin by competing for common renal tubular transport systems. Thus, with cimetidine increases in metformin plasma/blood concentration and AUC were observed to be 60% and 40%, respectively. Metformin had no effect on cimetidine PK. Although such interactions remain theoretical (except for cimetidine), careful monitoring of patients and doses of metformin and such medications are recommended.
Other: 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. Close monitoring of glycemic control and metformin dose adjustments are recommended when such drugs are administered or withdrawn for these patients.
There is an increased risk of lactic acidosis in acute alcohol intoxication (particularly in the case of fasting, malnutrition or hepatic insufficiency) due to the metformin active substance. Avoid consumption of alcohol and medicinal products containing alcohol (see Precautions).
Caution For Usage
Incompatibilities: Not applicable.
Storage
Store at temperatures not exceeding 30°C. Protect from moisture.
Action
Pharmacology: Pharmacodynamics: Vildagliptin/Metformin: The efficacy and safety of the separate components have been previously established and the co-administration of the separate components have been evaluated for efficacy and safety in clinical studies. These clinical studies established an added benefit of vildagliptin in patients with inadequately controlled type 2 diabetes while on metformin hydrochloride therapy (see Clinical Studies as follows).
Vildagliptin: The administration of vildagliptin results in rapid and complete inhibition of DPP-4 activity. In patients with type 2 diabetes, administration of vildagliptin led to inhibition of DPP-4 enzyme activity for a 24-hour period.
By increasing the endogenous levels of these incretin hormones, vildagliptin enhances the sensitivity of beta cells to glucose, resulting in improved glucose-dependent insulin secretion. Treatment with 50 to 100 mg daily in patients with type 2 diabetes significantly improved markers of beta-cell function. The degree of improvement in beta-cell function is dependent on the initial degree of impairment; in non-diabetic (normal glycemic) individuals, vildagliptin does not stimulate insulin secretion or reduce glucose levels.
By increasing endogenous GLP-1 levels, vildagliptin enhances the sensitivity of alpha cells to glucose, resulting in more glucose-appropriate glucagon secretion. The reduction in inappropriate glucagon during meals in turn attenuates insulin resistance.
The enhanced increase in the insulin/glucagon ratio during hyperglycemia due to increased incretin hormone levels results in a decrease in fasting and postprandial hepatic glucose production, leading to reduced glycemia.
The known effect of increased GLP-1 levels to delay gastric emptying is not observed with vildagliptin treatment. In addition, a reduction in postprandial lipemia that is not associated with vildagliptin’s incretin mediated effect to improve islet function, has been observed.
Metformin Hydrochloride: Metformin hydrochloride improves glucose tolerance in patients with type 2 diabetes, lowering both basal and postprandial plasma glucose. Unlike sulfonylureas, metformin hydrochloride does not produce hypoglycemia in either patients with type 2 diabetes or normal subjects (except in special circumstances), and does not cause hyperinsulinemia. With metformin hydrochloride therapy, insulin secretion remains unchanged while fasting insulin levels and day-long plasma insulin response may actually decrease.
In humans, independently of its action on glycemia, metformin hydrochloride has favorable effects on lipid metabolism. This has been shown at therapeutic doses in controlled, medium-term or long-term clinical studies: metformin hydrochloride reduces total cholesterol, LDLc and triglyceride levels.
Mechanism of Action (MOA): Vildagliptin + metformin (ProglinMet) combines two antihyperglycemic agents with different mechanisms of action to improve glycemic control in patients with type 2 diabetes: vildagliptin, a member of the DPP-4(dipeptidyl-peptidase-4) inhibitor class and metformin hydrochloride, a member of the biguanide class.
Vildagliptin, a member of the islet enhancer class, is a potent and selective dipeptidyl-peptidase-4 (DPP-4) inhibitor that improves glycemic control. Vildagliptin inhibition of DPP-4 results in increased fasting and postprandial endogenous levels of the incretin hormones GLP-1 (glucagon-like peptide 1) and GIP (glucose-dependent insulinotropic polypeptide).
Metformin hydrochloride decreases hepatic glucose production, decreases intestinal absorption of glucose and improves insulin sensitivity by increasing peripheral glucose uptake and utilization. Metformin hydrochloride stimulates intracellular glycogen synthesis by acting on glycogen synthase and increasing the transport capacity of specific types of membrane glucose transporters (GLUT-1 and GLUT-4).
Clinical Studies: Vildagliptin/Metformin: In a double-blind, placebo-controlled trial in patients with type 2 diabetes whose hyperglycemia was inadequately controlled on a maximal dose of metformin hydrochloride alone, the addition of vildagliptin (50 mg once daily or 100 mg in divided doses) for 24 weeks led to statistically significant reductions in HbA1c and increased the proportion of patients achieving at least a 0.7% reduction in HbA1c when compared to patients who were continued on metformin hydrochloride alone. Group mean baseline HbA1c (%) ranged from 8.3% (placebo plus metformin hydrochloride) to 8.4% (in both vildagliptin plus metformin hydrochloride groups). Vildagliptin combined with metformin hydrochloride resulted in additional statistically significant mean reductions in HbA1c compared to placebo (between group differences of -0.7% to -1.1% for vildagliptin 50 mg and 100 mg, respectively). The proportion of patients who achieved a clinically meaningful and robust decrease in HbA1c (defined as a decrease ≥0.7% from baseline) was statistically significantly higher in both vildagliptin plus metformin hydrochloride groups (46% and 60%, respectively) versus the metformin hydrochloride plus placebo group (20%).
Patients on the combination of vildagliptin plus metformin hydrochloride did not experience a meaningful change in body weight compared to baseline. After 24 weeks, there was a decrease from baseline for both systolic and diastolic blood pressure in the vildagliptin treatment groups combined with metformin hydrochloride. Mean changes from baseline were -2.0/-0.8 mmHg, -3.5/-2.2 mmHg, and -0.8/-0.1 mmHg, in patients receiving metformin hydrochloride combined with vildagliptin 50 mg once daily, vildagliptin 50 mg twice daily or placebo, respectively. The incidence of gastrointestinal side effects ranged from 10% to 15% in the vildagliptin plus metformin hydrochloride groups as compared to 18% in the metformin hydrochloride plus placebo group.
The effect of vildagliptin in combination with metformin hydrochloride was evaluated in another double-blind, placebo-controlled clinical trial of 52 weeks total duration (12-week core study plus a 40-week extension) involving 132 patients with type 2 diabetes on stable doses of metformin hydrochloride (1,500 mg to 3,000 mg daily). The addition of vildagliptin (50 mg once daily) to metformin hydrochloride resulted in an additional statistically significant reduction in mean HbA1c (-0.6%) from baseline compared to placebo plus metformin hydrochloride (+0.1%) at the end of the 12-week study interval (mean baseline HbA1c of 7.7% and 7.9%, respectively). Of these patients, 71 continued add-on treatment with vildagliptin or placebo for an additional 40 weeks (placebo-controlled, double-blind extension).
At 52 weeks, mean change from baseline in HbA1c was statistically significantly greater and sustained with vildagliptin (50 mg) plus metformin hydrochloride versus patients continued on metformin hydrochloride alone (between group difference of -1.1%) indicating a durable effect on glycemic control. In contrast, glycemic control in the metformin hydrochloride plus placebo group deteriorated over the course of the study.
In a 24-week trial (LAF2354) vildagliptin (50 mg twice daily) was compared to pioglitazone (30 mg once daily) in patients inadequately controlled with metformin. Mean reductions from baseline HbA1c of 8.4% were -0.9% with vildagliptin added to metformin and -1.0% with pioglitazone added to metformin. The decrease in HbA1c from baseline >9.0% was greater (-1.5%) in both treatment groups. Patients receiving pioglitazone in addition to metformin experienced an increase in weight of 1.9 kg. Patients receiving vildagliptin in addition to metformin experienced an increase in weight of 0.3 kg. In a 28-week extension, HbA1c reductions were similar between treatment groups and the body weight difference further increased.
In a long-term trial of up to more than 2 years (LAF2308), vildagliptin (100 mg/day) was compared to glimepiride (up to 6 mg/day) in patients treated with metformin. After 1 year, mean reductions in HbA1c were -0.4% with vildagliptin added to metformin and -0.5% with glimepiride added to metformin. Body weight change with vildagliptin was -0.2 kg vs +1.6 kg with glimepiride. The incidence of hypoglycemia was significantly lower in the vildagliptin group (1.7%) than in the glimepiride group (16.2%). At study endpoint (2 years), the HbA1c was similar to baseline values in both treatment groups and the body weight changes and hypoglycemia differences were maintained.
In a 52-week trial (LAF237A2338), vildagliptin (50 mg twice daily) was compared to gliclazide (up to 320 mg/day) in patients inadequately controlled with metformin. After 1 year, mean reductions in HbA1c were -0.81% with vildagliptin added to metformin (mean baseline HbA1c 8.4%) and -0.85% with gliclazide added to metformin (mean baseline HbA1c 8.5%); statistical non-inferiority was achieved. Body weight change with vildagliptin was +0.1 kg compared to a weight gain of +1.4 kg with gliclazide. The number of patients experiencing hypoglycemic events was the same in both treatment groups, however the number of patients experiencing two or more hypoglycemic events was higher in the gliclazide plus metformin group (0.8%) than in the vildagliptin plus metformin group (0.2%).In a 24-week trial (LMF237A2302) the efficacy of the fixed dose combination of vildagliptin and metformin (gradually titrated to a dose of 50 mg/500 mg twice daily or 50 mg/1,000 mg twice daily) as initial therapy in drug-naïve patients was evaluated. The mean HbA1c reductions were significantly greater with vildagliptin plus metformin combination therapy compared to either monotherapy. Vildagliptin/metformin 50 mg/1,000 mg twice daily reduced HbA1c by -1.82% and vildagliptin/metformin 50 mg/500 mg twice daily by -1.61% from a mean baseline HbA1c of 8.6%. The decrease in HbA1c observed in patients with a baseline ≥10.0% was greater. Body weight decreased in all groups, with a mean reduction of -1.2 kg for both vildagliptin plus metformin combinations. The incidence of hypoglycemia was similar across treatment groups (0% with vildagliptin plus metformin combinations and 0.7% with each monotherapy).
A 24-week randomized, double-blind, placebo-controlled trial was conducted in 449 patients to evaluate the efficacy and safety of vildagliptin (50 mg twice daily) in combination with a stable dose of basal or premixed insulin (mean daily dose 41 U), with (N=276) or without (N=173) concomitant metformin. Vildagliptin in combination with insulin significantly decreased HbA1c compared with placebo: in the overall population, the placebo-adjusted mean reduction from a mean baseline HbA1c 8.8% was -0.72%. In the subgroups treated with insulin with or without concomitant metformin the placebo-adjusted mean reduction in HbA1c was -0.63% and -0.84%, respectively. The incidence of hypoglycemia in the overall population was 8.4% and 7.2% in the vildagliptin and placebo groups, respectively. Changes in weight were +0.2 kg and -0.7 kg in the vildagliptin and placebo groups, respectively.
A 24-week randomized, double-blind, placebo-controlled study was conducted in 318 patients to evaluate the efficacy and safety of vildagliptin (50 mg twice daily) in combination with metformin (≥1,500 mg daily) and glimepiride (≥4 mg daily). Vildagliptin in combination with metformin and glimepiride significantly decreased HbA1c compared with placebo: the placebo-adjusted mean reduction from a mean baseline HbA1c 8.8% was -0.76%.
Vildagliptin: More than 15,000 patients with type 2 diabetes participated in double-blind, placebo- or active-controlled clinical trials of up to more than 2 years treatment duration. In these studies, vildagliptin was administered to more than 9,000 patients at daily doses of 50 mg once daily, 50 mg twice daily or 100 mg once daily. More than 5,000 male and more than 4,000 female patients received vildagliptin 50 mg once daily or 100 mg daily. More than 1,900 patients receiving vildagliptin 50 mg once daily or 100 mg daily were ≥65 years of age. In these trials, vildagliptin was administered as monotherapy in drug-naive patients with type 2 diabetes or in combination in patients not adequately controlled by other antidiabetic medicinal products. Overall, vildagliptin improved glycemic control when given as monotherapy or when used in combination with metformin hydrochloride, as measured by clinically relevant reductions in HbA1c and fasting plasma glucose from baseline at study endpoint. When given as monotherapy or in combination with metformin hydrochloride in studies of up to 52 weeks duration, these improvements in glucose homeostasis were durable.
A 52-week multi-center, randomized, double-blind trial was conducted in patients with type 2 diabetes and congestive heart failure (NYHA class I-III) to evaluate the effect of vildagliptin 50 mg bid (N=128) compared to placebo (N=126) on left ventricular ejection fraction (LVEF). Vildagliptin was not associated with a change in left-ventricular function or worsening of pre-existing CHF. Adjudicated cardiovascular events were overall balanced. There were slightly more cardiac events in vildagliptin treated patients with NYHA class III heart failure compared to placebo. However, there were imbalances in baseline CV risk favoring placebo and the number of events was low, precluding firm conclusions. Vildagliptin significantly decreased HbA1c compared with placebo (difference of 0.6%) from a mean baseline of 7.8%. The incidence of hypoglycemia in the overall population was 4.7% and 5.6% in the vildagliptin and placebo groups, respectively.
Cardiovascular risk: A meta-analysis of independently and prospectively adjudicated cardiovascular events from 25 phase III clinical studies of up to more than 2 years duration was performed. It involved 8956 patients with type 2 diabetes treated with vildagliptin and showed that vildagliptin treatment was not associated with an increase in cardiovascular risk. The composite endpoint of adjudicated cardio- and cerebrovascular (CCV) events [acute coronary syndrome (ACS), stroke or CCV death], was similar for vildagliptin versus combined active and placebo comparators [Mantel-Haenszel risk ratio 0.84 (95% confidence interval 0.63-1.12)] supporting the cardiovascular safety of vildagliptin. In total, 99 out of 8956 patients reported an event in the vildagliptin group versus 91 out of 6061 patients in the comparator group.
Metformin Hydrochloride: The prospective randomized (UKPDS) study has established the long-term benefit of intensive blood glucose control in type 2 diabetes. Analysis of the results for overweight patients treated with metformin hydrochloride after failure of diet alone showed: a significant reduction of the absolute risk of any diabetes-related complication in the metformin hydrochloride group (29.8 events/1,000 patient-years) versus diet alone (43.3 events/1,000 patient-years), p=0.0023, and versus the combined sulfonylurea and insulin monotherapy groups (40.1 events/1,000 patient-years), p=0.0034; a significant reduction of the absolute risk of diabetes-related mortality: metformin hydrochloride 7.5 events/1,000 patient-years, diet alone 12.7 events/1,000 patient-years, p=0.017; a significant reduction of the absolute risk of overall mortality: metformin hydrochloride 13.5 events/1,000 patient-years versus diet alone 20.6 events/1,000 patient-years (p=0.011), and versus the combined sulfonylurea and insulin monotherapy groups 18.9 events/1,000 patient-years (p=0.021); a significant reduction in the absolute risk of myocardial infarction: metformin hydrochloride 11 events/1,000 patient-years, diet alone 18 events/1,000 patient-years (p=0.01).
Pharmacokinetics: Absorption: Vildagliptin/Metformin: In the bioequivalence studies at three dose strengths (50 mg/500 mg, 50 mg/850 mg and 50 mg/1,000 mg), versus free combination of vildagliptin and metformin hydrochloride tablets at the corresponding doses, the area under the curve (AUC) and maximum concentration (Cmax) of both the vildagliptin component and the metformin hydrochloride components were demonstrated to be bioequivalent to that of free combination tablets.
Food does not affect the extent and rate of absorption of vildagliptin component. The Cmax and AUC of the metformin hydrochloride component were decreased by 26% and 7%, respectively when given with food. The absorption of metformin hydrochloride was also delayed as reflected by the Tmax (2.0 to 4.0 hrs) when given with food. These changes in Cmax and AUC are consistent but lower than those observed when metformin hydrochloride when given alone under fed conditions. The effects of food on the pharmacokinetics of both the combined vildagliptin component and metformin hydrochloride component were similar to the pharmacokinetics of vildagliptin and metformin hydrochloride when given alone with food.
Vildagliptin: Following oral administration in the fasting state, vildagliptin is rapidly absorbed with peak plasma concentrations observed at 1.75 hours. Co-administration with food slightly decreases the rate of absorption of vildagliptin, as characterized by a 19% decrease in peak concentrations, and a delay in the time to peak plasma concentration to 2.5 hours. There is no change in the extent of absorption, and food does not alter the overall exposure (AUC).
Metformin Hydrochloride: The absolute bioavailability of a 500 mg metformin hydrochloride tablet given under fasting conditions is approximately 50 to 60%. Studies using single oral doses of metformin hydrochloride tablets 500 mg to 1,500 mg, and 850 mg to 2,550 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 hydrochloride, as shown by approximately a 40% lower mean peak plasma concentration (Cmax), a 25% lower area under the plasma concentration versus time curve (AUC), and a 35-minute prolongation of time to peak plasma concentration (Tmax) following administration of a single 850 mg tablet of metformin hydrochloride with food, compared to the same tablet strength administered under fasting conditions. The clinical relevance of these decreases is unknown.
Distribution: Vildagliptin: The plasma protein binding of vildagliptin is low (9.3%), and vildagliptin is distributed equally between plasma and red blood cells. The mean volume of distribution of vildagliptin at steady state after intravenous administration (Vss) is 71 L, suggesting extravascular distribution.
Metformin Hydrochloride: The apparent volume of distribution (V/F) of metformin hydrochloride following single oral doses of 850 mg averaged 654 ± 358 L. Metformin hydrochloride is negligibly bound to plasma proteins, in contrast to sulfonylureas, which are more than 90% protein bound. Metformin hydrochloride partitions into erythrocytes, most likely as a function of time. At usual clinical doses and dosing schedules of metformin hydrochloride, steady state plasma concentrations of metformin hydrochloride are reached within 24 to 48 hours and are generally <1 microgram/mL. During controlled clinical trials of metformin hydrochloride, maximum metformin hydrochloride plasma levels did not exceed 5 micrograms/mL, even at maximum doses.
Biotransformation/metabolism: Vildagliptin: Metabolism is the major elimination pathway for vildagliptin in humans, accounting for 69% of the dose. The major metabolite, LAY151, is pharmacologically inactive and is the hydrolysis product of the cyano moiety, accounting for 57% of the dose, followed by the amide hydrolysis product (4% of the dose). DPP-4 contributes partially to the hydrolysis of vildagliptin as shown in an in-vivo study using DPP-4 deficient rats. Vildagliptin is not metabolized by cytochrome P450 enzymes to any quantifiable extent. In-vitro studies demonstrated that vildagliptin does not inhibit or induce cytochrome P450 enzymes.
Metformin Hydrochloride: Metformin is excreted unchanged in the urine. No metabolites have been identified in humans.
Elimination: Vildagliptin: Following oral administration of [14C]-vildagliptin, approximately 85% of the dose is excreted into the urine and 15% of the dose is recovered in the feces. Renal excretion of the unchanged vildagliptin accounts for 23% of the dose after oral administration. After an intravenous administration to healthy subjects, the total plasma and renal clearances of vildagliptin are 41 L/hour and 13 L/hour, respectively. The mean elimination half-life after intravenous administration is approximately 2 hours. The elimination half-life after oral administration is approximately 3 hours and is independent of dose.
Metformin Hydrochloride: Intravenous single-dose studies in normal subjects demonstrate that metformin hydrochloride is excreted unchanged in the urine and does not undergo hepatic metabolism (no metabolites have been identified in humans) nor biliary excretion. Renal clearance is approximately 3.5 times greater than creatinine clearance, which indicates that tubular secretion is the major route of 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.
Linearity: Vildagliptin is rapidly absorbed with an absolute oral bioavailability of 85%. Peak plasma concentrations for vildagliptin and the area under the plasma concentration versus time curve (AUC) increased in an approximately dose-proportional manner over the therapeutic dose range.
Special Populations: Gender: Vildagliptin: No differences in the pharmacokinetics of vildagliptin were observed between male and female subjects with a diverse range of age and body mass index (BMI). DPP-4 inhibition by vildagliptin was unaffected by gender.
Metformin Hydrochloride: Metformin hydrochloride pharmacokinetic parameters did not differ significantly between normal subjects and patients with type 2 diabetes when analyzed according to gender (males=19, females=16). Similarly, in controlled clinical studies in patients with type 2 diabetes, the antihyperglycemic effect of metformin hydrochloride was comparable in males and females.
Obesity: Vildagliptin: BMI does not show any impact on the pharmacokinetic parameters of vildagliptin. DPP-4 inhibition by vildagliptin was unaffected by BMI.
Hepatic impairment: Vildagliptin: The effect of impaired hepatic function on the pharmacokinetics of vildagliptin was studied in subjects with mild, moderate, and severe hepatic impairment based on the Child-Pugh scores (ranging from 6 for mild to 12 for severe) in comparison to subjects with normal hepatic function. The exposure to vildagliptin (100 mg) after a single dose in subjects with mild and moderate hepatic impairment was decreased (20% and 8%, respectively), while the exposure to vildagliptin for subjects with severe impairment was increased by 22%. The maximum change (increase or decrease) in the exposure to vildagliptin is Yulex30%, which is not considered to be clinically relevant. There was no correlation between the severity of hepatic function impairment and changes in exposure to vildagliptin.
The use of vildagliptin is not recommended in patients with hepatic impairment including patients with a pre-treatment ALT or AST >2.5X the upper limit of normal.
Metformin Hydrochloride: No pharmacokinetic studies of metformin hydrochloride have been conducted in subjects with hepatic insufficiency.
Renal impairment: Vildagliptin: Vildagliptin AUC increased on average 1.4, 1.7 and 2-fold in patients with mild, moderate and severe renal impairment, respectively, compared to normal healthy subjects. AUC of the metabolites LAY151 increased 1.6, 3.2 and 7.3-fold and that of BQS867 increased on average about 1.4, 2.7 and 7.3- fold in patients with mild, moderate and severe renal impairment, respectively, compared to healthy volunteers. Limited data from patients with end stage renal disease (ESRD) indicate that vildagliptin exposure is similar to that in patients with severe renal impairment. LAY151 concentrations in ESRD patients were approximately 2-3-fold higher than in patients with severe renal impairment. Vildagliptin was removed by hemodialysis to a limited extent (3% over a 3-4 hour hemodialysis session starting 4 hours post dose).
Metformin Hydrochloride: In patients with decreased renal function (based on measured creatinine clearance), the plasma and blood half-life of metformin hydrochloride is prolonged and the renal clearance is decreased in proportion to the decrease in creatinine clearance.
Geriatric patients: Vildagliptin: In otherwise healthy elderly subjects (≥70 years), the overall exposure to vildagliptin (100 mg once daily) was increased by 32% with an 18% increase in peak plasma concentration compared to younger healthy subjects (18 to 40 years). These changes are not considered to be clinically relevant. DPP-4 inhibition by vildagliptin is not affected by age in the age groups studied.
Metformin Hydrochloride: Limited data from controlled pharmacokinetic studies of metformin hydrochloride in healthy elderly subjects suggest that total plasma clearance of metformin hydrochloride is decreased, the half-life is prolonged, and Cmax is increased, compared to healthy young subjects. From these data, it appears that the change in metformin hydrochloride pharmacokinetics with aging is primarily accounted for by a change in renal function.
Treatment should not be initiated in patients ≥80 years of age unless measurement of creatinine clearance demonstrates that renal function is not reduced.
Pediatric patients: No pharmacokinetic data available.
Ethnic Group: Vildagliptin: There was no evidence that ethnicity affects the pharmacokinetics of vildagliptin.
Metformin Hydrochloride: No studies of metformin hydrochloride pharmacokinetic parameters according to race have been performed. In controlled clinical studies of metformin hydrochloride in patients with type 2 diabetes, the antihyperglycemic effect was comparable in whites (n=249), blacks (n=51) and Hispanics (n=24).
Toxicology: No new toxicities associated with the combination were identified during animal studies of up to 13 weeks. The following data are findings from studies performed with vildagliptin or metformin individually.
Vildagliptin: A two-year carcinogenicity study was conducted in rats at oral doses up to 900 mg/kg (approximately 200 times the human exposure at the maximum recommended dose). No increases in tumor incidence attributable to vildagliptin were observed. A two-year carcinogenicity study was conducted in mice at oral doses up to 1,000 mg/kg (up to 240 times the human exposure at the maximum recommended dose). Mammary tumor incidence was increased in female mice at approximately 150 times the maximum anticipated human exposure to vildagliptin; it was not increased at approximately 60 times the maximum human exposure. The incidence of hemangiosarcoma was increased in male mice treated at 42 to 240 times the maximum human exposure to vildagliptin and in female mice at 150 times the maximum human exposure. No significant increases in hemangiosarcoma incidences were observed at approximately 16 times the maximum human exposure to vildagliptin in males and approximately 60 times the maximum human exposure in females.
Vildagliptin was not mutagenic in a variety of mutagenicity tests including a bacterial reverse mutation Ames assay and a human lymphocyte chromosomal aberration assay. Oral bone marrow micronucleus tests in both rats and mice did not reveal clastogenic or aneugenic potential up to 2,000 mg/kg or approximately 400 times the maximum human exposure. An in-vivo mouse liver comet assay using the same dose was also negative.
In a 13-week toxicology study in cynomolgus monkeys, skin lesions have been recorded at doses ≥5 mg/kg/day. These were consistently located on the extremities (hands, feet, ears and tail). At 5 mg/kg/day (approximately equivalent to human AUC exposure at the 100 mg dose), only blisters were observed. They were reversible despite continued treatment and were not associated with histopathological abnormalities. Flaking skin, peeling skin, scabs and tail sores with correlating histopathological changes were noted at doses ≥20 mg/kg/day (approximately 3 times human AUC exposure at the 100 mg dose). Necrotic lesions of the tail were observed at ≥80 mg/kg/day. It should be noted that vildagliptin exhibits a significantly higher pharmacological potency in monkeys compared with humans. Skin lesions were not reversible in the monkeys treated at 160 mg/kg/day during a 4-week recovery period. Skin lesions have not been observed in other animal species or in humans treated with vildagliptin.
Metformin Hydrochloride: Preclinical data on metformin reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential and toxicity to reproduction.
Long-term carcinogenicity studies with metformin hydrochloride have been performed in rats (dosing duration 104 weeks) and mice (dosing duration of 91 weeks) at doses up to and including 900 mg/kg/day and 1,500 mg/kg/day, respectively. These doses are both approximately four times the maximum recommended human daily dose of 2,000 mg based on body surface area comparisons. No evidence of carcinogenicity with metformin hydrochloride was found in either male or female mice. Similarly, there was no tumorigenic potential observed with metformin hydrochloride in male rats. There was, however, an increased incidence of benign stromal uterine polyps in female rats treated with 900 mg/kg/day. This is a frequent spontaneous reproductive tract lesion in rats and its relevance in terms of toxicological and carcinogenicity study outcomes for humans is uncertain.
There was no evidence of mutagenic potential of metformin hydrochloride in the following in-vitro tests: Ames test (S. typhimurium), and gene mutation test (mouse lymphoma cells) or chromosomal aberrations test (human lymphocytes). Results in the in-vivo mouse micronucleus test were also negative.
Vildagliptin: The administration of vildagliptin results in rapid and complete inhibition of DPP-4 activity. In patients with type 2 diabetes, administration of vildagliptin led to inhibition of DPP-4 enzyme activity for a 24-hour period.
By increasing the endogenous levels of these incretin hormones, vildagliptin enhances the sensitivity of beta cells to glucose, resulting in improved glucose-dependent insulin secretion. Treatment with 50 to 100 mg daily in patients with type 2 diabetes significantly improved markers of beta-cell function. The degree of improvement in beta-cell function is dependent on the initial degree of impairment; in non-diabetic (normal glycemic) individuals, vildagliptin does not stimulate insulin secretion or reduce glucose levels.
By increasing endogenous GLP-1 levels, vildagliptin enhances the sensitivity of alpha cells to glucose, resulting in more glucose-appropriate glucagon secretion. The reduction in inappropriate glucagon during meals in turn attenuates insulin resistance.
The enhanced increase in the insulin/glucagon ratio during hyperglycemia due to increased incretin hormone levels results in a decrease in fasting and postprandial hepatic glucose production, leading to reduced glycemia.
The known effect of increased GLP-1 levels to delay gastric emptying is not observed with vildagliptin treatment. In addition, a reduction in postprandial lipemia that is not associated with vildagliptin’s incretin mediated effect to improve islet function, has been observed.
Metformin Hydrochloride: Metformin hydrochloride improves glucose tolerance in patients with type 2 diabetes, lowering both basal and postprandial plasma glucose. Unlike sulfonylureas, metformin hydrochloride does not produce hypoglycemia in either patients with type 2 diabetes or normal subjects (except in special circumstances), and does not cause hyperinsulinemia. With metformin hydrochloride therapy, insulin secretion remains unchanged while fasting insulin levels and day-long plasma insulin response may actually decrease.
In humans, independently of its action on glycemia, metformin hydrochloride has favorable effects on lipid metabolism. This has been shown at therapeutic doses in controlled, medium-term or long-term clinical studies: metformin hydrochloride reduces total cholesterol, LDLc and triglyceride levels.
Mechanism of Action (MOA): Vildagliptin + metformin (ProglinMet) combines two antihyperglycemic agents with different mechanisms of action to improve glycemic control in patients with type 2 diabetes: vildagliptin, a member of the DPP-4(dipeptidyl-peptidase-4) inhibitor class and metformin hydrochloride, a member of the biguanide class.
Vildagliptin, a member of the islet enhancer class, is a potent and selective dipeptidyl-peptidase-4 (DPP-4) inhibitor that improves glycemic control. Vildagliptin inhibition of DPP-4 results in increased fasting and postprandial endogenous levels of the incretin hormones GLP-1 (glucagon-like peptide 1) and GIP (glucose-dependent insulinotropic polypeptide).
Metformin hydrochloride decreases hepatic glucose production, decreases intestinal absorption of glucose and improves insulin sensitivity by increasing peripheral glucose uptake and utilization. Metformin hydrochloride stimulates intracellular glycogen synthesis by acting on glycogen synthase and increasing the transport capacity of specific types of membrane glucose transporters (GLUT-1 and GLUT-4).
Clinical Studies: Vildagliptin/Metformin: In a double-blind, placebo-controlled trial in patients with type 2 diabetes whose hyperglycemia was inadequately controlled on a maximal dose of metformin hydrochloride alone, the addition of vildagliptin (50 mg once daily or 100 mg in divided doses) for 24 weeks led to statistically significant reductions in HbA1c and increased the proportion of patients achieving at least a 0.7% reduction in HbA1c when compared to patients who were continued on metformin hydrochloride alone. Group mean baseline HbA1c (%) ranged from 8.3% (placebo plus metformin hydrochloride) to 8.4% (in both vildagliptin plus metformin hydrochloride groups). Vildagliptin combined with metformin hydrochloride resulted in additional statistically significant mean reductions in HbA1c compared to placebo (between group differences of -0.7% to -1.1% for vildagliptin 50 mg and 100 mg, respectively). The proportion of patients who achieved a clinically meaningful and robust decrease in HbA1c (defined as a decrease ≥0.7% from baseline) was statistically significantly higher in both vildagliptin plus metformin hydrochloride groups (46% and 60%, respectively) versus the metformin hydrochloride plus placebo group (20%).
Patients on the combination of vildagliptin plus metformin hydrochloride did not experience a meaningful change in body weight compared to baseline. After 24 weeks, there was a decrease from baseline for both systolic and diastolic blood pressure in the vildagliptin treatment groups combined with metformin hydrochloride. Mean changes from baseline were -2.0/-0.8 mmHg, -3.5/-2.2 mmHg, and -0.8/-0.1 mmHg, in patients receiving metformin hydrochloride combined with vildagliptin 50 mg once daily, vildagliptin 50 mg twice daily or placebo, respectively. The incidence of gastrointestinal side effects ranged from 10% to 15% in the vildagliptin plus metformin hydrochloride groups as compared to 18% in the metformin hydrochloride plus placebo group.
The effect of vildagliptin in combination with metformin hydrochloride was evaluated in another double-blind, placebo-controlled clinical trial of 52 weeks total duration (12-week core study plus a 40-week extension) involving 132 patients with type 2 diabetes on stable doses of metformin hydrochloride (1,500 mg to 3,000 mg daily). The addition of vildagliptin (50 mg once daily) to metformin hydrochloride resulted in an additional statistically significant reduction in mean HbA1c (-0.6%) from baseline compared to placebo plus metformin hydrochloride (+0.1%) at the end of the 12-week study interval (mean baseline HbA1c of 7.7% and 7.9%, respectively). Of these patients, 71 continued add-on treatment with vildagliptin or placebo for an additional 40 weeks (placebo-controlled, double-blind extension).
At 52 weeks, mean change from baseline in HbA1c was statistically significantly greater and sustained with vildagliptin (50 mg) plus metformin hydrochloride versus patients continued on metformin hydrochloride alone (between group difference of -1.1%) indicating a durable effect on glycemic control. In contrast, glycemic control in the metformin hydrochloride plus placebo group deteriorated over the course of the study.
In a 24-week trial (LAF2354) vildagliptin (50 mg twice daily) was compared to pioglitazone (30 mg once daily) in patients inadequately controlled with metformin. Mean reductions from baseline HbA1c of 8.4% were -0.9% with vildagliptin added to metformin and -1.0% with pioglitazone added to metformin. The decrease in HbA1c from baseline >9.0% was greater (-1.5%) in both treatment groups. Patients receiving pioglitazone in addition to metformin experienced an increase in weight of 1.9 kg. Patients receiving vildagliptin in addition to metformin experienced an increase in weight of 0.3 kg. In a 28-week extension, HbA1c reductions were similar between treatment groups and the body weight difference further increased.
In a long-term trial of up to more than 2 years (LAF2308), vildagliptin (100 mg/day) was compared to glimepiride (up to 6 mg/day) in patients treated with metformin. After 1 year, mean reductions in HbA1c were -0.4% with vildagliptin added to metformin and -0.5% with glimepiride added to metformin. Body weight change with vildagliptin was -0.2 kg vs +1.6 kg with glimepiride. The incidence of hypoglycemia was significantly lower in the vildagliptin group (1.7%) than in the glimepiride group (16.2%). At study endpoint (2 years), the HbA1c was similar to baseline values in both treatment groups and the body weight changes and hypoglycemia differences were maintained.
In a 52-week trial (LAF237A2338), vildagliptin (50 mg twice daily) was compared to gliclazide (up to 320 mg/day) in patients inadequately controlled with metformin. After 1 year, mean reductions in HbA1c were -0.81% with vildagliptin added to metformin (mean baseline HbA1c 8.4%) and -0.85% with gliclazide added to metformin (mean baseline HbA1c 8.5%); statistical non-inferiority was achieved. Body weight change with vildagliptin was +0.1 kg compared to a weight gain of +1.4 kg with gliclazide. The number of patients experiencing hypoglycemic events was the same in both treatment groups, however the number of patients experiencing two or more hypoglycemic events was higher in the gliclazide plus metformin group (0.8%) than in the vildagliptin plus metformin group (0.2%).In a 24-week trial (LMF237A2302) the efficacy of the fixed dose combination of vildagliptin and metformin (gradually titrated to a dose of 50 mg/500 mg twice daily or 50 mg/1,000 mg twice daily) as initial therapy in drug-naïve patients was evaluated. The mean HbA1c reductions were significantly greater with vildagliptin plus metformin combination therapy compared to either monotherapy. Vildagliptin/metformin 50 mg/1,000 mg twice daily reduced HbA1c by -1.82% and vildagliptin/metformin 50 mg/500 mg twice daily by -1.61% from a mean baseline HbA1c of 8.6%. The decrease in HbA1c observed in patients with a baseline ≥10.0% was greater. Body weight decreased in all groups, with a mean reduction of -1.2 kg for both vildagliptin plus metformin combinations. The incidence of hypoglycemia was similar across treatment groups (0% with vildagliptin plus metformin combinations and 0.7% with each monotherapy).
A 24-week randomized, double-blind, placebo-controlled trial was conducted in 449 patients to evaluate the efficacy and safety of vildagliptin (50 mg twice daily) in combination with a stable dose of basal or premixed insulin (mean daily dose 41 U), with (N=276) or without (N=173) concomitant metformin. Vildagliptin in combination with insulin significantly decreased HbA1c compared with placebo: in the overall population, the placebo-adjusted mean reduction from a mean baseline HbA1c 8.8% was -0.72%. In the subgroups treated with insulin with or without concomitant metformin the placebo-adjusted mean reduction in HbA1c was -0.63% and -0.84%, respectively. The incidence of hypoglycemia in the overall population was 8.4% and 7.2% in the vildagliptin and placebo groups, respectively. Changes in weight were +0.2 kg and -0.7 kg in the vildagliptin and placebo groups, respectively.
A 24-week randomized, double-blind, placebo-controlled study was conducted in 318 patients to evaluate the efficacy and safety of vildagliptin (50 mg twice daily) in combination with metformin (≥1,500 mg daily) and glimepiride (≥4 mg daily). Vildagliptin in combination with metformin and glimepiride significantly decreased HbA1c compared with placebo: the placebo-adjusted mean reduction from a mean baseline HbA1c 8.8% was -0.76%.
Vildagliptin: More than 15,000 patients with type 2 diabetes participated in double-blind, placebo- or active-controlled clinical trials of up to more than 2 years treatment duration. In these studies, vildagliptin was administered to more than 9,000 patients at daily doses of 50 mg once daily, 50 mg twice daily or 100 mg once daily. More than 5,000 male and more than 4,000 female patients received vildagliptin 50 mg once daily or 100 mg daily. More than 1,900 patients receiving vildagliptin 50 mg once daily or 100 mg daily were ≥65 years of age. In these trials, vildagliptin was administered as monotherapy in drug-naive patients with type 2 diabetes or in combination in patients not adequately controlled by other antidiabetic medicinal products. Overall, vildagliptin improved glycemic control when given as monotherapy or when used in combination with metformin hydrochloride, as measured by clinically relevant reductions in HbA1c and fasting plasma glucose from baseline at study endpoint. When given as monotherapy or in combination with metformin hydrochloride in studies of up to 52 weeks duration, these improvements in glucose homeostasis were durable.
A 52-week multi-center, randomized, double-blind trial was conducted in patients with type 2 diabetes and congestive heart failure (NYHA class I-III) to evaluate the effect of vildagliptin 50 mg bid (N=128) compared to placebo (N=126) on left ventricular ejection fraction (LVEF). Vildagliptin was not associated with a change in left-ventricular function or worsening of pre-existing CHF. Adjudicated cardiovascular events were overall balanced. There were slightly more cardiac events in vildagliptin treated patients with NYHA class III heart failure compared to placebo. However, there were imbalances in baseline CV risk favoring placebo and the number of events was low, precluding firm conclusions. Vildagliptin significantly decreased HbA1c compared with placebo (difference of 0.6%) from a mean baseline of 7.8%. The incidence of hypoglycemia in the overall population was 4.7% and 5.6% in the vildagliptin and placebo groups, respectively.
Cardiovascular risk: A meta-analysis of independently and prospectively adjudicated cardiovascular events from 25 phase III clinical studies of up to more than 2 years duration was performed. It involved 8956 patients with type 2 diabetes treated with vildagliptin and showed that vildagliptin treatment was not associated with an increase in cardiovascular risk. The composite endpoint of adjudicated cardio- and cerebrovascular (CCV) events [acute coronary syndrome (ACS), stroke or CCV death], was similar for vildagliptin versus combined active and placebo comparators [Mantel-Haenszel risk ratio 0.84 (95% confidence interval 0.63-1.12)] supporting the cardiovascular safety of vildagliptin. In total, 99 out of 8956 patients reported an event in the vildagliptin group versus 91 out of 6061 patients in the comparator group.
Metformin Hydrochloride: The prospective randomized (UKPDS) study has established the long-term benefit of intensive blood glucose control in type 2 diabetes. Analysis of the results for overweight patients treated with metformin hydrochloride after failure of diet alone showed: a significant reduction of the absolute risk of any diabetes-related complication in the metformin hydrochloride group (29.8 events/1,000 patient-years) versus diet alone (43.3 events/1,000 patient-years), p=0.0023, and versus the combined sulfonylurea and insulin monotherapy groups (40.1 events/1,000 patient-years), p=0.0034; a significant reduction of the absolute risk of diabetes-related mortality: metformin hydrochloride 7.5 events/1,000 patient-years, diet alone 12.7 events/1,000 patient-years, p=0.017; a significant reduction of the absolute risk of overall mortality: metformin hydrochloride 13.5 events/1,000 patient-years versus diet alone 20.6 events/1,000 patient-years (p=0.011), and versus the combined sulfonylurea and insulin monotherapy groups 18.9 events/1,000 patient-years (p=0.021); a significant reduction in the absolute risk of myocardial infarction: metformin hydrochloride 11 events/1,000 patient-years, diet alone 18 events/1,000 patient-years (p=0.01).
Pharmacokinetics: Absorption: Vildagliptin/Metformin: In the bioequivalence studies at three dose strengths (50 mg/500 mg, 50 mg/850 mg and 50 mg/1,000 mg), versus free combination of vildagliptin and metformin hydrochloride tablets at the corresponding doses, the area under the curve (AUC) and maximum concentration (Cmax) of both the vildagliptin component and the metformin hydrochloride components were demonstrated to be bioequivalent to that of free combination tablets.
Food does not affect the extent and rate of absorption of vildagliptin component. The Cmax and AUC of the metformin hydrochloride component were decreased by 26% and 7%, respectively when given with food. The absorption of metformin hydrochloride was also delayed as reflected by the Tmax (2.0 to 4.0 hrs) when given with food. These changes in Cmax and AUC are consistent but lower than those observed when metformin hydrochloride when given alone under fed conditions. The effects of food on the pharmacokinetics of both the combined vildagliptin component and metformin hydrochloride component were similar to the pharmacokinetics of vildagliptin and metformin hydrochloride when given alone with food.
Vildagliptin: Following oral administration in the fasting state, vildagliptin is rapidly absorbed with peak plasma concentrations observed at 1.75 hours. Co-administration with food slightly decreases the rate of absorption of vildagliptin, as characterized by a 19% decrease in peak concentrations, and a delay in the time to peak plasma concentration to 2.5 hours. There is no change in the extent of absorption, and food does not alter the overall exposure (AUC).
Metformin Hydrochloride: The absolute bioavailability of a 500 mg metformin hydrochloride tablet given under fasting conditions is approximately 50 to 60%. Studies using single oral doses of metformin hydrochloride tablets 500 mg to 1,500 mg, and 850 mg to 2,550 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 hydrochloride, as shown by approximately a 40% lower mean peak plasma concentration (Cmax), a 25% lower area under the plasma concentration versus time curve (AUC), and a 35-minute prolongation of time to peak plasma concentration (Tmax) following administration of a single 850 mg tablet of metformin hydrochloride with food, compared to the same tablet strength administered under fasting conditions. The clinical relevance of these decreases is unknown.
Distribution: Vildagliptin: The plasma protein binding of vildagliptin is low (9.3%), and vildagliptin is distributed equally between plasma and red blood cells. The mean volume of distribution of vildagliptin at steady state after intravenous administration (Vss) is 71 L, suggesting extravascular distribution.
Metformin Hydrochloride: The apparent volume of distribution (V/F) of metformin hydrochloride following single oral doses of 850 mg averaged 654 ± 358 L. Metformin hydrochloride is negligibly bound to plasma proteins, in contrast to sulfonylureas, which are more than 90% protein bound. Metformin hydrochloride partitions into erythrocytes, most likely as a function of time. At usual clinical doses and dosing schedules of metformin hydrochloride, steady state plasma concentrations of metformin hydrochloride are reached within 24 to 48 hours and are generally <1 microgram/mL. During controlled clinical trials of metformin hydrochloride, maximum metformin hydrochloride plasma levels did not exceed 5 micrograms/mL, even at maximum doses.
Biotransformation/metabolism: Vildagliptin: Metabolism is the major elimination pathway for vildagliptin in humans, accounting for 69% of the dose. The major metabolite, LAY151, is pharmacologically inactive and is the hydrolysis product of the cyano moiety, accounting for 57% of the dose, followed by the amide hydrolysis product (4% of the dose). DPP-4 contributes partially to the hydrolysis of vildagliptin as shown in an in-vivo study using DPP-4 deficient rats. Vildagliptin is not metabolized by cytochrome P450 enzymes to any quantifiable extent. In-vitro studies demonstrated that vildagliptin does not inhibit or induce cytochrome P450 enzymes.
Metformin Hydrochloride: Metformin is excreted unchanged in the urine. No metabolites have been identified in humans.
Elimination: Vildagliptin: Following oral administration of [14C]-vildagliptin, approximately 85% of the dose is excreted into the urine and 15% of the dose is recovered in the feces. Renal excretion of the unchanged vildagliptin accounts for 23% of the dose after oral administration. After an intravenous administration to healthy subjects, the total plasma and renal clearances of vildagliptin are 41 L/hour and 13 L/hour, respectively. The mean elimination half-life after intravenous administration is approximately 2 hours. The elimination half-life after oral administration is approximately 3 hours and is independent of dose.
Metformin Hydrochloride: Intravenous single-dose studies in normal subjects demonstrate that metformin hydrochloride is excreted unchanged in the urine and does not undergo hepatic metabolism (no metabolites have been identified in humans) nor biliary excretion. Renal clearance is approximately 3.5 times greater than creatinine clearance, which indicates that tubular secretion is the major route of 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.
Linearity: Vildagliptin is rapidly absorbed with an absolute oral bioavailability of 85%. Peak plasma concentrations for vildagliptin and the area under the plasma concentration versus time curve (AUC) increased in an approximately dose-proportional manner over the therapeutic dose range.
Special Populations: Gender: Vildagliptin: No differences in the pharmacokinetics of vildagliptin were observed between male and female subjects with a diverse range of age and body mass index (BMI). DPP-4 inhibition by vildagliptin was unaffected by gender.
Metformin Hydrochloride: Metformin hydrochloride pharmacokinetic parameters did not differ significantly between normal subjects and patients with type 2 diabetes when analyzed according to gender (males=19, females=16). Similarly, in controlled clinical studies in patients with type 2 diabetes, the antihyperglycemic effect of metformin hydrochloride was comparable in males and females.
Obesity: Vildagliptin: BMI does not show any impact on the pharmacokinetic parameters of vildagliptin. DPP-4 inhibition by vildagliptin was unaffected by BMI.
Hepatic impairment: Vildagliptin: The effect of impaired hepatic function on the pharmacokinetics of vildagliptin was studied in subjects with mild, moderate, and severe hepatic impairment based on the Child-Pugh scores (ranging from 6 for mild to 12 for severe) in comparison to subjects with normal hepatic function. The exposure to vildagliptin (100 mg) after a single dose in subjects with mild and moderate hepatic impairment was decreased (20% and 8%, respectively), while the exposure to vildagliptin for subjects with severe impairment was increased by 22%. The maximum change (increase or decrease) in the exposure to vildagliptin is Yulex30%, which is not considered to be clinically relevant. There was no correlation between the severity of hepatic function impairment and changes in exposure to vildagliptin.
The use of vildagliptin is not recommended in patients with hepatic impairment including patients with a pre-treatment ALT or AST >2.5X the upper limit of normal.
Metformin Hydrochloride: No pharmacokinetic studies of metformin hydrochloride have been conducted in subjects with hepatic insufficiency.
Renal impairment: Vildagliptin: Vildagliptin AUC increased on average 1.4, 1.7 and 2-fold in patients with mild, moderate and severe renal impairment, respectively, compared to normal healthy subjects. AUC of the metabolites LAY151 increased 1.6, 3.2 and 7.3-fold and that of BQS867 increased on average about 1.4, 2.7 and 7.3- fold in patients with mild, moderate and severe renal impairment, respectively, compared to healthy volunteers. Limited data from patients with end stage renal disease (ESRD) indicate that vildagliptin exposure is similar to that in patients with severe renal impairment. LAY151 concentrations in ESRD patients were approximately 2-3-fold higher than in patients with severe renal impairment. Vildagliptin was removed by hemodialysis to a limited extent (3% over a 3-4 hour hemodialysis session starting 4 hours post dose).
Metformin Hydrochloride: In patients with decreased renal function (based on measured creatinine clearance), the plasma and blood half-life of metformin hydrochloride is prolonged and the renal clearance is decreased in proportion to the decrease in creatinine clearance.
Geriatric patients: Vildagliptin: In otherwise healthy elderly subjects (≥70 years), the overall exposure to vildagliptin (100 mg once daily) was increased by 32% with an 18% increase in peak plasma concentration compared to younger healthy subjects (18 to 40 years). These changes are not considered to be clinically relevant. DPP-4 inhibition by vildagliptin is not affected by age in the age groups studied.
Metformin Hydrochloride: Limited data from controlled pharmacokinetic studies of metformin hydrochloride in healthy elderly subjects suggest that total plasma clearance of metformin hydrochloride is decreased, the half-life is prolonged, and Cmax is increased, compared to healthy young subjects. From these data, it appears that the change in metformin hydrochloride pharmacokinetics with aging is primarily accounted for by a change in renal function.
Treatment should not be initiated in patients ≥80 years of age unless measurement of creatinine clearance demonstrates that renal function is not reduced.
Pediatric patients: No pharmacokinetic data available.
Ethnic Group: Vildagliptin: There was no evidence that ethnicity affects the pharmacokinetics of vildagliptin.
Metformin Hydrochloride: No studies of metformin hydrochloride pharmacokinetic parameters according to race have been performed. In controlled clinical studies of metformin hydrochloride in patients with type 2 diabetes, the antihyperglycemic effect was comparable in whites (n=249), blacks (n=51) and Hispanics (n=24).
Toxicology: No new toxicities associated with the combination were identified during animal studies of up to 13 weeks. The following data are findings from studies performed with vildagliptin or metformin individually.
Vildagliptin: A two-year carcinogenicity study was conducted in rats at oral doses up to 900 mg/kg (approximately 200 times the human exposure at the maximum recommended dose). No increases in tumor incidence attributable to vildagliptin were observed. A two-year carcinogenicity study was conducted in mice at oral doses up to 1,000 mg/kg (up to 240 times the human exposure at the maximum recommended dose). Mammary tumor incidence was increased in female mice at approximately 150 times the maximum anticipated human exposure to vildagliptin; it was not increased at approximately 60 times the maximum human exposure. The incidence of hemangiosarcoma was increased in male mice treated at 42 to 240 times the maximum human exposure to vildagliptin and in female mice at 150 times the maximum human exposure. No significant increases in hemangiosarcoma incidences were observed at approximately 16 times the maximum human exposure to vildagliptin in males and approximately 60 times the maximum human exposure in females.
Vildagliptin was not mutagenic in a variety of mutagenicity tests including a bacterial reverse mutation Ames assay and a human lymphocyte chromosomal aberration assay. Oral bone marrow micronucleus tests in both rats and mice did not reveal clastogenic or aneugenic potential up to 2,000 mg/kg or approximately 400 times the maximum human exposure. An in-vivo mouse liver comet assay using the same dose was also negative.
In a 13-week toxicology study in cynomolgus monkeys, skin lesions have been recorded at doses ≥5 mg/kg/day. These were consistently located on the extremities (hands, feet, ears and tail). At 5 mg/kg/day (approximately equivalent to human AUC exposure at the 100 mg dose), only blisters were observed. They were reversible despite continued treatment and were not associated with histopathological abnormalities. Flaking skin, peeling skin, scabs and tail sores with correlating histopathological changes were noted at doses ≥20 mg/kg/day (approximately 3 times human AUC exposure at the 100 mg dose). Necrotic lesions of the tail were observed at ≥80 mg/kg/day. It should be noted that vildagliptin exhibits a significantly higher pharmacological potency in monkeys compared with humans. Skin lesions were not reversible in the monkeys treated at 160 mg/kg/day during a 4-week recovery period. Skin lesions have not been observed in other animal species or in humans treated with vildagliptin.
Metformin Hydrochloride: Preclinical data on metformin reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential and toxicity to reproduction.
Long-term carcinogenicity studies with metformin hydrochloride have been performed in rats (dosing duration 104 weeks) and mice (dosing duration of 91 weeks) at doses up to and including 900 mg/kg/day and 1,500 mg/kg/day, respectively. These doses are both approximately four times the maximum recommended human daily dose of 2,000 mg based on body surface area comparisons. No evidence of carcinogenicity with metformin hydrochloride was found in either male or female mice. Similarly, there was no tumorigenic potential observed with metformin hydrochloride in male rats. There was, however, an increased incidence of benign stromal uterine polyps in female rats treated with 900 mg/kg/day. This is a frequent spontaneous reproductive tract lesion in rats and its relevance in terms of toxicological and carcinogenicity study outcomes for humans is uncertain.
There was no evidence of mutagenic potential of metformin hydrochloride in the following in-vitro tests: Ames test (S. typhimurium), and gene mutation test (mouse lymphoma cells) or chromosomal aberrations test (human lymphocytes). Results in the in-vivo mouse micronucleus test were also negative.
MedsGo Class
Antidiabetic Agents
Features
Brand
ProglinMet
Full Details
Dosage Strength
50 mg / 850 mg
Drug Ingredients
- Metformin
- Vildagliptin
Drug Packaging
Film-Coated Tablet 30's
Generic Name
Vildagliptin / Metformin Hydrochloride
Dosage Form
Film-Coated Tablet
Registration Number
DRP-4795-01
Drug Classification
Prescription Drug (RX)
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