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Janumet, INN-Sitagliptin/Metformin

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Janumet, INN-Sitagliptin/Metformin ANNEX I SUMMARY OF PRODUCT CHARACTERISTICS 1 1. NAME OF THE MEDICINAL PRODUCT Janumet 50 mg/850 mg film-coated tablets 2. QUALITATIVE AND QUANTITATIVE COMPOSITION Each tablet contains sitagliptin phosphate monohydrate equivalent to 50 mg of sitagliptin and 850 mg of metformin hydrochloride. For the full list of excipients, see section 6.1. 3. PHARMACEUTICAL FORM Film-coated tablet (tablet). Capsule-shaped, pink film-coated tablet with “515” debossed on one side. 4. CLINICAL PARTICULARS 4.1 Therapeutic indications For adult patients with type 2 diabetes mellitus: Janumet is indicated as an adjunct to diet and exercise to improve glycaemic control in patients inadequately controlled on their maximal tolerated dose of metformin alone or those already being treated with the combination of sitagliptin and metformin. Janumet is indicated in combination with a sulphonylurea (i.e., triple combination therapy) as an adjunct to diet and exercise in patients inadequately controlled on their maximal tolerated dose of metformin and a sulphonylurea. Janumet is indicated as triple combination therapy with a peroxisome proliferator-activated receptor gamma (PPAR) agonist (i.e., a thiazolidinedione) as an adjunct to diet and exercise in patients inadequately controlled on their maximal tolerated dose of metformin and a PPAR agonist. Janumet is also indicated as add-on to insulin (i.e., triple combination therapy) as an adjunct to diet and exercise to improve glycaemic control in patients when stable dose of insulin and metformin alone do not provide adequate glycaemic control. 4.2 Posology and method of administration Posology The dose of antihyperglycaemic therapy with Janumet should be individualised on the basis of the patient’s current regimen, effectiveness, and tolerability while not exceeding the maximum recommended daily dose of 100 mg sitagliptin. Adults with normal renal function (GFR ≥ 90 mL/min) For patients inadequately controlled on maximal tolerated dose of metformin monotherapy For patients not adequately controlled on metformin alone, the usual starting dose should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) plus the dose of metformin already being taken. 2 For patients switching from co-administration of sitagliptin and metformin For patients switching from co-administration of sitagliptin and metformin, Janumet should be initiated at the dose of sitagliptin and metformin already being taken. For patients inadequately controlled on dual combination therapy with the maximal tolerated dose of metformin and a sulphonylurea The dose should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken. When Janumet is used in combination with a sulphonylurea, a lower dose of the sulphonylurea may be required to reduce the risk of hypoglycaemia (see section 4.4). For patients inadequately controlled on dual combination therapy with the maximal tolerated dose of metformin and a PPAR agonist The dose should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken. For patients inadequately controlled on dual combination therapy with insulin and the maximal tolerated dose of metformin The dose should provide sitagliptin dosed as 50 mg twice daily (100 mg total daily dose) and a dose of metformin similar to the dose already being taken. When Janumet is used in combination with insulin, a lower dose of insulin may be required to reduce the risk of hypoglycaemia (see section 4.4). For the different doses on metformin, Janumet is available in strengths of 50 mg sitagliptin and 850 mg metformin hydrochloride or 1,000 mg metformin hydrochloride. All patients should continue their recommended diet with an adequate distribution of carbohydrate intake during the day. Special populations Renal impairment No dose adjustment is needed for patients with mild renal impairment (glomerular filtration rate [GFR] 60 mL/min). A GFR should be assessed before initiation of treatment with metformin- containing products and at least annually thereafter. In patients at increased risk of further progression of renal impairment and in the elderly, renal function should be assessed more frequently, e.g. every 3-6 months. The maximum daily dose of metformin should preferably be divided into 2-3 daily doses. Factors that may increase the risk of lactic acidosis (see section 4.4) should be reviewed before considering initiation of metformin in patients with GFR < 60 mL/min. If no adequate strength of Janumet is available, individual monocomponents should be used instead of the fixed-dose combination. GFR mL/min Metformin Sitagliptin 60-89 Maximum daily dose is 3,000 mg. Maximum daily dose is 100 mg. Dose reduction may be considered in relation to declining renal function. 45-59 Maximum daily dose is 2,000 mg. Maximum daily dose is 100 mg. The starting dose is at most half of the maximum dose. 30-44 Maximum daily dose is 1,000 mg. Maximum daily dose is 50 mg. The starting dose is at most half of the maximum dose. 3 < 30 Metformin is contraindicated. Maximum daily dose is 25 mg. Hepatic impairment Janumet must not be used in patients with hepatic impairment (see section 5.2). Elderly As metformin and sitagliptin are excreted by the kidney, Janumet should be used with caution as age increases. Monitoring of renal function is necessary to aid in prevention of metformin-associated lactic acidosis, particularly in the elderly (see sections 4.3 and 4.4). Paediatric population Janumet should not be used in children and adolescents 10 to 17 years of age because of insufficient efficacy. Currently available data are described in sections 4.8, 5.1, and 5.2. Janumet has not been studied in paediatric patients under 10 years of age. Method of administration Janumet should be given twice daily with meals to reduce the gastrointestinal adverse reactions associated with metformin. 4.3 Contraindications Janumet is contraindicated in patients with: - hypersensitivity to the active substances or to any of the excipients listed in section 6.1 (see sections 4.4 and 4.8); - any type of acute metabolic acidosis (such as lactic acidosis, diabetic ketoacidosis); - diabetic pre-coma; - severe renal failure (GFR< 30 mL/min) (see section 4.4); - acute conditions with the potential to alter renal function such as: - dehydration, - severe infection, - shock, - intravascular administration of iodinated contrast agents (see section 4.4); - acute or chronic disease which may cause tissue hypoxia such as: - cardiac or respiratory failure, - recent myocardial infarction, - shock; - hepatic impairment; - acute alcohol intoxication, alcoholism; - breast-feeding. 4.4 Special warnings and precautions for use General Janumet should not be used in patients with type 1 diabetes and must not be used for the treatment of diabetic ketoacidosis. Acute pancreatitis Use of DPP-4 inhibitors has been associated with a risk of developing acute pancreatitis. Patients should be informed of the characteristic symptom of acute pancreatitis: persistent, severe abdominal pain. Resolution of pancreatitis has been observed after discontinuation of sitagliptin (with or without supportive treatment), but very rare cases of necrotising or haemorrhagic pancreatitis and/or death have been reported. If pancreatitis is suspected, Janumet and other potentially suspect medicinal products should be discontinued; if acute pancreatitis is confirmed, Janumet should not be restarted. Caution should be exercised in patients with a history of pancreatitis. 4 Lact ic acidosis Lactic acidosis, a rare but serious metabolic complication, most often occurs at acute worsening of renal function or cardiorespiratory illness or sepsis. Metformin accumulation occurs at acute worsening of renal function and increases the risk of lactic acidosis. In case of dehydration (severe vomiting, diarrhoea, fever or reduced fluid intake), metformin should be temporarily discontinued and contact with a health care professional is recommended. Medicinal products that can acutely impair renal function (such as antihypertensives, diuretics and NSAIDs) should be initiated with caution in metformin-treated patients. Other risk factors for lactic acidosis are excessive alcohol intake, hepatic insufficiency, inadequately controlled diabetes, ketosis, prolonged fasting and any conditions associated with hypoxia, as well as concomitant use of medicinal products that may cause lactic acidosis (see sections 4.3 and 4.5). Patients and/or care-givers should be informed of the risk of lactic acidosis. Lactic acidosis is characterised by acidotic dyspnoea, abdominal pain, muscle cramps, asthenia and hypothermia followed by coma. In case of suspected symptoms, the patient should stop taking metformin and seek immediate medical attention. Diagnostic laboratory findings are decreased blood pH (< 7.35), increased plasma lactate levels (> 5 mmol/L) and an increased anion gap and lactate/pyruvate ratio. Renal function GFR should be assessed before treatment initiation and regularly thereafter (see section 4.2). Janumet is contraindicated in patients with GFR < 30 mL/min and should be temporarily discontinued during conditions with the potential to alter renal function (see section 4.3). Hypoglycaemia Patients receiving Janumet in combination with a sulphonylurea or with insulin may be at risk for hypoglycaemia. Therefore, a reduction in the dose of the sulphonylurea or insulin may be necessary.
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