XIGDUO XR SIDE EFFECTS
- Generic Name: dapagliflozin and metformin hcl extended-release tablets
- Brand Name: Xigduo XR
- Drug Class: Antidiabetics, SGLT2 Inhibitors
SIDE EFFECTS
The following important adverse reactions are described below and elsewhere in the labeling:
- Lactic Acidosis
- Volume Depletion
- Ketoacidosis
- Urosepsis and Pyelonephritis
- Use with Medications Known to Cause Hypoglycemia
- Necrotizing Fasciitis of the Perineum (Fournier’s Gangrene)
- Vitamin B12 Concentrations
- Genital Mycotic Infections
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 clinical practice.
Dapagliflozin And Metformin HCl
Data from a prespecified pool of patients from 8 short-term, placebo-controlled studies of dapagliflozin coadministered with metformin immediate-or extended-release was used to evaluate safety. This pool included several add-on studies (metformin alone and in combination with a dipeptidyl peptidase-4 [DPP4] inhibitor and metformin, or insulin and metformin, 2 initial combination with metformin studies, and 2 studies of patients with CVD and type 2 diabetes mellitus who received their usual treatment [with metformin as background therapy]). For studies that included background therapy with and without metformin, only patients who received metformin were included in the 8-study placebo-controlled pool. Across these 8 studies 983 patients were treated once daily with dapagliflozin 10 mg and metformin and 1185 were treated with placebo and metformin. These 8 studies provide a mean duration of exposure of 23 weeks. The mean age of the population was 57 years and 2% were older than 75 years. Fifty-four percent (54%) of the population was male; 88% White, 6% Asian, and 3% Black or African American. At baseline, the population had diabetes for an average of 8 years, mean hemoglobin A1c (HbA1c) was 8.4%, and renal function was normal or mildly impaired in 90% of patients and moderately impaired in 10% of patients.
The overall incidence of adverse events for the 8-study, short-term, placebo-controlled pool in patients treated with dapagliflozin 10 mg and metformin was 60.3% compared to 58.2% for the placebo and metformin group. Discontinuation of therapy due to adverse events in patients who received dapagliflozin 10 mg and metformin was 4% compared to 3.3% for the placebo and metformin group. The most commonly reported events leading to discontinuation and reported in at least 3 patients treated with dapagliflozin 10 mg and metformin were renal impairment (0.7%), increased blood creatinine (0.2%), decreased renal creatinine clearance (0.2%), and urinary tract infection (0.2%).
Table 1 shows common adverse reactions associated with the use of dapagliflozin and metformin. These adverse reactions were not present at baseline, occurred more commonly on dapagliflozin and metformin than on placebo, and occurred in at least 2% of patients treated with either dapagliflozin 5 mg or dapagliflozin 10 mg.
Table 1: Adverse Reactions in Placebo-Controlled Studies Reported in ≥2% of Patients Treated with Dapagliflozin and Metformin
| Adverse Reaction | % of Patients | ||
| Pool of 8 Placebo-Controlled Studies | |||
| Placebo and Metformin N=1185 |
Dapagliflozin 5 mg and Metformin N=410 |
Dapagliflozin 10 mg and Metformin N=983 |
|
| Female genital mycotic infections* | 1.5 | 9.4 | 9.3 |
| Nasopharyngitis | 5.9 | 6.3 | 5.2 |
| Urinary tract infections† | 3.6 | 6.1 | 5.5 |
| Diarrhea | 5.6 | 5.9 | 4.2 |
| Headache | 2.8 | 5.4 | 3.3 |
| Male genital mycotic infections‡ | 0 | 4.3 | 3.6 |
| Influenza | 2.4 | 4.1 | 2.6 |
| Nausea | 2.0 | 3.9 | 2.6 |
| Back pain | 3.2 | 3.4 | 2.5 |
| Dizziness | 2.2 | 3.2 | 1.8 |
| Cough | 1.9 | 3.2 | 1.4 |
| Constipation | 1.6 | 2.9 | 1.9 |
| Dyslipidemia | 1.4 | 2.7 | 1.5 |
| Pharyngitis | 1.1 | 2.7 | 1.5 |
| Increased urination§ | 1.4 | 2.4 | 2.6 |
| Discomfort with urination | 1.1 | 2.2 | 1.6 |
| * Genital mycotic infections include the following adverse reactions, listed in order of frequency reported for females: vulvovaginal mycotic infection, vaginal infection, genital infection, vulvovaginitis, fungal genital infection, vulvovaginal candidiasis, vulval abscess, genital candidiasis, and vaginitis bacterial. (N for females: Placebo and metformin=534, dapagliflozin 5 mg and metformin=223, dapagliflozin 10 mg and metformin=430). † Urinary tract infections include the following adverse reactions, listed in order of frequency reported: urinary tract infection, cystitis, pyelonephritis, urethritis, and prostatitis. ‡ Genital mycotic infections include the following adverse reactions, listed in order of frequency reported for males: balanitis, fungal genital infection, balanitis candida, genital candidiasis, genital infection, posthitis, and balanoposthitis. (N for males: Placebo and metformin=651, dapagliflozin 5 mg and metformin=187, dapagliflozin 10 mg and metformin=553). § Increased urination includes the following adverse reactions, listed in order of frequency reported: pollakiuria, polyuria, and urine output increased. |
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Metformin HCl
In placebo-controlled monotherapy trials of metformin extended-release, diarrhea and nausea/vomiting were reported in >5% of metformin-treated patients and more commonly than in placebo-treated patients (9.6% versus 2.6% for diarrhea and 6.5% versus 1.5% for nausea/vomiting). Diarrhea led to discontinuation of study medication in 0.6% of the patients treated with metformin extended-release.
Dapagliflozin
Dapagliflozin 10 mg has been evaluated in clinical trials in patients with type 2 diabetes mellitus and patients with heart failure. The overall safety profile of dapagliflozin was consistent across the studied indications. No new adverse reactions were identified in the DAPA-HF study.
Pool of 12 Placebo-Controlled Studies for Dapagliflozin 5 and 10 mg for Glycemic Control
Dapagliflozin
The data in Table 2 are derived from 12 glycemic control placebo-controlled studies ranging from 12 to 24 weeks. In 4 studies dapagliflozin was used as monotherapy, and in 8 studies dapagliflozin was used as add-on to background antidiabetic therapy or as combination therapy with metformin.
These data reflect exposure of 2338 patients to dapagliflozin with a mean exposure duration of 21 weeks. Patients received placebo (N=1393), dapagliflozin 5 mg (N=1145), or dapagliflozin 10 mg (N=1193) once daily. The mean age of the population was 55 years and 2% were older than 75 years of age. Fifty percent (50%) of the population were male; 81% were White, 14% were Asian, and 3% were Black or African American. At baseline, the population had diabetes for an average of 6 years, had a mean HbA1c of 8.3%, and 21% had established microvascular complications of diabetes. Baseline renal function was normal or mildly impaired in 92% of patients and moderately impaired in 8% of patients (mean eGFR 86 mL/min/1.73 m2).
Table 2 shows common adverse reactions associated with the use of dapagliflozin. These adverse reactions were not present at baseline, occurred more commonly on dapagliflozin than on placebo, and occurred in at least 2% of patients treated with either dapagliflozin 5 mg or dapagliflozin 10 mg.
Table 2: Adverse Reactions in Placebo-Controlled Studies of Glycemic Control Reported in ≥2% of Patients Treated with Dapagliflozin
| Adverse Reaction | % of Patients | ||
| Pool of 12 Placebo-Controlled Studies | |||
| Placebo N=1393 |
Dapagliflozin 5 mg N=1145 |
Dapagliflozin 10 mg N=1193 |
|
| Female genital mycotic infections* | 1.5 | 8.4 | 6.9 |
| Nasopharyngitis | 6.2 | 6.6 | 6.3 |
| Urinary tract infections† | 3.7 | 5.7 | 4.3 |
| Back pain | 3.2 | 3.1 | 4.2 |
| Increased urination‡ | 1.7 | 2.9 | 3.8 |
| Male genital mycotic infections§ | 0.3 | 2.8 | 2.7 |
| Nausea | 2.4 | 2.8 | 2.5 |
| Influenza | 2.3 | 2.7 | 2.3 |
| Dyslipidemia | 1.5 | 2.1 | 2.5 |
| Constipation | 1.5 | 2.2 | 1.9 |
| Discomfort with urination | 0.7 | 1.6 | 2.1 |
| Pain in extremity | 1.4 | 2.0 | 1.7 |
| * Genital mycotic infections include the following adverse reactions, listed in order of frequency reported for females: vulvovaginal mycotic infection, vaginal infection, vulvovaginal candidiasis, vulvovaginitis, genital infection, genital candidiasis, fungal genital infection, vulvitis, genitourinary tract infection, vulval abscess, and vaginitis bacterial. (N for females: Placebo=677, dapagliflozin 5 mg=581, dapagliflozin 10 mg=598). † Urinary tract infections include the following adverse reactions, listed in order of frequency reported: urinary tract infection, cystitis, Escherichia urinary tract infection, genitourinary tract infection, pyelonephritis, trigonitis, urethritis, kidney infection, and prostatitis. ‡ Increased urination includes the following adverse reactions, listed in order of frequency reported: pollakiuria, polyuria, and urine output increased. § Genital mycotic infections include the following adverse reactions, listed in order of frequency reported for males: balanitis, fungal genital infection, balanitis candida, genital candidiasis, genital infection male, penile infection, balanoposthitis, balanoposthitis infective, genital infection, and posthitis. (N for males: Placebo=716, dapagliflozin 5 mg=564, dapagliflozin 10 mg=595). |
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Pool of 13 Placebo-Controlled Studies for Dapagliflozin 10 mg for Glycemic Control
Dapagliflozin 10 mg was also evaluated in a larger glycemic control placebo-controlled study pool. This pool combined 13 placebo-controlled studies, including 3 monotherapy studies, 9 add-on to background antidiabetic therapy studies, and an initial combination with metformin study. Across these 13 studies, 2360 patients were treated once daily with dapagliflozin 10 mg for a mean duration of exposure of 22 weeks. The mean age of the population was 59 years and 4% were older than 75 years. Fifty-eight percent (58%) of the population were male; 84% were White, 9% were Asian, and 3% were Black or African American. At baseline, the population had diabetes for an average of 9 years, had a mean HbA1c of 8.2%, and 30% had established microvascular disease. Baseline renal function was normal or mildly impaired in 88% of patients and moderately impaired in 11% of patients (mean eGFR 82 mL/min/1.73 m2).
Volume Depletion
Dapagliflozin causes an osmotic diuresis, which may lead to a reduction in intravascular volume. Adverse reactions related to volume depletion (including reports of dehydration, hypovolemia, orthostatic hypotension, or hypotension) for the 12-study and 13-study, short-term, placebo-controlled pools and for the DECLARE study are shown in Table 3.
Table 3: Adverse Reactions Related to Volume Depletion* in Clinical Studies with Dapagliflozin
| Pool of 12 Placebo-Controlled Studies | Pool of 13 Placebo-Controlled Studies | DECLARE Study | |||||
| Placebo | Dapagliflozin 5 mg | Dapagliflozin 10 mg | Placebo | Dapagliflozin 10 mg | Placebo | Dapagliflozin 10 mg | |
| Overall population N (%) | N=1393 5 (0.4%) |
N=1145 7 (0.6%) |
N=1193 9 (0.8%) |
N=2295 17 (0.7%) |
N=2360 27 (1.1%) |
N=8569 207 (2.4%) |
N=8574 213 (2.5%) |
| Patient Subgroup n (%) | |||||||
| Patients on loop diuretics | n=55 1 (1.8%) |
n=40 0 |
n=31 3 (9.7%) |
n=267 4 (1.5%) |
n=236 6 (2.5%) |
n=934 57 (6.1%) |
n=866 57 (6.6%) |
| Patients with moderate renal impairment with eGFR ≥30 and <60 mL/min /1.73 m2 | n=107 2 (1.9%) |
n=107 1 (0.9%) |
n=89 1 (1.1%) |
n=268 4 (1.5%) |
n=265 5 (1.9%) |
n=658 30 (4.6%) |
n=604 35 (5.8%) |
| Patients ≥65 years of age | n=276 1 (0.4%) |
n=216 1 (0.5%) |
n=216 1 (0.5%) |
n=711 6 (0.8%) |
n=665 11 (1.7%) |
n=3950 121 (3.1%) |
n=3948 117 (3.0%) |
| * Volume depletion includes reports of dehydration, hypovolemia, orthostatic hypotension, or hypotension. | |||||||
Hypoglycemia
The frequency of hypoglycemia by study is shown in Table 4. Hypoglycemia was more frequent when dapagliflozin was added to sulfonylurea or insulin.
Table 4: Incidence of Severe Hypoglycemia* and Hypoglycemia with Glucose < 54 mg/dL† in Controlled Glycemic Control Clinical Studies
| Placebo | Dapagliflozin 5 mg | Dapagliflozin 10 mg | |
| Add-on to DPP4 inhibitor (with or without Metformin) (24 weeks) | N=226 | – | N=225 |
| Severe [n (%)] | 0 | – | 1 (0.4) |
| Glucose < 54 mg/dL [n (%)] | 1 (0.4) | – | 1 (0.4) |
| Add-on to Insulin with or without other OADs‡ (24 weeks) | N=197 | N=212 | N=196 |
| Severe [n (%)] | 1 (0.5) | 2 (0.9) | 2 (1.0) |
| Glucose < 54 mg/dL [n (%)] | 43 (21.8) | 55 (25.9) | 45 (23.0) |
| * Severe episodes of hypoglycemia were defined as episodes of severe impairment in consciousness or behavior, requiring external (third party) assistance, and with prompt recovery after intervention regardless of glucose level. † Episodes of hypoglycemia with glucose < 54 mg/dL (3 mmol/L) were defined as reported episodes of hypoglycemia meeting the glucose criteria that did not also qualify as a severe episode. ‡ OAD = oral antidiabetic therapy. |
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In the DECLARE study, severe events of hypoglycemia were reported in 58 (0.7%) out of 8574 patients treated with dapagliflozin 10 mg and 83 (1.0%) out of 8569 patients treated with placebo.
Genital Mycotic Infections
In the glycemic control studies, genital mycotic infections were more frequent with dapagliflozin treatment. Genital mycotic infections were reported in 0.9% of patients on placebo, 5.7% on dapagliflozin 5 mg, and 4.8% on dapagliflozin 10 mg, in the 12-study placebo-controlled pool. Discontinuation from study due to genital infection occurred in 0% of placebo-treated patients and 0.2% of patients treated with dapagliflozin 10 mg. Infections were more frequently reported in females than in males (see Table 2). The most frequently reported genital mycotic infections were vulvovaginal mycotic infections in females and balanitis in males. Patients with a history of genital mycotic infections were more likely to have a genital mycotic infection during the study than those with no prior history (10.0%, 23.1%, and 25.0% versus 0.8%, 5.9%, and 5.0% on placebo, dapagliflozin 5 mg, and dapagliflozin 10 mg, respectively). In the DECLARE study, serious genital mycotic infections were reported in <0.1% of patients treated with dapagliflozin 10 mg and <0.1% of patients treated with placebo. Genital mycotic infections that caused study drug discontinuation were reported in 0.9% of patients treated with dapagliflozin 10 mg and <0.1% of patients treated with placebo.
Hypersensitivity Reactions
Hypersensitivity reactions (e.g., angioedema, urticaria, hypersensitivity) were reported with dapagliflozin treatment. In glycemic control studies, serious anaphylactic reactions and severe cutaneous adverse reactions and angioedema were reported in 0.2% of comparator-treated patients and 0.3% of dapagliflozin-treated patients. If hypersensitivity reactions occur, discontinue use of dapagliflozin; treat per standard of care and monitor until signs and symptoms resolve.
Ketoacidosis
In the DECLARE study, events of diabetic ketoacidosis (DKA) were reported in 27 out of 8574 patients in the dapagliflozin-treated group and in 12 out of 8569 patients in the placebo group. The events were evenly distributed over the study period.
Laboratory Tests
Increases in Serum Creatinine and Decreases in eGFR
Dapagliflozin
Initiation of SGLT2 inhibitors, including dapagliflozin, causes a small increase in serum creatinine and decrease in eGFR. In patients with normal or mildly impaired renal function at baseline, these changes in serum creatinine and eGFR generally occur within weeks of starting therapy and then stabilize. Increases that do not fit this pattern should prompt further evaluation to exclude the possibility of acute kidney injury. The acute effect on eGFR reverses after treatment discontinuation, suggesting acute hemodynamic changes may play a role in the renal function changes observed with dapagliflozin.
Increase in Hematocrit
Dapagliflozin
In the pool of 13 placebo-controlled studies of glycemic control, increases from baseline in mean hematocrit values were observed in dapagliflozin-treated patients starting at Week 1 and continuing up to Week 16, when the maximum mean difference from baseline was observed. At Week 24, the mean changes from baseline in hematocrit were −0.33% in the placebo group and 2.30% in the dapagliflozin 10 mg group. By Week 24, hematocrit values >55% were reported in 0.4% of placebo-treated patients and 1.3% of dapagliflozin 10 mg–treated patients.
Increase in Low-Density Lipoprotein Cholesterol
Dapagliflozin
In the pool of 13 placebo-controlled studies of glycemic control, changes from baseline in mean lipid values were reported in dapagliflozin-treated patients compared to placebo-treated patients. Mean percent changes from baseline at Week 24 were 0.0% versus 2.5% for total cholesterol, and -1.0% versus 2.9% for LDL cholesterol in the placebo and dapagliflozin 10 mg groups, respectively. In the DECLARE study , mean changes from baseline after 4 years were 0.4 mg/dL versus -4.1 mg/dL for total cholesterol, and -2.5 mg/dL versus -4.4 mg/dL for LDL cholesterol, in dapagliflozin 10 mg-treated and the placebo groups, respectively.
Vitamin B12 Concentrations
Metformin HClIn metformin clinical trials of 29-week duration, a decrease to subnormal levels of previously normal serum vitamin B12 levels was observed in approximately 7% of patients.
Postmarketing Experience
Dapagliflozin
Additional adverse reactions have been identified during postapproval use of dapagliflozin. Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
- Ketoacidosis
- Acute Kidney Injury
- Urosepsis and Pyelonephritis
- Necrotizing Fasciitis of the Perineum (Fournier’s Gangrene)
- Rash
Metformin HCl
- Cholestatic, hepatocellular, and mixed hepatocellular liver injury
SRC: NLM .