Januvia Drug Information
Generic name: SITAGLIPTIN
Uses of Januvia
® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. JANUVIA is a dipeptidyl peptidase-4 (DPP-4) inhibitor indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations of Use: JANUVIA should not be used in patients with type 1 diabetes JANUVIA has not been studied in patients with a history of pancreatitis.
Limitations of Use JANUVIA should not be used in patients with type 1 diabetes. JANUVIA has not been studied in patients with a history of pancreatitis. It is unknown whether patients with a history of pancreatitis are at increased risk for the development of pancreatitis while using JANUVIA.
Dosage & Administration of Januvia
| eGFR greater than or equal to 30 mL/min/1.73 m2 to less than 45 mL/min/1.73 m2 | eGFR less than 30 mL/min/1.73 m2 (including patients with end stage renal disease [ESRD] on dialysis) |
|---|---|
| 50 mg once daily | 25 mg once daily |
Side Effects of Januvia
Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. In controlled clinical studies as both monotherapy and combination therapy with metformin, pioglitazone, or rosiglitazone and metformin, the overall incidence of adverse reactions, hypoglycemia, and discontinuation of therapy due to clinical adverse reactions with JANUVIA were similar to placebo. In combination with glimepiride, with or without metformin, the overall incidence of clinical adverse reactions with JANUVIA was higher than with placebo, in part related to a higher incidence of hypoglycemia (see Table 3); the incidence of discontinuation due to clinical adverse reactions was similar to placebo.
Two placebo-controlled monotherapy studies, one of 18- and one of 24-week duration, included patients treated with JANUVIA 100 mg daily, JANUVIA 200 mg daily, and placebo. Five placebo-controlled add-on combination therapy studies were also conducted: one with metformin; one with pioglitazone; one with metformin and rosiglitazone; one with glimepiride (with or without metformin); and one with insulin (with or without metformin). In these trials, patients with inadequate glycemic control on a stable dose of the background therapy were randomized to add-on therapy with JANUVIA 100 mg daily or placebo. The adverse reactions, excluding hypoglycemia, reported regardless of investigator assessment of causality in ≥5% of patients treated with JANUVIA 100 mg daily and more commonly than in patients treated with placebo, are shown in Table 1 for the clinical trials of at least 18 weeks duration.
Incidences of hypoglycemia are shown in Table 3. Table 1: Placebo-Controlled Clinical Studies of JANUVIA Monotherapy or Add-on Combination Therapy with Pioglitazone, Metformin + Rosiglitazone, or Glimepiride +/- Metformin: Adverse Reactions (Excluding Hypoglycemia) Reported in ≥5% of Patients and More Commonly than in Patients Given Placebo, Regardless of Investigator Assessment of Causality Intent-to-treat population Number of Patients (%) Monotherapy (18 or 24 weeks) JANUVIA 100 mg Placebo N = 443 N = 363 Nasopharyngitis 23 12 Combination with Pioglitazone (24 weeks) JANUVIA 100 mg + Pioglitazone Placebo + Pioglitazone N = 175 N = 178 Upper Respiratory Tract Infection 11 6 Headache 9 7 Combination with Metformin + Rosiglitazone (18 weeks) JANUVIA 100 mg + Metformin + Rosiglitazone Placebo + Metformin + Rosiglitazone N = 181 N = 97 Upper Respiratory Tract Infection 10 5 Nasopharyngitis 11 4 Combination with Glimepiride (+/- Metformin) (24 weeks) JANUVIA 100 mg + Glimepiride (+/- Metformin) Placebo + Glimepiride (+/- Metformin) N = 222 N = 219 Nasopharyngitis 14 10 Headache 13 5 In the 24-week study of patients receiving JANUVIA as add-on combination therapy with metformin, there were no adverse reactions reported regardless of investigator assessment of causality in ≥5% of patients and more commonly than in patients given placebo. In the 24-week study of patients receiving JANUVIA as add-on therapy to insulin (with or without metformin), there were no adverse reactions reported regardless of investigator assessment of causality in ≥5% of patients and more commonly than in patients given placebo, except for hypoglycemia (see Table 3). In the study of JANUVIA as add-on combination therapy with metformin and rosiglitazone (Table 1), through Week 54 the adverse reactions reported regardless of investigator assessment of causality in ≥5% of patients treated with JANUVIA and more commonly than in patients treated with placebo were: upper respiratory tract infection (JANUVIA, 15.5%; placebo, 6.2%), nasopharyngitis (11.0%, 9.3%), peripheral edema (8.3%, 5.2%), and headache (5.5%, 4.1%). In a pooled analysis of the two monotherapy studies, the add-on to metformin study, and the add-on to pioglitazone study, the incidence of selected gastrointestinal adverse reactions in patients treated with JANUVIA was as follows: abdominal pain (JANUVIA 100 mg, 2.3%; placebo, 2.1%), nausea (1.4%, 0.6%), and diarrhea (3.0%, 2.3%). In an additional, 24-week, placebo-controlled factorial study of initial therapy with sitagliptin in combination with metformin, the adverse reactions reported (regardless of investigator assessment of causality) in ≥5% of patients are shown in Table 2. Table 2: Initial Therapy with Combination of Sitagliptin and Metformin: Adverse Reactions Reported (Regardless of Investigator Assessment of Causality) in ≥5% of Patients Receiving Combination Therapy (and Greater than in Patients Receiving Metformin alone, Sitagliptin alone, and Placebo) Intent-to-treat population. Number of Patients (%) Placebo Sitagliptin (JANUVIA) 100 mg QD Metformin HCl 500 or 1000 mg bid Data pooled for the patients given the lower and higher doses of metformin.
Sitagliptin 50 mg bid + Metformin HCl 500 or 1000 mg bid N = 176 N = 179 N = 364 N = 372 Upper Respiratory Infection 9 8 19 23 Headache 5 2 14 22 In a 24-week study of initial therapy with JANUVIA in combination with pioglitazone, there were no adverse reactions reported (regardless of investigator assessment of causality) in ≥5% of patients and more commonly than in patients given pioglitazone alone. No clinically meaningful changes in vital signs or in ECG (including in QTc interval) were observed in patients treated with JANUVIA. In a pooled analysis of 19 double-blind clinical trials that included data from 10,246 patients randomized to receive sitagliptin 100 mg/day (N=5429) or corresponding (active or placebo) control (N=4817), the incidence of acute pancreatitis was 0.1 per 100 patient-years in each group (4 patients with an event in 4708 patient-years for sitagliptin and 4 patients with an event in 3942 patient-years for control). Hypoglycemia In the above studies (N=9), adverse reactions of hypoglycemia were based on all reports of symptomatic hypoglycemia. A concurrent blood glucose measurement was not required although most (74%) reports of hypoglycemia were accompanied by a blood glucose measurement ≤70 mg/dL. When JANUVIA was coadministered with a sulfonylurea or with insulin, the percentage of patients with at least one adverse reaction of hypoglycemia was higher than in the corresponding placebo group (Table 3). Table 3: Incidence and Rate of Hypoglycemia Adverse reactions of hypoglycemia were based on all reports of symptomatic hypoglycemia; a concurrent glucose measurement was not required; intent-to-treat population. in Placebo-Controlled Clinical Studies when JANUVIA was used as Add-On Therapy to Glimepiride (with or without Metformin) or Insulin (with or without Metformin), Regardless of Investigator Assessment of Causality Add-On to Glimepiride (+/- Metformin) (24 weeks) JANUVIA 100 mg + Glimepiride (+/- Metformin) Placebo + Glimepiride (+/- Metformin) N = 222 N = 219 Overall (%) 27 4 Rate (episodes/patient-year) Based on total number of events (i.e., a single patient may have had multiple events). 0.59 0.24 Severe (%) Severe events of hypoglycemia were defined as those events requiring medical assistance or exhibiting depressed level/loss of consciousness or seizure. 0 0 Add-On to Insulin (+/- Metformin) (24 weeks) JANUVIA 100 mg + Insulin (+/- Metformin) Placebo + Insulin (+/- Metformin) N = 322 N = 319 Overall (%) 50 25 Rate (episodes/patient-year) 1.06 0.51 Severe (%) 2 1 In a pooled analysis of the two monotherapy studies, the add-on to metformin study, and the add-on to pioglitazone study, the overall incidence of adverse reactions of hypoglycemia was 1.2% in patients treated with JANUVIA 100 mg and 0.9% in patients treated with placebo.
In the study of JANUVIA as add-on combination therapy with metformin and rosiglitazone, the overall incidence of hypoglycemia was 2.2% in patients given add-on JANUVIA and 0.0% in patients given add-on placebo through Week 18. Through Week 54, the overall incidence of hypoglycemia was 3.9% in patients given add-on JANUVIA and 1.0% in patients given add-on placebo. In the 24-week, placebo-controlled factorial study of initial therapy with JANUVIA in combination with metformin, the incidence of hypoglycemia was 0.6% in patients given placebo, 0.6% in patients given JANUVIA alone, 0.8% in patients given metformin alone, and 1.6% in patients given JANUVIA in combination with metformin. In the study of JANUVIA as initial therapy with pioglitazone, one patient taking JANUVIA experienced a severe episode of hypoglycemia.
There were no severe hypoglycemia episodes reported in other studies except in the study involving coadministration with insulin. In an additional, 30-week placebo-controlled, study of patients with type 2 diabetes inadequately controlled with metformin comparing the maintenance of sitagliptin 100 mg versus withdrawal of sitagliptin when initiating basal insulin therapy, the event rate and incidence of documented symptomatic hypoglycemia (blood glucose measurement ≤70 mg/dL) did not differ between the sitagliptin and placebo groups. Laboratory Tests Across clinical studies, the incidence of laboratory adverse reactions was similar in patients treated with JANUVIA 100 mg compared to patients treated with placebo.
A small increase in white blood cell count (WBC) was observed due to an increase in neutrophils. This increase in WBC (of approximately 200 cells/microL vs placebo, in four pooled placebo-controlled clinical studies, with a mean baseline WBC count of approximately 6600 cells/microL) is not considered to be clinically relevant. In a 12-week study of 91 patients with chronic renal insufficiency, 37 patients with moderate renal insufficiency were randomized to JANUVIA 50 mg daily, while 14 patients with the same magnitude of renal impairment were randomized to placebo.
Mean (SE) increases in serum creatinine were observed in patients treated with JANUVIA and in patients treated with placebo. The clinical significance of this added increase in serum creatinine relative to placebo is not known.
Postmarketing Experience Additional adverse reactions have been identified during postapproval use of
JANUVIA as monotherapy and/or in combination with other antihyperglycemic agents. Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Hypersensitivity reactions including anaphylaxis, angioedema, rash, urticaria, cutaneous vasculitis, and exfoliative skin conditions including Stevens-Johnson syndrome; hepatic enzyme elevations; acute pancreatitis, including fatal and non-fatal hemorrhagic and necrotizing pancreatitis ; worsening renal function, including acute renal failure (sometimes requiring dialysis), and tubulointerstitial nephritis; severe and disabling arthralgia ; bullous pemphigoid ; constipation; vomiting; headache; myalgia; pain in extremity; back pain; pruritus; mouth ulceration; stomatitis; rhabdomyolysis.
Warnings & Cautions for Januvia
Pancreatitis
There have been postmarketing reports of acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis, in patients taking JANUVIA. After initiation of JANUVIA, patients should be observed carefully for signs and symptoms of pancreatitis. If pancreatitis is suspected, JANUVIA should promptly be discontinued and appropriate management should be initiated. It is unknown whether patients with a history of pancreatitis are at increased risk for the development of pancreatitis while using JANUVIA.
Heart Failure
An association between dipeptidyl peptidase-4 (DPP-4) inhibitor treatment and heart failure has been observed in cardiovascular outcomes trials for two other members of the DPP-4 inhibitor class. These trials evaluated patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease. Consider the risks and benefits of JANUVIA prior to initiating treatment in patients at risk for heart failure, such as those with a prior history of heart failure and a history of renal impairment, and observe these patients for signs and symptoms of heart failure during therapy.
Advise patients of the characteristic symptoms of heart failure and to immediately report such symptoms. If heart failure develops, evaluate and manage according to current standards of care and consider discontinuation of JANUVIA.
Acute Renal Failure
There have been postmarketing reports of worsening renal function, including acute renal failure, sometimes requiring dialysis. A subset of these reports involved patients with renal impairment, some of whom were prescribed inappropriate doses of sitagliptin. A return to baseline levels of renal impairment has been observed with supportive treatment and discontinuation of potentially causative agents.
Consideration can be given to cautiously reinitiating JANUVIA if another etiology is deemed likely to have precipitated the acute worsening of renal function. Assessment of renal function is recommended prior to initiating JANUVIA and periodically thereafter. A dosage adjustment is recommended in patients with moderate or severe renal impairment and in patients with ESRD requiring hemodialysis or peritoneal dialysis.
Hypoglycemia with
Concomitant Use with Insulin or Insulin Secretagogues When JANUVIA was used in combination with insulin or insulin secretagogues (e.g., sulfonylurea), medications known to cause hypoglycemia, the incidence of hypoglycemia was increased over that of placebo used in combination with a sulfonylurea or with insulin. Therefore, a lower dose of sulfonylurea or insulin may be required to reduce the risk of hypoglycemia.
Hypersensitivity Reactions
There have been postmarketing reports of serious hypersensitivity reactions in patients treated with JANUVIA. These reactions include anaphylaxis, angioedema, and exfoliative skin conditions including Stevens-Johnson syndrome. Onset of these reactions occurred within the first 3 months after initiation of treatment with JANUVIA, with some reports occurring after the first dose. If a hypersensitivity reaction is suspected, discontinue JANUVIA, assess for other potential causes for the event, and institute alternative treatment for diabetes.
Angioedema has also been reported with other DPP-4 inhibitors. Use caution in a patient with a history of angioedema with another DPP-4 inhibitor because it is unknown whether such patients will be predisposed to angioedema with JANUVIA.
Severe and Disabling Arthralgia
There have been postmarketing reports of severe and disabling arthralgia in patients taking DPP-4 inhibitors. The time to onset of symptoms following initiation of drug therapy varied from one day to years. Patients experienced relief of symptoms upon discontinuation of the medication.
A subset of patients experienced a recurrence of symptoms when restarting the same drug or a different DPP-4 inhibitor. Consider DPP-4 inhibitors as a possible cause for severe joint pain and discontinue drug if appropriate.
Bullous Pemphigoid Postmarketing cases of bullous pemphigoid requiring hospitalization have been reported
with DPP-4 inhibitor use. In reported cases, patients typically recovered with topical or systemic immunosuppressive treatment and discontinuation of the DPP-4 inhibitor. Tell patients to report development of blisters or erosions while receiving JANUVIA. If bullous pemphigoid is suspected, JANUVIA should be discontinued and referral to a dermatologist should be considered for diagnosis and appropriate treatment.
Drug Interactions with Januvia
Insulin Secretagogues or Insulin Coadministration of
JANUVIA with an insulin secretagogue (e.g., sulfonylurea) or insulin may require lower doses of the insulin secretagogue or insulin to reduce the risk of hypoglycemia.
Pregnancy Safety for Januvia
Pregnancy Risk Summary The limited available data with JANUVIA in pregnant women are not sufficient to inform a drug-associated risk for major birth defects and miscarriage. There are risks to the mother and fetus associated with poorly controlled diabetes in pregnancy. No adverse developmental effects were observed when sitagliptin was administered to pregnant rats and rabbits during organogenesis at oral doses up to 30-times and 20-times, respectively, the 100 mg clinical dose, based on AUC . The estimated background risk of major birth defects is 6-10% in women with pre-gestational diabetes with a Hemoglobin A1c >7% and has been reported to be as high as 20-25% in women with a Hemoglobin A1c >10%. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.
Clinical Considerations Disease-Associated Maternal and/or Embryo/Fetal Risk Poorly controlled diabetes in pregnancy increases the maternal risk for diabetic ketoacidosis, pre-eclampsia, spontaneous abortions, preterm delivery, and delivery complications. Poorly controlled diabetes increases the fetal risk for major birth defects, still birth, and macrosomia related morbidity. Data Animal Data In embryo-fetal development studies, sitagliptin administered to pregnant rats and rabbits during organogenesis (gestation day 6 to 20) did not adversely affect developmental outcomes at oral doses up to 250 mg/kg (30-times the 100 mg clinical dose) and 125 mg/kg (20-times the 100 mg clinical dose), respectively, based on AUC. Higher doses in rats associated with maternal toxicity increased the incidence of rib malformations in offspring at 1000 mg/kg, or approximately 100-times the clinical dose, based on AUC. Placental transfer of sitagliptin was observed in pregnant rats and rabbits.
Sitagliptin administered to female rats from gestation day 6 to lactation day 21 caused no functional or behavioral toxicity in offspring of rats at doses up to 1000 mg/kg.
Pediatric Use of Januvia
Pediatric Use The safety and effectiveness of JANUVIA have not been established in pediatric patients. Three 20-week double-blind, placebo-controlled studies each with 34-week extensions were conducted to evaluate the efficacy and safety of sitagliptin in 410 pediatric patients aged 10 to 17 years with inadequately controlled type 2 diabetes, with or without insulin therapy (HbA1c 6.5-10% for patients not on insulin, HbA1c 7-10% for patients on insulin). At study entry, patients in study 1 were not treated with oral antihyperglycemic agents; patients in studies 2 and 3 were on maximally tolerated metformin therapy. The primary efficacy endpoint was the change from baseline in HbA1c after 20 weeks of therapy.
The pre-specified primary efficacy analyses included data from study 1 and pooled data from studies 2 and 3, regardless of glycemic rescue or treatment discontinuation. In both efficacy analyses, the effect of treatment with sitagliptin was not significantly different from placebo. In study 1, the mean baseline HbA1c was 7.5%, and 12% of patients were on insulin therapy.
At week 20, the change from baseline in HbA1c in patients treated with JANUVIA (N=95) was 0.06% compared to 0.23% in patients treated with placebo (N=95), a difference of -0.17% (95% CI: -0.62, 0.28). In studies 2 and 3, the mean baseline HbA1c was 8.0%, 15% of patients were on insulin and 72% were on metformin HCl doses of greater than 1,500 mg daily. At week 20, the change from baseline in HbA1c in patients treated with sitagliptin (N=107) was -0.23% compared to 0.09% in patients treated with placebo (N=113), a difference of -0.33% (95% CI: -0.70, 0.05).
Contraindications for Januvia
History of a serious hypersensitivity reaction to sitagliptin, such as anaphylaxis or angioedema. History of a serious hypersensitivity reaction to sitagliptin, such as anaphylaxis or angioedema
Overdosage Information for Januvia
In the event of an overdose with JANUVIA, contact the Poison Control Center. In the event of an overdose, it is reasonable to employ supportive measures, e.g., remove unabsorbed material from the gastrointestinal tract, employ clinical monitoring (including obtaining an electrocardiogram), and institute supportive therapy as dictated by the patient's clinical status. Sitagliptin is modestly dialyzable.
In clinical studies, approximately 13.5% of the dose was removed over a 3- to 4-hour hemodialysis session. Prolonged hemodialysis may be considered if clinically appropriate. It is not known if sitagliptin is dialyzable by peritoneal dialysis.
Clinical Studies of Januvia
Monotherapy
A total of 1262 patients with type 2 diabetes participated in two double-blind, placebo-controlled studies, one of 18-week and another of 24-week duration, to evaluate the efficacy and safety of JANUVIA monotherapy. In both monotherapy studies, patients currently on an antihyperglycemic agent discontinued the agent, and underwent a diet, exercise, and drug washout period of about 7 weeks. Patients with inadequate glycemic control (A1C 7% to 10%) after the washout period were randomized after completing a 2-week single-blind placebo run-in period; patients not currently on antihyperglycemic agents (off therapy for at least 8 weeks) with inadequate glycemic control (A1C 7% to 10%) were randomized after completing the 2-week single-blind placebo run-in period.
In the 18-week study, 521 patients were randomized to placebo, JANUVIA 100 mg, or JANUVIA 200 mg, and in the 24-week study 741 patients were randomized to placebo, JANUVIA 100 mg, or JANUVIA 200 mg. Patients who failed to meet specific glycemic goals during the studies were treated with metformin rescue, added on to placebo or JANUVIA. Treatment with JANUVIA at 100 mg daily provided significant improvements in A1C, FPG, and 2-hour PPG compared to placebo (Table 6). In the 18-week study, 9% of patients receiving JANUVIA 100 mg and 17% who received placebo required rescue therapy. In the 24-week study, 9% of patients receiving JANUVIA 100 mg and 21% of patients receiving placebo required rescue therapy.
The improvement in A1C compared to placebo was not affected by gender, age, race, prior antihyperglycemic therapy, or baseline BMI. As is typical for trials of agents to treat type 2 diabetes, the mean reduction in A1C with JANUVIA appears to be related to the degree of A1C elevation at baseline. In these 18- and 24-week studies, among patients who were not on an antihyperglycemic agent at study entry, the reductions from baseline in A1C were -0.7% and -0.8%, respectively, for those given JANUVIA, and -0.1% and -0.2%, respectively, for those given placebo. Overall, the 200 mg daily dose did not provide greater glycemic efficacy than the 100 mg daily dose.
The effect of JANUVIA on lipid endpoints was similar to placebo. Body weight did not increase from baseline with JANUVIA therapy in either study, compared to a small reduction in patients given placebo. Table 6: Glycemic Parameters in 18- and 24-Week Placebo-Controlled Studies of JANUVIA in Patients with Type 2 Diabetes Intent-to-treat population using last observation on study prior to metformin rescue therapy. 18-Week Study 24-Week Study JANUVIA 100 mg Placebo JANUVIA 100 mg Placebo A1C (%) N = 193 N = 103 N = 229 N = 244 Baseline (mean) 8.0 8.1 8.0
Change from baseline (adjusted mean Least squares means adjusted for prior antihyperglycemic
therapy status and baseline value. ) -0.5 0.1 -0.6
Difference from placebo (adjusted mean ) (95% CI) -0.6 p<0.001 compared to
placebo. (-0.8, -0.4) -0.8 (-1.0, -0.6) Patients (%) achieving A1C <7% 69 (36%) 16 (16%) 93 (41%) 41 (17%) FPG (mg/dL) N = 201 N = 107 N = 234 N = 247 Baseline (mean) 180 184 170 176 Change from baseline (adjusted mean ) -13 7 -12 5 Difference from placebo (adjusted mean ) (95% CI) -20 (-31, -9) -17 (-24, -10) 2-hour PPG (mg/dL) Data not available. N = 201 N = 204 Baseline (mean) 257 271 Change from baseline (adjusted mean ) -49 -2 Difference from placebo (adjusted mean ) (95% CI) -47 (-59, -34) Additional Monotherapy Study A multinational, randomized, double-blind, placebo-controlled study was also conducted to assess the safety and tolerability of JANUVIA in 91 patients with type 2 diabetes and chronic renal insufficiency (creatinine clearance <50 mL/min). Patients with moderate renal insufficiency received 50 mg daily of JANUVIA and those with severe renal insufficiency or with ESRD on hemodialysis or peritoneal dialysis received 25 mg daily. In this study, the safety and tolerability of JANUVIA were generally similar to placebo.
A small increase in serum creatinine was reported in patients with moderate renal insufficiency treated with JANUVIA relative to those on placebo. In addition, the reductions in A1C and FPG with JANUVIA compared to placebo were generally similar to those observed in other monotherapy studies.
Combination Therapy Add-on Combination Therapy with Metformin
A total of 701 patients with type 2 diabetes participated in a 24-week, randomized, double-blind, placebo-controlled study designed to assess the efficacy of JANUVIA in combination with metformin. Patients already on metformin HCl (N=431) at a dose of at least 1500 mg per day were randomized after completing a 2-week single-blind placebo run-in period. Patients on metformin and another antihyperglycemic agent (N=229) and patients not on any antihyperglycemic agents (off therapy for at least 8 weeks, N=41) were randomized after a run-in period of approximately 10 weeks on metformin HCl (at a dose of at least 1500 mg per day) in monotherapy.
Patients with inadequate glycemic control (A1C 7% to 10%) were randomized to the addition of either 100 mg of JANUVIA or placebo, administered once daily. Patients who failed to meet specific glycemic goals during the studies were treated with pioglitazone rescue. In combination with metformin, JANUVIA provided significant improvements in A1C, FPG, and 2-hour PPG compared to placebo with metformin (Table 7). Rescue glycemic therapy was used in 5% of patients treated with JANUVIA 100 mg and 14% of patients treated with placebo.
A similar decrease in body weight was observed for both treatment groups. Table 7: Glycemic Parameters at Final Visit (24-Week Study) for JANUVIA in Add-on Combination Therapy with Metformin Intent-to-treat population using last observation on study prior to pioglitazone rescue therapy. JANUVIA 100 mg + Metformin Placebo + Metformin A1C (%) N = 453 N = 224 Baseline (mean) 8.0
Change from baseline (adjusted mean Least squares means adjusted for prior antihyperglycemic
therapy and baseline value. ) -0.7 -
Difference from placebo + metformin (adjusted mean ) (95% CI) -0.7 p<0.001
compared to placebo + metformin. (-0.8, -0.5) Patients (%) achieving A1C <7% 213 (47%) 41 (18%) FPG (mg/dL) N = 454 N = 226 Baseline (mean) 170 174 Change from baseline (adjusted mean ) -17 9 Difference from placebo + metformin (adjusted mean ) (95% CI) -25 (-31, -20) 2-hour PPG (mg/dL) N = 387 N = 182 Baseline (mean) 275 272 Change from baseline (adjusted mean ) -62 -11 Difference from placebo + metformin (adjusted mean ) (95% CI) -51 (-61, -41) Initial Combination Therapy with Metformin A total of 1091 patients with type 2 diabetes and inadequate glycemic control on diet and exercise participated in a 24-week, randomized, double-blind, placebo-controlled factorial study designed to assess the efficacy of sitagliptin as initial therapy in combination with metformin. Patients on an antihyperglycemic agent (N=541) discontinued the agent, and underwent a diet, exercise, and drug washout period of up to 12 weeks duration. After the washout period, patients with inadequate glycemic control (A1C 7.5% to 11%) were randomized after completing a 2-week single-blind placebo run-in period.
Patients not on antihyperglycemic agents at study entry (N=550) with inadequate glycemic control (A1C 7.5% to 11%) immediately entered the 2-week single-blind placebo run-in period and then were randomized. Approximately equal numbers of patients were randomized to receive initial therapy with placebo, 100 mg of JANUVIA once daily, 500 mg or 1000 mg of metformin HCl twice daily, or 50 mg of sitagliptin twice daily in combination with 500 mg or 1000 mg of metformin HCl twice daily. Patients who failed to meet specific glycemic goals during the study were treated with glyburide (glibenclamide) rescue.
Initial therapy with the combination of JANUVIA and metformin provided significant improvements in A1C, FPG, and 2-hour PPG compared to placebo, to metformin alone, and to JANUVIA alone (Table 8, Figure 1). Mean reductions from baseline in A1C were generally greater for patients with higher baseline A1C values. For patients not on an antihyperglycemic agent at study entry, mean reductions from baseline in A1C were: JANUVIA 100 mg once daily, -1.1%; metformin HCl 500 mg bid, -1.1%; metformin HCl 1000 mg bid, -1.2%; sitagliptin 50 mg bid with metformin HCl 500 mg bid, -1.6%; sitagliptin 50 mg bid with metformin HCl 1000 mg bid, -1.9%; and for patients receiving placebo, -0.2%. Lipid effects were generally neutral. The decrease in body weight in the groups given sitagliptin in combination with metformin was similar to that in the groups given metformin alone or placebo.
Table 8: Glycemic Parameters at Final Visit (24-Week Study) for Sitagliptin and Metformin, Alone and in Combination as Initial Therapy Intent-to-treat population using last observation on study prior to glyburide (glibenclamide) rescue therapy. Placebo Sitagliptin (JANUVIA) 100 mg QD Metformin HCl 500 mg bid Metformin HCl 1000 mg bid Sitagliptin 50 mg bid + Metformin HCl 500 mg bid Sitagliptin 50 mg bid + Metformin HCl 1000 mg bid A1C (%) N = 165 N = 175 N = 178 N = 177 N = 183 N = 178 Baseline (mean) 8.7 8.9 8.9 8.7 8.8
Change from baseline (adjusted mean Least squares means adjusted for prior antihyperglycemic
therapy status and baseline value. ) 0.2 -0.7 -0.8 -1.1 -1.4 -
Difference from placebo (adjusted mean ) (95% CI) -0.8 p<0.001 compared to
placebo. (-1.1, -0.6) -1.0 (-1.2, -0.8) -1.3 (-1.5, -1.1) -1.6 (-1.8, -1.3) -2.1 (-2.3, -1.8) Patients (%) achieving A1C <7% 15 (9%) 35 (20%) 41 (23%) 68 (38%) 79 (43%) 118 (66%) % Patients receiving rescue medication 32 21 17 12 8 2 FPG (mg/dL) N = 169 N = 178 N = 179 N = 179 N = 183 N = 180 Baseline (mean) 196 201 205 197 204 197 Change from baseline (adjusted mean ) 6 -17 -27 -29 -47 -64 Difference from placebo (adjusted mean ) (95% CI) -23 (-33, -14) -33 (-43, -24) -35 (-45, -26) -53 (-62, -43) -70 (-79, -60) 2-hour PPG (mg/dL) N = 129 N = 136 N = 141 N = 138 N = 147 N = 152 Baseline (mean) 277 285 293 283 292 287 Change from baseline (adjusted mean ) 0 -52 -53 -78 -93 -117 Difference from placebo (adjusted mean ) (95% CI) -52 (-67, -37) -54 (-69, -39) -78 (-93, -63) -93 (-107, -78) -117 (-131, -102) Figure 1: Mean Change from Baseline for A1C (%) over 24 Weeks with Sitagliptin and Metformin, Alone and in Combination as Initial Therapy in Patients with Type 2 Diabetes All Patients Treated Population: least squares means adjusted for prior antihyperglycemic therapy and baseline value. Initial combination therapy or maintenance of combination therapy may not be appropriate for all patients. These management options are left to the discretion of the health care provider.
Active-Controlled Study vs Glipizide in Combination with Metformin The efficacy of JANUVIA was evaluated in a 52-week, double-blind, glipizide-controlled noninferiority trial in patients with type 2 diabetes. Patients not on treatment or on other antihyperglycemic agents entered a run-in treatment period of up to 12 weeks duration with metformin HCl monotherapy (dose of ≥1500 mg per day) which included washout of medications other than metformin, if applicable. After the run-in period, those with inadequate glycemic control (A1C 6.5% to 10%) were randomized 1:1 to the addition of JANUVIA 100 mg once daily or glipizide for 52 weeks.
Patients receiving glipizide were given an initial dosage of 5 mg/day and then electively titrated over the next 18 weeks to a maximum dosage of 20 mg/day as needed to optimize glycemic control. Thereafter, the glipizide dose was to be kept constant, except for down-titration to prevent hypoglycemia. The mean dose of glipizide after the titration period was 10 mg.
After 52 weeks, JANUVIA and glipizide had similar mean reductions from baseline in A1C in the intent-to-treat analysis (Table 9). These results were consistent with the per protocol analysis (Figure 2). A conclusion in favor of the non-inferiority of JANUVIA to glipizide may be limited to patients with baseline A1C comparable to those included in the study (over 70% of patients had baseline A1C <8% and over 90% had A1C <9%). Table 9: Glycemic Parameters in a 52-Week Study Comparing JANUVIA to Glipizide as Add-On Therapy in Patients Inadequately Controlled on Metformin (Intent-to-Treat Population) The intent-to-treat analysis used the patients' last observation in the study prior to discontinuation. JANUVIA 100 mg Glipizide A1C (%) N = 576 N = 559 Baseline (mean) 7.7
Change from baseline (adjusted mean Least squares means adjusted for prior antihyperglycemic
therapy status and baseline A1C value. ) -0.5 -
FPG (mg/dL) N = 583 N = 568 Baseline (mean) 166 164
Change from baseline (adjusted mean ) -8 -8 Figure 2: Mean Change from Baseline for A1C (%) Over 52 Weeks in a Study Comparing JANUVIA to Glipizide as Add-On Therapy in Patients Inadequately Controlled on Metformin (Per Protocol Population) The per protocol population (mean baseline A1C of 7.5%) included patients without major protocol violations who had observations at baseline and at Week 52. The incidence of hypoglycemia in the JANUVIA group (4.9%) was significantly (p<0.001) lower than that in the glipizide group (32.0%). Patients treated with JANUVIA exhibited a significant mean decrease from baseline in body weight compared to a significant weight gain in patients administered glipizide (-1.5 kg vs +1.1 kg). Add-on Combination Therapy with Pioglitazone A total of 353 patients with type 2 diabetes participated in a 24-week, randomized, double-blind, placebo-controlled study designed to assess the efficacy of JANUVIA in combination with pioglitazone. Patients on any oral antihyperglycemic agent in monotherapy (N=212) or on a PPARγ agent in combination therapy (N=106) or not on an antihyperglycemic agent (off therapy for at least 8 weeks, N=34) were switched to monotherapy with pioglitazone (at a dose of 30-45 mg per day), and completed a run-in period of approximately 12 weeks in duration. After the run-in period on pioglitazone monotherapy, patients with inadequate glycemic control (A1C 7% to 10%) were randomized to the addition of either 100 mg of JANUVIA or placebo, administered once daily.
Patients who failed to meet specific glycemic goals during the studies were treated with metformin rescue. Glycemic endpoints measured were A1C and fasting glucose. In combination with pioglitazone, JANUVIA provided significant improvements in A1C and FPG compared to placebo with pioglitazone (Table 10). Rescue therapy was used in 7% of patients treated with JANUVIA 100 mg and 14% of patients treated with placebo.
There was no significant difference between JANUVIA and placebo in body weight change. Table 10: Glycemic Parameters at Final Visit (24-Week Study) for JANUVIA in Add-on Combination Therapy with Pioglitazone Intent-to-treat population using last observation on study prior to metformin rescue therapy. JANUVIA 100 mg + Pioglitazone Placebo + Pioglitazone A1C (%) N = 163 N = 174 Baseline (mean) 8.1
Change from baseline (adjusted mean Least squares means adjusted for prior antihyperglycemic
therapy status and baseline value. ) -0.9 -
Difference from placebo + pioglitazone (adjusted mean ) (95% CI) -0.7 p<0.001
compared to placebo + pioglitazone. (-0.9, -0.5) Patients (%) achieving A1C <7% 74 (45%) 40 (23%) FPG (mg/dL) N = 163 N = 174 Baseline (mean) 168 166 Change from baseline (adjusted mean ) -17 1 Difference from placebo + pioglitazone (adjusted mean ) (95% CI) -18 (-24, -11) Initial Combination Therapy with Pioglitazone A total of 520 patients with type 2 diabetes and inadequate glycemic control on diet and exercise participated in a 24-week, randomized, double-blind study designed to assess the efficacy of JANUVIA as initial therapy in combination with pioglitazone. Patients not on antihyperglycemic agents at study entry (<4 weeks cumulative therapy over the past 2 years, and with no treatment over the prior 4 months) with inadequate glycemic control (A1C 8% to 12%) immediately entered the 2-week single-blind placebo run-in period and then were randomized. Approximately equal numbers of patients were randomized to receive initial therapy with 100 mg of JANUVIA in combination with 30 mg of pioglitazone once daily or 30 mg of pioglitazone once daily as monotherapy.
There was no glycemic rescue therapy in this study. Initial therapy with the combination of JANUVIA and pioglitazone provided significant improvements in A1C, FPG, and 2-hour PPG compared to pioglitazone monotherapy (Table 11). The improvement in A1C was generally consistent across subgroups defined by gender, age, race, baseline BMI, baseline A1C, or duration of disease. In this study, patients treated with JANUVIA in combination with pioglitazone had a mean increase in body weight of 1.1 kg compared to pioglitazone alone (3.0 kg vs. 1.9 kg). Lipid effects were generally neutral.
Table 11: Glycemic Parameters at Final Visit (24-Week Study) for JANUVIA in Combination with Pioglitazone as Initial Therapy Intent-to-treat population using last observation on study. JANUVIA 100 mg + Pioglitazone Pioglitazone A1C (%) N = 251 N = 246 Baseline (mean) 9.5
Change from baseline (adjusted mean Least squares means adjusted for baseline value.
) -2.4 -
Difference from pioglitazone (adjusted mean ) (95% CI) -0.9 p<0.001 compared to
placebo + pioglitazone. (-1.1, -0.7) Patients (%) achieving A1C <7% 151 (60%) 68 (28%) FPG (mg/dL) N = 256 N = 253 Baseline (mean) 203 201 Change from baseline (adjusted mean ) -63 -40 Difference from pioglitazone (adjusted mean ) (95% CI) -23 (-30, -15) 2-hour PPG (mg/dL) N = 216 N = 211 Baseline (mean) 283 284 Change from baseline (adjusted mean ) -114 -69 Difference from pioglitazone (adjusted mean ) (95% CI) -45 (-57, -32) Add-on Combination Therapy with Metformin and Rosiglitazone A total of 278 patients with type 2 diabetes participated in a 54-week, randomized, double-blind, placebo-controlled study designed to assess the efficacy of JANUVIA in combination with metformin and rosiglitazone. Patients on dual therapy with metformin HCl ≥1500 mg/day and rosiglitazone ≥4 mg/day or with metformin HCl ≥1500 mg/day and pioglitazone ≥30 mg/day (switched to rosiglitazone ≥4 mg/day) entered a dose-stable run-in period of 6 weeks. Patients on other dual therapy were switched to metformin HCl ≥1500 mg/day and rosiglitazone ≥4 mg/day in a dose titration/stabilization run-in period of up to 20 weeks in duration.
After the run-in period, patients with inadequate glycemic control (A1C 7.5% to 11%) were randomized 2:1 to the addition of either 100 mg of JANUVIA or placebo, administered once daily. Patients who failed to meet specific glycemic goals during the study were treated with glipizide (or other sulfonylurea) rescue. The primary time point for evaluation of glycemic parameters was Week 18. In combination with metformin and rosiglitazone, JANUVIA provided significant improvements in A1C, FPG, and 2-hour PPG compared to placebo with metformin and rosiglitazone (Table 12) at Week 18. At Week 54, mean reduction in A1C was -1.0% for patients treated with JANUVIA and -0.3% for patients treated with placebo in an analysis based on the intent-to-treat population.
Rescue therapy was used in 18% of patients treated with JANUVIA 100 mg and 40% of patients treated with placebo. There was no significant difference between JANUVIA and placebo in body weight change. Table 12: Glycemic Parameters at Week 18 for JANUVIA in Add-on Combination Therapy with Metformin and Rosiglitazone Intent-to-treat population using last observation on study prior to glipizide (or other sulfonylurea) rescue therapy.
JANUVIA 100 mg + Metformin + Rosiglitazone Placebo + Metformin + Rosiglitazone A1C (%) N = 176 N = 93 Baseline (mean) 8.8
Change from baseline (adjusted mean Least squares means adjusted for prior antihyperglycemic
therapy status and baseline value. ) -1.0 -
Difference from placebo + rosiglitazone + metformin (adjusted mean ) (95% CI)
-0.7 p<0.001 compared to placebo + metformin + rosiglitazone. (-0.9, -0.4) Patients (%) achieving A1C <7% 39 (22%) 9 (10%) FPG (mg/dL) N = 179 N = 94 Baseline (mean) 181 182 Change from baseline (adjusted mean ) -30 -11 Difference from placebo + rosiglitazone + metformin (adjusted mean ) (95% CI) -18 (-26, -10) 2-hour PPG (mg/dL) N = 152 N = 80 Baseline (mean) 256 248 Change from baseline (adjusted mean ) -59 -21 Difference from placebo + rosiglitazone + metformin (adjusted mean ) (95% CI) -39 (-51, -26) Add-on Combination Therapy with Glimepiride, with or without Metformin A total of 441 patients with type 2 diabetes participated in a 24-week, randomized, double-blind, placebo-controlled study designed to assess the efficacy of JANUVIA in combination with glimepiride, with or without metformin. Patients entered a run-in treatment period on glimepiride (≥4 mg per day) alone or glimepiride in combination with metformin HCl (≥1500 mg per day). After a dose-titration and dose-stable run-in period of up to 16 weeks and a 2-week placebo run-in period, patients with inadequate glycemic control (A1C 7.5% to 10.5%) were randomized to the addition of either 100 mg of JANUVIA or placebo, administered once daily. Patients who failed to meet specific glycemic goals during the studies were treated with pioglitazone rescue.
In combination with glimepiride, with or without metformin, JANUVIA provided significant improvements in A1C and FPG compared to placebo (Table 13). In the entire study population (patients on JANUVIA in combination with glimepiride and patients on JANUVIA in combination with glimepiride and metformin), a mean reduction from baseline relative to placebo in A1C of -0.7% and in FPG of -20 mg/dL was seen. Rescue therapy was used in 12% of patients treated with JANUVIA 100 mg and 27% of patients treated with placebo. In this study, patients treated with JANUVIA had a mean increase in body weight of 1.1 kg vs. placebo (+0.8 kg vs. -0.4 kg). In addition, there was an increased rate of hypoglycemia.
Table 13: Glycemic Parameters at Final Visit (24-Week Study) for JANUVIA as Add-On Combination Therapy with Glimepiride, with or without Metformin Intent-to-treat population using last observation on study prior to pioglitazone rescue therapy. JANUVIA 100 mg + Glimepiride Placebo + Glimepiride JANUVIA 100 mg + Glimepiride + Metformin Placebo + Glimepiride + Metformin A1C (%) N = 102 N = 103 N = 115 N = 105 Baseline (mean) 8.4 8.5 8.3
Change from baseline (adjusted mean Least squares means adjusted for prior antihyperglycemic
therapy status and baseline value. ) -0.3 0.3 -0.6
Difference from placebo (adjusted mean ) (95% CI) -0.6 p<0.001 compared to
placebo. (-0.8, -0.3) -0.9 (-1.1, -0.7) Patients (%) achieving A1C <7% 11 (11%) 9 (9%) 26 (23%) 1 (1%) FPG (mg/dL) N = 104 N = 104 N = 115 N = 109 Baseline (mean) 183 185 179 179 Change from baseline (adjusted mean ) -1 18 -8 13 Difference from placebo (adjusted mean ) (95% CI) -19 p<0.01 compared to placebo. (-32, -7) -21 (-32, -10) Add-on Combination Therapy with Insulin (with or without Metformin) A total of 641 patients with type 2 diabetes participated in a 24-week, randomized, double-blind, placebo-controlled study designed to assess the efficacy of JANUVIA as add-on to insulin therapy (with or without metformin). The racial distribution in this study was approximately 70% white, 18% Asian, 7% black, and 5% other groups. Approximately 14% of the patients in this study were Hispanic. Patients entered a 2-week, single-blind run-in treatment period on pre-mixed, long-acting, or intermediate-acting insulin, with or without metformin HCl (≥1500 mg per day). Patients using short-acting insulins were excluded unless the short-acting insulin was administered as part of a pre-mixed insulin.
After the run-in period, patients with inadequate glycemic control (A1C 7.5% to 11%) were randomized to the addition of either 100 mg of JANUVIA or placebo, administered once daily. Patients were on a stable dose of insulin prior to enrollment with no changes in insulin dose permitted during the run-in period. Patients who failed to meet specific glycemic goals during the double-blind treatment period were to have uptitration of the background insulin dose as rescue therapy.
The median daily insulin dose at baseline was 42 units in the patients treated with JANUVIA and 45 units in the placebo-treated patients. The median change from baseline in daily dose of insulin was zero for both groups at the end of the study. In combination with insulin (with or without metformin), JANUVIA provided significant improvements in A1C, FPG, and 2-hour PPG compared to placebo (Table 14). Both treatment groups had an adjusted mean increase in body weight of 0.1 kg from baseline to Week 24. There was an increased rate of hypoglycemia in patients treated with JANUVIA. Table 14: Glycemic Parameters at Final Visit (24-Week Study) for JANUVIA as Add-on Combination Therapy with Insulin Intent-to-treat population using last observation on study prior to rescue therapy.
JANUVIA 100 mg + Insulin (+/- Metformin) Placebo + Insulin (+/- Metformin) A1C (%) N = 305 N = 312 Baseline (mean) 8.7
Change from baseline (adjusted mean Least squares means adjusted for metformin use
at the screening visit (yes/no), type of insulin used at the screening visit (pre-mixed vs. non-pre-mixed ), and baseline value. ) -0.6 -
Difference from placebo (adjusted mean, Treatment by stratum interaction was not significant
(p>0.10) for metformin stratum and for insulin stratum. ) (95% CI) -0.6 p<0.001 compared to placebo. (-0.7, -0.4) Patients (%) achieving A1C <7% 39 (12.8%) 16 (5.1%) FPG (mg/dL) N = 310 N = 313 Baseline (mean) 176 179 Change from baseline (adjusted mean ) -18 -4 Difference from placebo (adjusted mean ) (95% CI) -15 (-23, -7) 2-hour PPG (mg/dL) N = 240 N = 257 Baseline (mean) 291 292 Change from baseline (adjusted mean ) -31 5 Difference from placebo (adjusted mean ) (95% CI) -36 (-47, -25) Maintenance of JANUVIA During Initiation and Titration of Insulin Glargine A total of 746 patients with type 2 diabetes (mean baseline HbA1C 8.8%, disease duration 10.8 years) participated in a 30-week, randomized, double-blind, placebo-controlled study to assess the efficacy and safety of continuing JANUVIA during the initiation and uptitration of insulin glargine. Patients who were on a stable dose of metformin HCl (≥1500 mg/day) in combination with a DPP-4 inhibitor and/or sulfonylurea but with inadequate glycemic control (A1C 7.5% to 11%) were enrolled in the study. Those on metformin and JANUVIA (100 mg/day) directly entered the double-blind treatment period; those on another DPP-4 inhibitor and/or on a sulfonylurea entered a 4-8 week run-in period in which they were maintained on metformin and switched to JANUVIA (100 mg); other DPP-4 inhibitors and sulfonylureas were discontinued.
At randomization patients were randomized either to continue JANUVIA or to discontinue JANUVIA and switch to a matching placebo. On the day of randomization, insulin glargine was initiated at a dose of 10 units subcutaneously in the evening. Patients were instructed to uptitrate their insulin dose in the evening based on fasting blood glucose measurements to achieve a target of 72-100 mg/dL. At 30 weeks, the mean reduction in A1C was greater in the sitagliptin group than in the placebo group (Table 15). At the end of the trial, 27.3% of patients in the sitagliptin group and 27.3% in the placebo group had a fasting plasma glucose (FPG) in the target range; there was no significant difference in insulin dose between arms.
Table 15: Change from Baseline in A1C and FPG at Week 30 in the Maintenance of JANUVIA During Initiation and Titration of Insulin Glargine Study Sitagliptin 100 mg +Metformin + Insulin Glargine Placebo +Metformin + Insulin Glargine A1C (%) N = 373 N is the number of randomized and treated patients. N = 370 Baseline (mean) 8.8
Week 30 (mean) 6.9 7.3 Change from baseline (adjusted mean) Analysis of
Covariance including all post-baseline data regardless of rescue or treatment discontinuation. Model estimates calculated using multiple imputation to model washout of the treatment effect using placebo data for all subjects having missing Week 30 data. -1.9 -
Difference from placebo (adjusted mean) (95% CI) -0.4 (-0.6, -0.3) p<0.001 compared
to placebo. Patients (%) with A1C <7% 202 (54.2%) 131 (35.4%) FPG (mg/dL) N = 373 N = 370 Baseline (mean) 199 201 Week 30 (mean) 118 123 Change from baseline (adjusted mean) -81 -76 Image of Figure 1 image of Figure 2
Drug information sourced from the FDA. This content is for informational purposes only and does not constitute medical advice. Consult a healthcare professional before making any medication decisions.
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