Vokanamet 50 mg/1000 mg film-coated tablets
Each tablet contains canagliflozin hemihydrate, equivalent to 50 mg of canagliflozin, and 1000 mg of metformin hydrochloride.
For the list of excipients, see section 6.1.
Film-coated tablet.
- The tablet is beige, capsule-shaped, 21 mm in length, immediate-release, film-coated, and debossed with “CM” on one side and “551” on the other side.
Vokanamet is indicated in adults aged 18 years and older with type 2 diabetes mellitus as an adjunct to diet and exercise to improve glycaemic control:
• in patients not adequately controlled on their maximally tolerated doses of metformin alone
• in patients on their maximally tolerated doses of metformin along with other glucose-lowering medicinal products including insulin, when these do not provide adequate glycaemic control (see sections 4.4, 4.5, and 5.1 for available data on different add-on therapies)
• in patients already being treated with the combination of canagliflozin and metformin as separate tablets.
Posology
The dose of glucose-lowering therapy with Vokanamet should be individualised on the basis of the patient's current regimen, effectiveness, and tolerability, using the recommended daily dose of 100 mg or 300 mg canagliflozin and not exceeding the maximum recommended daily dose of metformin orally.
For patients inadequately controlled on maximal tolerated dose of metformin
For patients not adequately controlled on metformin, the recommended starting dose of Vokanamet should provide canagliflozin dosed at 50 mg twice daily plus the dose of metformin already being taken or the nearest therapeutically appropriate dose. For patients who are tolerating a Vokanamet dose containing canagliflozin 50 mg who need tighter glycemic control, the dose can be increased to Vokanamet containing 150 mg canagliflozin twice daily (see below and section 4.4).
For patients switching from separate tablets of canagliflozin and metformin
For patients switching from separate tablets of canagliflozin and metformin, Vokanamet should be initiated at the same total daily dose of canagliflozin and metformin already being taken or the nearest therapeutically appropriate dose of metformin.
Dose titration with canagliflozin (added to the optimal dose of metformin) should be considered before the patient is switched to Vokanamet.
In patients tolerating Vokanamet containing canagliflozin 50 mg who need tighter glycaemic control, increasing the dose to Vokanamet containing canagliflozin 150 mg may be considered.
Care should be taken when increasing the dose of Vokanamet containing 50 mg of canagliflozin to 150 mg of canagliflozin in patients ≥ 75 years of age, patients with known cardiovascular disease, or other patients for whom the initial canagliflozin-induced diuresis poses a risk (see section 4.4). In patients with evidence of volume depletion, correcting this condition prior to initiation of Vokanamet is recommended (see section 4.4).
When Vokanamet is used as add-on therapy with insulin or an insulin secretagogue (e.g., a sulphonylurea), a lower dose of insulin or the insulin secretagogue may be considered to reduce the risk of hypoglycaemia (see sections 4.5 and 4.8).
Special populations
Elderly (≥ 65 years old)
Because metformin is eliminated in part by the kidney and elderly patients are more likely to have decreased renal function, Vokanamet should be used with caution as age increases. Regular assessment of renal function is necessary to aid in prevention of metformin-associated lactic acidosis, particularly in elderly patients. The risk of volume depletion associated with canagliflozin should be taken into account (see sections 4.3 and 4.4).
Patients with renal impairment
For patients with an estimated glomerular filtration rate (eGFR) 60 mL/min/1.73 m2 to < 90 mL/min/1.73m2 or creatinine clearance (CrCl) of 60 mL/min to < 90 mL/min, no dose adjustment is needed.
Vokanamet must not be used in patients with moderate or severe renal impairment (eGFR < 60 mL/min/1.73m2 or CrCl < 60 mL/min) due to the active substance metformin (see sections 4.3, 4.4 and 5.2).
Patients with hepatic impairment
Vokanamet is not recommended in patients with hepatic impairment due to the active substance metformin (see sections 4.3 and 5.2). There is no clinical experience with Vokanamet in patients with hepatic impariment.
Paediatric population
The safety and efficacy of Vokanamet in children under 18 years of age have not been established. No data are available.
Method of administration
For oral use
Vokanamet should be taken orally twice daily with meals to reduce the gastrointestinal undesirable effects associated with metformin. Tablets are to be swallowed whole.
If a dose is missed, it should be taken as soon as the patient remembers unless it is nearly time for the next dose in which case patients should skip the missed dose and take the medicine at the next regularly scheduled time.
• Hypersensitivity to the active substances or any of the excipients (see section 6.1);
• Diabetic ketoacidosis, diabetic pre-coma;
• Moderate and severe renal impairment (patients with eGFR < 60 mL/min/1.73 m2 or CrCl < 60 mL/min), (see sections 4.2 and 4.4);
• Acute conditions with the potential to alter renal function such as: dehydration, severe infection, shock (see section 4.4);
• Acute or chronic disease which may cause tissue hypoxia such as: cardiac or respiratory failure, recent myocardial infarction, shock;
• Hepatic impairment, acute alcohol intoxication, alcoholism (see sections 4.2 and 4.5).
General
Vokanamet has not been studied in patients with type 1 diabetes and is therefore not recommended for use in these patients.
Lactic acidosis
Lactic acidosis is a rare, but serious (high mortality in the absence of prompt treatment), 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 impairment, and any conditions associated with hypoxia.
Diagnosis
The risk of lactic acidosis must be considered in the event of non-specific signs such as muscle cramps with digestive disorders as abdominal pain and severe asthenia.
This can be followed by acidotic dyspnea, abdominal pain, hypothermia and 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 should be hospitalised immediately (see section 4.9). Physicians should alert the patients on the risk and on the symptoms of lactic acidosis.
Renal function
As metformin is excreted by the kidney, and metformin accumulation may precipitate lactic acidosis, eGFR or creatinine clearance should be determined before initiating treatment and regularly thereafter:
• at least annually in patients with normal renal function
• at least two to four times a year in patients with eGFR (creatinine clearance) at the lower limit of normal and in elderly patients.
Decreased renal function in elderly patients is frequent and asymptomatic. Special caution should be exercised in situations where renal function may become impaired; for example, when initiating antihypertensive or diuretic therapy and when starting treatment with a non-steroidal anti-inflammatory drug (NSAID).
Administration of iodinated contrast agent
The intravascular administration of iodinated contrast agents in radiologic studies can lead to renal failure. This may induce metformin accumulation which may increase the risk for lactic acidosis. Vokanamet must be discontinued prior to, or at the time of the test and not be reinstituted until 48 hours afterwards, and only after renal function has been re-eva luated and found to be normal (see section 4.5).
Surgery
As Vokanamet contains metformin, therapy must be discontinued 48 hours before elective surgery with general, spinal, or peridural anaesthesia. Therapy may be restarted no earlier than 48 hours following surgery or resumption of oral nutrition and only if normal renal function has been established.
Use in patients at risk for adverse reactions related to volume depletion
Due to its mechanism of action, canagliflozin, by increasing urinary glucose excretion (UGE), induces an osmotic diuresis, which may reduce intravascular volume and decrease blood pressure (see section 5.1). In controlled clinical studies of canagliflozin, increases in adverse reactions related to volume depletion (e.g., postural dizziness, orthostatic hypotension, or hypotension) were seen more commonly with a daily dose of 300 mg canaliflozin and occurred most frequently in the first three months (see section 4.8).
Caution should be exercised in patients for whom a canagliflozin-induced drop in blood pressure could pose a risk, such as patients with known cardiovascular disease, patients on anti-hypertensive therapy with a history of hypotension, patients on diuretics, or elderly patients (≥ 65 years of age) (see sections 4.2 and 4.8).
Due to volume depletion, generally small mean decreases in eGFR were seen within the first 6 weeks of treatment initiation with canagliflozin. In patients susceptible to greater reductions in intravascular volume as described above, larger decreases in eGFR (> 30%) were sometimes seen, which subsequently improved, and infrequently required interruption of treatment with canagliflozin (see section 4.8).
Patients should be advised to report symptoms of volume depletion. Canagliflozin is not recommended for use in patients receiving loop diuretics (see section 4.5) or who are volume depleted, e.g., due to acute illness (such as gastrointestinal illness).
For patients receiving Vokanamet, in case of intercurrent conditions that may lead to volume depletion (such as a gastrointestinal illness), careful monitoring of volume status (e.g., physical examination, blood pressure measurements, laboratory tests including renal function tests), and serum electrolytes is recommended. Temporary interruption of treatment with Vokanamet may be considered for patients who develop volume depletion while on Vokanamet therapy until the condition is corrected. If interrupted, consideration should be given to more frequent glucose monitoring.
Elevated haematocrit
Haematocrit increase was observed with canagliflozin treatment (see section 4.8); therefore, caution in patients with already elevated haematocrit is warranted.
Elderly (≥ 65 years old)
Elderly patients may be at a greater risk for volume depletion, are more likely to be treated with diuretics, and to have impaired renal function. In patients ≥ 75 years of age, a higher incidence of adverse reactions associated with volume depletion (e.g., postural dizziness, orthostatic hypotension, hypotension) was reported with canagliflozin therapy. In addition, in such patients greater decreases in eGFR were reported (see sections 4.2 and 4.8).
Genital mycotic infections
Consistent with the mechanism of sodium glucose co-transporter 2 (SGLT2) inhibition with increased UGE, vulvovaginal candidiasis in females and balanitis or balanoposthitis in males were reported in clinical trials with canagliflozin (see section 4.8). Male and female patients with a history of genital mycotic infections were more likely to develop an infection. Balanitis or balanoposthitis occurred primarily in uncircumcised male patients. In rare instances, phimosis was reported and sometimes circumcision was performed. The majority of genital mycotic infections were treated with topical antifungal treatments, either prescribed by a healthcare professional or self-treated while continuing therapy with Vokanamet.
Cardiac failure
Experience in New York Heart Association (NYHA) class III is limited, and there is no experience in clinical studies with canagliflozin in NYHA class IV.
Urine laboratory assessments
Due to canagliflozin's mechanism of action, patients taking Vokanamet will test positive for glucose in their urine.
Pharmacokinetic drug interaction studies with Vokanamet have not been performed; however, such studies have been conducted with the individual active substances (canagliflozin and metformin). Co-administration of canagliflozin (300 mg once daily) and metformin (2000 mg once daily) had no clinically relevant effect on the pharmacokinetics of either canagliflozin or metformin.
CANAGLIFLOZIN
Pharmacodynamic interactions
Diuretics
Canagliflozin may add to the effect of diuretics and may increase the risk of dehydration and hypotension (see section 4.4).
Canagliflozin is not recommended for use in patients receiving loop diuretics.
Insulin and insulin secretagogues
Insulin and insulin secretagogues, such as sulphonylureas, can cause hypoglycaemia. Therefore, a lower dose of insulin or an insulin secretagogue may be required to reduce the risk of hypoglycaemia when used in combination with Vokanamet (see sections 4.2 and 4.8).
Pharmacokinetic interactions
Effects of other medicinal products on canagliflozin
The metabolism of canagliflozin is primarily via glucuronide conjugation mediated by UDP glucuronosyl transferase 1A9 (UGT1A9) and 2B4 (UGT2B4). Canagliflozin is transported by P-glycoprotein (P-gp) and Breast Cancer Resistance Protein (BCRP).
Enzyme inducers (such as St. John's wort [Hypericum perforatum], rifampicin, barbiturates, phenytoin, carbamazepine, ritonavir, efavirenz) may give rise to decreased exposure of canagliflozin. Following co-administration of canagliflozin with rifampicin (an inducer of various active transporters and drug-metabolising enzymes), 51% and 28% decreases in canagliflozin systemic exposure (area under the curve, AUC) and peak concentration (Cmax) were observed. These decreases in exposure to canagliflozin may decrease efficacy.
If a combined inducer of these UGT enzymes and transport proteins must be co-administered with canagliflozin, monitoring of glycaemic control to assess response to canagliflozin is appropriate. If an inducer of these UGT enzymes must be co-administered with canagliflozin, increasing the dose to Vokanamet containing 150 mg twice daily may be considered if patients are currently tolerating canagliflozin 50 mg twice daily and require additional glycaemic control (see sections 4.2 and 4.4).
Cholestyramine may potentially reduce canagliflozin exposure. Dosing of canagliflozin should occur at least 1 hour before or 4-6 hours after administration of a bile acid sequestrant to minimise possible interference with their absorption.
Interaction studies suggest that the pharmacokinetics of canagliflozin are not altered by metformin, hydrochlorothiazide, oral contraceptives (ethinyl estradiol and levonorgestrol), ciclosporin, and/or probenecid.
Effects of canagliflozin on other medicinal products
Digoxin
The combination of canagliflozin 300 mg once daily for 7 days with a single dose of digoxin 0.5 mg followed by 0.25 mg daily for 6 days resulted in a 20% increase in AUC and a 36% increase in Cmax of digoxin, probably due to inhibition of P-gp. Canagliflozin has been observed to inhibit P-gp in vitro. Patients taking digoxin or other cardiac glycosides (e.g., digitoxin) should be monitored appropriately.
Dabigatran
The effect of concomitant administration of canagliflozin (a weak P-gp inhibitor) on dabigatran etexilate (a P-gp substrate) has not been studied. As dabigatran concentrations may be increased in the presence of canagliflozin, monitoring (looking for signs of bleeding or anaemia) should be exercised when dabigatran is combined with canagliflozin.
Simvastatin
The combination of canagliflozin 300 mg once daily for 6 days with a single dose of simvastatin (CYP3A4 substrate) 40 mg resulted in a 12% increase in AUC and a 9% increase in Cmax of simvastatin and an 18% increase in AUC and a 26% increase in Cmax of simvastatin acid. The increases in simvastatin and simvastatin acid exposures are not considered clinically relevant.
Inhibition of BCRP by canagliflozin cannot be excluded at an intestinal level and increased exposure may therefore occur for medicinal products transported by BCRP, e.g., certain statins like rosuvastatin and some anti-cancer medicinal products.
In interaction studies, canagliflozin at steady-state had no clinically relevant effect on the pharmacokinetics of metformin, oral contraceptives (ethinyl estradiol and levonorgestrol), glibenclamide, paracetamol, hydrochlorothiazide, or warfarin.
Drug/laboratory test interference
1,5-AG assay
Increases in urinary glucose excretion with canagliflozin can falsely lower 1,5-anhydroglucitol (1,5-AG) levels and make measurements of 1,5-AG unreliable in assessing glycemic control. Therefore, 1,5-AG assays should not be used for assessment of glycemic control in patients on Vokanamet. For further detail, it may be advisable to contact the specific manufacturer of the 1,5-AG assay.
METFORMIN
Combinations not recommended
Alcohol
There is an increased risk of lactic acidosis in acute alcohol intoxication (particularly in the case of fasting, malnutrition, or hepatic impairment) due to the metformin active substance of Vokanamet (see section 4.4). Consumption of alcohol and medicinal products containing alcohol should be avoided.
Iodinated contrast agents
The intravascular administration of iodinated contrast agents in radiological studies may lead to renal failure, resulting in metformin accumulation and a risk of lactic acidosis. Therefore, Vokanamet must be discontinued prior to, or at the time of the test and not reinstituted until 48 hours afterwards, and only after renal function has been re-eva luated and found to be normal (see section 4.4).
Cationic medicinal products
Cationic medicinal products that are eliminated by renal tubular secretion (e.g., cimetidine) may interact with metformin by competing for common renal tubular transport systems. A study conducted in seven normal healthy volunteers showed that cimetidine, administered as 400 mg twice daily, increased metformin AUC by 50% and Cmax by 81%. Therefore, close monitoring of glycaemic control, dose adjustment within the recommended posology and changes in diabetic treatment should be considered when cationic medicinal products that are eliminated by renal tubular secretion are co-administered (see sections 4.4 and 5.1).
Combinations requiring precautions for use
Glucocorticoids (given by systemic and local routes), beta-2-agonists, and diuretics have intrinsic hyperglycaemic activity. The patient should be informed and more frequent blood glucose monitoring performed, especially at the beginning of treatment with such medicinal products. If necessary, the dose of glucose-lowering medicinal products should be adjusted during therapy with the other medicinal product and on its discontinuation.
Due to their potential to decrease renal function, diuretics (especially loop diuretics) may increase the risk of lactic acidosis associated with metformin.
Pregnancy
There are no data from the use of canagliflozin alone or Vokanamet in pregnant women. Studies in animals with canagliflozin have shown reproductive toxicity (see section 5.3).
A limited amount of data from the use of metformin in pregnant women does not indicate an increased risk of congenital malformations. Animal studies with metformin do not indicate harmful effects with respect to pregnancy, embryonic or foetal development, parturition, or postnatal development (see section 5.3).
Vokanamet should not be used during pregnancy. When pregnancy is detected, treatment with Vokanamet should be discontinued.
Breast-feeding
No studies in lactating animals have been conducted with the combined active substances of Vokanamet. It is unknown whether canagliflozin and/or its metabolites are excreted in human milk. Available pharmacodynamic/toxicological data in animals have shown excretion of canagliflozin/metabolites in milk, as well as pharmacologically mediated effects in breast-feeding offspring and juvenile rats exposed to canagliflozin (see section 5.3). Metformin is excreted into human breast milk in small amounts. A risk to newborns/infants cannot be excluded. Vokanamet should not be used during breast-feeding.
Fertility
The effect of Vokanamet on fertility in humans has not been studied. No effects of canagliflozin or metformin on fertility were observed in animal studies (see section 5.3).
Vokanamet has no or negligible influence on the ability to drive and use machines. However, patients should be alerted to the risk of hypoglycaemia when Vokanamet is used as add-on therapy with insulin or an insulin secretagogue, and to the elevated risk of adverse reactions related to volume depletion, such as postural dizziness (see sections 4.2, 4.4, and 4.8).
CANAGLIFLOZIN
Summary of safety profile
The safety of canagliflozin was eva luated in 10,285 patients with type 2 diabetes, including 5,151 patients treated with canagliflozin in combination with metformin. In addition, an 18-week double-blind, placebo-controlled phase 2 study with twice daily dosing (canagliflozin 50 mg or 150 mg as add-on therapy with metformin 500 mg) was conducted in 279 patients in which 186 patients were treated with canagliflozin as add-on therapy with metformin.
The primary assessment of safety and tolerability was conducted in a pooled analysis (N=2,313) of four 26-week placebo-controlled clinical studies (monotherapy and add-on therapy with metformin, metformin and a sulphonylurea, and metformin and pioglitazone). The most commonly reported adverse reactions during treatment were hypoglycaemia in combination with insulin or a sulphonylurea, vulvovaginal candidiasis, urinary tract infection, and polyuria or pollakiuria (i.e., urinary frequency). Adverse reactions leading to discontinuation of ≥ 0.5% of all canagliflozin-treated patients in these studies were vulvovaginal candidiasis (0.7% of female patients) and balanitis or balanoposthitis (0.5% of male patients). Additional safety analyses (including long-term data) from data across the entire canagliflozin programme (placebo- and active-controlled studies) were conducted to assess reported adverse events in order to identify adverse reactions (see table 1) (see sections 4.2 and 4.4).
Tabulated list of adverse reactions
Adverse reactions in table 1 are based on the pooled analysis of the four 26-week placebo-controlled studies (n=2,313) described above. Adverse reactions listed below are classified according to frequency and system organ class (SOC). Frequency categories are defined according to the following convention: 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), not known (cannot be estimated from the available data).
Table 1: Frequency of adverse reactions (MedDRA) in placebo-controlled studiesa
|
System organ class
Frequency
|
Adverse reaction
|
|
Metabolism and nutrition disorders
|
|
very common
|
Hypoglycaemia in combination with insulin or sulphonylurea
|
|
uncommon
|
Dehydration*
|
|
Nervous system disorders
|
|
uncommon
|
Dizziness postural*, Syncope*
|
|
Vascular disorders
|
|
uncommon
|
Hypotension*, Orthostatic hypotension*
|
|
Gastrointestinal disorders
|
|
common
|
Constipation, Thirstb, Nausea
|
|
Skin and subcutaneous tissue disorders
|
|
uncommon
|
Rashc, Urticaria
|
|
Musculoskeletal and connective tissue disorders
|
|
uncommon
|
Bone fractured
|
|
Renal and urinary disorders
|
|
common
|
Polyuria or Pollakiuriae, Urinary tract infectionf
|
|
Reproductive system and breast disorders
|
|
very common
|
Vulvovaginal candidiasis**, g
|
|
common
|
Balanitis or balanoposthitis**, h
|
|
Investigations
|
|
common
|
Dyslipidemiai, Haematocrit increased**, j
|
|
uncommon
|
Blood creatinine increased**, k, Blood urea increased**, l, Blood potassium increased**, m, Blood phosphate increasedn
|
* Related volume depletion; see section 4.4.
** See section 4.4.
a Safety data profiles from individual pivotal studies (including studies in moderately renally impaired patients; older patients [≥ 55 years of age to ≤ 80 years of age]; patients with increased CV-risk) were generally consistent with the adverse reactions identified in this table.
b Thirst includes the terms thirst, dry mouth, and polydipsia.
c Rash includes the terms rash erythematous, rash generalised, rash macular, rash maculopapular, rash papular, rash pruritic, rash pustular, and rash vesicular.
d Bone fracture was reported in 0.7% and 0.6% for canagliflozin 100 mg and 300 mg, respectively, compared to 0.3% for placebo. See bone fracture section below for additional information.
e Polyuria or pollakiuria includes the terms polyuria, pollakiuria, micturition urgency, nocturia, and urine output increased.
f Urinary tract infection includes the terms urinary tract infection, cystitis, kidney infection, and urosepsis. There was no imbalance among canagliflozin 100 mg, canagliflozin 300 mg, and placebo for kidney infection or urosepsis.
g Vulvovaginal candidiasis includes the terms vulvovaginal candidiasis, vulvovaginal mycotic infection, vulvovaginitis, vaginal infection, vulvitis, and genital infection fungal.
h Balanitis or balanoposthitis includes the terms balanitis, balanoposthitis, balanitis candida, and genital infection fungal.
i Mean percent increases from baseline for canagliflozin 100 mg and 300 mg versus placebo, respectively, were total cholesterol 3.4% and 5.2% versus 0.9%; HDL-cholesterol 9.4% and 10.3% versus 4.0%; LDL-cholesterol 5.7% and 9.3% versus 1.3%; non-HDL-cholesterol 2.2% and 4.4% versus 0.7%; triglycerides 2.4% and 0.0% versus 7.6%.
j Mean changes from baseline in haematocrit were 2.4% and 2.5% for canagliflozin 100 mg and 300 mg, respectively, compared to 0.0% for placebo.
k Mean percent changes from baseline in creatinine were 2.8% and 4.0% for canagliflozin 100 mg and 300 mg, respectively, compared to 1.5 % for placebo.
l Mean percent changes from baseline in blood urea nitrogen were 17.1% and 18.0% for canagliflozin 100 mg and 300 mg, respectively, compared to 2.7% for placebo.
m Mean percent changes from baseline in blood potassium were 0.5% and 1.0% for canagliflozin 100 mg and 300 mg, respectively, compared to 0.6% for placebo.
n Mean percent changes from baseline in serum phosphate were 3.6% and 5.1% for canagliflozin 100 mg and 300 mg, compared to 1.5% for placebo.
Description of selected adverse reactions
Adverse reactions related to volume depletion
In the pooled analysis of the four 26-week, placebo-controlled studies, the incidence of all adverse reactions related to volume depletion (e.g., postural dizziness, orthostatic hypotension, hypotension, dehydration, and syncope) was 1.2% for canagliflozin 100 mg once daily, 1.3% for canagliflozin 300 mg once daily, and 1.1% for placebo. The incidence with canagliflozin treatment in the two active-controlled studies was similar to comparators.
In the dedicated cardiovascular study, where patients were generally older with a higher rate of diabetes complications, the incidences of adverse reactions related to volume depletion were 2.8% with canagliflozin 100 mg once daily, 4.6% with canagliflozin 300 mg once daily, and 1.9% with placebo.
To assess risk factors for these adverse reactions, a larger pooled analysis (N=9,439) of patients from eight controlled phase 3 studies including both doses of canagliflozin was conducted. In this pooled analysis, patients on loop diuretics, patients with a baseline eGFR 30 mL/min/1.73 m2 to < 60 mL/min/1.73 m2, and patients ≥ 75 years of age had generally higher incidences of these adverse reactions. For patients on loop diuretics, the incidences were 3.2% on canagliflozin 100 mg once daily and 8.8% on canagliflozin 300 mg once daily compared to 4.7% in the control group. For patients with a baseline eGFR 30 mL/min/1.73 m2 to < 60 mL/min/1.73 m2 or CrCl 30 to < 60 mL/min, the incidences were 4.8% on canagliflozin 100 mg once daily and 8.1% on canagliflozin 300 mg once daily compared to 2.6% in the control group. In patients ≥ 75 years of age, the incidences were 4.9% on canagliflozin 100 mg once daily and 8.7% on canagliflozin 300 mg once daily compared to 2.6% in the control group (see sections 4.2 and 4.4).
In the dedicated cardiovascular study and the larger pooled analysis, discontinuations due to adverse reactions related to volume depletion and serious adverse reactions related to volume depletion were not increased with canagliflozin.
Hypoglycaemia in add-on therapy with insulin or insulin secretagogues
The frequency of hypoglycaemia was low (approximately 4%) among treatment groups, including placebo, when used as monotherapy or as an add-on to metformin. When canagliflozin was added to insulin therapy, hypoglycaemia was observed in 49.3%, 48.2%, and 36.8% of patients treated with canagliflozin 100 mg once daily, canagliflozin 300 mg once daily, and placebo, respectively, and severe hypoglycaemia occurred in 1.8%, 2.7%, and 2.5% of patients treated with canagliflozin 100 mg once daily, canagliflozin 300 mg once daily, and placebo, respectively. When canagliflozin was added to a sulphonylurea therapy, hypoglycaemia was observed in 4.1%, 12.5%, and 5.8% of patients treated with canagliflozin 100 mg once daily, canagliflozin 300 mg once daily, and placebo, respectively (see sections 4.2 and 4.5).
Genital mycotic infections
Vulvovaginal candidiasis (including vulvovaginitis and vulvovaginal mycotic infection) was reported in 10.4% and 11.4% of female patients treated with canagliflozin 100 mg once daily and canagliflozin 300 mg once daily, respectively, compared to 3.2% in placebo-treated female patients. Most reports of vulvovaginal candidiasis occurred during the first four months of treatment with canagliflozin. Among female patients taking canagliflozin, 2.3% experienced more than one infection. Overall, 0.7% of all female patients discontinued canagliflozin due to vulvovaginal candidiasis (see section 4.4).
Candidal balanitis or balanoposthitis was reported in 4.2% and 3.7% of male patients treated with canagliflozin 100 mg once daily and canagliflozin 300 mg once daily, respectively, compared to 0.6% in placebo-treated male patients. Among male patients taking canagliflozin, 0.9% had more than one infection. Overall, 0.5% of male patients discontinued canagliflozin due to candidial balanitis or balanoposthitis. In rare instances, phimosis was reported and sometimes circumcision was performed (see section 4.4).
Urinary tract infections
Urinary tract infections were more frequently reported for canagliflozin 100 mg and 300 mg once daily (5.9% versus 4.3%, respectively) compared to 4.0% with placebo. Most infections were mild to moderate with no increase in the occurrence of serious adverse reactions. Subjects responded to standard treatments while continuing canagliflozin treatment. The incidence of recurrent infections was not increased with canagliflozin.
Bone fracture
In a cardiovascular study of 4,327 patients with known or at high risk for cardiovascular disease, the incidence rates of bone fracture were 1.6, 1.6, and 1.1 per 100 patient years of exposure to canagliflozin 100 mg, canagliflozin 300 mg, and placebo, respectively, with the fracture imbalance initially occurring within the first 26 weeks of therapy. In other type 2 diabetes studies with canagliflozin, which enrolled a general diabetes population of approximately 5,800 patients, no difference in fracture risk was observed relative to control. After 104 weeks of treatment, canagliflozin did not adversely affect bone mineral density.
Special populations
Elderly (≥ 65 years old)
In a pooled analysis of eight placebo-controlled and active-controlled studies, the safety profile of canagliflozin in elderly patients was generally consistent with younger patients. Patients ≥ 75 years of age had a higher incidence of adverse reactions related to volume depletion (such as postural dizziness, orthostatic hypotension, hypotension) with incidences of 4.9%, 8.7% and 2.6% on canagliflozin 100 mg once daily, canagliflozin 300 mg once daily, and in the control group, respectively. Decreases in eGFR (-3.6% and -5.2%) were reported with canagliflozin 100 mg and canagliflozin 300 mg, respectively, compared to the control group (-3.0%) (see sections 4.2 and 4.4).
Metformin
Table 2 presents adverse reactions by SOC and by frequency category reported in patients who received metformin as monotherapy and that were not observed in patients receiving canagliflozin. Frequency categories are based on information available from the metformin Summary of Product Characteristics.
Table 2: The frequency of metformin adverse reactions identified from clinical trial and postmarketing data
|
System organ class
Frequency
|
Adverse reaction
|
|
Metabolism and nutrition disorders
|
|
very rare
|
Lactic acidosis, Vitamin B12 deficiencya
|
|
Nervous system disorders
|
|
common
|
Taste disturbance
|
|
Gastrointestinal disorders
|
|
very common
|
|
