Empagliflozin and Metformin Hydrochloride Tablets

Dosage Forms And Strengths

SYNJARDY is a combination of empagliflozin and metformin hydrochloride. SYNJARDY is available in the following dosage forms and strengths:

• 5 mg empagliflozin/500 mg metformin hydrochloride tablets are orange yellow, oval, biconvex, film-coated tablets. One side is debossed with the Boehringer Ingelheim company symbol and “S5” the other side is debossed with “500”.
• 5 mg empagliflozin/1000 mg metformin hydrochloride tablets are brownish yellow, oval, biconvex, filmcoated tablets. One side is debossed with the Boehringer Ingelheim company symbol and “S5” the other side is debossed with “1000”.
• 12.5 mg empagliflozin/500 mg metformin hydrochloride tablets are pale brownish purple, oval, biconvex, film-coated tablets. One side is debossed with the Boehringer Ingelheim company symbol and “S12” the other side is debossed with “500”.
• 12.5 mg empagliflozin/1000 mg metformin hydrochloride tablets are dark brownish purple, oval, biconvex, film-coated tablets. One side is debossed with the Boehringer Ingelheim company symbol and “S12” the other side is debossed with “1000”.

Storage And Handling

SYNJARDY (empagliflozin and metformin hydrochloride) tablets are available in the following strengths and packages:

Store at 25°XC (77°XF); excursions permitted to 15°X-30°XC (59°X-86°XF) [see USP Controlled Room Temperature]. Store in a safe place out of reach of children.

Distributed by: Boehringer Ingelheim Pharmaceuticals, Inc.; Ridgefield, CT 06877 USA. Revised: Dec 2016

The following important adverse reactions are described below and elsewhere in the labeling:

• Lactic Acidosis [see BOX WARNING and WARNINGS AND PRECAUTIONS]
• Hypotension [see WARNINGS AND PRECAUTIONS]
• Ketoacidosis [see WARNINGS AND PRECAUTIONS]
• Acute Kidney Injury and Impairment in Renal Function [see WARNINGS AND PRECAUTIONS]
• Urosepsis and Pyelonephritis [see WARNINGS AND PRECAUTIONS]
• Hypoglycemia with Concomitant Use with Insulin and Insulin Secretagogues [see WARNINGS AND PRECAUTIONS]
• Genital Mycotic Infections [see WARNINGS AND PRECAUTIONS]
• Vitamin B12 Deficiency [see WARNINGS AND PRECAUTIONS]
• Increased Low-Density Lipoprotein Cholesterol (LDL-C) [see WARNINGS AND PRECAUTIONS]

Clinical Trials Experience

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

The safety of concomitantly administered empagliflozin (daily dose 10 mg and 25 mg) and metformin hydrochloride (mean daily dose of approximately 1800 mg) has been evaluated in 3456 patients with type 2 diabetes mellitus treated for 16 to 24 weeks, of which 926 patients received placebo, 1271 patients received a daily dose of empagliflozin 10 mg, and 1259 patients received a daily dose of empagliflozin 25 mg. Discontinuation of therapy due to adverse events across treatment groups was 3.0%, 2.8%, and 2.9% for placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively.

Empagliflozin Add-On Combination Therapy With Metformin

In a 24-week placebo-controlled trial of empagliflozin 10 mg and 25 mg administered once daily added to metformin, there were no adverse reactions reported regardless of investigator assessment of causality in ≥5% of patients and more commonly than in patients given placebo.

Empagliflozin Add-On Combination Therapy With Metformin And Sulfonylurea

In a 24-week placebo-controlled trial of empagliflozin 10 mg and 25 mg administered once daily added to metformin and sulfonylurea, adverse reactions reported regardless of investigator assessment of causality in ≥5% of patients and more commonly than in patients given placebo are presented in Table 1 (see also Table 4).

Table 1: Adverse Reactions Reported in ≥5% of Patients Treated with Empagliflozin added on to Metformin plus Sulfonylurea and Greater than with Placebo in a 24-week Placebo Controlled Clinical Study

Empagliflozin

The data in Table 2 are derived from a pool of four 24-week placebo-controlled trials and 18-week data from a placebo-controlled trial with basal insulin. Empagliflozin was used as monotherapy in one trial and as add-on therapy in four trials [see Clinical Studies].

These data reflect exposure of 1976 patients to empagliflozin with a mean exposure duration of approximately 23 weeks. Patients received placebo (N=995), empagliflozin 10 mg (N=999), or empagliflozin 25 mg (N=977) once daily. The mean age of the population was 56 years and 3% were older than 75 years of age. More than half (55%) of the population was male; 46% were White, 50% were Asian, and 3% were Black or African American. At baseline, 57% of the population had diabetes more than 5 years and had a mean hemoglobin A1c (HbA1c) of 8%. Established microvascular complications of diabetes at baseline included diabetic nephropathy (7%), retinopathy (8%), or neuropathy (16%). Baseline renal function was normal or mildly impaired in 91% of patients and moderately impaired in 9% of patients (mean eGFR 86.8 mL/min/1.73 m2).

Table 2 shows common adverse reactions (excluding hypoglycemia) associated with the use of empagliflozin. The adverse reactions were not present at baseline, occurred more commonly on empagliflozin than on placebo and occurred in greater than or equal to 2% of patients treated with empagliflozin 10 mg or empagliflozin 25 mg.

Table 2 Adverse Reactions Reported in .2% of Patients Treated with Empagliflozin and Greater than Placebo in Pooled Placebo-Controlled Clinical Studies of Empagliflozin Monotherapy or Combination Therapy

Thirst (including polydipsia) was reported in 0%, 1.7%, and 1.5% for placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively.

Empagliflozin causes an osmotic diuresis, which may lead to intravascular volume contraction and adverse reactions related to volume depletion. In the pool of five placebo-controlled clinical trials, adverse reactions related to volume depletion (e.g., blood pressure (ambulatory) decreased, blood pressure systolic decreased, dehydration, hypotension, hypovolemia, orthostatic hypotension, and syncope) were reported by 0.3%, 0.5%, and 0.3% of patients treated with placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively. Empagliflozin may increase the risk of hypotension in patients at risk for volume contraction [see WARNINGS AND PRECAUTIONS and Use In Specific Populations].

In the pool of five placebo-controlled clinical trials, adverse reactions of increased urination (e.g., polyuria, pollakiuria, and nocturia) occurred more frequently on empagliflozin than on placebo (see Table 3).

Specifically, nocturia was reported by 0.4%, 0.3%, and 0.8% of patients treated with placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively.

Treatment with empagliflozin was associated with increases in serum creatinine and decreases in eGFR (see Table 3). Patients with moderate renal impairment at baseline had larger mean changes [see WARNINGS AND PRECAUTIONS and Use In Specific Populations].

In a long-term cardiovascular outcome trial, the acute impairment in renal function was observed to reverse after treatment discontinuation suggesting acute hemodynamic changes play a role in the renal function changes observed with empagliflozin.

Table 3 Changes from Baseline in Serum Creatinine and eGFRa in the Pool of Four 24-week Placebo-Controlled Studies and Renal Impairment Study

The incidence of hypoglycemia by study is shown in Table 4. The incidence of hypoglycemia increased when empagliflozin was administered with insulin or sulfonylurea [see WARNINGS AND PRECAUTIONS].

Table 4 Incidence of Overalla and Severeb Hypoglycemic Events in Placebo-Controlled Clinical Studiesc

In the pool of five placebo-controlled clinical trials, the incidence of genital mycotic infections (e.g., vaginal mycotic infection, vaginal infection, genital infection fungal, vulvovaginal candidiasis, and vulvitis) was increased in patients treated with empagliflozin compared to placebo, occurring in 0.9%, 4.1%, and 3.7% of patients randomized to placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively. Discontinuation from study due to genital infection occurred in 0% of placebo-treated patients and 0.2% of patients treated with either empagliflozin 10 or 25 mg.

Genital mycotic infections occurred more frequently in female than male patients (see Table 2).

Phimosis occurred more frequently in male patients treated with empagliflozin 10 mg (less than 0.1%) and empagliflozin 25 mg (0.1%) than placebo (0%).

In the pool of five placebo-controlled clinical trials, the incidence of urinary tract infections (e.g., urinary tract infection, asymptomatic bacteriuria, and cystitis) was increased in patients treated with empagliflozin compared to placebo (see Table 2). Patients with a history of chronic or recurrent urinary tract infections were more likely to experience a urinary tract infection. The rate of treatment discontinuation due to urinary tract infections was 0.1%, 0.2%, and 0.1% for placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively.

Urinary tract infections occurred more frequently in female patients. The incidence of urinary tract infections in female patients randomized to placebo, empagliflozin 10 mg, and empagliflozin 25 mg was 16.6%, 18.4%, and 17.0%, respectively. The incidence of urinary tract infections in male patients randomized to placebo, empagliflozin 10 mg, and empagliflozin 25 mg was 3.2%, 3.6%, and 4.1%, respectively [see WARNINGS AND PRECAUTIONS and Use In Specific Populations].

Metformin

The most common (>5%) established adverse reactions due to initiation of metformin therapy are diarrhea, nausea/vomiting, flatulence, abdominal discomfort, indigestion, asthenia, and headache.

Long-term treatment with metformin has been associated with a decrease in vitamin B12 absorption which may very rarely result in clinically significant vitamin B12 deficiency (e.g., megaloblastic anemia) [see WARNINGS AND PRECAUTIONS].

Laboratory Tests

Increase in Low-Density Lipoprotein Cholesterol (LDL-C): Dose-related increases in low-density lipoprotein cholesterol (LDL-C) were observed in patients treated with empagliflozin. LDL-C increased by 2.3%, 4.6%, and 6.5% in patients treated with placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively [see WARNINGS AND PRECAUTIONS]. The range of mean baseline LDL-C levels was 90.3 to 90.6 mg/dL across treatment groups.

Increase in Hematocrit: In a pool of four placebo-controlled studies, median hematocrit decreased by 1.3% in placebo and increased by 2.8% in empagliflozin 10 mg and 2.8% in empagliflozin 25 mg treated patients. At the end of treatment, 0.6%, 2.7%, and 3.5% of patients with hematocrits initially within the reference range had values above the upper limit of the reference range with placebo, empagliflozin 10 mg, and empagliflozin 25 mg, respectively.

In controlled clinical trials of metformin of 29 weeks’ duration, a decrease to subnormal levels of previously normal serum Vitamin B12 levels, without clinical manifestations, was observed in approximately 7% of patients. Such decrease, possibly due to interference with B12 absorption from the B12-intrinsic factor complex, is, however, very rarely associated with anemia and appears to be rapidly reversible with discontinuation of metformin or Vitamin B12 supplementation [see WARNINGS AND PRECAUTIONS].

Postmarketing Experience

Additional adverse reactions have been identified during postapproval use of empagliflozin. 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 [see WARNINGS AND PRECAUTIONS]
• Urosepsis and pyelonephritis [see WARNINGS AND PRECAUTIONS]

In the event of an overdose with SYNJARDY, contact the Poison Control Center. Employ the usual supportive measures (e.g., remove unabsorbed material from the gastrointestinal tract, employ clinical monitoring, and institute supportive treatment) as dictated by the patient’s clinical status. Removal of empagliflozin by hemodialysis has not been studied. However, metformin is dialyzable with a clearance of up to 170 mL/min under good hemodynamic conditions. Therefore, hemodialysis may be useful partly for removal of accumulated metformin from patients in whom SYNJARDY overdosage is suspected.

Metformin Hydrochloride

Overdose of metformin hydrochloride has occurred, including ingestion of amounts greater than 50 grams. Hypoglycemia was reported in approximately 10% of cases, but no causal association with metformin has been established. Lactic acidosis has been reported in approximately 32% of metformin overdose cases [see BOX WARNING and WARNINGS AND PRECAUTIONS].

SYNJARDYR®
(sin-JAR-dee)
(empagliflozin and metformin hydrochloride) Tablets

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

Serious side effects can happen in people taking SYNJARDY, including:

Lactic Acidosis. Metformin, one of the medicines in SYNJARDY can cause a rare but serious condition called lactic acidosis (a build-up of lactic acid in the blood) that can cause death. Lactic acidosis is a medical emergency and must be treated in a hospital.

Call your doctor right away if you have any of the following symptoms, which could be signs of lactic acidosis:

• you feel cold in your hands or feet
• you feel dizzy or lightheaded
• you have a slow or irregular heartbeat
• you feel very weak or tired
• You have unusual (not normal) muscle pain
• you have trouble breathing
• you feel sleepy or drowsy
• you have stomach pains, nausea or vomiting

Most people who have had lactic acidosis with metformin have other things that, combined with metformin, led to the lactic acidosis. Tell your doctor if you have any of the following, because you have a higher chance for getting lactic acidosis with SYNJARDY if you:

• have moderate to severe kidney problems or your kidneys are affected by certain x-ray tests that use injectable dye.
• have liver problems
• drink alcohol very often, or drink a lot of alcohol in the short-term (“binge” drinking)
• get dehydrated (lose a large amount of body fluids). This can happen if you are sick with a fever, vomiting, or diarrhea. Dehydration can also happen when you sweat a lot with activity or exercise and do not drink enough fluids.
• have surgery
• have a heart attack, severe infection, or stroke

The best way to keep from having a problem with lactic acidosis from metformin is to tell your doctor if you have any of the problems in the list above. Your doctor may decide to stop your SYNJARDY for a while if you have any of these things.

SYNJARDY can have other serious side effects. See “What are the possible side effects of SYNJARDY?”

What is SYNJARDY?

• SYNJARDY is a prescription medicine that contains 2 prescription diabetes medicines, empagliflozin and metformin. SYNJARDY can be used:
  • along with diet and exercise to improve blood sugar in adults with type 2 diabetes,
  • in adults with type 2 diabetes who have known cardiovascular disease when both empagliflozin and metformin is appropriate and empagliflozin is needed to reduce the risk of cardiovascular death.
• SYNJARDY is not for people with type 1 diabetes.
• SYNJARDY is not for people with diabetic ketoacidosis (increased ketones in the blood or urine).
• It is not known if SYNJARDY is safe and effective in children under 18 years of age.

Who should not take SYNJARDY?

Do not take SYNJARDY if you:

• have moderate to severe kidney problems or are on dialysis
• have a condition called metabolic acidosis or diabetic ketoacidosis (increased ketones in the blood or urine)
• are allergic to empagliflozin, metformin, or any of the ingredients in SYNJARDY. See the end of this Medication Guide for a list of ingredients in SYNJARDY.

What should I tell my doctor before using SYNJARDY?

Before taking SYNJARDY, tell your healthcare provider about all of your medical conditions, including if you:

• have moderate to severe kidney problems
• have liver problems
• have a history of urinary tract infection or problems with urination
• have heart problems, including congestive heart failure
• are going to have surgery
• are eating less due to illness, surgery, or a change in your diet
• have or have had problems with your pancreas, including pancreatitis or surgery on your pancreas
• drink alcohol very often, or drink a lot of alcohol in the short term (“binge” drinking)
• are going to get an injection of dye or contrast agents for an x-ray procedure. SYNJARDY may need to be stopped for a short time. Talk to your doctor about when you should stop SYNJARDY and when you should start SYNJARDY again. See “What is the most important information I should know about SYNJARDY?”
• have a history of urinary tract infections or problems with urination
• have type 1 diabetes. SYNJARDY should not be used to treat people with type 1 diabetes.
• have any other medical conditions
• are pregnant or planning to become pregnant. SYNJARDY may harm your unborn baby. If you become pregnant while taking SYNJARDY, tell your doctor as soon as possible. Talk with your doctor about the best way to control your blood sugar while you are pregnant.
• are a premenopausal woman (before the “change of life”), who does not have periods regularly or at all. Talk to your doctor about birth control choices while taking SYNJARDY if you are not planning to become pregnant since SYNJARDY may increase your chance of becoming pregnant. Tell your doctor right away if you become pregnant while taking SYNJARDY.
• are breastfeeding or plan to breastfeed. SYNJARDY may pass into your breast milk and may harm your baby. Talk with your doctor about the best way to feed your baby if you are taking SYNJARDY. Do not breastfeed while taking SYNJARDY.

Tell your healthcare provider about all the medicines you take, including prescription or over-the-counter medicines, vitamins, or herbal supplements.

How should I take SYNJARDY?

• Take SYNJARDY exactly as your doctor tells you to take it.
• Take SYNJARDY by mouth 2 times each day with meals. Taking SYNJARDY with meals may lower your chance of having an upset stomach.
• Your doctor will tell you how much SYNJARDY to take and when to take it.
• Your doctor may change your dose if needed.
• If you miss a dose, take it as soon as you remember. If you do not remember until it is time for your next dose, skip the missed dose and go back to your regular schedule. Do not take two doses of SYNJARDY at the same time. Talk with your doctor if you have questions about a missed dose.
• Your doctor may tell you to take SYNJARDY along with other diabetes medicines. Low blood sugar can happen more often when SYNJARDY is taken with certain other diabetes medicines. See “What are the possible side effects of SYNJARDY?”
• If you take too much SYNJARDY, call your doctor or go to the nearest hospital emergency room right away.
• When your body is under some types of stress, such as fever, trauma (such as a car accident), infection, or surgery, the amount of diabetes medicine that you need may change. Tell your doctor right away if you have any of these conditions and follow your doctor’s instructions.
• check your blood sugar as your doctor tells you to.
• When taking SYNJARDY, you may have sugar in your urine, which will show up on a urine test.
• Stay on your prescribed diet and exercise program while taking SYNJARDY.
• Talk to your doctor about how to prevent, recognize and manage low blood sugar (hypoglycemia), high blood sugar (hyperglycemia), and complications of diabetes.
• Your doctor will check your diabetes with regular blood tests, including your blood sugar levels and your hemoglobin A1C.
• Your doctor will do blood tests to check how well your kidneys are working before and during your treatment with SYNJARDY.
• Your doctor may do certain blood tests before you start SYNJARDY and during treatment.

What should I avoid while taking SYNJARDY?

Avoid drinking alcohol very often, or drinking a lot of alcohol in a short period of time (“binge” drinking). It can increase your chances of getting serious side effects.

What are the possible side effects of SYNJARDY?

SYNJARDY may cause serious side effects, including:

• See “What is the most important information I should know about SYNJARDY?”
• Dehydration. SYNJARDY can cause some people to have dehydration (the loss of body water and salt). Dehydration may cause you to feel dizzy, faint, light-headed, or weak, especially when you stand up (orthostatic hypotension). You may be at higher risk of dehydration if you:
  • have low blood pressure o are on low sodium (salt) diet
  • have kidney problems
  • are 65 years of age or older
  • take medicines to lower your blood pressure, including diuretics (water pill)
• Ketoacidosis (increased ketones in your blood or urine). Ketoacidosis has happened in people who have type 1 diabetes or type 2 diabetes, during treatment with empagliflozin, one of the medicines in SYNJARDY. Ketoacidosis is a serious condition, which may need to be treated in a hospital. Ketoacidosis may lead to death. Ketoacidosis can happen with SYNJARDY even if your blood sugar is less than 250 mg/dL. Stop taking SYNJARDY and call your doctor right away if you get any of the following symptoms:
  • nausea
  • tiredness
  • vomiting
  • trouble breathing
  • stomach-area (abdominal) pain

If you get any of these symptoms during treatment with SYNJARDY, if possible, check for ketones in your urine, even if your blood sugar is less than 250 mg/dL.

• Kidney problems. Sudden kidney injury has happened to people taking SYNJARDY. Talk to your doctor right away if you:
  • reduce the amount of food or liquid you drink for example, if you are sick or cannot eat or
  • you start to lose liquids from your body for example, from vomiting, diarrhea or being in the sun too long
• Serious urinary tract infections. Serious urinary tract infections that may lead to hospitalization have happened in people who are taking empagliflozin, one of the medicines in SYNJARDY. Tell your doctor if you have any signs or symptoms of a urinary tract infection such as a burning feeling when passing urine, a need to urinate often, the need to urinate right away, pain in the lower part of your stomach (pelvis), or blood in the urine. Sometimes people also may have a fever, back pain, nausea or vomiting.
• Low blood sugar (hypoglycemia). If you take SYNJARDY with another medicine that can cause low blood sugar, such as a sulfonylurea or insulin, your risk of getting low blood sugar is higher. The dose of your sulfonylurea medicine or insulin may need to be lowered while you take SYNJARDY. Signs and symptoms of low blood sugar may include:
  • headache
  • irritability
  • confusion
  • dizziness
  • drowsiness
  • hunger
  • shaking or feeling jittery
  • sweating
  • weakness
  • fast heartbeat
• Vaginal yeast infection. Women who take SYNJARDY may get vaginal yeast infections. Symptoms of a vaginal yeast infection include vaginal odor, white or yellowish vaginal discharge (discharge may be lumpy or look like cottage cheese), or vaginal itching.
• Yeast infection of the penis (balanitis). Men who take SYNJARDY may get a yeast infection of the skin around the penis. Certain men who are not circumcised may have swelling of the penis that makes it difficult to pull back the skin around the tip of the penis. Other symptoms of yeast infection of the penis include redness, itching, or swelling of the penis, rash of the penis, foul smelling discharge from the penis, or pain in the skin around the penis.

Talk to your doctor about what to do if you get symptoms of a yeast infection of the vagina or penis. Your doctor may suggest you use an over-the-counter antifungal medicine. Talk to your doctor right away if you use an over-thecounter antifungal medication and your symptoms do not go away.

• Low vitamin B12 (vitamin B12 deficiency). Using metformin for long periods of time may cause a decrease in the amount of vitamin B12 in your blood, especially if you have had low vitamin B12 blood levels before. Your doctor may do blood tests to check your vitamin B12 levels.
• Increased fats in your blood (cholesterol)

The most common side effects of SYNJARDY include stuffy or runny nose and sore throat.

These are not all the possible side effects of SYNJARDY. For more information, ask your doctor or pharmacist.

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 SYNJARDY?

Store SYNJARDY at room temperature 68°F to 77°F (20°C to 25°C).

General information about the safe and effective use of SYNJARDY.

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

This Medication Guide summarizes the most important information about SYNJARDY. If you would like more information, talk with your doctor. You can ask your pharmacist or healthcare provider for information about SYNJARDY that is written for health professionals.

What are the ingredients in SYNJARDY?

Active Ingredients: empagliflozin and metformin hydrochloride

Inactive Ingredients: copovidone, corn starch, colloidal silicon dioxide, magnesium stearate. In addition, the film coating contains the following inactive ingredients: hypromellose, titanium dioxide, talc, and polyethylene glycol 400. 5 mg/500 mg and 5 mg/1000 mg tablets also contain yellow ferric oxide;12.5 mg/500 mg and 12.5 mg/1000 mg tablets also contain red ferric oxide and black ferrosoferric oxide

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