NATEGLINIDE tablet, coated

Nateglinide by

Drug Labeling and Warnings

Nateglinide by is a Prescription medication manufactured, distributed, or labeled by Cadila Pharmaceuticals Limited. Drug facts, warnings, and ingredients follow.

Drug Details [pdf]

  • 1 INDICATIONS & USAGE


    Nateglinide tablets are indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
    Limitations of Use:

    Nateglinide tablets should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis.




  • 2 DOSAGE & ADMINISTRATION


    The recommended dose of nateglinide tablets is 120 mg orally three times daily before meals.
    The recommended dose of nateglinide tablets is 60 mg orally three times daily before meals in patients who are near glycemic goal when treatment is initiated.
    Instruct patients to take nateglinide tablets 1 to 30 minutes before meals.
    In patients who skip meals, instruct patients to skip the scheduled dose of nateglinide tablets to reduce the risk of hypoglycemia [see Warnings and Precautions (5.1)].

  • 3 DOSAGE FORMS & STRENGTHS


     60 mg tablets: Pink, round, beveled edge  tablet with “C” debossed on one side and “123” on the other side
     120 mg tablets: Yellow, ovaloid  tablet with “C” debossed on one side and “125” on the other side

  • 4 CONTRAINDICATIONS

    Nateglinide is contraindicated in patients with a history of hypersensitivity to nateglinide or its inactive ingredients.

  • 5 WARNINGS AND PRECAUTIONS

    5.1 Hypoglycemia

    All glinides, including nateglinide can cause hypoglycemia [see Adverse Reactions (6.1)]. 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 neuropathy (nerve disease), in patients using medications that block the sympathetic nervous system (e.g., beta-blockers) [see Drug Interactions (7)], 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 coadministered medication [see Drug Interactions (7)], 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 (8.6, 8.7), Clinical Pharmacology (12.3)].

    Patients should take nateglinide before meals and be instructed to skip the dose of nateglinide if a meal is skipped [see Dosage and Administration (2)]. 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.


    5.2 Macrovascular Outcomes

    There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with nateglinide.

  • 6 ADVERSE REACTIONS


    The following serious adverse reaction is also described elsewhere in the labeling: 
               Hypoglycemia [see Warnings and Precautions (5.1)]



    6.1 Clinical Trials Experience


    Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.


    In clinical trials, approximately 2,600 patients with type 2 diabetes mellitus were treated with nateglinide. Of these, approximately 1,335 patients were treated for 6 months or longer and approximately 190 patients for one year or longer. Table 1 shows the most common adverse reactions associated with nateglinide.

    Table 1: Adverse Reactions other than Hypoglycemia (%) occurring Greater than or Equal to 2% in Nateglinide -Treated Patients from Pool of 12 to 64 week Placebo Controlled Trials



     
    		Placebo
    		Nateglinide
     
    		N=458
    		N=1,441
    Preferred Term
    		 
    		 
    Upper Respiratory Infection
    		8.1
    		10.5
    Back Pain
    		3.7
    		4.0
    Flu Symptoms
    		2.6
    		3.6
    Dizziness
    		2.2
    		3.6
    Arthropathy
    		2.2
    		3.3
    Diarrhea
    		3.1
    		3.2
    Accidental Trauma
    		1.7
    		2.9
    Bronchitis
    		2.6
    		2.7
    Coughing
    		2.2
    		2.4

    Hypoglycemia
    Episodes of severe hypoglycemia (plasma glucose less than 36 mg/dL) were reported in two patients treated with nateglinide tablets. Non-severe hypoglycemia occurred in 2.4 % of nateglinide tablets treated patients and 0.4 % of placebo treated patients [see Warnings and Precautions (5.1)].

    Weight Gain
    Patients treated with nateglinide tablets had statistically significant mean increases in weight compared to placebo. In clinical trials, the mean weight increases with nateglinide tablets 60 mg (3 times daily) and nateglinide tablets 120 mg (3 times daily) compared to placebo were 1.0 kg and 1.6 kg respectively.

    Laboratory Test
    Increases in Uric Acid: There were increases in mean uric acid levels for patients treated with nateglinide tablets alone, nateglinide tablets in combination with metformin, metformin alone, and glyburide alone. The respective differences from placebo were 0.29 mg/dL, 0.45 mg/dL, 0.28 mg/dL, and 0.19 mg/dL.

    6.2 Postmarketing Experience


    The following adverse reactions have been identified during post-approval use of nateglinide 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.


     Hypersensitivity reactions: Rash, itching, and urticaria
     Hepatobiliary Disorders: Jaundice, cholestatic hepatitis, and elevated liver enzymes



  • 7 DRUG INTERACTIONS


    Table 2 includes a list of drugs with clinically important drug interactions when concomitantly administered or withdrawn with nateglinide tablets and instructions for managing or preventing them.


    Table 2: Clinically Significant Drug Interactions with Nateglinide


    Drugs That May Increase the Blood-Glucose-Lowering Effect of  Nateglinide and Susceptibility to Hypoglycemia




    Drugs:    		Nonsteroidal anti-inflammatory drugs (NSAIDs), salicylates, monoamine oxidase inhibitors, non-selective beta-adrenergic-blocking agents, anabolic hormones (e.g. methandrostenolone), guanethidine, gymnema sylvestre, glucomannan, thioctic acid, and inhibitors of CYP2C9 (e.g. amiodarone, fluconazole, voriconazole, sulfinpyrazone), or in patients known to be poor metabolizers of CYP2C9 substrates, alcohol.


    Intervention:    		Dose reductions and increased frequency of glucose monitoring may be required when nateglinide tablets are coadministered with these drugs.
    Drugs and Herbals That May Reduce the Blood-Glucose-Lowering Effect of Nateglinide and Increase Susceptibility to Hyperglycemia
     

    Drugs:        		Thiazides, corticosteroids, thyroid products, sympathomimetics, somatropin, somatostatin analogues (e.g. lanreotide, octreotide), and CYP inducers (e.g. rifampin, phenytoin and St John’s Wort).



    Intervention:          		Dose increases and increased frequency of glucose monitoring may be required when nateglinide tablets are coadministered with these drugs.
    Drugs That May Blunt Signs and Symptoms of Hypoglycemia


    Drugs:    		beta-blockers, clonidine, guanethidine, and reserpine

    Intervention:          		Increased frequency of glucose monitoring may be required when nateglinide tablets are co-administered with these drugs.Drugs: beta-blockers, clonidine, guanethidine, and reserpine Intervention: Increased frequency of glucose monitoring may be required when nateglinide tablets are coadministered with these drugs.



  • 8 USE IN SPECIFIC POPULATIONS

    8.1 Pregnancy

    There are no adequate and well-controlled studies of nateglinide in pregnant women. It is unknown whether nateglinide can cause fetal harm when administered to a pregnant woman. Nateglinide tablets should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

    In the rabbit, embryonic development was adversely affected and the incidence of gall bladder agenesis or small gallbladder was increased at a dose of 500 mg/kg (approximately 27 times the human therapeutic exposure of 120 mg three times daily, based on body surface area). Nateglinide was not teratogenic in rats at doses up to 1,000 mg/kg (approximately 27 times the human therapeutic exposure based on body surface area).

    8.2 Labor & Delivery

    8.3 Nursing Mothers

    It is not known whether nateglinide is excreted in human milk. Nateglinide is excreted in rat milk. Offspring of rats exposed to 1,000 mg/kg nateglinide (approximately 27 times the human therapeutic exposure of 120 mg three times daily, based on body surface area) had lower body weight. Because the potential for hypoglycemia in nursing infants may exist, a decision should be made as to whether nateglinide should be discontinued in nursing mothers, or if mothers should discontinue nursing.

    8.4 Pediatric Use

    The safety and effectiveness of nateglinide have not been established in pediatric patients.

    8.5 Geriatric Use

    436 patients 65 years and older, and 80 patients 75 years and older were exposed to nateglinide in clinical studies. No differences were observed in safety or efficacy of nateglinide tablets between patients age 65 and over, and those under age 65. However, greater sensitivity of some older individuals to nateglinide tablets therapy cannot be ruled out.

    8.6 Renal Impairment

    No dosage adjustment is recommended in patients with mild to severe renal impairment [see Clinical Pharmacology (12.3)].

    8.7 Hepatic Impairment

    No dose adjustment is recommended for patients with mild hepatic impairment. Use of nateglinide in patients with moderate-to-severe hepatic impairment has not been studied and therefore, should be used with caution in these patients [see Clinical Pharmacology (12.3)].

  • 10 OVERDOSAGE

    There have been no instances of overdose with nateglinide in clinical trials. However, an overdose may result in an exaggerated glucose-lowering effect with the development of hypoglycemic symptoms. Hypoglycemic symptoms without loss of consciousness or neurological findings should be treated with oral glucose and adjustments in dosage and/or meal patterns. Severe hypoglycemic reactions with coma, seizure, or other neurological symptoms should be treated with intravenous glucose. As nateglinide are highly protein bound, dialysis is not an efficient means of removing it from the blood.

  • 11 DESCRIPTION


     Nateglinide, USP is an oral blood glucose-lowering drug of the glinide class. Nateglinide, USP 
    (-)-N-[(trans-4-isopropylcyclohexane)carbonyl]-D-phenylalanine, is structurally unrelated to the oral sulfonylurea insulin secretagogues.
    The structural formula is as shown:


    nate-spl-strc




    Nateglinide is a white or almost white powder with a molecular weight of 317.42. It is freely soluble in methanol, methylene chloride and in alcohol, soluble in ether, sparingly soluble in acetonitrile and in octanol, practically insoluble in water. Nateglinide tablets contain 60 mg, or 120mg, of nateglinide for oral administration.


    Inactive ingredients: colloidal silicon dioxide, corn starch, croscarmellose sodium, hypromellose, mannitol, iron oxide (yellow and red), polyethylene glycol, povidone, pre-gelatinized starch, sodium lauryl sulphate, sodium starch glycolate , sodium stearyl fumarate, talc and titanium dioxide.





    Film-coating material contains opadry pink and opadry yellow for the 60 mg and 120 mg. Opadry pink contains hypromellose, iron oxide red, macrogol and titanium dioxide. Opadry yellow contains hypromellose, iron oxides (yellow and red), macrogol, titanium dioxide, and talc.

  • 12 CLINICAL PHARMACOLOGY

    12.1 Mechanism of Action

    Nateglinide lowers blood glucose levels by stimulating insulin secretion from the pancreas. This action is dependent upon functioning beta-cells in the pancreatic islets. Nateglinide interacts with the ATP-sensitive potassium (K+ATP) channel on pancreatic beta-cells. The subsequent depolarization of the beta cell opens the calcium channel, producing calcium influx and insulin secretion. The extent of insulin release is glucose dependent and diminishes at low glucose levels. Nateglinide is highly tissue selective with low affinity for heart and skeletal muscle.

    12.2 Pharmacodynamics

    Nateglinide tablets stimulates pancreatic insulin secretion within 20 minutes of oral administration. When nateglinide tablets are dosed before meals, the peak rise in plasma insulin occurs approximately 1 hour after dosing and falls to baseline by 4 hours after dosing.

    12.3 Pharmacokinetics


    In patients with Type 2 diabetes, multiple dose administration of nateglinide over the dosage range of 60 mg to 240 mg shows linear pharmacokinetics for both AUC and Cmax. In patients with Type 2 diabetes, there is no apparent accumulation of nateglinide upon multiple dosing of up to 240 mg three times daily for 7 days.
     
    Absorption
    Absolute bioavailability of nateglinide is approximately 73%. Plasma profiles are characterized by multiple plasma concentration peaks when nateglinide is administered under fasting conditions. This effect is diminished when nateglinide is taken prior to a meal. Following oral administration immediately prior to a meal, the mean peak plasma nateglinide concentrations (Cmax) generally occur within 1 hour (Tmax) after dosing. Tmax is independent of dose.


    The pharmacokinetics of nateglinide are not affected by the composition of a meal (high protein, fat, or carbohydrate). However, peak plasma levels are significantly reduced when nateglinide tablets are administered 10 minutes prior to a liquid meal as compared to solid meal. When given with or after meals, the extent of nateglinide absorption (AUC) remains unaffected. However, there is a delay in the rate of absorption characterized by a decrease in Cmax and a delay in time to peak plasma concentration (Tmax).


    Nateglinide tablets did not have any effect on gastric emptying in healthy subjects as assessed by acetaminophen testing.


    Distribution
    Following intravenous (IV) administration of nateglinide, the steady-state volume of distribution of nateglinide is estimated to be approximately 10 L in healthy subjects. Nateglinide is extensively bound (98%) to serum proteins, primarily serum albumin, and to a lesser extent α1 acid glycoprotein. The extent of serum protein binding is independent of drug concentration over the test range of 0.1 to 10 mcg/mL.





    Elimination
    In healthy volunteers and patients with type 2 diabetes mellitus, nateglinide plasma concentrations declined with an average elimination half-life of approximately 1.5 hours.


    Metabolism
    In vitro     drug metabolism studies indicate that nateglinide tablets are predominantly metabolized by the cytochrome P450 isozyme CYP2C9 (70%) and to a lesser extent CYP3A4 (30%).


    The major routes of metabolism are hydroxylation followed by glucuronide conjugation. The major metabolites are less potent antidiabetic agents than nateglinide. The isoprene minor metabolite possesses potency similar to that of the parent compound nateglinide.


    Excretion
    Nateglinide and its metabolites are rapidly and completely eliminated following oral administration. Eighty-three percent of the 14C-nateglinide was excreted in the urine with an additional 10% eliminated in the feces. Approximately 16% of the 14C-Nateglinide was excreted in the urine as parent compound.





    Specific Populations
    Renal Impairment

    No pharmacokinetic data are available in subjects with mild renal impairment (CrCl 60 to 89 mL/min). Compared to healthy matched subjects, patients with type 2 diabetes mellitus and moderate and severe renal impairment (CrCl 15 to 50 mL/min) not on dialysis displayed similar apparent clearance, AUC, and Cmax. Patients with type 2 diabetes and renal failure on dialysis exhibited reduced overall drug exposure (Cmax decreased by 49%; not statistically significant). However, hemodialysis patients also experienced reductions in plasma protein binding compared to the matched healthy volunteers.

     
    In a cohort of 8 patients with type 2 diabetes and end-stage renal disease (ESRD) (eGFR < 15 mL/min/1.73m2) M1 metabolite accumulation up to 1.2 ng/mL occurred with a dosage of 90 mg once daily for 1 to 3 months. In another cohort of 8 patients with type 2 diabetes on hemodialysis, M1 concentration decreased after a single session of hemodialysis. Although the hypoglycemic activity of the M1 metabolite is approximately 5 times lower than nateglinide, metabolite accumulation may increase the hypoglycemic effect of the administered dose.

     
    Hepatic Impairment
    In patients with mild hepatic impairment, the mean increase in Cmax and AUC of nateglinide were 37% and 30 % respectively, as compared to healthy matched control subjects. There is no data on pharmacokinetics of nateglinide tablets in patients with moderate-to-severe hepatic impairment.


    Gender
    No clinically significant differences in nateglinide pharmacokinetics were observed between men and women.


    Race
    Results of a population pharmacokinetic analysis including subjects of Caucasian, Black, and other ethnic origins suggest that race has little influence on the pharmacokinetics of nateglinide.


    Age
    Age does not influence the pharmacokinetic properties of nateglinide.

    Drug Interactions:

    In vitro assessment of drug interactions
    Nateglinide is a potential inhibitor of the CYP2C9 isoenzyme in vivo as indicated by its ability to inhibit the in vitro metabolism of tolbutamide. Inhibition of CYP3A4 metabolic reactions was not detected in in vitro experiments.


    In vitro displacement studies with highly protein-bound drugs such as furosemide, propranolol, captopril, nicardipine, pravastatin, glyburide, warfarin, phenytoin, acetylsalicylic acid, tolbutamide, and metformin showed no influence on the extent of nateglinide protein binding. Similarly, nateglinide had no influence on the serum protein binding of propranolol, glyburide, nicardipine, warfarin, phenytoin, acetylsalicylic acid, and tolbutamide in vitro. However, prudent evaluation of individual cases is warranted in the clinical setting.

    In vivo assessment of drug interactions
    The effect of coadministered drugs on the pharmacokinetics of nateglinide and the effect of nateglinide on pharmacokinetics of coadministered drugs are shown in Tables 3 and 4. No clinically relevant change in pharmacokinetic parameters of either agent was reported when nateglinide was coadministered with glyburide, metformin, digoxin, warfarin, and diclofenac.

    Table 3: Effect of Coadministered Drugs on Pharmacokinetics of Nateglinide


    Coadministered drug
    		Dosing regimen of coadministered drug
    		Dosing regimen of nateglinide
    		Change in Cmax
    		Change in AUC
    Glyburide
    		10 mg once daily for 3 weeks
    		120 mg three times a day, single dose
    		8.78% ↓
    		3.53 % ↓
    Metformin
    		500 mg three times a
    		120 mg three times a
    		AM: 7.14% ↑
    		AM: 1.51% ↑
     
    		day for 3 weeks
    		day, single dose
    		PM: 11.4% ↓
    		PM: 5.97% ↑
    Digoxin
    		1 mg, single dose
    		120 mg three times a
    		AM: 2.17% ↓
    		AM: 7.62% ↑
     
    		 
    		day, single dose
    		PM: 3.19% ↑
    		PM: 2.22% ↑
    Warfarin
    		30 mg, single dose
    		120 mg three times a day for 4 days
    		2.65% ↑
    		3.72% ↓
    Diclofenac
    		75 mg, single dose
    		120 mg twice daily,
    single dose
    		AM: 13.23% ↓
    *PM: 3.76% ↑
    		AM: 2.2% ↓
    *PM: 7.5% ↑

    AM: after morning dose; PM: after evening dose; * after second dose; ↑: increase in the parameter; ↓: decrease in the parameter

    Table 4: Effect of Nateglinide on Pharmacokinetics of Coadministered Drugs


    Coadministered drug
    		Dosing regimen of Coadministered drug
    		Dosing regimen of nateglinide
    		Change in Cmax
    		Change in AUC
    Glyburide
    		10 mg once daily for 3 weeks
    		120 mg three times a day, single dose
    		3.18% ↓
    		7.34% ↓
    Metformin
    		500 mg three times a day for 3 weeks
    		120 mg three times a day, single dose
    		AM: 10.7% ↑
    PM: 0.40% ↑
    		AM: 13.3% ↑
    PM: 2.27% ↓
    Digoxin
    		1 mg, single dose
    		120 mg three times a
    day, single dose
    		5.41% ↓
    		6.58 % ↑
    Warfarin
    		30 mg, single dose
    		120 mg three times a day for 4  days
    		warfarin: 1.03% ↓
    warfarin: 0.85% ↓
    		warfarin: 0.74% ↑
    warfarin: 7.23% ↑
    Diclofenac
    		75 mg, single dose
    		120 mg twice daily, single dose
    		2.19% ↑
    		7.97% ↑

    AM: after morning dose; PM: after evening dose; SD: single dose; ↑: increase in the parameter; ↓: decrease in the parameter


  • 13 NONCLINICAL TOXICOLOGY

    13.1 Carcinogenesis & Mutagenesis & Impairment Of Fertility

    Carcinogenicity: Nateglinide did not increase tumors in two year carcinogenicity studies conducted in mice and rats. Oral doses of nateglinide up to 900 mg/kg in rats and 400 mg/kg in mice were tested, which produced exposures in rats approximately 30 to 40 times and in mice 10 to 30 times the human therapeutic exposure of nateglinide at a dose of 120 mg three times daily, based on AUC.

    Mutagenesis: Nateglinide was not genotoxic in the in vitro Ames test, mouse lymphoma assay, chromosome aberration assay or in the in vivo mouse micronucleus test.

    Impairment of Fertility: Fertility was unaffected by administration of nateglinide to rats at doses up to 600 mg/kg (approximately 16 times the human therapeutic exposure with a recommended nateglinide tablets dose of 120 mg three times daily before meals).

  • 14 CLINICAL STUDIES

    14.1 Monotherapy

    In a 24-week, double-blind, placebo-controlled study, patients with type 2 diabetes were randomized to receive either nateglinide tablets (60 mg or 120 mg three times daily before meals) or placebo. Patients previously treated with antidiabetic medications were required to discontinue that medication for at least 2 months before randomization.

    At Week 24, treatment with nateglinide tablets before meals resulted in statistically significant reductions in mean HbA1C and mean fasting plasma glucose (FPG) compared to placebo (see Table 5). The reductions in HbA1C and FPG were similar for patient’s naïve to, and those previously exposed to, antidiabetic medications.

    Table 5: Endpoint Results for a 24-week, Fixed Dose Study of Nateglinide Monotherapy

     
     
     
     
     
     
    HbA1C (%)
    		Placebo
     
     
     
     
     
    N=168
    		Nateglinide
    Tablets
    60 mg
    three times
    daily
    before meals
    N=167
    		Nateglinide
    Tablets
    120 mg
    three times
    daily
    before meals
    N=168
    Baseline (mean)
    		8.0
    		7.9
    		8.1
    Change from baseline (mean)
    		+0.2
    		-0.3
    		-0.5
    Difference from placebo (mean)
    		 
    		-0.5a
    		-0.7a
    FPG (mg/dL)
    		N=172
    		N=171
    		N=169
    Baseline (mean)
    		167.9
    		161.0
    		166.5
    Change from baseline (mean)
    		+9.1
    		+0.4
    		-4.5
    Difference from placebo (mean)
    		 
    		-8.7 a
    		-13.6 a

    a p-value £ 0.004






    14.2 Monotherapy Compared to Glyburide

    In a 24-week, double-blind, active-controlled trial, patients with type 2 diabetes who had been on a sulfonylurea for 3 or more months and who had a baseline HbA1C greater than or equal to 6.5% were randomized to receive nateglinide tablets (60 mg or 120 mg three times daily before meals) or glyburide 10 mg once daily. Patients randomized to nateglinide tablets had statistically significant increases in mean HbA1C and mean FPG at endpoint compared to patients randomized to glyburide.

    Table 6: Endpoint Results for a 24-week Study of Nateglinide Monotherapy Compared to Glyburide



     
    Glyburide 10 mg Once daily
    Nateglinide
    60 mg three times daily
    before meals
    Nateglinide
    120 mg three times daily
    before meals
    HbA1C (%)

    N=183
    N=178
    N=179
    Baseline (mean)
    7.8
    8.0
    7.9
    Change from baseline (mean)
    0.3
    1.3
    1.1
    Difference from glyburide
    		 
    1.0 a
    0.9 a
    FPG (mmol/L)

    N=184
    N=182
    N=180
    Baseline (mean)
    9.44
    9.67
    9.61
    Change from baseline (mean)
    0.19
    3.06
    2.84
    Difference from glyburide
    		 
    2.87 a
    2.66 a
    a p-value <0.001



    14.3 Monotherapy and In Combination With Metformin

    In a 24-week, double-blind, active- and placebo-controlled study, patients with type 2 diabetes were randomized to receive either nateglinide alone (120 mg three times daily before meals), metformin alone (500 mg three times daily), a combination of nateglinide tablets 120 mg (three times daily before meals) and metformin (500 mg three times daily), or placebo. Fifty-seven percent of patients were previously untreated with oral antidiabetic therapy. Patients previously treated with antidiabetic medications were required to discontinue medication for at least 2 months before randomization.

    At Week 24, statistically significant reductions in mean HbA1c and FPG were observed with metformin monotherapy compared to nateglinide tablets monotherapy, and the combination of nateglinide tablets and metformin compared to either nateglinide tablets or metformin monotherapy (see Table 7).

    Compared to placebo, nateglinide monotherapy was associated with a statistically significant increase in mean body weight, while no significant change in body weight was observed with metformin monotherapy or combination of nateglinide and metformin therapy (see Table 7). Among the subset of patients previously treated with other antidiabetic agents, primarily glyburide, HbA1C in the nateglinide monotherapy group increased slightly from baseline, whereas HbA1C was reduced in the metformin monotherapy group (see Table 7).

    Table 7: Endpoint results for a 24-week study of Nateglinide Monotherapy and Combination with Metformin

     
    		Placebo
    		Nateglinide
    120 mg three times daily before meals
    		Metformin 500 mg three times daily
    		Nateglinide
    120 mg before meals plus Metformin*
    HbA1C (%)
    		 
    		 
    		 
    		 
    All
    		N=160
    		N=171
    		N=172
    		N=162
    Baseline (mean)
    		8.3
    		8.3
    		8.4
    		8.4
    Change from baseline (mean)
    		+0.4
    		-0.4 bc
    		-0.8 c
    		-1.5
    Difference from placebo
    		 
    		-0.8 a
    		-1.2 a
    		-1.9 a
    Naїve
    		N=98
    		N=99
    		N=98
    		N=81
    Baseline (mean)
    		8.2
    		8.1
    		8.3
    		8.2
    Change from baseline (mean)
    		+0.3
    		-0.7 c
    		-0.8 c
    		-1.6
    Difference from placebo
    		 
    		-1.0 a
    		-1.1 a
    		-1.9 a
    Non-Naїve
    		N=62
    		N=72
    		N=74
    		N=81
    Baseline (mean)
    		8.3
    		8.5
    		8.7
    		8.7
    Change from baseline (mean)
    		+0.6
    		+0.004 bc
    		-0.8 c
    		-1.4
    Difference from placebo
    		 
    		-0.6 a
    		-1.4 a
    		-2.0 a
    FPG (mg/dL)
    		 
    		 
    		 
    		 
    All
    		N=166
    		N=173
    		N=174
    		N=167
    Baseline (mean)
    		194.0
    		196.5
    		196.0
    		197.7
    Change from baseline (mean)
    		+8.0
    		-13.1 bc
    		-30.0 c
    		-44.9
    Difference from placebo
    		 
    		-21.1 a
    		-38.0 a
    		-52.9 a

    a p-value £ 0.05 vs. placebo
    b p-value £ 0.03 vs. metformin
    c p-value £ 0.05 vs. combination
    * Metformin was administered three times daily

    In another 24-week, double-blind, placebo-controlled trial, patients with type 2 diabetes with HbA1C greater than or equal to 6.8% after treatment with metformin (greater than or equal to
    1,500 mg daily for at least 1 month) were first entered into a four week run-in period of metformin monotherapy (2,000 mg daily) and then randomized to receive either nateglinide tablets (60 mg or 120 mg three times daily before meals) or placebo as add-on to metformin. At the end of treatment, nateglinide tablets 60 mg and 120 mg three times daily resulted in a statistically significantly greater reductions in HbA1C compared to placebo when added to metformin (-0.4% and -0.6% for nateglinide tablets 60 mg and nateglinide tablets 120 mg plus metformin, respectively).

    Table 8: Endpoint Results for a 24-week Study of Nateglinide Monotherapy as Add-on to Metformin



     
    Placebo
    +
    metformin
    Nateglinide 60 mg
    +
    metformin
    Nateglinide 120 mg
    +
    metformin
    HbA1C (%)

    N=150
    N=152
    N=154
    Baseline (mean)
    8.2
    8.0
    8.2
    Change from baseline (mean)
    0.01
    -0.4
    -0.6
    Difference from metformin
    		 
    -0.4a
    -0.6b
    a p-value 0.003 vs. metformin
    b p-value < 0.001 vs. metformin
    All nateglinide /placebo taken three times daily before meals; all metformin 1,000 mg twice daily.

    14.4 Add-On Combination Therapy With Rosiglitazone

    A 24-week, double blind, multicenter, placebo-controlled trial was performed in patients with type 2 diabetes not adequately controlled on rosiglitazone 8 mg daily. The addition of nateglinide (120 mg three times per day with meals) was associated with statistically significantly greater reductions in HbA1C compared to placebo as add-on to rosiglitazone. The mean change in weight from baseline was +3 kg for patients treated with nateglinide tablets compared to +1 kg for patients treated with placebo when added to rosiglitazone.

    Table 9: Endpoint Results for a 24-week Study of the Effect of Adding Nateglinide or placebo to Rosiglitazone

     
    		Placebo +
    rosiglitazone
    8 mg
    once daily
    		Nateglinide 120 mg
    before meals +
    rosiglitazone
    8 mg
    once daily
    HbA1C (%)
    		N=191
    		N=194
    Baseline(mean)
    		8.4
    		8.3
    Changefrom baseline (mean)
    		0.03
    		-0.7
    Differencefrom rosiglitazone (mean)
    		 
    		-0.7a
    ap-value≤ 0.0001
    		 
    		 

    14.5 Add-On Combination Therapy With Glyburide

    In a 12-week study of patients with type 2 diabetes inadequately controlled on glyburide 10 mg once daily, the addition of nateglinide (60 mg or 120 mg three times daily before meals) did not produce any additional benefit.

    Table 10: Endpoint Results for a 12-week Study of the Effect of Adding Nateglinide or placebo to Glyburide

     
    		Placebo +
    glyburide
    10 mg
    once daily
    		Nateglinide
    60 mg
    before meals +
    glyburide
    10 mg
    once daily
    		Nateglinide
    120 mg
    before meals + glyburide
    10 mg
    once daily
    HbA1C (%)
    		N=58
    		N=55
    		N=54
    Baseline (mean)
    		8.7
    		8.7
    		8.7
    Change from baseline (mean)
    		0.3
    		0.2
    		-0.02
    Difference from glyburide (mean)
    		 
    		-0.1a
    		-0.3b
    Placebo or nateglinide tablets given 10 minutes prior to breakfast, lunch, and dinner; glyburide given with the breakfast dose of nateglinide tablets or placebo.
    a p-value 0.6959
    b p-value 0.1246


  • 16 HOW SUPPLIED/STORAGE AND HANDLING

    60 mg
    Nateglinide tablets, USP 60 mg are supplied as pink, round, beveled edge tablet with "C" debossed on one side and "123" on the other side.

    NDC Number                 Size
    NDC: 71209-030-05    bottle of 100

    120 mg
    Nateglinide tablets, USP 120 mg are supplied as yellow, ovaloid tablet with "C" debossed on one side and "125" on the other side.

    NDC Number                 Size
    NDC: 71209-031-05    bottle of 100

    Storage and Handling
    Store at 20º to 25ºC (68º to 77ºF); excursions permitted between 15º to 30ºC (59º to 86ºF) [see USP Controlled Room Temperature.] Dispense in a tight container (USP).

  • 17 PATIENT COUNSELING INFORMATION

    Administration
    Instruct patients to take nateglinide tablets 1 to 30 minutes before meals. Instruct patients that skip meals to skip their dose of nateglinide tablets [see Dosage and Administration (2)].

    Hypoglycemia
    Inform patients that nateglinide tablets 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 (5.1)].

    Drug Interactions
    Discuss potential drug interactions with patients and inform them of potential drug-drug interactions with nateglinide tablets.

    Manufactured by:
    Cadila Pharmaceuticals Limited
    1389 Trasad Road,
    Dholka – 382225,
    District - Ahmedabad, Gujarat, INDIA

    May, 2019

  • PACKAGE LABEL.PRINCIPAL DISPLAY PANEL

    NATEGLINIDE TABLETS, USP 60 mg and 120 mg

    NATEGLINIDE TABLETS, USP 60 mg
    71209-030-05
    Rx only
    100 Tablets



    cont-label-60mg-100s


    NATEGLINIDE TABLETS, USP 120 mg
    71209-031-05
    Rx only
    100 Tablets



    cont-label-120mg-100s
  • INGREDIENTS AND APPEARANCE
    NATEGLINIDE 
    nateglinide tablet, coated
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 71209-030
    Route of AdministrationORAL
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    NATEGLINIDE (UNII: 41X3PWK4O2) (NATEGLINIDE - UNII:41X3PWK4O2) NATEGLINIDE60 mg
    Inactive Ingredients
    Ingredient NameStrength
    SILICON DIOXIDE (UNII: ETJ7Z6XBU4)  
    STARCH, CORN (UNII: O8232NY3SJ)  
    CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)  
    HYPROMELLOSES (UNII: 3NXW29V3WO)  
    MANNITOL (UNII: 3OWL53L36A)  
    FERRIC OXIDE RED (UNII: 1K09F3G675)  
    POLYETHYLENE GLYCOL 6000 (UNII: 30IQX730WE)  
    POVIDONE K30 (UNII: U725QWY32X)  
    SODIUM STARCH GLYCOLATE TYPE A POTATO (UNII: 5856J3G2A2)  
    SODIUM LAURYL SULFATE (UNII: 368GB5141J)  
    SODIUM STEARYL FUMARATE (UNII: 7CV7WJK4UI)  
    TALC (UNII: 7SEV7J4R1U)  
    TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
    Product Characteristics
    ColorPINKScoreno score
    ShapeROUNDSize9mm
    FlavorImprint Code C123
    Contains    
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 71209-030-05100 in 1 BOTTLE; Type 0: Not a Combination Product02/10/2014
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA20643202/10/2014
    NATEGLINIDE 
    nateglinide tablet, coated
    Product Information
    Product TypeHUMAN PRESCRIPTION DRUGItem Code (Source)NDC: 71209-031
    Route of AdministrationORAL
    Active Ingredient/Active Moiety
    Ingredient NameBasis of StrengthStrength
    NATEGLINIDE (UNII: 41X3PWK4O2) (NATEGLINIDE - UNII:41X3PWK4O2) NATEGLINIDE120 mg
    Inactive Ingredients
    Ingredient NameStrength
    SILICON DIOXIDE (UNII: ETJ7Z6XBU4)  
    STARCH, CORN (UNII: O8232NY3SJ)  
    CROSCARMELLOSE SODIUM (UNII: M28OL1HH48)  
    HYPROMELLOSES (UNII: 3NXW29V3WO)  
    MANNITOL (UNII: 3OWL53L36A)  
    FERRIC OXIDE RED (UNII: 1K09F3G675)  
    FERRIC OXIDE YELLOW (UNII: EX438O2MRT)  
    POLYETHYLENE GLYCOL 400 (UNII: B697894SGQ)  
    POVIDONE K30 (UNII: U725QWY32X)  
    SODIUM STARCH GLYCOLATE TYPE A POTATO (UNII: 5856J3G2A2)  
    SODIUM LAURYL SULFATE (UNII: 368GB5141J)  
    SODIUM STEARYL FUMARATE (UNII: 7CV7WJK4UI)  
    TALC (UNII: 7SEV7J4R1U)  
    TITANIUM DIOXIDE (UNII: 15FIX9V2JP)  
    Product Characteristics
    ColorYELLOWScoreno score
    ShapeOVALSize18mm
    FlavorImprint Code C125
    Contains    
    Packaging
    #Item CodePackage DescriptionMarketing Start DateMarketing End Date
    1NDC: 71209-031-05100 in 1 BOTTLE; Type 0: Not a Combination Product02/10/2014
    Marketing Information
    Marketing CategoryApplication Number or Monograph CitationMarketing Start DateMarketing End Date
    ANDAANDA20643202/10/2014
    Labeler - Cadila Pharmaceuticals Limited (862257719)
    Establishment
    NameAddressID/FEIBusiness Operations
    Cadila Pharmaceuticals Limited918451696ANALYSIS(71209-030, 71209-031) , LABEL(71209-030, 71209-031) , MANUFACTURE(71209-030, 71209-031) , PACK(71209-030, 71209-031)
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