Metformin hydrochloride

• The recommended starting dose of Metformin Hydrochloride Extended-Release Tablets is 500 mg orally once daily with the evening meal.
• Increase the dose in increments of 500 mg every 1 to 2 weeks on the basis of glycemic control and tolerability, up to a maximum of 2,000 mg once daily with the evening meal.
• Patients receiving metformin hydrochloride (HCl) may be switched to Metformin Hydrochloride Extended-Release Tablets once daily at the same total daily dose, up to 2,000 mg once daily.
• Swallow Metformin Hydrochloride Extended-Release Tablets whole and never crush, cut or chew.
• If a dose of Metformin Hydrochloride Extended-Release Tablets is missed, instruct patients not to take two doses the same day and to resume their usual dose of Metformin Hydrochloride Extended-Release Tablets with the next schedule dose.

• Assess renal function prior to initiation of Metformin Hydrochloride Extended-Release Tablets and periodically thereafter.
• Metformin Hydrochloride Extended-Release Tablets are contraindicated in patients with an estimated glomerular filtration rate (eGFR) below 30 mL/minute/1.73 m ².
• Initiation of Metformin Hydrochloride Extended-Release Tablets in patients with an eGFR between 30 to 45 mL/minute/1.73 m ²is not recommended.
• In patients taking Metformin Hydrochloride Extended-Release Tablets whose eGFR later falls below 45 mL/minute/1.73 m ², assess the benefit risk of continuing therapy.
• Discontinue Metformin Hydrochloride Extended-Release Tablets if the patient’s eGFR later falls below 30 mL/minute/1.73 m ²
  [see Contraindications ( 4) and Warnings and Precautions ( 5.1)] .

Discontinue Metformin Hydrochloride Extended-Release Tablets at the time of, or prior to, an iodinated contrast imaging procedure in patients with an eGFR between 30 and 60 mL/minute/1.73 m2; in patients with a history of liver disease, alcoholism or heart failure; or in patients who will be administered intra-arterial iodinated contrast. Re-evaluate eGFR 48 hours after the imaging procedure; restart Metformin Hydrochloride Extended-Release Tablets if renal function is stable [see Warnings and Precautions ( 5.1)].

There have been postmarketing cases of metformin-associated lactic acidosis, including fatal cases. These cases had a subtle onset and were accompanied by nonspecific symptoms such as malaise, myalgias, abdominal pain, respiratory distress, or increased somnolence; however, hypothermia, hypotension and resistant bradyarrhythmias have occurred with severe acidosis. Metformin-associated lactic acidosis was characterized by elevated blood lactate concentrations (>5 mmol/Liter), anion gap acidosis (without evidence of ketonuria or ketonemia), and an increased lactate/pyruvate ratio; metformin plasma levels were generally >5 mcg/mL. Metformin decreases liver uptake of lactate increasing lactate blood levels which may increase the risk of lactic acidosis, especially in patients at risk.

If metformin-associated lactic acidosis is suspected, general supportive measures should be instituted promptly in a hospital setting, along with immediate discontinuation of Metformin Hydrochloride Extended-Release Tablets. In Metformin Hydrochloride Extended-Release Tablets-treated patients with a diagnosis or strong suspicion of lactic acidosis, prompt hemodialysis is recommended to correct the acidosis and remove accumulated metformin (metformin HCl is dialyzable, with a clearance of up to 170 mL/minute under good hemodynamic conditions). Hemodialysis has often resulted in reversal of symptoms and recovery.

Educate patients and their families about the symptoms of lactic acidosis and if these symptoms occur, instruct them to discontinue Metformin Hydrochloride Extended-Release Tablets and report these symptoms to their healthcare provider.

For each of the known and possible risk factors for metformin-associated lactic acidosis, recommendations to reduce the risk of and manage metformin-associated lactic acidosis are provided below:

• Renal Impairment:The postmarketing metformin-associated lactic acidosis cases primarily occurred in patients with significant renal impairment.
  The risk of metformin accumulation and metformin-associated lactic acidosis increases with the severity of renal impairment because metformin is substantially excreted by the kidney. Clinical recommendations based upon the patient’s renal function include [see Dosage and Administration ( 2.2) and Clinical Pharmacology ( 12.3)]:
• Before initiating Metformin Hydrochloride Extended-Release Tablets, obtain an estimated glomerular filtration rate (eGFR).
• Metformin Hydrochloride Extended-Release Tablets are contraindicated in patients with an eGFR less than 30 mL/minute/1.73 m ² [see Contraindications ( 4)].
• Initiation of Metformin Hydrochloride Extended-Release Tablets is not recommended in patients with eGFR between 30 to 45 mL/minute/1.73 m ².
• Obtain an eGFR at least annually in all patients taking Metformin Hydrochloride Extended-Release Tablets. In patients at increased risk for the development of renal impairment (e.g., the elderly), renal function should be assessed more frequently.
• In patients taking Metformin Hydrochloride Extended-Release Tablets whose eGFR later falls below 45 mL/minute/1.73 m ², assess the benefit and risk of continuing therapy.
• Drug Interactions:The concomitant use of Metformin Hydrochloride Extended-Release Tablets with specific drugs may increase the risk of metformin-associated lactic acidosis: those that impair renal function, result in significant hemodynamic change, interfere with acid-base balance or increase metformin accumulation [see Drug Interactions ( 7)]. Therefore, consider more frequent monitoring of patients.
• Age 65 or Greater:The risk of metformin-associated lactic acidosis increases with the patient’s age because elderly patients have a greater likelihood of having hepatic, renal, or cardiac impairment than younger patients. Assess renal function more frequently in elderly patients [see Use in Specific Populations ( 8.5)].
• Radiological Studies with Contrast:Administration of intravascular iodinated contrast agents in metformin-treated patients has led to an acute decrease in renal function and the occurrence of lactic acidosis. Stop Metformin Hydrochloride Extended-Release Tablets at the time of, or prior to, an iodinated contrast imaging procedure in patients with an eGFR between 30 and 60 mL/minute/1.73 m ²; in patients with a history of hepatic impairment, alcoholism, or heart failure; or in patients who will be administered intra-arterial iodinated contrast. Re-evaluate eGFR 48 hours after the imaging procedure, and restart Metformin Hydrochloride Extended-Release Tablets if renal function is stable.
• Surgery and Other Procedures:Withholding of food and fluids during surgical or other procedures may increase the risk for volume depletion, hypotension and renal impairment. Metformin Hydrochloride Extended-Release Tablets should be temporarily discontinued while patients have restricted food and fluid intake.
• Hypoxic States:Several of the postmarketing cases of metformin-associated lactic acidosis occurred in the setting of acute congestive heart failure (particularly when accompanied by hypoperfusion and hypoxemia). Cardiovascular collapse (shock), acute myocardial infarction, sepsis, and other conditions associated with hypoxemia have been associated with lactic acidosis and may also cause prerenal azotemia. When such events occur, discontinue Metformin Hydrochloride Extended-Release Tablets.
• Excessive Alcohol Intake:Alcohol potentiates the effect of metformin on lactate metabolism, and this may increase the risk of metformin-associated lactic acidosis. Warn patients against excessive alcohol intake while receiving Metformin Hydrochloride Extended-Release Tablets.
• Hepatic Impairment:Patients with hepatic impairment have developed cases of metformin-associated lactic acidosis. This may be due to impaired lactate clearance resulting in higher lactate blood levels. Therefore, avoid use of Metformin Hydrochloride Extended-Release Tablets in patients with clinical or laboratory evidence of hepatic disease.

In clinical trials of 29-week duration with metformin HCl tablets, a decrease to subnormal levels of previously normal serum vitamin B ₁₂levels was observed in approximately 7% of patients. Such decrease, possibly due to interference with B ₁₂absorption from the B ₁₂-intrinsic factor complex, may be associated with anemia but appears to be rapidly reversible with discontinuation of metformin or vitamin B ₁₂supplementation. Certain individuals (those with inadequate vitamin B ₁₂or calcium intake or absorption) appear to be predisposed to developing subnormal vitamin B ₁₂levels. Measure hematologic parameters on an annual basis and vitamin B ₁₂at 2 to 3 year intervals in patients on Metformin Hydrochloride Extended-Release Tablets and manage any abnormalities [ see Adverse Reactions ( 6.1)] .

Insulin and insulin secretagogues (e.g., sulfonylurea) are known to cause hypoglycemia. Metformin Hydrochloride Extended-Release Tablets may increase the risk of hypoglycemia when combined with insulin and/or an insulin secretagogue. Therefore, a lower dose of insulin or insulin secretagogue may be required to minimize the risk of hypoglycemia when used in combination with Metformin Hydrochloride Extended-Release Tablets [see Drug Interactions ( 7)] .

There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Metformin Hydrochloride Extended-Release Tablets.

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 clinical trials conducted in the U.S., over 1,000 patients with type 2 diabetes mellitus have been treated with Metformin Hydrochloride Extended-Release Tablets 1,500 to 2,000 mg/day in active-controlled and placebo-controlled studies with the 500 mg dosage form.

In the add-on to sulfonylurea study, patients receiving background glyburide therapy were randomized to receive add-on treatment of either one of three different regimens of Metformin Hydrochloride Extended-Release Tablets or placebo. In total, 431 patients received Metformin Hydrochloride Extended-Release Tablets and glyburide and 144 patients received placebo and glyburide.

Adverse reactions reported in greater than 5% of patients treated with Metformin Hydrochloride Extended-Release Tablets that were more common in the combined Metformin Hydrochloride Extended-Release Tablets and glyburide group than in the placebo and glyburide group are shown in Table 1. In 0.7% of patients treated with Metformin Hydrochloride Extended-Release Tablets and glyburide, diarrhea was responsible for discontinuation of study medication compared to no patients in the placebo and glyburide group.

Laboratory Tests
Vitamin B ₁₂Concentrations
In clinical trials of 29-week duration with metformin HCl tablets, a decrease to subnormal levels of previously normal serum vitamin B ₁₂levels was observed in approximately 7% of patients.

The following adverse reactions have been identified during post-approval use of Metformin Hydrochloride Extended-Release Tablets. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Cholestatic, hepatocellular, and mixed hepatocellular liver injury have been reported with postmarketing use of metformin.

Risk Summary

Limited data with Metformin Hydrochloride Extended-Release Tablets in pregnant women are not sufficient to determine a drug-associated risk for major birth defects or miscarriage. Published studies with metformin use during pregnancy have not reported a clear association with metformin and major birth defect or miscarriage risk [see Data]. There are risks to the mother and fetus associated with poorly controlled diabetes mellitus in pregnancy [see Clinical Considerations].

No adverse developmental effects were observed when metformin was administered to pregnant Sprague Dawley rats and rabbits during the period of organogenesis at doses up to 3 and 1 times, respectively, a 2,000 mg clinical dose, based on body surface area [see Data].

The estimated background risk of major birth defects is 6–10% in women with pregestational diabetes mellitus with an HbA1c >7 and has been reported to be as high as 20–25% in women with an 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 mellitus in pregnancy increases the maternal risk for diabetic ketoacidosis, pre-eclampsia, spontaneous abortions, preterm delivery, stillbirth and delivery complications. Poorly controlled diabetes mellitus increases the fetal risk for major birth defects, stillbirth, and macrosomia-related morbidity.

Data

Human Data

Published data from postmarketing studies have not reported a clear association with metformin and major birth defects, miscarriage, or adverse maternal or fetal outcomes when metformin was used during pregnancy. However, these studies cannot definitely establish the absence of any metformin-associated risk because of methodological limitations, including small sample size and inconsistent comparator groups.

Animal Data

Metformin HCl was not teratogenic or embyrolethal when administered to rats prior to pregnancy through the period of organogenesis at doses up to 900 mg/kg, or when administered to rabbits during the period of organogenesis at doses up to 90 mg/kg.

Risk Summary

Limited published studies report that metformin is present in human milk [see Data]. However, there is insufficient information to determine the effects of metformin on the breastfed infant and no available information on the effects of metformin on milk production. Therefore, the developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Metformin Hydrochloride Extended-Release Tablets and any potential adverse effects on the breastfed child from Metformin Hydrochloride Extended-Release Tablets or from the underlying maternal condition.

Data

Published clinical lactation studies report that metformin is present in human milk which resulted in infant doses approximately 0.11% to 1% of the maternal weight-adjusted dosage and a milk/plasma ratio ranging between 0.13 and 1. However, the studies were not designed to definitely establish the risk of use of metformin during lactation because of small sample size and limited adverse event data collected in infants.

Discuss the potential for unintended pregnancy with premenopausal women as therapy with Metformin Hydrochloride Extended-Release Tablets may result in ovulation in some anovulatory women.

Safety and effectiveness of Metformin Hydrochloride Extended-Release Tablets in pediatric patients have not been established.

Clinical studies of Metformin Hydrochloride Extended-Release Tablets did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy and the higher risk of lactic acidosis. Assess renal function more frequently in elderly patients. [see Dosage and Administration ( 2.2) and Warnings and Precautions ( 5.1).]

Metformin is substantially excreted by the kidney, and the risk of metformin accumulation and lactic acidosis increases with the degree of renal impairment. Metformin Hydrochloride Extended-Release Tablets are contraindicated in severe renal impairment, patients with an estimated glomerular filtration rate (eGFR) below 30 mL/minute/1.73 m ². [see Dosage and Administration ( 2.2), Contraindications ( 4), Warnings and Precautions ( 5.1), and Clinical Pharmacology ( 12.3).]

Use of metformin in patients with hepatic impairment has been associated with some cases of lactic acidosis. Metformin Hydrochloride Extended-Release Tablets are not recommended in patients with hepatic impairment . [see Warnings and Precautions ( 5.1).]

Metformin is a biguanide that improves glucose tolerance in patients with type 2 diabetes, lowering both basal and postprandial plasma glucose. Metformin decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization. With metformin therapy, insulin secretion remains unchanged while fasting insulin levels and day-long plasma insulin response may decrease.

Absorption

Following a single oral dose of 1,000 mg (2x500 mg tablets) Metformin Hydrochloride Extended-Release Tablets after a meal, the time to reach maximum plasma metformin concentration (T _max) is achieved at approximately 7-8 hours. In both single- and multiple-dose studies in healthy subjects, once daily 1,000 mg (2x500 mg tablets) dosing provides equivalent systemic exposure, as measured by area under the curve (AUC), and up to 35% higher C _max, of metformin relative to the immediate-release given as 500 mg twice daily. At usual clinical doses and dosing schedules of metformin, steady state plasma concentrations of metformin are reached within 24-48 hours and are generally <1 mcg/mL.

In a two-way, single-dose, crossover study in healthy volunteers, the 1,000 mg tablet was found to be similar to two 500 mg tablets under fed conditions based on equivalent C _maxand AUCs for the two formulations.

Single oral doses of Metformin Hydrochloride Extended-Release Tablets from 500 mg to 2,500 mg resulted in less than proportional increase in both AUC and C _max.

Effect of food:Low-fat and high-fat meals increased the systemic exposure (as measured by AUC) from Metformin Hydrochloride Extended-Release Tablets by about 38% and 73%, respectively, relative to fasting. Both meals prolonged metformin T _maxby approximately 3 hours but C _maxwas not affected.

Distribution

The apparent volume of distribution (V/F) of metformin following single oral doses of 850 mg metformin HCl averaged 654±358 L. Metformin is negligibly bound to plasma proteins. Metformin partitions into erythrocytes, most likely as a function of time.

Metabolism

Intravenous, single-dose studies in healthy subjects demonstrate that metformin is excreted unchanged in the urine and does not undergo hepatic metabolism (no metabolites have been identified in humans), nor biliary excretion.

Excretion

Renal clearance is approximately 3.5 times greater than creatinine clearance, which indicates that tubular secretion is the major route of metformin elimination. Following oral administration, approximately 90% of the absorbed drug is eliminated via the renal route within the first 24 hours, with a plasma elimination half-life of approximately 6.2 hours. In blood, the elimination half-life is approximately 17.6 hours, suggesting that the erythrocyte mass may be a compartment of distribution.

Special Populations

Renal Impairment
Following a single-dose administration of Metformin Hydrochloride Extended-Release Tablets 500 mg in subjects with mild and moderate renal impairment, the oral and renal clearance of metformin were decreased by 33% and 50% and 16% and 53%, respectively .Metformin peak and systemic exposure was 27% and 61% greater, respectively in subjects with mild renal impairment and 74% and 2.36-fold greater in subjects with moderate renal impairment as compared to healthy subjects. [see Dosage and Administration ( 2.2), Contraindications ( 4), and Warnings and Precautions ( 5.1).]

Hepatic Impairment
No pharmacokinetic studies of Metformin Hydrochloride Extended-Release Tablets have been conducted in subjects with hepatic impairment, [see Warnings and Precautions ( 5.1) and Use in Specific Populations ( 8.7)]

Geriatrics
Limited data from controlled pharmacokinetic studies of metformin HCl in healthy elderly subjects suggest that total plasma clearance of metformin is decreased by 35%, the half-life is prolonged by 64% and C _maxis increased by 76%, compared to healthy young subjects. From these data, it appears that the change in metformin pharmacokinetics with aging is primarily accounted for by a change in renal function. [see Dosage and Administration ( 2) and Warnings and Precautions ( 5.1).]

Gender
In the pharmacokinetic studies in healthy volunteers, there were no important differences between male and female subjects with respect to metformin AUC and t1/2. However, C _maxfor metformin was 40% higher in female subjects as compared to males. In controlled clinical studies in patients with type 2 diabetes, the antihyperglycemic effect of metformin HCl tablets was comparable in males and females. The gender differences for C _maxare unlikely to be clinically important.

Race
A trend towards 10% higher metformin C _maxand AUC values for metformin are obtained in Asian subjects when compared to Caucasian, Hispanic and Black subjects. The differences between the Asian and Caucasian groups are unlikely to be clinically important. In controlled clinical studies of metformin HCl in patients with type 2 diabetes, the antihyperglycemic effect was comparable in whites (n=249), blacks (n=51) and Hispanics (n=24).

Pediatrics
There are no available pharmacokinetic data with Metformin Hydrochloride Extended-Release Tablets in pediatric patients.

Drug Interactions
Specific pharmacokinetic drug interaction studies with Metformin Hydrochloride Extended-Release Tablets have not been performed except for one with glyburide. However, such studies have been performed on metformin HCl tablets.

Long-term carcinogenicity studies have been performed in Sprague Dawley rats at doses of 150, 300, and 450 mg/kg/day in males and 150, 450, 900, and 1,200 mg/kg/day in females. These doses are approximately 2, 4, and 8 times in males, and 3, 7, 12, and 16 times in females of the maximum recommended human daily dose of 2,000 mg based on body surface area comparisons. No evidence of carcinogenicity with metformin was found in either male or female rats. A carcinogenicity study was also performed in Tg.AC transgenic mice at doses up to 2,000 mg applied dermally. No evidence of carcinogenicity was observed in male or female mice.

Genotoxicity assessments in the Ames test, gene mutation test (mouse lymphoma cells), chromosomal aberrations test (human lymphocytes) and in vivo mouse micronucleus tests were negative. Fertility of male or female rats was not affected by metformin when administered at doses up to 600 mg/kg/day, which is approximately 3 times the maximum recommended human daily dose based on body surface area comparisons.