Prandin Generic Name: repaglinide Brand Name: Prandin side effects drug center prandin (repaglinide) drug Related Drugs Actos Amaryl Byetta Capoten Duetact Fiasp Glucophage Glucotrol Glucotrol XL Humalog Humalog 50-50 Humalog 75-25 Invokana Jentadueto XR Micronase Monopril Novolog Mix 70-30 Onglyza Ozempic Soliqua Starlix Trulicity Zegalogue Zestril Health Resources Diabetes (Type 1 and Type 2) Diabetes Treatment: Medication, Diet, and Insulin New Diabetes Medications List Oral Diabetes Prescription Medications Type 2 Diabetes Related Supplements Acetyl-L-Carnitine Agaricus Mushroom Alpha-Lipoic Acid Beer Blond Psyllium Caffeine Capsicum Chromium Coffee Gamma Linolenic Acid Ginkgo Ginseng, Panax Glucomannan Guar Gum Iodine Magnesium Milk Thistle Oats Prickly Pear Cactus Soy Wine Xanthan Gum Prandin User Reviews PROFESSIONAL CONSUMER SIDE EFFECTS Contents Drug Description Indications & Dosage Side Effects Drug Interactions Warnings & Precautions Overdosage & Contraindications Clinical Pharmacology Medication Guide Drug Description What is Prandin and how is it used? Prandin is a prescription medicine used to treat the symptoms of Type 2 Diabetes Mellitus. Prandin may be used alone or with other medications. Prandin belongs to a class of drugs called Antidiabetics, Maglitinides Derivates. It is not known if Prandin is safe and effective in children. What are the possible side effects of Prandin? Prandin may cause serious side effects including: hives, difficulty breathing, swelling of your face, lips, tongue, or throat, severe pain in your upper stomach spreading to your back, nausea, vomiting, fast heart rate, pale or yellowed skin, dark colored urine, fever, confusion, weakness, sore throat, burning in your eyes, skin pain, and followed by a red or purple skin rash that spreads (especially in the face or upper body) and causes blistering and peeling Get medical help right away, if you have any of the symptoms listed above. The most common side effects of Prandin include: low blood sugar, nausea, diarrhea, headache, back pain, joint pain, and cold symptoms (stuffy nose, sneezing, sore throat) Tell the doctor if you have any side effect that bothers you or that does not go away. These are not all the possible side effects of Prandin. For more information, ask your doctor or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. DESCRIPTION PRANDIN (repaglinide) is an oral blood glucose-lowering drug of the glinide class. Repaglinide, S(+)2-ethoxy-4(2((3-methyl-1-(2-(1piperidinyl) phenyl)-butyl) amino)-2-oxoethyl) benzoic acid, is chemically unrelated to the oral sulfonylurea insulin secretagogues. Structural Formula of Repaglinide Repaglinide is a white to off-white powder with molecular formula C27H36N2O4 and a molecular weight of 452.6. PRANDIN tablets contain 0.5 mg, 1 mg, or 2 mg of repaglinide. In addition each tablet contains the following inactive ingredients: calcium hydrogen phosphate (anhydrous), microcrystalline cellulose, maize starch, polacrilin potassium, povidone, glycerol (85%), magnesium stearate, meglumine, and poloxamer. The 1 mg and 2 mg tablets contain iron oxides (yellow and red, respectively) as coloring agents. Indications & Dosage INDICATIONS PRANDIN is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitation Of Use PRANDIN should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. DOSAGE AND ADMINISTRATION Recommended Dosage And Administration The recommended starting dose for patients whose HbA1c is less than 8% is 0.5 mg orally before each meal. For patients whose HbA1c is 8% or greater the starting dose is 1 or 2 mg orally before each meal. The recommended dose range is 0.5 mg to 4 mg before meals, with a maximum daily dose of 16 mg. The patient’s dose should be doubled up to 4 mg with each meal until satisfactory glycemic control is achieved. At least one week should elapse to assess response after each dose adjustment. Instruct patients to take PRANDIN within 30 minutes before meals. PRANDIN may be dosed 2, 3, or 4 times a day in response to changes in the patient’s meal pattern. In patients who skip meals, instruct patients to skip the scheduled dose of PRANDIN to reduce the risk of hypoglycemia. In patients who experience hypoglycemia, the dose of PRANDIN should be reduced [see WARNINGS AND PRECAUTIONS]. Patients With Severe Renal Impairment In patients with severe renal impairment (CrCl = 20 – 40 mL/min) initiate PRANDIN 0.5 mg orally before each meal. Gradually titrate the dose, if needed to achieve glycemic control. Dose Modifications For Drug Interactions Dosage adjustments are recommended in patients taking concomitant strong CYP3A4 or CYP2C8 inhibitors or strong CYP3A4 or CYP2C8 inducers [see DRUG INTERACTIONS, CLINICAL PHARMACOLOGY]. Concomitant use with gemfibrozil is contraindicated [see CONTRAINDICATIONS]. Avoid concomitant use of PRANDIN with clopidogrel. If concomitant use cannot be avoided, initiate PRANDIN at 0.5 mg before each meal and do not exceed a total daily dose of 4 mg [see DRUG INTERACTIONS, CLINICAL PHARMACOLOGY]. Do not exceed a total daily dose of 6 mg of PRANDIN in patients receiving cyclosporine [see DRUG INTERACTIONS, CLINICAL PHARMACOLOGY]. HOW SUPPLIED Dosage Forms And Strengths 0.5 mg tablets (white, biconvex tablets) 1 mg tablets (yellow, round, biconvex tablets) 2 mg tablets (pink, round, biconvex tablets) Storage And Handling PRANDIN (repaglinide) tablets are supplied as biconvex tablets available in 0.5 mg (white), 1 mg (yellow) and 2 mg (peach) strengths. 0.5 mg tablets (white) Bottles of 100 NDC 0169-0081-81 Bottles of 500 NDC 0169-0081-82 1 mg tablets (yellow) Bottles of 100 NDC 0169-0082-81 Bottles of 500 NDC 0169-0082-82 2 mg tablets (peach) Bottles of 100 NDC 0169-0084-81 Bottles of 500 NDC 0169-0084-82 All strengths of Prandin are not being marketed. Store at 20° to 25° C (68° to 77° F) [see USP Controlled Room Temperature]. Protect from moisture. Keep bottles tightly close. Dispense in tight containers with safety closures. Manufactured for: Gemini Laboratories, LLC Bridgewater, NJ 08807. Rev. Jun 2018 Side Effects SIDE EFFECTS The following serious adverse reaction is also described elsewhere in the labeling: Hypoglycemia [see WARNINGS AND PRECAUTIONS] Clinical Trials Experience Because clinical trials are conducted under widely varying designs, the adverse reaction rates reported in one clinical trial may not be easily compared to those rates reported in another clinical trial, and may not reflect the rates actually observed in clinical practice. PRANDIN has been administered to 2931 individuals during clinical trials. Approximately 1500 of these individuals with type 2 diabetes have been treated for at least 3 months, 1000 for at least 6 months, and 800 for at least 1 year. The majority of these individuals (1228) received PRANDIN in one of five 1-year, active-controlled trials. Over one year, 13% of PRANDIN patients were discontinued due to adverse reactions. The most common adverse reactions leading to withdrawal were hyperglycemia, hypoglycemia, and related symptoms. Table 1 lists the common adverse reactions for PRANDIN patients compared to placebo in trials 12 to 24 weeks duration. Table 1: Adverse Reactions (%) occurring ≥ 2% in PRANDIN Treated Patients from Pool of 12 to 24 Week Placebo Controlled Trials* PRANDIN N=352 Placebo N=108 Upper Respiratory Infection 16 8 Headache 11 10 Sinusitis 6 2 Arthralgia 6 3 Nausea 5 5 Diarrhea 5 2 Back Pain 5 4 Rhinitis 3 3 Constipation 3 2 Vomiting 3 3 Paresthesia 3 3 Chest pain 3 1 Bronchitis 2 1 Dyspepsia 2 2 Urinary tract infection 2 1 Tooth disorder 2 0 Allergy 2 0 *See trial descriptions in Clinical Trials Hypoglycemia In clinical trials with PRANDIN, hypoglycemia is the most commonly observed adverse reaction. Mild or moderate hypoglycemia occurred in 31% of PRANDIN treated patients and 7% of placebo treated patients [see WARNINGS AND PRECAUTIONS). Hypoglycemia was reported in 16% of 1228 PRANDIN patients, 20% of 417 glyburide patients, and 19% of 81 glipizide patients in 1year controlled trials. Of PRANDIN-treated patients with symptomatic hypoglycemia, none developed coma or required hospitalization. In a 24-week placebo controlled trial, patients who were naive to oral hypoglycemic agent therapy and patients with a HbA1c below 8% at baseline had a higher frequency of hypoglycemia. Weight Gain There was no average gain in body weight when patients previously treated with oral hypoglycemic agents were switched to PRANDIN. The average weight gain in patients treated with PRANDIN and not previously treated with sulfonylurea drugs was 3.3%. Cardiovascular Events The incidence of total serious cardiovascular adverse events, including ischemia, was higher for PRANDIN (51/1228 or 4%) than for sulfonylurea drugs (13/498 or 3%) in controlled comparator clinical trials. Table 2: Summary of Serious Cardiovascular Events in Trials Comparing PRANDIN to Sulfonylureas (% of total patients with events) PRANDIN SU* Total Exposed 1228 498 Serious CV Events 4% 3% Cardiac Ischemic Events 2% 2% Deaths due to CV Events 0.5% 0.4% *: glyburide and glipizide Seven controlled clinical trials included PRANDIN combination therapy with NPH-insulin (n=431), insulin formulations alone (n=388) or other combinations (sulfonylurea plus NPH-insulin or PRANDIN plus metformin) (n=120). There were six serious adverse events of myocardial ischemia in patients treated with PRANDIN plus NPH-insulin from two studies, and one event in patients using insulin formulations alone from another study [see WARNINGS AND PRECAUTIONS]. Combination Therapy With Thiazolidinediones Hypoglycemia During 24-week treatment clinical trials of PRANDIN-rosiglitazone or PRANDIN-pioglitazone combination therapy (a total of 250 patients in combination therapy), hypoglycemia (blood glucose < 50 mg/dL) occurred in 7% of patients in combination therapy compared to 7% for PRANDIN monotherapy, and 2% for thiazolidinedione monotherapy. Peripheral Edema And Heart Failure Peripheral edema was reported in 12 out of 250 (4.8%) PRANDIN-thiazolidinedione combination therapy patients and 3 out of 124 (2.4%) thiazolidinedione monotherapy patients, with no cases reported in these trials for PRANDIN monotherapy. There were reports in 2 of 250 patients (0.8%) treated with PRANDIN-thiazolidinedione therapy of episodes of edema with congestive heart failure. Both patients had a prior history of coronary artery disease and recovered after treatment with diuretic agents. No comparable cases in the monotherapy treatment groups were reported. Weight Gain Mean weight increases associated with combination, PRANDIN and pioglitazone therapy were 5.5 kg, 0.3 kg, and 2.0 kg respectively. Mean weight increases associated with combination, PRANDIN and rosiglitazone therapy were 4.5 kg, 1.3 kg, and 3.3 kg respectively. Infrequent Adverse Events (<1% of Patients) Less common adverse clinical or laboratory events observed in clinical trials included elevated liver enzymes, thrombocytopenia, leukopenia, and anaphylactoid reactions. Postmarketing Experience The following additional adverse reactions have been identified during post approval use of PRANDIN. Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or a causal relationship to drug exposure. Alopecia Hemolytic anemia Pancreatitis Stevens-JohnsonSyndrome Severe hepatic dysfunction including jaundice and hepatitis Drug Interactions DRUG INTERACTIONS Clinically Important Drug Interactions With PRANDIN Table 3 includes a list of drugs with clinically important drug interactions when administered concomitantly with PRANDIN and instructions for preventing or managing them. Table 3: Clinically Important Drug Interactions with PRANDIN Gemfibrozil Clinical Impact: Gemfibrozil significantly increased repaglinide exposures by 8.1 fold [see CLINICAL PHARMACOLOGY] Intervention: Do not administer PRANDIN to patients receiving gemfibrozil [see CONTRAINDICATIONS]. Clopidogrel Clinical Impact: Clopidogrel increased repaglinide exposures by 3.9-5.1 fold [see CLINICAL PHARMACOLOGY] Intervention: Avoid concomitant use of PRANDIN with clopidogrel. If concomitant use cannot be avoided, initiate PRANDIN at 0.5 mg before each meal and do not exceed a total daily dose of 4 mg [see DOSAGE AND ADMINISTRATION]. Increased frequency of glucose monitoring may be required during concomitant use. Cyclosporine Clinical Impact: Cyclosporine increased low dose repaglinide exposures by 2.5 fold [see CLINICAL PHARMACOLOGY] Intervention: Daily maximum PRANDIN dose should be limited to 6 mg, and increased frequency of glucose monitoring may be required when PRANDIN is co-administered with cyclosporine. CYP2C8 and CYP3A4 Inhibitors Intervention: PRANDIN dose reductions and increased frequency of glucose monitoring may be required when co-administered. Examples: Drugs that are known to inhibit CYP3A4 include antifungal agents (ketoconazole, itraconazole) and antibacterial agents (clarithromycin, erythromycin). Drugs that are known to inhibit CYP2C8 include trimethoprim, gemfibrozil, montelukast, deferasirox, and clopidiogrel. CYP2C8 and CYP3A4 Inducers Intervention: PRANDIN dose increases and increased frequency of glucose monitoring may be required when co-administered. Examples: Drugs that induce the CYP3A4 and/or 2C8 enzyme systems include rifampin, barbiturates, and carbamezapine Drugs That May Increase the Risk of Hypoglycemia Intervention: PRANDIN dose reductions and increased frequency of glucose monitoring may be required when co-administered. Examples: Antidiabetic agents, ACE inhibitors, angiotensin II receptor blocking agents, disopyramide, fibrates, fluoxetine, monoamine oxidase inhibitors, nonsteroidal anti-inflammatory agents (NSAIDs), pentoxifylline, pramlintide, propoxyphene, salicylates, somatostatin analogs (e.g., octreotide), and sulfonamide antibiotics Drugs That May Decrease the Blood Glucose Lowering Effect of PRANDIN Intervention: PRANDIN dose increases and increased frequency of glucose monitoring may be required when co-administered. Examples: Atypical antipsychotics (e.g., olanzapine and clozapine), calcium channel antagonists, corticosteroids, danazol, diuretics, estrogens, glucagon, isoniazid, niacin, oral contraceptives, phenothiazines, progestogens (e.g., in oral contraceptives), protease inhibitors, somatropin, sympathomimetic agents (e.g., albuterol, epinephrine, terbutaline), and thyroid hormones. Drugs That May Blunt Signs and Symptoms of Hypoglycemia Intervention: Increased frequency of glucose monitoring may be required when PRANDIN is co-administered with these drugs. Examples: beta-blockers, clonidine, guanethidine, and reserpine Warnings & Precautions WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Hypoglycemia All glinides, including PRANDIN, can cause hypoglycemia [see ADVERSE REACTIONS]. Severe hypoglycemia can cause seizures, may be life-threatening, or cause death. Hypoglycemia can impair concentration ability and reaction time; this may place an individual and others at risk in situations where these abilities are important (e.g., driving or operating other machinery). Hypoglycemia can happen suddenly and symptoms may differ in each individual and change over time in the same individual. Symptomatic awareness of hypoglycemia may be less pronounced in patients with longstanding diabetes, in patients with diabetic nerve disease, in patients using medications that block the sympathetic nervous system (e.g., beta-blockers) [see DRUG INTERACTIONS], or in patients who experience recurrent hypoglycemia. Factors which may increase the risk of hypoglycemia include changes in meal pattern (e.g., macronutrient content), changes in level of physical activity, changes to co-administered medication [see DRUG INTERACTIONS], and concomitant use with other antidiabetic agents. Patients with renal or hepatic impairment may be at higher risk of hypoglycemia [see Use In Specific Populations]. Patients should administer PRANDIN before meals and be instructed to skip the dose of PRANDIN if a meal is skipped. In patients who experience hypoglycemia, the dose of PRANDIN should be reduced [see DOSAGE AND ADMINISTRATION]. Patients and caregivers must be educated to recognize and manage hypoglycemia. Self-monitoring of blood glucose plays an essential role in the prevention and management of hypoglycemia. In patients at higher risk for hypoglycemia and patients who have reduced symptomatic awareness of hypoglycemia, increased frequency of blood glucose monitoring is recommended. Serious Cardiovascular Adverse Reactions With Concomitant Use With NPH-insulin Across seven controlled trials, there were six serious adverse events of myocardial ischemia in patients treated with PRANDIN plus NPH-insulin from two studies, and one event in patients using insulin formulations alone from another study [See ADVERSE REACTIONS]. PRANDIN is not indicated for use in combination with NPH-insulin. Macrovascular Outcomes There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with PRANDIN. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility In a 104-week carcinogenicity study in rats at doses up to 120 mg/kg/day, which is approximately 90 times clinical exposure on a mg/m² basis, the incidences of benign adenomas of the thyroid and liver were increased in male rats. No evidence of carcinogenicity was found in female rats. The higher incidences of thyroid and liver tumors in male rats were not seen at lower dose of 30 mg/kg/day and 60 mg/kg/day respectively (which are over 20 and 45 times, respectively, clinical exposures on a mg/m² basis). In a 104-week carcinogenicity study in mice at doses up to 500 mg/kg/day, no evidence of carcinogenicity was found in mice (which is approximately 187 times clinical exposure on a mg/m² basis). Repaglinide was non-genotoxic in a battery of in vivo and in vitro studies: Bacterial mutagenesis (Ames test), in vitro forward cell mutation assay in V79 cells (HGPRT), in vitro chromosomal aberration assay in human lymphocytes, unscheduled and replicating DNA synthesis in rat liver, and in vivo mouse and rat micronucleus tests. In a rat fertility study, repaglinide was administered to male and female rats at doses up to 300 and 80 mg/kg/day, respectively. No adverse effects on fertility were observed (which are over 60 times clinical exposure on a mg/m² basis). Use In Specific Populations Pregnancy Risk Summary Limited available data from case reports and case series with PRANDIN use in pregnant women have not identified a drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes. There are risks to the mother and fetus associated with poorly controlled diabetes in pregnancy (see Clinical Considerations). Teratogenicity was not observed in rats and rabbits administered repaglinide during organogenesis at approximately 60 and 1 times the maximum daily clinical dose, based on body surface area. No adverse developmental effects were observed in offspring of rats administered repaglinide during late gestation and lactation at approximately 4 times the maximum daily clinical dose (see Data). The estimated background risk of major birth defects is 6-10% in women with pre-gestational diabetes with a HbA1c>7 and has been reported to be as high as 20-25% in women with a HbA1c>10. The estimated background risk of miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. Clinical Considerations Disease-Associated Maternal And/Or Embryo/Fetal Risk Poorly controlled diabetes in pregnancy increases the maternal risk for diabetic ketoacidosis, pre-eclampsia, spontaneous abortions, preterm delivery, and delivery complications. Poorly controlled diabetes increases the fetal risk for major birth defects, stillbirth and macrosomia related morbidity. Data Animal Data Repaglinide was not teratogenic in rats or rabbits at doses 60 times (rats) and approximately 1 times (rabbit) clinical exposure (on a mg/m² basis) when administered during the period of organogenesis. Offspring of rat dams exposed to repaglinide at ≥22 times clinical exposure on a mg/m² basis during days 17 to 22 of gestation and during lactation were less viable and developed skeletal deformations consisting of shortening, thickening, and bending of the humerus during the postnatal period. This effect was not seen at doses up to 4 times clinical exposure (on a mg/m² basis). Lactation Risk Summary There are no data on the presence of repaglinide in human milk, the effects on the breastfeeding infant, or the effects on milk production. The drug is present in animal milk. When a drug is present in animal milk, it is likely that the drug will be present in human milk (see Data). Because of the potential for hypoglycemia in breastfed infants, PRANDIN is not recommended for use when breastfeeding. Data In rat reproduction studies, measurable levels of repaglinide were detected in the breast milk of the dams and lowered blood glucose levels were observed in the pups. Cross fostering studies indicated that skeletal changes [see Use In Specific Populations] could be induced in control pups nursed by treated dams, although this occurred to a lesser degree than those pups treated in utero. Pediatric Use Safety and effectiveness have not been established in pediatric patients. Geriatric Use In clinical studies of 24 weeks or greater duration, 415 patients were over 65 years of age and no patients were greater than 75 years of age. In one-year, active-controlled trials, no differences were seen in effectiveness or adverse events between these subjects and those less than 65. There was no increase in frequency or severity of hypoglycemia in older subjects, but greater sensitivity of some older individuals to PRANDIN therapy cannot be ruled out. Renal Impairment Pharmacokinetic studies of repaglinide were conducted in patients with mild to moderate renal function impairment (CrCl = 40 – 80 mL/min), and severe renal function impairment (CrCl = 20 – 40 mL/min). Initial dose adjustment is not required in patients with mild to moderate renal dysfunction. However, patients with severe renal function impairment should initiate PRANDIN therapy with the 0.5 mg dose and be carefully titrated [see DOSAGE AND ADMINISTRATION]. Studies were not conducted in patients with creatinine clearances below 20 mL/min or patients with renal failure requiring hemodialysis. Hepatic Impairment A single-dose study was conducted 12 patients with chronic liver disease. Patients with moderate to severe impairment of liver function had higher and more prolonged serum concentrations. Therefore, PRANDIN should be used cautiously in patients with impaired liver function. Longer intervals between dose adjustments may be needed to allow full assessment of response. Overdosage & Contraindications OVERDOSE Severe hypoglycemic reactions with coma, seizure, or other neurological impairment may occur and constitute medical emergencies requiring immediate hospitalization. Hypoglycemic symptoms without loss of consciousness or neurologic findings should be treated aggressively with oral glucose and adjustments in drug dosage and/or meal patterns. Close monitoring may continue until the physician is assured that the patient is out of danger. Patients should be closely monitored for a minimum of 24 to 48 hours, since hypoglycemia may recur after apparent clinical recovery. There is no evidence that PRANDIN is dialyzable using hemodialysis. CONTRAINDICATIONS PRANDIN is contraindicated in patients with: Concomitant use of gemfibrozil [see DRUG INTERACTIONS] Known hypersensitivity to repaglinide or any inactive ingredients Clinical Pharmacology CLINICAL PHARMACOLOGY Mechanism Of Action Repaglinide lowers blood glucose levels by stimulating the release of insulin from the pancreas. This action is dependent upon functioning beta (β) cells in the pancreatic islets. Insulin release is glucose-dependent and diminishes at low glucose concentrations. Repaglinide closes ATP-dependent potassium channels in the β-cell membrane by binding at characterizable sites. This potassium channel blockade depolarizes the β-cell, which leads to an opening of calcium channels. The resulting increased calcium influx induces insulin secretion. The ion channel mechanism is highly tissue selective with low affinity for heart and skeletal muscle. Pharmacodynamics A four-week, double-blind, placebo-controlled dose-response trial was conducted in 138 patients with type 2 diabetes using doses ranging from 0.25 (not an approved dose) to 4 mg taken with each of three meals. PRANDIN therapy resulted in dose-proportional glucose lowering over the full dose range. Plasma insulin levels increased after meals and reverted toward baseline before the next meal. Most of the fasting blood glucose-lowering effect was demonstrated within 1-2 weeks. In a double-blind, placebo-controlled, 3-month dose titration study, PRANDIN or placebo doses for each patient were increased weekly from 0.25 mg (not an approved dose) through 0.5, 1, and 2 mg, to a maximum of 4 mg, until a fasting plasma glucose (FPG) level <160 mg/dL was achieved or the maximum dose reached. The dose that achieved the targeted control or the maximum dose was continued to end of study. FPG and 2-hour post-prandial glucose (PPG) increased in patients receiving placebo and decreased in patients treated with repaglinide. Differences between the repaglinide-and placebo-treated groups were -61 mg/dL (FPG) and -104 mg/dL (PPG) (Table 4). Table 4: PRANDIN vs Placebo : Mean Change from Baseline after 3 Months of Treatment Repaglinide Placebo N 66 33 Fasting Plasma Glucose (mg/dL) Baseline 220.2 215.3 Change from baseline (at last visit) -31.0* 30.3 Post Prandial Glucose (mg/dL) Baseline 261.7 245.2 Change from baseline (at last visit) -47.6* 56.5 *: p< 0.05 for between group difference The dosing of PRANDIN relative to meal-related insulin release was studied in three trials including 58 patients. Glycemic control was maintained during a period in which the meal and dosing pattern was varied (2, 3 or 4 meals per day; before meals x 2, 3, or 4) compared with a period of 3 regular meals and 3 doses per day (before meals x 3). Blood glucose-lowering effect did not differ when PRANDIN was administered at the start of a meal, 15 minutes before, or 30 minutes before the meal. Pharmacokinetics The pharmacokinetic parameters of repaglinide obtained from a single-dose, crossover study in healthy subjects and from a multiple-dose, parallel, dose-proportionality (0.5, 1, 2 and 4 mg) study in patients with type 2 diabetes are summarized in Tables 5 and 6. These data indicate that repaglinide did not accumulate in serum. Clearance of oral repaglinide did not change over the 0.5 -4 mg dose range, indicating a linear relationship between dose and plasma drug levels. Table 5: Pharmacokinetic Parameters for Repaglinide in Healthy Subjects Parameter CL (based on i.v.) 38 ± 16 L/hr Vss (based on i.v.) 31 ± 12 L AbsBio 56 ± 9% CL = total body clearance Vss = volume of distribution at steady state AbsBio = absolute bioavailability Table 6: Pharmacokinetic Parameters for Repaglinide in Patients with Type 2 Diabetes* Dose (m) Pharmacokinetic Parameter AUC0-24 hr (ng/mL*hr) Mean (SD) Cmax0-5 hr (ng/mL) Mean (SD) 0.5 68.9 (154.4) 9.8 (10.2) 1 125.8 (129.8) 18.3 (9.1) 2 152.4 (89.60) 26.0 (13.0) 4 447.4 (211.3) 65.8 (30.1) T max0-5 h rMeans (SD) T½ Means (Ind Range) 0.5 -4 1.0 - 1.4 (0.3 - 0.5) hr 1.0 - 1.4 (0.4 - 8.0) hr *dosed preprandially with three meals Absorption After oral administration, repaglinide is completely absorbed from the gastrointestinal tract. After single and multiple oral doses in healthy subjects or in patients, peak plasma drug levels (Cmax) occur within 1 hour (Tmax). Repaglinide is eliminated from the blood stream with a half-life of approximately 1 hour. The mean absolute bioavailability is 56%. When repaglinide was given with food, the meanTmax wasnotchanged,butthe meanCmax and AUC(areaunderthetime/plasmaconcentrationcurve) weredecreased20%and 12.4%, respectively. Distribution After intravenous (IV) dosing in healthy subjects, the volume of distribution at steady state (Vss) was 31 L, and the total body clearance (CL) was 38 L/h. Protein binding and binding to human serum albumin was greater than 98%. Metabolism And Elimination Repaglinide is completely metabolized by oxidative biotransformation and direct conjugation with glucuronic acid after either an IV or oral dose. The major metabolites are an oxidized dicarboxylic acid (M2), the aromatic amine (M1), and the acyl glucuronide (M7). The cytochrome P-450 enzyme system, specifically 2C8 and 3A4, have been shown to be involved in the N-dealkylation of repaglinide to M2 and the further oxidation to M1. Metabolites do not contribute to the glucose-lowering effect of repaglinide. Within 96 hours after dosing with 14C-repaglinide as a single, oral dose, approximately 90% of the radiolabel was recovered in the feces and approximately 8% in the urine. Only 0.1% of the dose is cleared in the urine as parent compound. The major metabolite (M2) accounted for 60% of the administered dose. Less than 2% of parent drug was recovered in feces. Repaglinide appears to be a substrate for active hepatic uptake transporter (organic anion transporting protein OATP1B1). Variability Of Exposure Repaglinide AUC after multiple doses of 0.25 to 4 mg with each meal varies over a wide range. The intra-individual and inter-individual coefficients of variation were 36% and 69%, respectively. AUC over the therapeutic dose range included 69 to 1005 ng/mL*hr, but AUC exposure up to 5417 ng/mL*hr was reached in dose escalation studies without apparent adverse consequences. Specific Populations Geriatric Healthy volunteers were treated with a regimen of 2 mg PRANDIN taken before each of 3 meals. There were no significant differences in repaglinide pharmacokinetics between the group of patients <65 years of age and a comparably sized group of patients ≥65 years of age [see Use In Specific Populations]. Gender A comparison of pharmacokinetics in males and females showed the AUC over the 0.5 mg to 4 mg dose range to be 15% to 70% higher in females with type 2 diabetes. This difference was not reflected in the frequency of hypoglycemic episodes (male: 16%; female: 17%) or other adverse events. Race No pharmacokinetic studies to assess the effects of race have been performed, but in a U.S. 1-year study in patients with type 2 diabetes, the blood glucose-lowering effect was comparable between Caucasians (n=297) and African-Americans (n=33). In a U.S. dose-response study, there was no apparent difference in exposure (AUC) between Caucasians (n=74) and Hispanics (n=33). Renal Impairment Single-dose and steady-state pharmacokinetics of repaglinide were compared between patients with type 2 diabetes and normal renal function (CrCl > 80 mL/min), mild to moderate renal function impairment (CrCl = 40 – 80 mL/min), and severe renal function impairment (CrCl = 20 – 40 mL/min). Both AUC and Cmax of repaglinide were similar in patients with normal and mild to moderately impaired renal function (mean values 56.7 ng/mL*hr vs 57.2 ng/mL*hr and 37.5 ng/mL vs 37.7 ng/mL, respectively.) Patients with severely reduced renal function had elevated mean AUC and Cmax values (98.0ng/mL*hr and 50.7ng/mL, respectively), but this study showed only a weak correlation between repaglinide levels and creatinine clearance. Hepatic Impairment A single-dose, open-label study was conducted in 12 healthy subjects and 12 patients with chronic liver disease (CLD) classified by Child-Pugh scale and caffeine clearance. Patients with moderate to severe impairment of liver function had higher and more prolonged serum concentrations of both total and unbound repaglinide than healthy subjects (AUChealthy: 91.6 ng/mL*hr; AUCCLD patients: 368.9 ng/mL*hr; Cmax, healthy: 46.7 ng/mL; Cmax, CLD patients: 105.4 ng/mL). AUC was statistically correlated with caffeine clearance. No difference in glucose profiles was observed across patient groups. Drug-Drug Interactions Drug interaction studies performed in healthy volunteers show that PRANDIN had no clinically relevant effect on the pharmacokinetic properties of digoxin, theophylline, or warfarin. Co-administration of cimetidine with PRANDIN did not significantly alter the absorption and disposition of repaglinide. Additionally, the following drugs were studied in healthy volunteers with co-administration of PRANDIN. Table 7: Effect of Other Drugs on AUC and Cmax of Repaglinide Study Drug Dosing Repaglinide Dosing1 Repaglinide AUC Cmax Clarithromycin* 250 mg BID for 4 days 40% ↑ 67% ↑ Clopidogrel* 300 mg (Day 1) 75 mg QD (Day 2-3) 0.25 mg (Day 1 and 3) (day 1) 5.1 fold ↑ (3.9-6.6) (day 3) 3.9 fold ↑ (2.9-5.3) 2.5 fold ↑(1.8-3.5) 2.0 fold ↑ (1.3-3.1) Cyclosporine 100 mg (2 doses 12 hours apart) 2.5 fold↑ 1.8 fold↑ Deferasirox* 30 mg/kg QD for 4 days 0.5 mg 2.3 fold ↑ 62% ↑ Fenofibrate 200 mg QD for 5 days 0% 0% Gemfibrozil* 600 mg BID for 3 days 8.1 fold ↑ 2.4 fold ↑ Itraconazole* 100 mg BID for 3 days 1.4 fold ↑ 1.5 fold↑ Gemfibrozil + Itraconazole* Co-administration Gem: 600 mg BID for 3 days Itra: 100 mg BID for 3 days 19 fold ↑ 2.8 fold ↑ Ketoconazole 200 mg QD for 4 days 2 mg 15% ↑ 16%↑ Levonorgestrel/ethinyl Estradiol (0.15 mg/0.03 mg) Combination tablet QD for 21 days 2 mg 0% 20% ↑ Nifedipine* 10 mg TID for 4 days 2 mg 0% 0% Rifampin* 600 mg QD for 6-7 days 4 mg 32-80% ↓ 17-79% ↓ Simvastatin 20 mg QD for 4 days 2 mg 0% 26% ↑ Trimethoprim* 160 mg BID for 2 days 61% ↑ 41% ↑ 160 mg QD for 1 day 1Unless indicated all drug interactions were observed with single dose of 0.25 mg repaglinide ↑indicates increase ↓indicates decrease * Indicates data are from published literature Clinical Studies Monotherapy Trials A double-blind, placebo-controlled trial was carried out in 362 patients treated for 24 weeks. HbA1c for the PRANDIN-treated groups (1 and 4 mg groups combined) at the end of the study was decreased compared to the placebo-treated group in treatment naïve patients and in patients previously treated with oral hypoglycemic agents by 2.1% and 1.7%, respectively. In this fixed-dose trial, patients who were treatment naïve to oral hypoglycemic agent therapy and patients with a HbA1c below 8% at baseline showed greater blood glucose-lowering. Combination Trials PRANDIN In Combination With Metformin PRANDIN was studied in combination with metformin in 83 patients not satisfactorily controlled on exercise, diet, and metformin alone. PRANDIN dosage was titrated for 4 to 8 weeks, followed by a 3-month maintenance period. Combination therapy with PRANDIN and metformin resulted in statistically significant improvement in HbA1c and fasting plasma glucose (FPG) compared to PRANDIN or metformin monotherapy (Table 8). In this study where metformin dosage was kept constant, the combination therapy of PRANDIN and metformin showed dose-sparing effects with respect to PRANDIN. The improvement in HbA1c and FPG of the combination group was achieved at a lower daily PRANDIN dosage than in the PRANDIN monotherapy group (Table 8). Table 8: PRANDIN in Combination with Metformin: Mean Change from Baseline after 4 to 5 Months of Treatment1 PRANDIN Monotherapy PRANDIN Combination Therapy with Metformin Metformin Monotherapy N 28 27 27 Median Final Dose (mg/day) 12 6 (PRANDIN) 1500 (metformin) 1500 HbA1C (%) Baseline 8.6 8.3 8.6 Change from baseline -0.38 -1.41* -0.33 Fasting Plasma Glucose (mg/dL) Baseline 174 184 194 Change from baseline 8.8 -39.2* -4.5 Weight (kg) Baseline 87 93 91 Change from baseline 3.0 2.4# -0.90 1: based on intent-to-treat analysis *: p< 0.05, for pairwise comparisons with PRANDIN and metformin monotherapy. #: p< 0.05, for pairwise comparison with metformin. PRANDIN In Combination With Pioglitazone A combination therapy regimen of PRANDIN and pioglitazone (N=123) was compared to PRANDIN alone (N=61) and pioglitazone alone (N=62) in a 24-week trial that enrolled 246 patients previously treated with sulfonylurea or metformin monotherapy (HbA1c > 7.0%). PRANDIN dosage was titrated during the first 12 weeks, followed by a 12-week maintenance period. Combination therapy resulted in statistically significant improvement in HbA1c and FPG compared to monotherapy (Figure 1). The changes from baseline for completers in FPG (mg/dL) and HbA1c (%), respectively were: -39.8 mg/dL and -0.1% for PRANDIN, -35.3 mg/dL and -0.1% for pioglitazone and -92.4 mg/dL and -1.9% for the combination. In this study where pioglitazone dosage was kept constant, the combination therapy group showed dose-sparing effects with respect to PRANDIN (see Figure 1 Legend). The improvement in HbA1c and FPG of the combination group was achieved at a lower daily PRANDIN dosage than in the PRANDIN monotherapy group. Figure 1: PRANDIN in Combination with Pioglitazone: HbA1c Values LEGEND: HbA1c values by study week for patients who completed study (combination, N = 101; PRANDIN, N = 35, pioglitazone, N = 26). Subjects with FPG above 270 mg/dL were withdrawn from the study. Pioglitazone dose: fixed at 30 mg/day; PRANDIN median final dose: 6 mg/day for combination and 10 mg/day for monotherapy. PRANDIN In Combination With Rosiglitazone A combination therapy regimen of PRANDIN and rosiglitazone was compared to monotherapy with either agent alone in a 24-week trial that enrolled 252 patients previously treated with sulfonylurea or metformin (HbA1c > 7.0%). Combination therapy resulted in statistically significant improvement in HbA1c and FPG compared to monotherapy (Table 9 below). The glycemic effects of the combination therapy were dose-sparing with respect to both total daily PRANDIN dosage and total daily rosiglitazone dosage (see Table 9 Legend). The improvement in HbA1c and FPG of the combination therapy group was achieved with lower daily dose of PRANDIN and rosiglitazone, as compared to the respective monotherapy groups. Table 9: PRANDIN in Combination with Rosiglitazone: Mean Change from Baseline in a 24-Week Study1 PRANDIN Monotherapy PRANDIN Combination Therapy with Rosiglitazone Rosiglitazone Monotherapy N 63 127 62 Median Final Dose (mg/day) 12 6 (PRANDIN) 4 (Rosiglitazone) 8 HbA1C (%) Baseline 9.3 9.1 9.0 Change from baseline -0.17 -1.43 * -0.56 Fasting Plasma Glucose (mg/dL) Baseline 269 257 252 Change from baseline -54 -94* -67 Change in Weight (kg) + 1.3 +4.5# +3.3 1: based on intent-to-treat analysis *: p< 0.001 for comparison to either monotherapy #: p< 0.05 for comparison to PRAND Medication Guide PATIENT INFORMATION Hypoglycemia Inform patients that PRANDIN can cause hypoglycemia and instruct patients and their caregivers on self-management procedures including glucose monitoring and management of hypoglycemia. Inform patients that their ability to concentrate and react may be impaired as a result of hypoglycemia. In patients at higher risk for hypoglycemia and patients who have reduced symptomatic awareness of hypoglycemia, increased frequency of blood glucose monitoring is recommended [see WARNINGS AND PRECAUTIONS]. Administration Instruct patients to take PRANDIN within 30 minutes before meals. Instruct patients to skip their dose of PRANDIN when a meal is skipped. [see DOSAGE AND ADMINISTRATION]. Drug Interactions Discuss potential drug interactions with patients and inform them of potential drug-drug interactions with PRANDIN. [see DRUG INTERACTIONS].
