Avandia

Black Box Warnings

Congestive heart failure risk

Thiazolidinediones, including rosiglitazone, cause or exacerbate congestive heart failure in some patients

After initiation, and after dose increases, observe patients carefully for signs and symptoms of heart failure (including excessive, rapid weight gain, dyspnea, and/or edema)

If these signs and symptoms develop, the heart failure should be managed according to current standards of care

Furthermore, discontinuation or dose reduction must be considered

Not recommended in patients with symptomatic heart failure

Initiation with established NYHA Class III or IV heart failure is contraindicated

Contraindications

Hypersensitivity to rosiglitazone

Diabetic ketoacidosis

Heart failure NYHA class III-IV

Active liver disease: do not start rosiglitazone if ALT >2.5 x ULN

Cautions

Fluid retention, which may exacerbate or lead to heart failure, may occur; combination use with insulin and use in congestive heart failure NYHA Class I and II may increase risk of other cardiovascular effects

If ALT >3 x ULN stop treatment; if 1.5-3 x normal, retest qWeek until normal or 3 x normal and need to discontinue

Not for use in diabetes mellitus type 1; mechanism requires presence of endogenous insulin; use with insulin may increase risk of heart failure; not recommended

Thiazolidinediones, which are peroxisome proliferator-activated receptor (PPAR) gamma agonists, can cause dose-related fluid retention, particularly when used in combination with insulin; dose-related edema and weight gain may occur

When used in combination with other hypoglycemic agents, a dose reduction of concomitant agent may be necessary to reduce risk of hypoglycemia

Associated with rare cases of new onset or worsening of macular edema

May result in ovulation in some premenopausal anovulatory women; ensure adequate contraception

Increased risk of fractures of upper arm, hand, or foot in female patients

Dose-related decreases in hemoglobin and hemocrit reported

• GlaxoSmithKline LLC

Tell your doctor about all the medicines you take including prescription and non-prescription medicines, vitamins or herbal supplements. Especially tell your doctor if you take:

• insulin
• any medicines for high blood pressure
• any medicines for high cholesterol
• any medicines for heart failure
• any medicines for prevention of heart disease or stroke

This is not a complete list of Avandia drug interactions. Ask your doctor or pharmacist for more information.

Avandia is available only through an access program. Both you and your doctor must be enrolled in the program so that you can get Avandia. To enroll, you must:

• talk to your doctor
• understand the risks and benefits of Avandia 
• agree to enroll in the program

Avandia may cause serious side effects, including:

New or worse heart failure

• Avandia can cause your body to keep extra fluid (fluid retention), which leads to swelling (edema) and weight gain. Extra body fluid can make some heart problems worse or lead to heart failure. Heart failure means your heart does not pump blood well enough.
• If you have severe heart failure, you cannot start Avandia.
• If you have heart failure with symptoms (such as shortness of breath or swelling), even if these symptoms are not severe, Avandia may not be right for you.

Call your doctor right away if you have any of the following:

• swelling or fluid retention, especially in the ankles or legs
• shortness of breath or trouble breathing, especially when you lie down
• an unusually fast increase in weight
• unusual tiredness

Avandia may raise the risk of a heart attack. The risk of having a heart attack may be higher in people who take Avandia with insulin. Most people who take insulin should not also take Avandia.

Symptoms of a heart attack can include the following:

• chest discomfort in the center of your chest that lasts for more than a few minutes, or that goes away or comes back
• chest discomfort that feels like uncomfortable pressure, squeezing, fullness or pain
• pain or discomfort in your arms, back, neck, jaw or stomach
• shortness of breath with or without chest discomfort
• breaking out in a cold sweat
• nausea or vomiting
• feeling lightheaded

Call your doctor or go to the nearest hospital emergency room right away if you think you are having a heart attack.

People with diabetes have a greater risk for heart problems. It is important to work with your doctor to manage other conditions, such as high blood pressure or high cholesterol.

Avandia can have other serious side effects. See "Side Effects".

Tell your doctor if you are pregnant or plan to become pregnant. Avandia should not be used during pregnancy. It is not known if Avandia can harm your unborn baby. You and your doctor should talk about the best way to control your diabetes during pregnancy. If you are a premenopausal woman (before the “change of life”) who does not have regular monthly periods, Avandia may increase your chances of becoming pregnant. Talk to your doctor about birth control choices while taking Avandia. Tell your doctor right away if you become pregnant while taking Avandia.

Take Avandia exactly as prescribed. Follow the directions on your prescription label carefully. Your doctor may start you on a dose of 4 mg and increase the dose if necessary.

The maximum recommended daily dose of Avandia is 8 mg.

You should not use rosiglitazone if you are allergic to it, or if you have severe or uncontrolled heart failure. Do not use rosiglitazone if you are in a state of diabetic ketoacidosis (call your doctor for treatment with insulin).

To make sure rosiglitazone is safe for you, tell your doctor if you have:

• congestive heart failure, heart disease, a history of heart attack or stroke;

• fluid retention;

• eye problems caused by diabetes; or

• liver disease.

Women may be more likely than men to have bone fractures in the upper arm, hand, or foot while taking rosiglitazone. Talk with your doctor if you are concerned about this possibility.

It is not known whether rosiglitazone will harm an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant while using this medicine.

Some women using rosiglitazone have started having menstrual periods, even after not having a period for a long time due to a medical condition. You may be able to get pregnant if your periods restart. Talk with your doctor about the need for birth control.

It is not known whether rosiglitazone passes into breast milk or if it could harm a nursing baby. You should not breast-feed while using this medicine.

Rosiglitazone is not approved for use by anyone younger than 18 years old.

Treatment of Diabetes Mellitus

Used as monotherapy or in combination with a sulfonylurea, metformin, or a sulfonylurea and metformin as an adjunct to diet and exercise for the management of type 2 (noninsulin-dependent) diabetes mellitus (NIDDM).1 30 106 110 111 112 118 121 122

May be added to glyburide/metformin fixed-combination therapy if hyperglycemia is not adequately controlled with the fixed combination.111

May be used in combination with repaglinide if hyperglycemia is not adequately controlled with repaglinide monotherapy.115

May use fixed combination of rosiglitazone/metformin (Avandamet) when treatment with rosiglitazone and metformin is appropriate.110

May use fixed combination of rosiglitazone/glimepiride (Avandaryl) when treatment with rosiglitazone and glimepiride is appropriate.118

Metformin is the preferred initial oral antidiabetic agent for patients with type 2 diabetes mellitus.121 Thiazolidinediones are one of several second-line agents used with other oral antidiabetic agents (e.g., metformin) in patients who are inadequately controlled on their current oral therapy.121 Because of potential for serious adverse effects (see Boxed Warning), American Diabetes Association (ADA) recommends that clinicians carefully weigh the potential risks and benefits of thiazolidinediones versus other second-line agents (i.e., insulin, sulfonylureas).1 148

Use in combination with insulin not recommended.1 110 118 (See Congestive Heart Failure under Cautions and also see Specific Drugs under Interactions.)

Because endogenous insulin is required for activity, not indicated for type 1 diabetes mellitus or diabetic ketoacidosis.1 110 118 146

Absorption

Bioavailability

Peak plasma concentrations attained about 1 hour after dosing.1

Absolute bioavailability is 99%.1 110 118 219

Fixed-combination preparation containing 4 mg of rosiglitazone and 4 mg of glimepiride is bioequivalent to the individual components administered separately at the same dosages in fasted state.118

Fixed-combination preparation containing 4 mg of rosiglitazone and 500 mg of metformin hydrochloride is bioequivalent to the individual components administered separately at the same dosages in fasted state.110

Onset

A therapeutic response usually is apparent within 2 weeks.1 110 118 136 Maximum response occurs within 2–3 months.1 110 118 136

Food

Food decreases peak plasma concentration and delays time to peak concentration; not clinically relevant.1 110 118 (See Administration under Dosage and Administration.)

Distribution

Extent

Distributed into milk in rats.1 110 Not known whether the drug distributes into human milk.1 110 118 Crosses human placenta and is detectable in fetal tissues.1 110 118 Clinical importance unknown.1 110 118

Plasma Protein Binding

Approximately 99.8% (mainly albumin).1 110 118

Elimination

Metabolism

Extensively metabolized, principally by CYP2C81 110 118 and, to a lesser extent, by CYP2C9.1 110 118

Elimination Route

Excreted primarily in urine (64%) and in feces (23%) as metabolites.1 110 118

Half-life

Approximately 3–4 hours.1 110 118 219

Special Populations

In patients with hepatic disease, elimination half-life is prolonged by about 2 hours.1 110 118 In patients with moderate to severe hepatic impairment (Child-Pugh class B or C), clearance of unbound drug decreased.1 110 118

• It is used to lower blood sugar in patients with high blood sugar (diabetes).

• If your symptoms or health problems do not get better or if they become worse, call your doctor.
• Do not share your drugs with others and do not take anyone else's drugs.
• Keep a list of all your drugs (prescription, natural products, vitamins, OTC) with you. Give this list to your doctor.
• Talk with the doctor before starting any new drug, including prescription or OTC, natural products, or vitamins.
• This medicine comes with an extra patient fact sheet called a Medication Guide. Read it with care. Read it again each time this medicine is refilled. If you have any questions about Avandia (rosiglitazone), please talk with the doctor, pharmacist, or other health care provider.
• If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.

This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about Avandia. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using Avandia.

Review Date: October 4, 2017

Avandia is a thiazolidinedione antidiabetic agent indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Important Limitations of Use:

• Due to its mechanism of action, Avandia is active only in the presence of endogenous insulin. Therefore, Avandia should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. • The coadministration of Avandia and insulin is not recommended [see Warnings and Precautions (5.1)].

Cardiac Failure

Avandia, like other thiazolidinediones, alone or in combination with other antidiabetic agents, can cause fluid retention, which may exacerbate or lead to heart failure. Patients should be observed for signs and symptoms of heart failure. If these signs and symptoms develop, the heart failure should be managed according to current standards of care. Furthermore, discontinuation or dose reduction of rosiglitazone must be considered [see Boxed Warning].

Patients with congestive heart failure (CHF) NYHA Class I and II treated with Avandia have an increased risk of cardiovascular events. A 52-week, double-blind, placebo-controlled, echocardiographic trial was conducted in 224 patients with type 2 diabetes mellitus and NYHA Class I or II CHF (ejection fraction ≤45%) on background antidiabetic and CHF therapy. An independent committee conducted a blinded evaluation of fluid-related events (including congestive heart failure) and cardiovascular hospitalizations according to predefined criteria (adjudication). Separate from the adjudication, other cardiovascular adverse events were reported by investigators. Although no treatment difference in change from baseline of ejection fractions was observed, more cardiovascular adverse events were observed following treatment with Avandia compared with placebo during the 52-week trial (Table 1).

Table 1. Emergent Cardiovascular Adverse Events in Patients with Congestive Heart Failure (NYHA Class I and II) Treated with Avandia or Placebo (in Addition to Background Antidiabetic and CHF Therapy)

Events	Avandia N = 110 n (%)	Placebo N = 114 n (%)
Adjudicated
Cardiovascular deaths	5 (5%)	4 (4%)
CHF worsening	7 (6%)	4 (4%)
– with overnight hospitalization	5 (5%)	4 (4%)
– without overnight hospitalization	2 (2%)	0 (0%)
New or worsening edema	28 (25%)	10 (9%)
New or worsening dyspnea	29 (26%)	19 (17%)
Increases in CHF medication	36 (33%)	20 (18%)
Cardiovascular hospitalizationa	21 (19%)	15 (13%)
Investigator-reported, non-adjudicated
Ischemic adverse events	10 (9%)	5 (4%)
– Myocardial infarction	5 (5%)	2 (2%)
– Angina	6 (5%)	3 (3%)

a   Includes hospitalization for any cardiovascular reason.

In a long-term, cardiovascular outcome trial (RECORD) in patients with type 2 diabetes [see Adverse Reactions (6.1)], the incidence of heart failure was higher in patients treated with Avandia [2.7% (61/2,220) compared with active control 1.3% (29/2,227), HR 2.10 (95% CI: 1.35, 3.27)].

Initiation of Avandia in patients with established NYHA Class III or IV heart failure is contraindicated. Avandia is not recommended in patients with symptomatic heart failure. [See Boxed Warning.]

Patients experiencing acute coronary syndromes have not been studied in controlled clinical trials. In view of the potential for development of heart failure in patients having an acute coronary event, initiation of Avandia is not recommended for patients experiencing an acute coronary event, and discontinuation of Avandia during this acute phase should be considered.

Patients with NYHA Class III and IV cardiac status (with or without CHF) have not been studied in controlled clinical trials. Avandia is not recommended in patients with NYHA Class III and IV cardiac status.

Congestive Heart Failure during Coadministration of Avandia with Insulin

In trials in which Avandia was added to insulin, Avandia increased the risk of congestive heart failure. Coadministration of Avandia and insulin is not recommended. [See Indications and Usage (1), Warnings and Precautions (5.2).]

In 7 controlled, randomized, double-blind trials which had durations from 16 to 26 weeks and which were included in a meta-analysis [see Warnings and Precautions (5.2)], patients with type 2 diabetes mellitus were randomized to coadministration of Avandia and insulin (N = 1,018) or insulin (N = 815). In these 7 trials, Avandia was added to insulin. These trials included patients with long-standing diabetes (median duration of 12 years) and a high prevalence of pre-existing medical conditions, including peripheral neuropathy, retinopathy, ischemic heart disease, vascular disease, and congestive heart failure. The total number of patients with emergent congestive heart failure was 23 (2.3%) and 8 (1.0%) in the group receiving Avandia plus insulin and the insulin group, respectively.

Heart Failure in Observational Studies of Elderly Diabetic Patients Comparing Avandia with Pioglitazone

Three observational studies in elderly diabetic patients (age 65 years and older) found that Avandia statistically significantly increased the risk of hospitalized heart failure compared with use of pioglitazone. One other observational study in patients with a mean age of 54 years, which also included an analysis in a subpopulation of patients >65 years of age, found no statistically significant increase in emergency department visits or hospitalization for heart failure in patients treated with Avandia compared with pioglitazone in the older subgroup.

Major Adverse Cardiovascular Events

Data from long-term, prospective, randomized, controlled clinical trials of Avandia versus metformin or sulfonylureas, particularly a cardiovascular outcome trial (RECORD), observed no difference in overall mortality or in major adverse cardiovascular events (MACE) and its components. A meta-analysis of mostly short-term trials suggested an increased risk for myocardial infarction with Avandia compared with placebo.

Cardiovascular Events in Large, Long-term, Prospective, Randomized, Controlled Trials of Avandia

RECORD, a prospectively designed cardiovascular outcome trial (mean follow-up 5.5 years; 4,447 patients), compared the addition of Avandia to metformin or a sulfonylurea (N = 2,220) with a control group of metformin plus sulfonylurea (N = 2,227) in patients with type 2 diabetes [see Adverse Reactions (6.1)]. Non-inferiority was demonstrated for the primary endpoint, cardiovascular hospitalization or cardiovascular death, for Avandia compared with control [HR 0.99 (95% CI: 0.85, 1.16)] demonstrating no overall increased risk in cardiovascular morbidity or mortality. The hazard ratios for total mortality and MACE were consistent with the primary endpoint and the 95% CI similarly excluded a 20% increase in risk for Avandia. The hazard ratios for the components of MACE were 0.72 (95% CI: 0.49, 1.06) for stroke, 1.14 (95% CI: 0.80, 1.63) for myocardial infarction, and 0.84 (95% CI: 0.59, 1.18) for cardiovascular death.

The results of RECORD are consistent with the findings of 2 earlier long-term, prospective, randomized, controlled clinical trials (each trial >3 years’ duration; total of 9,620 patients) (see Figure 1). In patients with impaired glucose tolerance (DREAM trial), although the incidence of cardiovascular events was higher among subjects who were randomized to Avandia in combination with ramipril than among subjects randomized to ramipril alone, no statistically significant differences were observed for MACE and its components between Avandia and placebo. In patients with type 2 diabetes who were initiating oral agent monotherapy (ADOPT trial), no statistically significant differences were observed for MACE and its components between Avandia and metformin or a sulfonylurea.

Figure 1. Hazard Ratios for the Risk of MACE, Myocardial Infarction, and Total Mortality with Avandia Compared with a Control Group in Long-term Trials

Cardiovascular Events in a Group of 52 Clinical Trials

In a meta-analysis of 52 double-blind, randomized, controlled clinical trials designed to assess glucose-lowering efficacy in type 2 diabetes (mean duration 6 months), a statistically significant increased risk of myocardial infarction with Avandia versus pooled comparators was observed (0.4% versus 0.3%; OR 1.8, [95% CI: 1.03, 3.25]). A statistically non-significant increased risk of MACE was observed with Avandia versus pooled comparators (OR 1.44, 95% CI: 0.95, 2.20). In the placebo-controlled trials, a statistically significant increased risk of myocardial infarction (0.4% versus 0.2%, OR 2.23 [95% CI: 1.14, 4.64]) and statistically non-significant increased risk of MACE (0.7% versus 0.5%, OR 1.53 [95% CI: 0.94, 2.54]) with Avandia were observed. In the active-controlled trials, there was no increased risk of myocardial infarction or MACE.

Mortality in Observational Studies of Avandia Compared with Pioglitazone

Three observational studies in elderly diabetic patients (age 65 years and older) found that Avandia statistically significantly increased the risk of all-cause mortality compared with use of pioglitazone. One observational study in patients with a mean age of 54 years found no difference in all-cause mortality between patients treated with Avandia compared with pioglitazone and reported similar results in the subpopulation of patients >65 years of age. One additional small, prospective, observational study found no statistically significant differences for CV mortality and all-cause mortality in patients treated with Avandia compared with pioglitazone.

Edema

Avandia should be used with caution in patients with edema. In a clinical trial in healthy volunteers who received 8 mg of Avandia once daily for 8 weeks, there was a statistically significant increase in median plasma volume compared with placebo.

Since thiazolidinediones, including rosiglitazone, can cause fluid retention, which can exacerbate or lead to congestive heart failure, Avandia should be used with caution in patients at risk for heart failure. Patients should be monitored for signs and symptoms of heart failure [see Boxed Warning, Warnings and Precautions (5.1), Patient Counseling Information (17)].

In controlled clinical trials of patients with type 2 diabetes, mild to moderate edema was reported in patients treated with Avandia, and may be dose related. Patients with ongoing edema were more likely to have adverse events associated with edema if started on combination therapy with insulin and Avandia [see Adverse Reactions (6.1)].

Weight Gain

Dose-related weight gain was seen with Avandia alone and in combination with other hypoglycemic agents (Table 2). The mechanism of weight gain is unclear but probably involves a combination of fluid retention and fat accumulation.

In postmarketing experience, there have been reports of unusually rapid increases in weight and increases in excess of that generally observed in clinical trials. Patients who experience such increases should be assessed for fluid accumulation and volume-related events such as excessive edema and congestive heart failure [see Boxed Warning].

Table 2. Weight Changes (kg) from Baseline at Endpoint during Clinical Trials

Monotherapy	Duration	Control Group		Avandia 4 mg	Avandia 8 mg
			Median (25th, 75th percentiles)	Median (25th, 75th percentiles)	Median (25th, 75th percentiles)
	26 weeks	placebo	-0.9 (-2.8, 0.9) N = 210	1.0 (-0.9, 3.6) N = 436	3.1 (1.1, 5.8) N = 439
	52 weeks	sulfonylurea	2.0 (0, 4.0) N = 173	2.0 (-0.6, 4.0) N = 150	2.6 (0, 5.3) N = 157
Combination Therapy
Sulfonylurea	24-26 weeks	sulfonylurea	0 (-1.0, 1.3) N = 1,155	2.2 (0.5, 4.0) N = 613	3.5 (1.4, 5.9) N = 841
Metformin	26 weeks	metformin	-1.4 (-3.2, 0.2) N = 175	0.8 (-1.0, 2.6) N = 100	2.1 (0, 4.3) N = 184
Insulin	26 weeks	insulin	0.9 (-0.5, 2.7) N = 162	4.1 (1.4, 6.3) N = 164	5.4 (3.4, 7.3) N = 150
Sulfonylurea + metformin	26 weeks	sulfonylurea + metformin	0.2 (-1.2, 1.6) N = 272	2.5 (0.8, 4.6) N = 275	4.5 (2.4, 7.3) N = 276

In a 4- to 6-year, monotherapy, comparative trial (ADOPT) in patients recently diagnosed with type 2 diabetes not previously treated with antidiabetic medication [see Clinical Studies (14.1)], the median weight change (25th, 75th percentiles) from baseline at 4 years was 3.5 kg (0.0, 8.1) for Avandia, 2.0 kg (-1.0, 4.8) for glyburide, and -2.4 kg (-5.4, 0.5) for metformin.

In a 24-week trial in pediatric patients aged 10 to 17 years treated with Avandia 4 to 8 mg daily, a median weight gain of 2.8 kg (25th, 75th percentiles: 0.0, 5.8) was reported.

Hepatic Effects

Liver enzymes should be measured prior to the initiation of therapy with Avandia in all patients and periodically thereafter per the clinical judgment of the healthcare professional. Therapy with Avandia should not be initiated in patients with increased baseline liver enzyme levels (ALT >2.5X upper limit of normal). Patients with mildly elevated liver enzymes (ALT levels ≤2.5X upper limit of normal) at baseline or during therapy with Avandia should be evaluated to determine the cause of the liver enzyme elevation. Initiation of, or continuation of, therapy with Avandia in patients with mild liver enzyme elevations should proceed with caution and include close clinical follow-up, including liver enzyme monitoring, to determine if the liver enzyme elevations resolve or worsen. If at any time ALT levels increase to >3X the upper limit of normal in patients on therapy with Avandia, liver enzyme levels should be rechecked as soon as possible. If ALT levels remain >3X the upper limit of normal, therapy with Avandia should be discontinued.

If any patient develops symptoms suggesting hepatic dysfunction, which may include unexplained nausea, vomiting, abdominal pain, fatigue, anorexia and/or dark urine, liver enzymes should be checked. The decision whether to continue the patient on therapy with Avandia should be guided by clinical judgment pending laboratory evaluations. If jaundice is observed, drug therapy should be discontinued. [See Adverse Reactions (6.2, 6.3).]

Macular Edema

Macular edema has been reported in postmarketing experience in some diabetic patients who were taking Avandia or another thiazolidinedione. Some patients presented with blurred vision or decreased visual acuity, but some patients appear to have been diagnosed on routine ophthalmologic examination. Most patients had peripheral edema at the time macular edema was diagnosed. Some patients had improvement in their macular edema after discontinuation of their thiazolidinedione. Patients with diabetes should have regular eye exams by an ophthalmologist, per the Standards of Care of the American Diabetes Association. Additionally, any diabetic who reports any kind of visual symptom should be promptly referred to an ophthalmologist, regardless of the patient’s underlying medications or other physical findings. [See Adverse Reactions (6.1).]

Fractures

Long-term trials (ADOPT and RECORD) show an increased incidence of bone fracture in patients, particularly female patients, taking Avandia [see Adverse Reactions (6.1)]. This increased incidence was noted after the first year of treatment and persisted during the course of the trial. The majority of the fractures in the women who received Avandia occurred in the upper arm, hand, and foot. These sites of fracture are different from those usually associated with postmenopausal osteoporosis (e.g., hip or spine). Other trials suggest that this risk may also apply to men, although the risk of fracture among women appears higher than that among men. The risk of fracture should be considered in the care of patients treated with Avandia, and attention given to assessing and maintaining bone health according to current standards of care.

Hematologic Effects

Decreases in mean hemoglobin and hematocrit occurred in a dose-related fashion in adult patients treated with Avandia [see Adverse Reactions (6.2)]. The observed changes may be related to the increased plasma volume observed with treatment with Avandia.

Diabetes and Blood Glucose Control

Patients receiving Avandia in combination with other hypoglycemic agents may be at risk for hypoglycemia, and a reduction in the dose of the concomitant agent may be necessary.

Periodic fasting blood glucose and HbA1c measurements should be performed to monitor therapeutic response.

Ovulation

Therapy with Avandia, like other thiazolidinediones, may result in ovulation in some premenopausal anovulatory women. As a result, these patients may be at an increased risk for pregnancy while taking Avandia [see Use in Specific Populations (8.1)]. Thus, adequate contraception in premenopausal women should be recommended. This possible effect has not been specifically investigated in clinical trials; therefore, the frequency of this occurrence is not known.

Although hormonal imbalance has been seen in preclinical studies [see Nonclinical Toxicology (13.1)], the clinical significance of this finding is not known. If unexpected menstrual dysfunction occurs, the benefits of continued therapy with Avandia should be reviewed.

The following adverse reactions are discussed in more detail elsewhere in the labeling:

• Cardiac Failure [see Warnings and Precautions (5.1)] • Major Adverse Cardiovascular Events [see Warnings and Precautions (5.2)] • Edema [see Warnings and Precautions (5.3)] • Weight Gain [see Warnings and Precautions (5.4)] • Hepatic Effects [see Warnings and Precautions (5.5)] • Macular Edema [see Warnings and Precautions (5.6)] • Fractures [see Warnings and Precautions (5.7)] • Hematologic Effects [see Warnings and Precautions (5.8)] • Ovulation [see Warnings and Precautions (5.10)]

Clinical Trial 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 with rates in the clinical trials of another drug and may not reflect the rates observed in practice.

Adult

In clinical trials, approximately 9,900 patients with type 2 diabetes have been treated with Avandia.

Short-term Trials of Avandia as Monotherapy and in Combination with Other Hypoglycemic Agents: The incidence and types of adverse events reported in short-term clinical trials of Avandia as monotherapy are shown in Table 3.

Table 3. Adverse Events (≥5% in any Treatment Group) Reported by Patients in Short-terma Double-blind Clinical Trials with Avandia as Monotherapy

Preferred Term	Avandia Monotherapy	Placebo	Metformin	Sulfonylureasb
	N = 2,526	N = 601	N = 225	N = 626
	%	%	%	%
Upper respiratory tract infection	9.9	8.7	8.9	7.3
Injury	7.6	4.3	7.6	6.1
Headache	5.9	5.0	8.9	5.4
Back pain	4.0	3.8	4.0	5.0
Hyperglycemia	3.9	5.7	4.4	8.1
Fatigue	3.6	5.0	4.0	1.9
Sinusitis	3.2	4.5	5.3	3.0
Diarrhea	2.3	3.3	15.6	3.0
Hypoglycemia	0.6	0.2	1.3	5.9

a   Short-term trials ranged from 8 weeks to 1 year.

b   Includes patients receiving glyburide (N = 514), gliclazide (N = 91), or glipizide (N = 21).

Overall, the types of adverse reactions without regard to causality reported when Avandia was used in combination with a sulfonylurea or metformin were similar to those during monotherapy with Avandia.

Events of anemia and edema tended to be reported more frequently at higher doses, and were generally mild to moderate in severity and usually did not require discontinuation of treatment with Avandia.

In double-blind trials, anemia was reported in 1.9% of patients receiving Avandia as monotherapy compared with 0.7% on placebo, 0.6% on sulfonylureas, and 2.2% on metformin. Reports of anemia were greater in patients treated with a combination of Avandia and metformin (7.1%) and with a combination of Avandia and a sulfonylurea plus metformin (6.7%) compared with monotherapy with Avandia or in combination with a sulfonylurea (2.3%). Lower pre-treatment hemoglobin/hematocrit levels in patients enrolled in the metformin combination clinical trials may have contributed to the higher reporting rate of anemia in these trials [see Adverse Reactions (6.2)].

In clinical trials, edema was reported in 4.8% of patients receiving Avandia as monotherapy compared with 1.3% on placebo, 1.0% on sulfonylureas, and 2.2% on metformin. The reporting rate of edema was higher for Avandia 8 mg in sulfonylurea combinations (12.4%) compared with other combinations, with the exception of insulin. Edema was reported in 14.7% of patients receiving Avandia in the insulin combination trials compared with 5.4% on insulin alone. Reports of new onset or exacerbation of congestive heart failure occurred at rates of 1% for insulin alone, and 2% (4 mg) and 3% (8 mg) for insulin in combination with Avandia [see Boxed Warning, Warnings and Precautions (5.1)].

In controlled combination therapy trials with sulfonylureas, mild to moderate hypoglycemic symptoms, which appear to be dose related, were reported. Few patients were withdrawn for hypoglycemia (<1%) and few episodes of hypoglycemia were considered to be severe (<1%). Hypoglycemia was the most frequently reported adverse event in the fixed-dose insulin combination trials, although few patients withdrew for hypoglycemia (4 of 408 for Avandia plus insulin and 1 of 203 for insulin alone). Rates of hypoglycemia, confirmed by capillary blood glucose concentration ≤50 mg/dL, were 6% for insulin alone and 12% (4 mg) and 14% (8 mg) for insulin in combination with Avandia. [See Warnings and Precautions (5.9).]

Long-term Trial of Avandia as Monotherapy: A 4- to 6-year trial (ADOPT) compared the use of Avandia (n = 1,456), glyburide (n = 1,441), and metformin (n = 1,454) as monotherapy in patients recently diagnosed with type 2 diabetes who were not previously treated with antidiabetic medication. Table 4 presents adverse reactions without regard to causality; rates are expressed per 100 patient-years (PY) exposure to account for the differences in exposure to trial medication across the 3 treatment groups.

In ADOPT, fractures were reported in a greater number of women treated with Avandia (9.3%, 2.7/100 patient-years) compared with glyburide (3.5%, 1.3/100 patient-years) or metformin (5.1%, 1.5/100 patient-years). The majority of the fractures in the women who received rosiglitazone were reported in the upper arm, hand, and foot. [See Warnings and Precautions (5.7).] The observed incidence of fractures for male patients was similar among the 3 treatment groups.

Table 4. On-Therapy Adverse Events [≥5 Events/100 Patient-Years (PY)] in any Treatment Group Reported in a 4- to 6-Year Clinical Trial of Avandia as Monotherapy (ADOPT)

Preferred Term	Avandia	Glyburide	Metformin
	N = 1,456	N = 1,441	N = 1,454
	PY = 4,954	PY = 4,244	PY = 4,906
Nasopharyngitis	6.3	6.9	6.6
Back pain	5.1	4.9	5.3
Arthralgia	5.0	4.8	4.2
Hypertension	4.4	6.0	6.1
Upper respiratory tract infection	4.3	5.0	4.7
Hypoglycemia	2.9	13.0	3.4
Diarrhea	2.5	3.2	6.8

Long-term Trial of Avandia as Combination Therapy (RECORD): RECORD (Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycemia in Diabetes) was a multicenter, randomized, open-label, non-inferiority trial in subjects with type 2 diabetes inadequately controlled on maximum doses of metformin or sulfonylurea (glyburide, gliclazide, or glimepiride) to compare the time to reach the combined cardiovascular endpoint of cardiovascular death or cardiovascular hospitalization between patients randomized to the addition of Avandia versus metformin or sulfonylurea. The trial included patients who have failed metformin or sulfonylurea monotherapy; those who failed metformin (n = 2,222) were randomized to receive either Avandia as add-on therapy (n = 1,117) or add-on sulfonylurea (n = 1,105), and those who failed sulfonylurea (n = 2,225) were randomized to receive either Avandia as add-on therapy (n = 1,103) or add-on metformin (n = 1,122). Patients were treated to target HbA1c ≤7% throughout the trial.

The mean age of patients in this trial was 58 years, 52% were male, and the mean duration of follow-up was 5.5 years. Avandia demonstrated non-inferiority to active control for the primary endpoint of cardiovascular hospitalization or cardiovascular death (HR 0.99, 95% CI: 0.85-1.16). There were no significant differences between groups for secondary endpoints with the exception of congestive heart failure (Table 5). The incidence of congestive heart failure was significantly greater among patients randomized to Avandia.

Table 5. Cardiovascular (CV) Outcomes for the RECORD Trial

Primary Endpoint	Avandia N = 2,220	Active Control N = 2,227	Hazard Ratio	95% CI
CV death or CV hospitalization	321	323	0.99	0.85-1.16
Secondary Endpoint
All-cause death	136	157	0.86	0.68-1.08
CV death	60	71	0.84	0.59-1.18
Myocardial infarction	64	56	1.14	0.80-1.63
Stroke	46	63	0.72	0.49-1.06
CV death, myocardial infarction, or stroke	154	165	0.93	0.74-1.15
Heart failure	61	29	2.10	1.35-3.27

There was an increased incidence of bone fracture for subjects randomized to Avandia in addition to metformin or sulfonylurea compared with those randomized to metformin plus sulfonylurea (8.3% versus 5.3%) [see Warnings and Precautions (5.7)]. The majority of fractures were reported in the upper limbs and distal lower limbs. The risk of fracture appeared to be higher in females relative to control (11.5% versus 6.3%) than in males relative to control (5.3% versus 4.3%). Additional data are necessary to determine whether there is an increased risk of fracture in males after a longer period of follow-up.

Pediatric

Avandia has been evaluated for safety in a single, active-controlled trial of pediatric patients with type 2 diabetes in which 99 were treated with Avandia and 101 were treated with metformin. The most common adverse reactions (>10%) without regard to causality for either Avandia or metformin were headache (17% versus 14%), nausea (4% versus 11%), nasopharyngitis (3% versus 12%), and diarrhea (1% versus 13%). In this trial, one case of diabetic ketoacidosis was reported in the metformin group. In addition, there were 3 patients in the rosiglitazone group who had FPG of approximately 300 mg/dL, 2+ ketonuria, and an elevated anion gap.

Laboratory Abnormalities

Hematologic

Decreases in mean hemoglobin and hematocrit occurred in a dose-related fashion in adult patients treated with Avandia (mean decreases in individual trials as much as 1.0 g/dL hemoglobin and as much as 3.3% hematocrit). The changes occurred primarily during the first 3 months following initiation of therapy with Avandia or following a dose increase in Avandia. The time course and magnitude of decreases were similar in patients treated with a combination of Avandia and other hypoglycemic agents or monotherapy with Avandia. Pre-treatment levels of hemoglobin and hematocrit were lower in patients in metformin combination trials and may have contributed to the higher reporting rate of anemia. In a single trial in pediatric patients, decreases in hemoglobin and hematocrit (mean decreases of 0.29 g/dL and 0.95%, respectively) were reported. Small decreases in hemoglobin and hematocrit have also been reported in pediatric patients treated with Avandia. White blood cell counts also decreased slightly in adult patients treated with Avandia. Decreases in hematologic parameters may be related to increased plasma volume observed with treatment with Avandia.

Lipids

Changes in serum lipids have been observed following treatment with Avandia in adults [see Clinical Pharmacology (12.2)]. Small changes in serum lipid parameters were reported in children treated with Avandia for 24 weeks.

Serum Transaminase Levels

In pre-approval clinical trials in 4,598 patients treated with Avandia (3,600 patient-years of exposure) and in a long-term 4- to 6-year trial in 1,456 patients treated with Avandia (4,954 patient-years exposure), there was no evidence of drug-induced hepatotoxicity.

In pre-approval controlled trials, 0.2% of patients treated with Avandia had elevations in ALT >3X the upper limit of normal compared with 0.2% on placebo and 0.5% on active comparators. The ALT elevations in patients treated with Avandia were reversible. Hyperbilirubinemia was found in 0.3% of patients treated with Avandia compared with 0.9% treated with placebo and 1% in patients treated with active comparators. In pre-approval clinical trials, there were no cases of idiosyncratic drug reactions leading to hepatic failure. [See Warnings and Precautions (5.5).]

In the 4- to 6-year ADOPT trial, patients treated with Avandia (4,954 patient-years exposure), glyburide (4,244 patient-years exposure), or metformin (4,906 patient-years exposure), as monotherapy, had the same rate of ALT increase to >3X upper limit of normal (0.3 per 100 patient-years exposure).

In the RECORD trial, patients randomized to Avandia in addition to metformin or sulfonylurea (10,849 patient-years exposure) and to metformin plus sulfonylurea (10,209 patient-years exposure) had a rate of ALT increase to ≥3X upper limit of normal of approximately 0.2 and 0.3 per 100 patient-years exposure, respectively.

Postmarketing Experience

In addition to adverse reactions reported from clinical trials, the events described below have been identified during post-approval use of Avandia. Because these events are reported voluntarily from a population of unknown size, it is not possible to reliably estimate their frequency or to always establish a causal relationship to drug exposure.

In patients receiving thiazolidinedione therapy, serious adverse events with or without a fatal outcome, potentially related to volume expansion (e.g., congestive heart failure, pulmonary edema, and pleural effusions) have been reported [see Boxed Warning, Warnings and Precautions (5.1)].

There are postmarketing reports with Avandia of hepatitis, hepatic enzyme elevations to 3 or more times the upper limit of normal, and hepatic failure with and without fatal outcome, although causality has not been established.

There are postmarketing reports with Avandia of rash, pruritus, urticaria, angioedema, anaphylactic reaction, Stevens-Johnson syndrome [see Contraindications (4)], and new onset or worsening diabetic macular edema with decreased visual acuity [see Warnings and Precautions (5.6)].

Mechanism of Action

Rosiglitazone, a member of the thiazolidinedione class of antidiabetic agents, improves glycemic control by improving insulin sensitivity. Rosiglitazone is a highly selective and potent agonist for the peroxisome proliferator-activated receptor-gamma (PPARγ). In humans, PPAR receptors are found in key target tissues for insulin action such as adipose tissue, skeletal muscle, and liver. Activation of PPARγ nuclear receptors regulates the transcription of insulin-responsive genes involved in the control of glucose production, transport, and utilization. In addition, PPARγ-responsive genes also participate in the regulation of fatty acid metabolism.

Insulin resistance is a common feature characterizing the pathogenesis of type 2 diabetes. The antidiabetic activity of rosiglitazone has been demonstrated in animal models of type 2 diabetes in which hyperglycemia and/or impaired glucose tolerance is a consequence of insulin resistance in target tissues. Rosiglitazone reduces blood glucose concentrations and reduces hyperinsulinemia in the ob/ob obese mouse, db/db diabetic mouse, and fa/fa fatty Zucker rat.

In animal models, the antidiabetic activity of rosiglitazone was shown to be mediated by increased sensitivity to insulin’s action in the liver, muscle, and adipose tissues. Pharmacological studies in animal models indicate that rosiglitazone inhibits hepatic gluconeogenesis. The expression of the insulin-regulated glucose transporter GLUT-4 was increased in adipose tissue. Rosiglitazone did not induce hypoglycemia in animal models of type 2 diabetes and/or impaired glucose tolerance.

Pharmacodynamics

Patients with lipid abnormalities were not excluded from clinical trials of Avandia. In all 26-week controlled trials, across the recommended dose range, Avandia as monotherapy was associated with increases in total cholesterol, LDL, and HDL, and decreases in free fatty acids. These changes were statistically significantly different from placebo or glyburide controls (Table 7).

Increases in LDL occurred primarily during the first 1 to 2 months of therapy with Avandia and LDL levels remained elevated above baseline throughout the trials. In contrast, HDL continued to rise over time. As a result, the LDL/HDL ratio peaked after 2 months of therapy and then appeared to decrease over time. Because of the temporal nature of lipid changes, the 52-week, glyburide-controlled trial is most pertinent to assess long-term effects on lipids. At baseline, Week 26, and Week 52, mean LDL/HDL ratios were 3.1, 3.2, and 3.0, respectively, for Avandia 4 mg twice daily. The corresponding values for glyburide were 3.2, 3.1, and 2.9. The differences in change from baseline between Avandia and glyburide at Week 52 were statistically significant.

The pattern of LDL and HDL changes following therapy with Avandia in combination with other hypoglycemic agents were generally similar to those seen with Avandia in monotherapy.

The changes in triglycerides during therapy with Avandia were variable and were generally not statistically different from placebo or glyburide controls.

Table 7. Summary of Mean Lipid Changes in 26-Week, Placebo-Controlled and 52-Week, Glyburide-Controlled Monotherapy Trials

Parameter	Placebo-Controlled Trials Week 26			Glyburide-Controlled Trial Week 26 and Week 52
	Placebo	Avandia		Glyburide Titration		Avandia 8 mg
		4 mg Dailya	8 mg Dailya	Week 26	Week 52	Week 26	Week 52
Free fatty acids
N	207	428	436	181	168	166	145
Baseline (mean)	18.1	17.5	17.9	26.4	26.4	26.9	26.6
% Change from baseline (mean)	+0.2%	-7.8%	-14.7%	-2.4%	-4.7%	-20.8%	-21.5%
LDL
N	190	400	374	175	160	161	133
Baseline (mean)	123.7	126.8	125.3	142.7	141.9	142.1	142.1
% Change from baseline (mean)	+4.8%	+14.1%	+18.6%	-0.9%	-0.5%	+11.9%	+12.1%
HDL
N	208	429	436	184	170	170	145
Baseline (mean)	44.1	44.4	43.0	47.2	47.7	48.4	48.3
% Change from baseline (mean)	+8.0%	+11.4%	+14.2%	+4.3%	+8.7%	+14.0%	+18.5%

a   Once-daily and twice-daily dosing groups were combined.

Pharmacokinetics

Maximum plasma concentration (Cmax) and the area under the curve (AUC) of rosiglitazone increase in a dose-proportional manner over the therapeutic dose range (Table 8). The elimination half-life is 3 to 4 hours and is independent of dose.

Table 8. Mean (SD) Pharmacokinetic Parameters for Rosiglitazone following Single Oral Doses (N = 32)

Parameter	1 mg Fasting	2 mg Fasting	8 mg Fasting	8 mg Fed
AUC0-inf	358	733	2,971	2,890
(ng.h/mL)	(112)	(184)	(730)	(795)
Cmax	76	156	598	432
(ng/mL)	(13)	(42)	(117)	(92)
T½	3.16	3.15	3.37	3.59
(h)	(0.72)	(0.39)	(0.63)	(0.70)
CL/F	3.03	2.89	2.85	2.97
(L/h)	(0.87)	(0.71)	(0.69)	(0.81)

AUC = area under the curve; Cmax = maximum concentration; T½ = terminal half-life; CL/F = Oral clearance.

Absorption

The absolute bioavailability of rosiglitazone is 99%. Peak plasma concentrations are observed about 1 hour after dosing. Administration of rosiglitazone with food resulted in no change in overall exposure (AUC), but there was an approximately 28% decrease in Cmax and a delay in Tmax (1.75 hours). These changes are not likely to be clinically significant; therefore, Avandia may be administered with or without food.

Distribution

The mean (CV%) oral volume of distribution (Vss/F) of rosiglitazone is approximately 17.6 (30%) liters, based on a population pharmacokinetic analysis. Rosiglitazone is approximately 99.8% bound to plasma proteins, primarily albumin.

Metabolism

Rosiglitazone is extensively metabolized with no unchanged drug excreted in the urine. The major routes of metabolism were N-demethylation and hydroxylation, followed by conjugation with sulfate and glucuronic acid. All the circulating metabolites are considerably less potent than parent and, therefore, are not expected to contribute to the insulin-sensitizing activity of rosiglitazone.

In vitro data demonstrate that rosiglitazone is predominantly metabolized by Cytochrome P450 (CYP) isoenzyme 2C8, with CYP2C9 contributing as a minor pathway.

Excretion

Following oral or intravenous administration of [14C]rosiglitazone maleate, approximately 64% and 23% of the dose was eliminated in the urine and in the feces, respectively. The plasma half-life of [14C]related material ranged from 103 to 158 hours.

Population Pharmacokinetics in Patients with Type 2 Diabetes

Population pharmacokinetic analyses from 3 large clinical trials including 642 men and 405 women with type 2 diabetes (aged 35 to 80 years) showed that the pharmacokinetics of rosiglitazone are not influenced by age, race, smoking, or alcohol consumption. Both oral clearance (CL/F) and oral steady-state volume of distribution (Vss/F) were shown to increase with increases in body weight. Over the weight range observed in these analyses (50 to 150 kg), the range of predicted CL/F and Vss/F values varied by <1.7-fold and <2.3-fold, respectively. Additionally, rosiglitazone CL/F was shown to be influenced by both weight and gender, being lower (about 15%) in female patients.

Special Populations

Geriatric: Results of the population pharmacokinetic analysis (n = 716 <65 years; n = 331 ≥65 years) showed that age does not significantly affect the pharmacokinetics of rosiglitazone.

Gender: Results of the population pharmacokinetics analysis showed that the mean oral clearance of rosiglitazone in female patients (n = 405) was approximately 6% lower compared with male patients of the same body weight (n = 642).

As monotherapy and in combination with metformin, Avandia improved glycemic control in both males and females. In metformin combination trials, efficacy was demonstrated with no gender differences in glycemic response.

In monotherapy trials, a greater therapeutic response was observed in females; however, in more obese patients, gender differences were less evident. For a given BMI, females tend to have a greater fat mass than males. Since the molecular target PPARγ is expressed in adipose tissues, this differentiating characteristic may account, at least in part, for the greater response to Avandia in females. Since therapy should be individualized, no dose adjustments are necessary based on gender alone.

Hepatic Impairment: Unbound oral clearance of rosiglitazone was significantly lower in patients with moderate to severe liver disease (Child-Pugh Class B/C) compared with healthy subjects. As a result, unbound Cmax and AUC0-inf were increased 2- and 3-fold, respectively. Elimination half-life for rosiglitazone was about 2 hours longer in patients with liver disease, compared with healthy subjects.

Therapy with Avandia should not be initiated if the patient exhibits clinical evidence of active liver disease or increased serum transaminase levels (ALT >2.5X upper limit of normal) at baseline [see Warnings and Precautions (5.5)].

Pediatric: Pharmacokinetic parameters of rosiglitazone in pediatric patients were established using a population pharmacokinetic analysis with sparse data from 96 pediatric patients in a single pediatric clinical trial including 33 males and 63 females with ages ranging from 10 to 17 years (weights ranging from 35 to 178.3 kg). Population mean CL/F and V/F of rosiglitazone were 3.15 L/h and 13.5 L, respectively. These estimates of CL/F and V/F were consistent with the typical parameter estimates from a prior adult population analysis.

Renal Impairment: There are no clinically relevant differences in the pharmacokinetics of rosiglitazone in patients with mild to severe renal impairment or in hemodialysis-dependent patients compared with subjects with normal renal function. No dosage adjustment is therefore required in such patients receiving Avandia. Since metformin is contraindicated in patients with renal impairment, coadministration of metformin with Avandia is contraindicated in these patients.

Race: Results of a population pharmacokinetic analysis including subjects of Caucasian, black, and other ethnic origins indicate that race has no influence on the pharmacokinetics of rosiglitazone.

Drug-Drug Interactions

Drugs that Inhibit, Induce, or are Metabolized by Cytochrome P450

In vitro drug metabolism studies suggest that rosiglitazone does not inhibit any of the major P450 enzymes at clinically relevant concentrations. In vitro data demonstrate that rosiglitazone is predominantly metabolized by CYP2C8, and to a lesser extent, 2C9. Avandia (4 mg twice daily) was shown to have no clinically relevant effect on the pharmacokinetics of nifedipine and oral contraceptives (ethinyl estradiol and norethindrone), which are predominantly metabolized by CYP3A4.

Gemfibrozil: Concomitant administration of gemfibrozil (600 mg twice daily), an inhibitor of CYP2C8, and rosiglitazone (4 mg once daily) for 7 days increased rosiglitazone AUC by 127%, compared with the administration of rosiglitazone (4 mg once daily) alone. Given the potential for dose-related adverse events with rosiglitazone, a decrease in the dose of rosiglitazone may be needed when gemfibrozil is introduced [see Drug Interactions (7.1)].

Rifampin: Rifampin administration (600 mg once a day), an inducer of CYP2C8, for 6 days is reported to decrease rosiglitazone AUC by 66%, compared with the administration of rosiglitazone (8 mg) alone [see Drug Interactions (7.1)].1

Glyburide

Avandia (2 mg twice daily) taken concomitantly with glyburide (3.75 to 10 mg/day) for 7 days did not alter the mean steady-state 24-hour plasma glucose concentrations in diabetic patients stabilized on glyburide therapy. Repeat doses of Avandia (8 mg once daily) for 8 days in healthy adult Caucasian subjects caused a decrease in glyburide AUC and Cmax of approximately 30%. In Japanese subjects, glyburide AUC and Cmax slightly increased following coadministration of Avandia.

Glimepiride

Single oral doses of glimepiride in 14 healthy adult subjects had no clinically significant effect on the steady-state pharmacokinetics of Avandia. No clinically significant reductions in glimepiride AUC and Cmax were observed after repeat doses of Avandia (8 mg once daily) for 8 days in healthy adult subjects.

Metformin

Concurrent administration of Avandia (2 mg twice daily) and metformin (500 mg twice daily) in healthy volunteers for 4 days had no effect on the steady-state pharmacokinetics of either metformin or rosiglitazone.

Acarbose

Coadministration of acarbose (100 mg three times daily) for 7 days in healthy volunteers had no clinically relevant effect on the pharmacokinetics of a single oral dose of Avandia.

Digoxin

Repeat oral dosing of Avandia (8 mg once daily) for 14 days did not alter the steady-state pharmacokinetics of digoxin (0.375 mg once daily) in healthy volunteers.

Warfarin

Repeat dosing with Avandia had no clinically relevant effect on the steady-state pharmacokinetics of warfarin enantiomers.

Ethanol

A single administration of a moderate amount of alcohol did not increase the risk of acute hypoglycemia in patients with type 2 diabetes mellitus treated with Avandia.

Ranitidine

Pre-treatment with ranitidine (150 mg twice daily for 4 days) did not alter the pharmacokinetics of either single oral or intravenous doses of rosiglitazone in healthy volunteers. These results suggest that the absorption of oral rosiglitazone is not altered in conditions accompanied by increases in gastrointestinal pH.

Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenesis

A 2-year carcinogenicity study was conducted in Charles River CD-1 mice at doses of 0.4, 1.5, and 6 mg/kg/day in the diet (highest dose equivalent to approximately 12 times human AUC at the maximum recommended human daily dose). Sprague-Dawley rats were dosed for 2 years by oral gavage at doses of 0.05, 0.3, and 2 mg/kg/day (highest dose equivalent to approximately 10 and 20 times human AUC at the maximum recommended human daily dose for male and female rats, respectively).

Rosiglitazone was not carcinogenic in the mouse. There was an increase in incidence of adipose hyperplasia in the mouse at doses ≥1.5 mg/kg/day (approximately 2 times human AUC at the maximum recommended human daily dose). In rats, there was a significant increase in the incidence of benign adipose tissue tumors (lipomas) at doses ≥0.3 mg/kg/day (approximately 2 times human AUC at the maximum recommended human daily dose). These proliferative changes in both species are considered due to the persistent pharmacological overstimulation of adipose tissue.

Mutagenesis

Rosiglitazone was not mutagenic or clastogenic in the in vitro bacterial assays for gene mutation, the in vitro chromosome aberration test in human lymphocytes, the in vivo mouse micronucleus test, and the in vivo/in vitro rat UDS assay. There was a small (about 2-fold) increase in mutation in the in vitro mouse lymphoma assay in the presence of metabolic activation.

Impairment of Fertility

Rosiglitazone had no effects on mating or fertility of male rats given up to 40 mg/kg/day (approximately 116 times human AUC at the maximum recommended human daily dose). Rosiglitazone altered estrous cyclicity (2 mg/kg/day) and reduced fertility (40 mg/kg/day) of female rats in association with lower plasma levels of progesterone and estradiol (approximately 20 and 200 times human AUC at the maximum recommended human daily dose, respectively). No such effects were noted at 0.2 mg/kg/day (approximately 3 times human AUC at the maximum recommended human daily dose). In juvenile rats dosed from 27 days of age through to sexual maturity (at up to 40 mg/kg/day), there was no effect on male reproductive performance, or on estrous cyclicity, mating performance, or pregnancy incidence in females (approximately 68 times human AUC at the maximum recommended human daily dose). In monkeys, rosiglitazone (0.6 and 4.6 mg/kg/day; approximately 3 and 15 times human AUC at the maximum recommended human daily dose, respectively) diminished the follicular phase rise in serum estradiol with consequential reduction in the luteinizing hormone surge, lower luteal phase progesterone levels, and amenorrhea. The mechanism for these effects appears to be direct inhibition of ovarian steroidogenesis.

Animal Toxicology

Heart weights were increased in mice (3 mg/kg/day), rats (5 mg/kg/day), and dogs (2 mg/kg/day) with rosiglitazone treatments (approximately 5, 22, and 2 times human AUC at the maximum recommended human daily dose, respectively). Effects in juvenile rats were consistent with those seen in adults. Morphometric measurement indicated that there was hypertrophy in cardiac ventricular tissues, which may be due to increased heart work as a result of plasma volume expansion.

Each pentagonal film-coated TILTAB tablet contains rosiglitazone as the maleate as follows: 2 mg–pink, debossed with GSK on one side and 2 on the other; 4 mg–orange, debossed with GSK on one side and 4 on the other.

2 mg bottles of 60: NDC 0173-0861-18

4 mg bottles of 30: NDC 0173-0863-13

Store at 25°C (77°F); excursions 15° to 30°C (59° to 86°F). Dispense in a tight, light-resistant container.

Advise the patient to read the FDA-approved patient labeling (Medication Guide).

There are multiple medications available to treat type 2 diabetes. The benefits and risks of each available diabetes medication should be taken into account when choosing a particular diabetes medication for a given patient.

Patients should be informed of the following:

• Avandia is not recommended for patients with symptomatic heart failure. • A meta-analysis of mostly short-term trials suggested an increased risk for myocardial infarction with Avandia compared with placebo. Data from long-term clinical trials of Avandia versus other antidiabetes agents (metformin or sulfonylureas), including a cardiovascular outcome trial (RECORD), observed no difference in overall mortality or in major adverse cardiovascular events (MACE) and its components. • Avandia is not recommended for patients who are taking insulin. • Management of type 2 diabetes should include diet control. Caloric restriction, weight loss, and exercise are essential for the proper treatment of the diabetic patient because they help improve insulin sensitivity. This is important not only in the primary treatment of type 2 diabetes, but in maintaining the efficacy of drug therapy. • It is important to adhere to dietary instructions and to regularly have blood glucose and glycosylated hemoglobin tested. It can take 2 weeks to see a reduction in blood glucose and 2 to 3 months to see the full effect of Avandia. • Blood will be drawn to check their liver function prior to the start of therapy and periodically thereafter per the clinical judgment of the healthcare professional. Patients with unexplained symptoms of nausea, vomiting, abdominal pain, fatigue, anorexia, or dark urine should immediately report these symptoms to their physician. • Patients who experience an unusually rapid increase in weight or edema or who develop shortness of breath or other symptoms of heart failure while on Avandia should immediately report these symptoms to their physician. • Avandia can be taken with or without meals. • When using Avandia in combination with other hypoglycemic agents, the risk of hypoglycemia, its symptoms and treatment, and conditions that predispose to its development should be explained to patients and their family members. • Therapy with Avandia, like other thiazolidinediones, may result in ovulation in some premenopausal anovulatory women. As a result, these patients may be at an increased risk for pregnancy while taking Avandia. Thus, adequate contraception in premenopausal women should be recommended. This possible effect has not been specifically investigated in clinical trials so the frequency of this occurrence is not known.

Avandia and TILTAB are registered trademarks of the GSK group of companies.

GlaxoSmithKline

Research Triangle Park, NC 27709

©2016 the GSK group of companies. All rights reserved.

AVD:33PI

MEDICATION GUIDE

Avandia® (ah-VAN-dee-a)

(rosiglitazone maleate) tablets

Read this Medication Guide carefully before you start taking Avandia and each time you get a refill. There may be new information. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about Avandia, ask your doctor or pharmacist.

What is the most important information I should know about Avandia?

Avandia may cause serious side effects, including:

New or worse heart failure

• The risk of heart failure may be higher in people who take Avandia with insulin. Most people who take insulin should not also take Avandia. • Avandia can cause your body to keep extra fluid (fluid retention), which leads to swelling (edema) and weight gain. Extra body fluid can make some heart problems worse or lead to heart failure. Heart failure means your heart does not pump blood well enough. • If you have severe heart failure, you cannot start Avandia. • If you have heart failure with symptoms (such as shortness of breath or swelling), even if these symptoms are not severe, Avandia may not be right for you.

Call your doctor right away if you have any of the following:

• swelling or fluid retention, especially in the ankles or legs • shortness of breath or trouble breathing, especially when you lie down • an unusually fast increase in weight • unusual tiredness

Avandia can have other serious side effects. Be sure to read the section below “What are possible side effects of Avandia?”

What is Avandia?

Avandia is a prescription medicine used with diet and exercise to treat adults with type 2 (“adult-onset” or “non-insulin dependent”) diabetes mellitus (“high blood sugar”).

Avandia helps to control high blood sugar. Avandia may be used alone or with other diabetes medicines. Avandia can help your body respond better to insulin made in your body. Avandia does not cause your body to make more insulin.

Avandia is not for people with type 1 diabetes mellitus or to treat a condition called diabetic ketoacidosis.

It is not known if Avandia is safe and effective in children younger than 18 years old.

Who should not take Avandia?

Many people with heart failure should not start taking Avandia. See “What should I tell my doctor before taking Avandia?”

Do not take Avandia if you are allergic to rosiglitazone or any of the ingredients in Avandia. See the end of this leaflet for a complete list of ingredients in Avandia.

Symptoms of a severe allergic reaction with Avandia may include:

• swelling of your face, lips, tongue, or throat • problems with breathing or swallowing • skin rash or itching • raised red areas on your skin (hives) • blisters on your skin or in your mouth, nose, or eyes • peeling of your skin • fainting or feeling dizzy • very rapid heartbeat

What should I tell my doctor before taking Avandia?

Before starting Avandia, ask your doctor about what the choices are for diabetes medicines, and what the expected benefits and possible risks are for you in particular.

Before taking Avandia, tell your doctor about all of your medical conditions, including if you:

• have heart problems or heart failure. • have type 1 (“juvenile”) diabetes or had diabetic ketoacidosis. These conditions should be treated with insulin. • have a type of diabetic eye disease called macular edema (swelling of the back of the eye). • have liver problems. Your doctor should do blood tests to check your liver before you start taking Avandia and during treatment as needed. • had liver problems while taking REZULIN™ (troglitazone), another medicine for diabetes. • are pregnant or plan to become pregnant. It is not known if Avandia can harm your unborn baby. You and your doctor should talk about the best way to control your diabetes during pregnancy. If you are a premenopausal woman (before the “change of life”) who does not have regular monthly periods, Avandia may increase your chances of becoming pregnant. Talk to your doctor about birth control choices while taking Avandia. Tell your doctor right away if you become pregnant while taking Avandia. • are breastfeeding or planning to breastfeed. It is not known if Avandia passes into breast milk. You and your doctor should decide if you will take Avandia or breastfeed. You should not do both.

Tell your doctor about all of the medicines you take including prescription and over-the-counter medicines, vitamins, or herbal supplements. Avandia and certain other medicines can affect each other and may lead to serious side effects including high or low blood sugar, or heart problems. Especially tell your doctor if you take:

• insulin. • any medicines for high blood pressure, high cholesterol, or heart failure, or for prevention of heart disease or stroke.

Know the medicines you take. Keep a list of your medicines and show it to your doctor and pharmacist before you start a new medicine. They will tell you if it is alright to take Avandia with other medicines.

How should I take Avandia?

• Take Avandia exactly as prescribed. Your doctor will tell you how many tablets to take and how often. The usual daily starting dose is 4 mg a day taken one time each day or 2 mg taken two times each day. Your doctor may need to adjust your dose until your blood sugar is better controlled. • Avandia may be prescribed alone or with other diabetes medicines. This will depend on how well your blood sugar is controlled. • Take Avandia with or without food. • It can take 2 weeks for Avandia to start lowering blood sugar. It may take 2 to 3 months to see the full effect on your blood sugar level. • If you miss a dose of Avandia, take it as soon as you remember, unless it is time to take your next dose. Take your next dose at the usual time. Do not take double doses to make up for a missed dose. • If you take too much Avandia, call your doctor or poison control center right away. • Test your blood sugar regularly as your doctor tells you. • Diet and exercise can help your body use its blood sugar better. It is important to stay on your recommended diet, lose extra weight, and get regular exercise while taking Avandia. • Your doctor should do blood tests to check your liver before you start Avandia and during treatment as needed. Your doctor should also do regular blood sugar tests (for example, “A1C”) to monitor your response to Avandia.

What are possible side effects of Avandia?

Avandia may cause serious side effects including:

• New or worse heart failure. See “What is the most important information I should know about Avandia?” • Heart attack. Avandia may increase the risk of a heart attack. Talk to your doctor about what this means to you.
Symptoms of a heart attack can include the following: • chest discomfort in the center of your chest that lasts for more than a few minutes, or that goes away or comes back • chest discomfort that feels like uncomfortable pressure, squeezing, fullness, or pain • pain or discomfort in your arms, back, neck, jaw, or stomach • shortness of breath with or without chest discomfort • breaking out in a cold sweat • nausea or vomiting • feeling lightheaded   Call your doctor or go to the nearest hospital emergency room right away if you think you are having a heart attack. • Swelling (edema). Avandia can cause swelling due to fluid retention. See “What is the most important information I should know about Avandia?” • Weight gain. Avandia can cause weight gain that may be due to fluid retention or extra body fat. Weight gain can be a serious problem for people with certain conditions including heart problems. See “What is the most important information I should know about Avandia?” • Liver problems. It is important for your liver to be working normally when you take Avandia. Your doctor should do blood tests to check your liver before you start taking Avandia and during treatment as needed. Call your doctor right away if you have unexplained symptoms such as: • nausea or vomiting • stomach pain • unusual or unexplained tiredness • loss of appetite • dark urine • yellowing of your skin or the whites of your eyes. • Macular edema (a diabetic eye disease with swelling in the back of the eye). Tell your doctor right away if you have any changes in your vision. Your doctor should check your eyes regularly. Very rarely, some people have had vision changes due to swelling in the back of the eye while taking Avandia. • Fractures (broken bones), usually in the hand, upper arm, or foot. Talk to your doctor for advice on how to keep your bones healthy. • Low red blood cell count (anemia). • Low blood sugar (hypoglycemia). Lightheadedness, dizziness, shakiness or hunger may mean that your blood sugar is too low. This can happen if you skip meals, if you use another medicine that lowers blood sugar, or if you have certain medical problems. Call your doctor if low blood sugar levels are a problem for you. • Ovulation (release of egg from an ovary in a woman) leading to pregnancy. Ovulation may happen in premenopausal women who do not have regular monthly periods. This can increase the chance of pregnancy. See “What should I tell my doctor before taking Avandia?”

The most common side effects of Avandia reported in clinical trials included cold-like symptoms and headache.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

How should I store Avandia?

• Store Avandia at room temperature, 59°F to 86°F (15°C to 30°C). Keep Avandia in the container it comes in. • Safely, throw away Avandia that is out of date or no longer needed. • Keep Avandia and all medicines out of the reach of children.

General information about Avandia

Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use Avandia for a condition for which it was not prescribed. Do not give Avandia to other people, even if they have the same symptoms you have. It may harm them.

This Medication Guide summarizes important information about Avandia. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about Avandia that is written for healthcare professionals. You can also find out more about Avandia by calling 1-888-825-5249.

What are the ingredients in Avandia?

Active Ingredient: rosiglitazone maleate.

Inactive Ingredients: hypromellose 2910, lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol 3000, sodium starch glycolate, titanium dioxide, triacetin, and 1 or more of the following: synthetic red and yellow iron oxides and talc.

Always check to make sure that the medicine you are taking is the correct one. Avandia tablets are triangles with rounded corners and look like this:

2 mg – pink with “GSK” on one side and “2” on the other.

4 mg – orange with “GSK” on one side and “4” on the other.

Avandia is a registered trademark of the GSK group of companies.

REZULIN is a trademark of its respective owner and is not a trademark of the GSK group of companies. The maker of this brand is not affiliated with and does not endorse the GSK group of companies or its products.

This Medication Guide has been approved by the U.S. Food and Drug Administration.

GlaxoSmithKline

Research Triangle Park, NC 27709

©2016 the GSK group of companies. All rights reserved.

September 2016

AVD:9MG

PRINCIPAL DISPLAY PANEL

NDC 0173-0861-18

Avandia®

ROSIGLITAZONE MALEATE TABLETS

2 mg

60 Tiltab® Tablets

Rx only

Federal Law requires dispensing of Avandia® with the Medication Guide provided with this bottle.

Store at 25oC (77oF); excursions 15o – 30oC (59o – 86oF).

Do not use if printed safety seal under cap is broken or missing.

Each Tiltab® tablet contains rosiglitazone maleate equivalent to 2 mg rosiglitazone.

Dispense in a tight, light-resistant container.

Dosage: See accompanying prescribing information.

GlaxoSmithKline

Research Triangle Park, NC 27709

Made in Canada

Rev. 1/17

10000000143763

PRINCIPAL DISPLAY PANEL

NDC 0173-0863-13

Avandia®

ROSIGLITAZONE MALEATE TABLETS

4 mg

30 Tiltab® Tablets

Rx only

Federal Law requires dispensing of Avandia® with the Medication Guide provided with this bottle.

Store at 25oC (77oF); excursions 15o – 30oC (59o – 86oF).

Do not use if printed safety seal under cap is broken or missing.

Each Tiltab® tablet contains rosiglitazone maleate equivalent to 4 mg rosiglitazone.

Dispense in a tight, light-resistant container.

Dosage: See accompanying prescribing information.

GlaxoSmithKline

Research Triangle Park, NC 27709

Made in Canada

Rev. 1/17

10000000143762

Avandia  2MG rosiglitazone maleate tablet, film coated

Product Information Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:0173-0861 Route of Administration ORAL DEA Schedule

Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength ROSIGLITAZONE MALEATE (ROSIGLITAZONE) ROSIGLITAZONE 2 mg

Inactive Ingredients Ingredient Name Strength HYPROMELLOSE 2910 (3 MPA.S)   LACTOSE MONOHYDRATE   MAGNESIUM STEARATE   CELLULOSE, MICROCRYSTALLINE   POLYETHYLENE GLYCOL 3000   SODIUM STARCH GLYCOLATE TYPE A POTATO   TITANIUM DIOXIDE   TRIACETIN   TALC   FERRIC OXIDE RED   FERRIC OXIDE YELLOW

Product Characteristics Color PINK Score no score Shape FREEFORM (pentagonal) Size 10mm Flavor Imprint Code GSK;2 Contains

Packaging # Item Code Package Description 1 NDC:0173-0861-18 60 TABLET, FILM COATED in 1 BOTTLE

Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date NDA NDA021071 05/25/2011

Avandia  4MG rosiglitazone maleate tablet, film coated

Product Information Product Type HUMAN PRESCRIPTION DRUG LABEL Item Code (Source) NDC:0173-0863 Route of Administration ORAL DEA Schedule

Active Ingredient/Active Moiety Ingredient Name Basis of Strength Strength ROSIGLITAZONE MALEATE (ROSIGLITAZONE) ROSIGLITAZONE 4 mg

Inactive Ingredients Ingredient Name Strength HYPROMELLOSE 2910 (3 MPA.S)   LACTOSE MONOHYDRATE   MAGNESIUM STEARATE   CELLULOSE, MICROCRYSTALLINE   POLYETHYLENE GLYCOL 3000   SODIUM STARCH GLYCOLATE TYPE A POTATO   TITANIUM DIOXIDE   TRIACETIN   TALC   FERRIC OXIDE RED   FERRIC OXIDE YELLOW

Product Characteristics Color ORANGE Score no score Shape FREEFORM (pentagonal) Size 10mm Flavor Imprint Code GSK;4 Contains

Packaging # Item Code Package Description 1 NDC:0173-0863-13 30 TABLET, FILM COATED in 1 BOTTLE

Marketing Information Marketing Category Application Number or Monograph Citation Marketing Start Date Marketing End Date NDA NDA021071 05/25/2011

Labeler - GlaxoSmithKline LLC (167380711)

Revised: 09/2016   GlaxoSmithKline LLC

Common side effects of Avandia include: headache. Other side effects include: edema and nausea. See below for a comprehensive list of adverse effects.