Qtern

Qtern

Manufacturer:

AstraZeneca

Distributor:

Zuellig Pharma
Full Prescribing Info
Contents
Saxagliptin, dapagliflozin.
Description
QTERN 5/10 is available as a film-coated tablet containing 5 mg saxagliptin as saxagliptin hydrochloride and dapagliflozin propanediol monohydrate equivalent to 10 mg dapagliflozin.
QTERN (saxagliptin/dapagliflozin) fixed dose combination tablets contain two oral antihyperglycaemic drugs used in the management of type 2 diabetes: saxagliptin and dapagliflozin.
Saxagliptin: Saxagliptin is an orally-active inhibitor of the dipeptidyl peptidase-4 (DPP-4) enzyme.
Saxagliptin is described chemically as (1S,3S,5S)-2-[(2S)-2-amino-2-(3-hydroxytricyclo [3.3.1.13,7] dec-1-yl)acetyl]-2-azabicyclo[3.1.0]hexane-3-carbonitrile, monohydrate.
Molecular formula: C18H25N3O2·H2O.
Molecular weight: 333.43 (monohydrate).
Saxagliptin is a white to light yellow or light brown powder, non-hygroscopic, crystalline. It is soluble in polyethylene glycol 400, acetone, acetonitrile, ethanol, isopropyl alcohol, methanol; sparingly soluble in water and slightly soluble in ethyl acetate.
Dapagliflozin: Dapagliflozin propanediol monohydrate is an orally-active inhibitor of the human renal sodium-glucose co-transporter 2 (SGLT2), the major transporter responsible for renal glucose reabsorption.
Dapagliflozin is described chemically as (1S)-1,5-Anhydro-1-C-[4-chloro-3-[(4- ethoxyphenyl)methyl]phenyl]-D-glucitol, (S)-propylene glycol, monohydrate.
Molecular formula: C21H25ClO6 ·C3H8O2·H2O.
Molecular weight: 502.98.
Dapagliflozin drug substance is a white to off-white powder, is non-hygroscopic, crystalline. Dapagliflozin is 4.5 non-ionisable; thus, its aqueous solubility and partition coefficient are not affected by changes in pH. Dapagliflozin is a Biopharmaceutical Classification System (BCS) Class III drug.
Excipients/Inactive Ingredients: Each tablet contains the following inactive ingredients: microcrystalline cellulose, croscarmellose sodium, lactose, magnesium stearate, silicon dioxide, polyvinyl alcohol, macrogol 3350, titanium dioxide, purified talc, red iron oxide (CI77491), yellow iron oxide (CI77492) and OPACODE monogramming ink S-1-10619 Blue.
Action
Pharmacology: Mechanism of Action: QTERN combines saxagliptin and dapagliflozin with distinct and complementary mechanisms of action to improve glycaemic control. Saxagliptin, through the selective inhibition of dipeptidyl peptidase-4 (DPP-4), enhances glucose-mediated insulin secretion (incretin effect). Dapagliflozin, a selective inhibitor of sodium-glucose co-transporter 2 (SGLT2), inhibits renal glucose reabsorption independently of insulin. Actions of both drugs are regulated by the plasma glucose level. The combination of both agents delivers clinically meaningful reductions in HbA1c for improved glycaemic control in patients with T2DM. While saxagliptin has a neutral effect on weight, urinary glucose excretion (glucuresis) induced by dapagliflozin is associated with caloric and weight loss.
Saxagliptin: Saxagliptin is a member of a class of oral anti-hyperglycaemic agents called DPP-4 inhibitors. Saxagliptin is a reversible, competitive, DPP-4 inhibitor with nanomolar potency. Saxagliptin demonstrates selectivity for DPP-4 versus other DPP enzymes, with greater than 75-fold selectivity over DPP-8 and DPP-9. Saxagliptin has extended binding to the DPP-4 active site, prolonging its inhibition of DPP-4. Saxagliptin exerts its actions in patients with type 2 diabetes by slowing the inactivation of incretin hormones, including glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP). Concentrations of these active intact incretin hormones are increased by saxagliptin, thereby increasing and prolonging the actions of these hormones.
Dapagliflozin: Dapagliflozin is a reversible competitive inhibitor of sodium glucose co-transporter 2 (SGLT2) with nanomolar potency that improves glycaemic control in patients with type 2 diabetes mellitus by reducing renal glucose reabsorption leading to urinary glucose excretion (glucuresis).
SGLT2 is selectively expressed in the kidney with no expression detected in more than 70 other tissues including liver, skeletal muscle, adipose tissue, breast, bladder and brain. SGLT2 is the predominant transporter responsible for reabsorption of glucose from the glomerular filtrate back into the circulation. Despite the presence of hyperglycaemia in type 2 diabetes mellitus, reabsorption of filtered glucose continues. Dapagliflozin improves both fasting and post-prandial plasma glucose levels by reducing renal glucose reabsorption leading to urinary glucose excretion. This glucose excretion (glucuretic effect) is observed after the first dose, is continuous over the 24-hour dosing interval, and is sustained for the duration of treatment. The amount of glucose removed by the kidney through this mechanism is dependent upon the blood glucose concentration and GFR. Thus, in healthy subjects with normal glucose, dapagliflozin has a low propensity to cause hypoglycaemia. Dapagliflozin does not impair normal endogenous glucose production in response to hypoglycaemia. Dapagliflozin acts independently of insulin secretion and insulin action. Over time, improvement in beta cell function (HOMA-2) has been observed in clinical studies with dapagliflozin.
Urinary glucose excretion (glucuresis) induced by dapagliflozin is associated with caloric loss and reduction in weight. The majority of the weight reduction was body fat loss, including visceral fat rather than lean tissue or fluid loss as demonstrated by dual energy X-ray absorptiometry (DXA) and magnetic resonance imaging.
Dapagliflozin does not inhibit other glucose transporters important for glucose transport into peripheral tissues and is approximately 1000-3000 times more selective for SGLT2 vs. SGLT1, the major transporter in the gut responsible for glucose absorption.
Pharmacodynamic effects: Saxagliptin: In patients with type 2 diabetes, administration of saxagliptin led to inhibition of DPP-4 enzyme activity for a 24-hour period. After an oral glucose load or a meal, this DPP-4 inhibition resulted in a 2- to 3-fold increase in circulating levels of active GLP-1 and GIP, decreased glucagon concentrations, and increased glucose-dependent beta-cell responsiveness, which resulted in higher insulin and C peptide concentrations. The rise in insulin and the decrease in glucagon were associated with lower fasting glucose concentrations and reduced glucose excursion following an oral glucose load or a meal.
Dapagliflozin: Increases in the amount of glucose excreted in the urine were observed in healthy subjects and in patients with type 2 diabetes mellitus following the administration of dapagliflozin. Approximately 70 g of glucose was excreted in the urine per day (corresponding to 280 kcal/day) at a dapagliflozin dose of 10 mg/day in patients with type 2 diabetes mellitus for 12 weeks. This glucose elimination rate approached the maximum glucose excretion observed at 20 mg/day dose of dapagliflozin. Evidence of sustained glucose excretion was seen in patients with type 2 diabetes mellitus given dapagliflozin 10 mg/day for up to 2 years.
This urinary glucose excretion with dapagliflozin also results in osmotic diuresis and increases in urinary volume. Urinary volume increases in patients with type 2 diabetes mellitus treated with dapagliflozin 10 mg were sustained at 12 weeks and amounted to approximately 375 mL/day. The increase in urinary volume was associated with a small and transient increase in urinary sodium excretion that was not associated with changes in serum sodium concentrations.
Urinary uric acid excretion was also increased transiently (for 3-7 days) and accompanied by a reduction in serum uric acid concentration. At 24 weeks, reductions in serum uric acid concentrations ranged from 18.3 to 48.3 μmol/L.
Clinical Trials: Glycaemic control: Add-on therapy with dapagliflozin in patients inadequately controlled on saxagliptin plus metformin: In a 24-week randomised, double-blind, placebo-controlled study with the sequential addition of 10 mg dapagliflozin to 5 mg saxagliptin and metformin was compared to the addition of placebo to 5 mg saxagliptin and metformin in patients with inadequate glycaemic control (HbA1c ≥7% and ≤10.5% at Week-2). Subject disposition for this study is presented in Figure 1.
Mean duration of diabetes was 7.6 years at randomised baseline. Patients who completed the initial 24-week study period were eligible to enter a controlled 28-week long-term study extension (52 weeks). (See Figure 1.)

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The safety profile of dapagliflozin added to saxagliptin plus metformin in the long-term treatment period was consistent with that previously observed in the clinical trial experience for the concomitant therapy study and that observed in the 24-week treatment period in this study. The group with dapagliflozin sequentially added to saxagliptin and metformin achieved statistically significantly (p-value <0.0001) greater reductions in HbA1c versus the group with placebo sequentially added to saxagliptin plus metformin group at 24 weeks (see Table 1). The effect in HbA1c observed at Week 24 was sustained at Week 52.
Add-on therapy with saxagliptin in patients inadequately controlled on dapagliflozin plus metformin In a 24-week randomised, double-blind, placebo-controlled study with the sequential addition of saxagliptin 5 mg to dapagliflozin 10 mg and metformin was compared to the addition of placebo to dapagliflozin 10 mg (SGLT2 inhibitor) and metformin in subjects with T2DM with inadequate glycaemic control (HbA1c ≥7% and ≤10.5%) on metformin and dapagliflozin. Subject disposition for this study is presented in Figure 2.
Mean duration of diabetes was 7.7 years at randomised baseline. Patients who completed the initial 24-week study period were eligible to enter a controlled 28-week long-term study extension (52 weeks). (See Figure 2.)

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The safety profile of saxagliptin added to dapagliflozin plus metformin in the long-term treatment period was consistent with that previously observed in the clinical trial experience for the concomitant therapy study and that observed in the 24-week treatment period in this study.
The group with saxagliptin sequentially added to dapagliflozin and metformin achieved statistically significant (p-value <0.0001) greater reductions in HbA1c versus the group with placebo sequentially added to dapagliflozin plus metformin group at 24 weeks (see Table 1). The effect in HbA1c observed at Week 24 was sustained at Week 52. (See Table 1 and Table 2.)

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Body weight: In the concomitant therapy study, the adjusted mean change from baseline in body weight at Week-24 (excluding data after rescue) was -2.05 kg (-2.27%) in the saxagliptin 5 mg plus dapagliflozin 10 mg plus metformin group and -2.39 kg (-2.67%) in the dapagliflozin 10 mg plus metformin group, while the saxagliptin 5 mg plus metformin group had no change (0.03%). In the saxagliptin add-on study, both treatment groups had similar small mean changes in body weight at Week-24 from baseline: -0.53 kg (-0.50%) for the saxagliptin plus dapagliflozin plus metformin group and -0.51 kg (-0.55%) for the placebo plus dapagliflozin plus metformin group. In the dapagliflozin add-on study, the adjusted changes from baseline at Week 24 in body weight were -1.91 kg (-2.23%) in the dapagliflozin plus saxagliptin plus metformin group and -0.41 kg (-0.47%) in the placebo plus saxagliptin plus metformin group.
Blood pressure: Consistent with its mild diuretic effect, the pre-specified analysis of dapagliflozin-containing treatments in the three studies were associated with decreases from baseline in systolic and diastolic blood pressure. Treatment with saxagliptin/dapagliflozin combination resulted in change from baseline for systolic blood pressure ranging from -1.3 to -2.2 mmHg and for diastolic blood pressure ranging from -0.5 to -1.2 mmHg. The modest lowering effects on BP were consistent over time and a similar number of subjects had systolic BP <130 mmHg or diastolic BP <80 mmHg at Week-24 across the treatment groups.
Supportive Studies: For further information on clinical trial experience with saxagliptin and dapagliflozin, refer to the appropriate individual Product Information document.
Pharmacokinetics: Saxagliptin/dapagliflozin combination: Bioequivalence has been confirmed between the QTERN 5 mg/10 mg tablet and the individual saxagliptin 5 mg and dapagliflozin 10 mg tablets after single dose administration in the fasted state in healthy volunteers.
Administration of QTERN with a high-fat meal decreases dapagliflozin Cmax by up to 47% and prolongs Tmax by approximately 2 hours, but does not alter AUC as compared with the fasted state. These changes are not considered to be clinically meaningful. There was no food effect observed for saxagliptin. QTERN can be administered with or without food.
Saxagliptin: The pharmacokinetics of saxagliptin have been extensively characterised in healthy subjects and patients with type 2 diabetes. Saxagliptin was rapidly absorbed after oral administration, with maximum saxagliptin plasma concentrations (Cmax) usually attained within two hours after administration in the fasted state. The Cmax and AUC values increased proportionally to the increment in the saxagliptin dose. Following a 5 mg single oral dose of saxagliptin to healthy subjects, the mean plasma AUC(INF) values for saxagliptin and its major metabolite were 78 ng·h/mL and 214 ng·h/mL, respectively. The corresponding plasma Cmax values were 24 ng/mL and 47 ng/mL, respectively. The intra-subject coefficients of variation for saxagliptin Cmax and AUC were less than 12%.
Following a single oral dose of 5 mg saxagliptin to healthy subjects, the mean plasma terminal half-life (t½) for saxagliptin was 2.5 hours and the mean t½ value for plasma DPP-4 inhibition was 26.9 hours. The inhibition of plasma DPP-4 activity by saxagliptin for at least 24 hours after oral administration of saxagliptin is due to high potency, high affinity, and extended binding to the active site. No appreciable accumulation was observed with repeated once-daily dosing at any dose level. No dose- and time-dependence was observed in the clearance of saxagliptin and its major metabolite over 14 days of once-daily dosing with saxagliptin at doses ranging from 2.5 mg to 400 mg.
Results from population-based exposure modelling suggest that the pharmacokinetics of saxagliptin and its major metabolite were similar in healthy subjects and in patients with type 2 diabetes.
Absorption: Saxagliptin: The amount of saxagliptin absorbed following an oral dose is at least 75%. The absolute oral bioavailability of saxagliptin is approximately 50% (90% CI of 48-53%). Food had relatively modest effects on the pharmacokinetics of saxagliptin in healthy subjects. Administration with a high-fat meal resulted in no change in saxagliptin Cmax and a 27% increase in AUC compared with the fasted state. The time for saxagliptin to reach Cmax (Tmax) was increased by approximately 0.5 hours with food compared with the fasted state. These changes were not considered to be clinically meaningful.
Dapagliflozin: Dapagliflozin was rapidly and well absorbed after oral administration and can be administered with or without food. Maximum dapagliflozin plasma concentrations (Cmax) were usually attained within 2 hours after administration in the fasted state. The Cmax and AUC values increased proportional to the increment in dapagliflozin dose. The absolute oral bioavailability of dapagliflozin following the administration of a 10 mg dose is 78%. Food had relatively modest effects on the pharmacokinetics of dapagliflozin in healthy subjects. Administration with a high-fat meal decreased dapagliflozin Cmax by up to 50% and prolonged Tmax by approximately 1 hour, but did not alter AUC as compared with the fasted state. These changes are not considered to be clinically meaningful.
Distribution: Saxagliptin: The in vitro protein binding of saxagliptin and its major metabolite in human serum is below measurable levels. Thus, changes in blood protein levels in various disease states (e.g., renal or hepatic impairment) are not expected to alter the disposition of saxagliptin.
Dapagliflozin: Dapagliflozin is approximately 91% protein bound. Protein binding is not altered in various disease states (e.g., renal or hepatic impairment).
Metabolism: Saxagliptin: The metabolism of saxagliptin is primarily mediated by cytochrome P450 3A4/5 (CYP3A4/5). The major metabolite of saxagliptin is also a selective, reversible, competitive DPP-4 inhibitor, half as potent as saxagliptin.
Dapagliflozin: Dapagliflozin is extensively metabolised, primarily to yield dapagliflozin 3-O-glucuronide. Dapagliflozin 3-O-glucuronide, with a molar plasma AUC 52% higher than that of dapagliflozin itself at the clinical dose, is an inactive metabolite and does not contribute to the glucose lowering effects. The formation of dapagliflozin 3-O-glucuronide is mediated by UGT1A9, an enzyme present in the liver and kidney, and CYP mediated metabolism was a minor clearance pathway in humans.
Excretion: Saxagliptin: Saxagliptin is eliminated by both renal and hepatic pathways. Following a single 50 mg dose of 14C-saxagliptin, 24%, 36%, and 75% of the dose was excreted in the urine as saxagliptin, its major metabolite, and total radioactivity, respectively. The average renal clearance of saxagliptin (~230 mL/min) was greater than the average estimated glomerular filtration rate (~120 mL/min), suggesting some active renal excretion. For the major metabolite, renal clearance values were comparable to estimated glomerular filtration rate. A total of 22% of the administered radioactivity was recovered in faeces representing the fraction of the saxagliptin dose excreted in bile and/or unabsorbed drug from the gastrointestinal tract.
Dapagliflozin: Dapagliflozin and related metabolites are primarily eliminated via urinary excretion, of which less than 2% is unchanged dapagliflozin. After oral administration of 50 mg [14C] dapagliflozin dose, 96% was recovered, 75% in urine and 21% in faeces. In faeces, approximately 15% of the dose was excreted as parent drug. The mean plasma terminal half-life (t½) for dapagliflozin was 12.9 hours following a single oral dose of dapagliflozin 10 mg to healthy subjects.
Pharmacokinetics of the major metabolite: Saxagliptin: The Cmax and AUC values for the major metabolite of saxagliptin increased proportionally to the increment in the saxagliptin dose. Following single oral doses of 2.5 mg to 400 mg saxagliptin in the fed or fasted states, the mean AUC values for the major metabolite ranged from 2- and 7-times higher than the parent saxagliptin exposures on a molar basis. Following a single oral dose of 5 mg saxagliptin in the fasted state, the mean terminal half-life (t½) value for the major metabolite was 3.1 hours and no appreciable accumulation was observed upon repeated once-daily dosing at any dose.
Special Populations: Renal impairment: Saxagliptin/dapagliflozin combination: Use of QTERN is not recommended in patients with moderate or severe renal impairment or end-stage renal disease (see Precautions).
Saxagliptin: A single-dose, open-label study was conducted to evaluate the pharmacokinetics of saxagliptin (10 mg dose) in subjects with varying degrees of chronic renal impairment compared to subjects with normal renal function. The study included patients with renal impairment classified on the basis of creatinine clearance as mild (>50 to ≤80 mL/min), moderate (30 to ≤50 mL/min), and severe (<30 mL/min), as well as patients with End Stage Renal Disease (ESRD) on haemodialysis. Creatinine clearance was estimated from serum creatinine based on the Cockcroft-Gault formula: (See equation.)

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The degree of renal impairment did not affect the Cmax of saxagliptin or its major metabolite. In subjects with mild renal impairment, the AUC values of saxagliptin and its major metabolite were 1.2- and 1.7-fold higher, respectively, than AUC values in subjects with normal renal function. Increases of this magnitude are not clinically relevant, therefore dosage adjustment in patients with mild renal impairment is not recommended. In subjects with moderate or severe renal impairment or in subjects with ESRD on haemodialysis, the AUC values of saxagliptin and its major metabolite were up to 2.1- and 4.5-fold higher, respectively, than AUC values in subjects with normal renal function. Use of saxagliptin in patients with ESRD requiring haemodialysis is not recommended.
Dapagliflozin: Dapagliflozin should not be used in patients with moderate or severe renal impairment (eGFR persistently <45 mL/min/1.73 m2 or CrCl persistently <45 mL/min). At steady-state (20 mg once-daily dapagliflozin for 7 days), patients with type 2 diabetes and mild, moderate or severe renal impairment (as determined by iohexol clearance) had mean systemic exposures of dapagliflozin that were 32%, 60% and 87% higher, respectively, than those of patients with type 2 diabetes and normal renal function. At dapagliflozin 20 mg once-daily, higher systemic exposure to dapagliflozin in patients with type 2 diabetes mellitus and renal impairment did not result in a correspondingly higher renal glucose clearance or 24-hour glucose excretion. The renal glucose clearance and 24-hour glucose excretion were lower in patients with moderate or severe renal impairment as compared to patients with normal and mild renal impairment. The steady-state 24-h urinary glucose excretion was highly dependent on renal function and 85, 52, 18 and 11 g of glucose/day was excreted by patients with type 2 diabetes mellitus and normal renal function or mild, moderate or severe renal impairment, respectively. There were no differences in the protein binding of dapagliflozin between renal impairment groups or compared to healthy subjects. The impact of haemodialysis on dapagliflozin exposure is not known.
Hepatic impairment: Saxagliptin/dapagliflozin combination: See Precautions.
Saxagliptin: There were no clinically meaningful differences in pharmacokinetics for subjects with mild, moderate, or severe hepatic impairment; therefore, no dosage adjustment for saxagliptin is recommended for patients with hepatic impairment. In subjects with hepatic impairment (Child-Pugh classes A, B, and C), mean Cmax and AUC of saxagliptin were up to 8% and 77% higher, respectively, compared to healthy matched controls following administration of a single 10 mg dose of saxagliptin. The corresponding Cmax and AUC of the major metabolite were up to 59% and 33% lower, respectively, compared to healthy matched controls. These differences are not considered to be clinically meaningful.
Dapagliflozin: A single dose (10 mg) dapagliflozin clinical pharmacology study was conducted in patients with mild, moderate or severe hepatic impairment (Child-Pugh classes A, B, and C, respectively) and healthy matched controls in order to compare the pharmacokinetic characteristics of dapagliflozin between these populations. There were no differences in the protein binding of dapagliflozin between hepatic impairment groups or compared to healthy subjects. In patients with mild or moderate hepatic impairment mean Cmax and AUC of dapagliflozin were up to 12% and 36% higher, respectively, compared to healthy matched control subjects. These differences were not considered to be clinically meaningful and no dose adjustment from the proposed usual dose of 10 mg once daily for dapagliflozin is proposed for these populations. In patients with severe hepatic impairment (Child-Pugh class C) mean Cmax and AUC of dapagliflozin were up to 40% and 67% higher than matched healthy controls, respectively.
Body Mass Index: Saxagliptin: No dosage adjustment is recommended based on body mass index (BMI). BMI was not identified as a significant covariate on the apparent clearance of saxagliptin or its major metabolite in an exposure modelling analysis.
Dapagliflozin: In a population pharmacokinetic analysis using data from healthy subject and patient studies, systemic exposures in high body weight subjects (≥120 kg, n=91) were estimated to be 78.3% [90% CI: 78.2, 83.2%] of those of reference subjects with body weight between 75 and 100 kg. This difference is considered to be small, therefore, no dose adjustment from the proposed dose of 10 mg dapagliflozin once daily in type 2 diabetes mellitus patients with high body weight (≥120 kg) is recommended.
Subjects with low body weights (<50 kg) were not well represented in the healthy subject and patient studies used in the population pharmacokinetic analysis. Therefore, dapagliflozin systemic exposures were simulated with a large number of subjects. The simulated mean dapagliflozin systemic exposures in low body weight subjects were estimated to be 29% higher than subjects with the reference group body weight. This difference is considered to be small and based on these findings no dose adjustment from the proposed dose of 10 mg dapagliflozin once daily in type 2 diabetes mellitus patients with low body weight (<50 kg) is recommended.
Elderly: Saxagliptin/dapagliflozin combination: See Precautions.
Saxagliptin: Elderly subjects (65-80 years) had 23% and 59% higher geometric mean Cmax and geometric mean AUC values, respectively, for parent saxagliptin than young subjects (18-40 years). Differences in major metabolite pharmacokinetics between elderly and young subjects generally reflected the differences observed in parent saxagliptin pharmacokinetics. The difference between the pharmacokinetics of saxagliptin and the major metabolite in young and elderly subjects is likely to be due to multiple factors including declining renal function and metabolic capacity with increasing age. Age was not identified as a significant covariate on the apparent clearance of saxagliptin and its major metabolite in an exposure modelling analysis.
Dapagliflozin: The effect of age (young: ≥18 to <40 years [n=105] and elderly: ≥65 years [n=224]) was evaluated as a covariate in a population pharmacokinetic model and compared to patients ≥40 to <65 years using data from healthy subject and patient studies). The mean dapagliflozin systemic exposure (AUC) in young patients was estimated to be 10.4% lower than in the reference group [90% CI: 87.9, 92.2%] and 25% higher in elderly patients compared to the reference group [90% CI: 123, 129%]. However, an increased exposure due to age-related decrease in renal function can be expected. There are insufficient data to draw conclusions regarding exposure in patients >70 years old.
Paediatric and adolescent: Pharmacokinetics in the paediatric population have not been studied.
Gender: Saxagliptin/dapagliflozin combination: QTERN may be used regardless of gender.
Saxagliptin: There were no differences observed in saxagliptin pharmacokinetics between males and females. Compared to males, females had approximately 25% higher exposure values for the major metabolite than males, but this difference is unlikely to be of clinical relevance. Gender was not identified as a significant covariate on the apparent clearance of saxagliptin and its major metabolite in an exposure modelling analysis.
Dapagliflozin: Gender was evaluated as a covariate in a population pharmacokinetic model using data from healthy subject and patient studies. The mean dapagliflozin AUCss in females (n=619) was estimated to be 22% higher than in males (n=634) (90% CI; 117,124).
Race: Saxagliptin/dapagliflozin combination: QTERN may be used regardless of race.
Saxagliptin: An exposure modelling analysis compared the pharmacokinetics of saxagliptin and its major metabolite in 309 white subjects with 105 non-white subjects (consisting of 6 racial groups). No significant difference in the pharmacokinetics of saxagliptin and its major metabolite were detected between these two populations.
Dapagliflozin: Race (White, Black [African descent], or Asian) was evaluated as a covariate in a population pharmacokinetic model using data from healthy subject and patient studies. Differences in systemic exposures between these races were small. Compared to Whites (n=1147), Asian subjects (n=47) had no difference in estimated mean dapagliflozin systemic exposures [90% CI range; 3.7% lower, 1% higher]. Compared to Whites, Black (African descent) subjects (n=43) had 4.9% lower estimated mean dapagliflozin systemic exposures [90% CI range; 7.7% lower, 3.7% lower].
Indications/Uses
QTERN, fixed dose combination of saxagliptin and dapagliflozin, is indicated in adults aged 18 years and older with type 2 diabetes mellitus: to improve glycaemic control when metformin and one of the monocomponents of QTERN do not provide adequate glycaemic control, when already being treated with the free combination of dapagliflozin and saxagliptin.
Dosage/Direction for Use
The recommended dose of QTERN is one 5 mg/10 mg tablet taken once daily at any time of the day, with or without food. Tablet is to be swallowed whole.
Please refer to Precautions for information regarding combinations not studied.
Optimal medical management of patients with diabetes also involves attention to diet, exercise, blood glucose monitoring, assessment of complications and co-morbidities. Regular assessment and review of the compliance and benefit/risk of all therapies is recommended.
Special Populations: Patients with renal impairment: QTERN may be used in patients with mild renal impairment (see Precautions).
The glycaemic efficacy of dapagliflozin is dependent on renal function. Renal function should be evaluated prior to initiation of QTERN and periodically thereafter. QTERN should not be used in patients with an estimated glomerular filtration rate (eGFR) persistently < 45 ml/min/1.73 m2 as calculated by the Modification of Diet in Renal Disease (MDRD) formula or in patients with end-stage renal disease (ESRD) (see Precautions).
Patients with hepatic impairment: QTERN may be used in patients with mild or moderate hepatic impairment. QTERN should not be used in patients with severe hepatic impairment (see Precautions).
Paediatric and adolescent patients: Safety and effectiveness of QTERN in paediatric and adolescent patients (<18 years of age) have not been established.
Elderly patients: In general, no dosage adjustment is recommended based on age. Renal function and risk of volume depletion should be taken into account (see Precautions and Pharmacology under Actions). Due to the limited therapeutic experience in patients 75 years and older, initiation of QTERN therapy is not recommended in this patient group.
Patients at risk for volume depletion: In patients with volume depletion, correcting this condition prior to initiation of QTERN is recommended.
Overdosage
Saxagliptin/dapagliflozin combination: There is no information available on overdose with QTERN.
In the event of an overdose, appropriate supportive treatment should be initiated as dictated by the patient's clinical status.
Saxagliptin and its major metabolite are removed by haemodialysis (23% of dose over four hours).
The removal of dapagliflozin by haemodialysis has not been studied.
Contraindications
QTERN is contraindicated in patients with a history of any serious hypersensitivity reaction to the active substances or to any of the excipients, including anaphylaxis or angioedema following exposure to any dipeptidyl peptidase-4 (DPP4) inhibitor. QTERN is contraindicated in patients with a history of any serious hypersensitivity to dapagliflozin or to any of the excipients (see Precautions).
Special Precautions
QTERN should not be used in patients with type 1 diabetes (see Indications) or for the treatment of diabetic ketoacidosis (see Ketoacidosis as follows).
Use in patients at risk for volume depletion, hypotension and/or electrolyte imbalances: The diuretic effect of dapagliflozin is a potential concern for volume depleted patients. QTERN is not recommended for use in patients receiving loop diuretics or who are volume depleted.
When considering initiating QTERN, there may be patients for whom the additional diuretic effect of dapagliflozin is a potential concern either due to acute illness (such as gastrointestinal illness) or a history of hypotension or dehydration with diuretic therapy for patients who may become volume depleted. Initiation of therapy with QTERN is therefore not recommended in these patients.
For patients receiving QTERN, in case of intercurrent conditions that may lead to volume depletion, such as gastrointestinal illness, heat stress or severe infections, careful monitoring of volume status (e.g. physical examination, blood pressure measurements, laboratory tests including haematocrit) and electrolytes is recommended. Temporary interruption of QTERN is recommended for patients who develop volume depletion until the depletion is corrected (see Adverse Reactions).
Caution should be exercised in patients for whom a dapagliflozin-induced drop in blood pressure could pose a risk, such as patients with known cardiovascular disease, patients on antihypertensive therapy with a history of hypotension or elderly patients.
Use with medications known to cause hypoglycaemia: Both saxagliptin and dapagliflozin can individually increase the risk of hypoglycaemia when combined with insulin or an insulin secretagogue. Therefore, a lower dose of insulin or insulin secretagogue may be required to minimize the risk of hypoglycaemia if used in combination with QTERN (see Adverse Reactions).
Hypersensitivity reactions: During postmarketing experience the following adverse reactions have been reported with use of saxagliptin: serious hypersensitivity reactions, including anaphylaxis and angioedema. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency. If a serious hypersensitivity reaction to saxagliptin is suspected, discontinue QTERN, assess for other potential causes for the event, and institute alternative treatment for diabetes (see Contraindications and Adverse Reactions).
Pancreatitis: During postmarketing experience with saxagliptin, there have been spontaneously reported adverse reactions of acute pancreatitis. Patients should be informed of the characteristic symptom of acute pancreatitis: persistent, severe abdominal pain. If pancreatitis is suspected, QTERN should be discontinued (see Adverse Reactions).
In the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus-Thrombolysis in Myocardial Infarction (SAVOR) Trial, the incidence of adjudicated pancreatitis events was 0.3% in both saxagliptin-treated patients and placebo-treated patients in the intent-to-treat population (see Adverse Reactions).
Ketoacidosis: QTERN should not be used for the treatment of diabetic ketoacidosis (DKA).
There have been reports of ketoacidosis, including diabetic ketoacidosis (DKA), a serious life-threatening condition requiring urgent hospitalisation, in patients with type 1 and type 2 diabetes mellitus taking dapagliflozin and other SGLT2 inhibitors. Fatal cases of ketoacidosis have been reported in patients taking dapagliflozin. QTERN is not indicated for the treatment of patients with type 1 diabetes mellitus.
Patients treated with QTERN who present with signs and symptoms consistent with ketoacidosis, including nausea, vomiting, abdominal pain, malaise and shortness of breath, should be assessed for ketoacidosis, even if blood glucose levels are below 14 mmol/L (250 mg/dL). If ketoacidosis is suspected, QTERN should be suspended, the patient should be evaluated and prompt treatment initiated.
Treatment of ketoacidosis generally requires insulin, fluid, potassium and carbohydrate replacement.
Restarting SGLT2 inhibitor treatment in patients with previous DKA while on SGLT2 inhibitor treatment is not recommended unless another clear precipitating factor is identified and resolved. Before initiating QTERN, consider factors in the patient history that may predispose to ketoacidosis.
Factors that predispose patients to ketoacidosis include insulin deficiency from any cause (including insulin pump failure, history of pancreatitis or pancreatic surgery), insulin dose reduction, reduced caloric intake or increased insulin requirements due to infections, low carbohydrate diet, acute illness, surgery, a previous ketoacidosis, dehydration and alcohol abuse. QTERN should be used with caution in these patients. Consider monitoring patients for ketoacidosis and temporarily discontinuing QTERN in clinical situations known to predispose to ketoacidosis.
Urinary tract infections: There have been postmarketing reports of serious urinary tract infections including urosepsis and pyelonephritis requiring hospitalisation in patients receiving SGLT2 inhibitors, including dapagliflozin. Urinary tract infections were more frequently reported for dapagliflozin 10 mg compared to control in a placebo‐pooled analysis up to 24 weeks (4.7% vs. 3.5%, respectively). Urinary glucose excretion may be associated with an increased risk of urinary tract infection. Evaluate patients for signs and symptoms of urinary tract infections and treat promptly, if indicated (see Adverse Reactions). Temporary interruption of QTERN should be considered when treating pyelonephritis or urosepsis. Discontinuation of QTERN may be considered in cases of recurrent urinary tract infections; see Adverse Reactions
Necrotising fasciitis of the perineum (Fournier's gangrene): Postmarketing cases of necrotising fasciitis of the perineum (also known as Fournier's gangrene), a rare, but serious and potentially life-threatening necrotising infection, have been reported in female and male patients with diabetes mellitus treated with SGLT2 inhibitors, including dapagliflozin. Serious outcomes have included hospitalisation, multiple surgeries, and death.
Patients treated with QTERN who present with pain or tenderness, erythema, swelling in the genital or perineal area, fever, malaise should be evaluated for necrotising fasciitis. If suspected, QTERN should be discontinued and prompt treatment should be instituted (including broad-spectrum antibiotics and surgical debridement if necessary).
Skin disorders: Ulcerative and necrotic skin lesions have been reported in extremities of monkeys in non-clinical toxicology studies with saxagliptin. Although skin lesions were not observed at an increased incidence in clinical trials, there is limited experience in patients with diabetic skin complications. Postmarketing reports of rash have been described in the DPP4 inhibitor class. Rash is also noted as an adverse event for saxagliptin (see Adverse Reactions). Therefore, in keeping with routine care of the diabetic patient, monitoring for skin disorders, such as blistering, ulceration or rash, is recommended.
Bullous pemphigoid: Postmarketing cases of bullous pemphigoid requiring hospitalisation have been reported with DPP4 inhibitor use, including saxagliptin. In reported cases, patients typically responded to topical or systemic immunosuppressive treatment and discontinuation of the DPP4 inhibitor. If a patient develops blisters or erosions while receiving QTERN and bullous pemphigoid is suspected, QTERN should be discontinued and referral to a dermatologist should be considered for diagnosis and appropriate treatment (see Adverse Reactions).
Cardiac failure: Saxagliptin: Experience in NYHA class III-IV is still limited. In the SAVOR trial a small increase in the rate for hospitalisation for heart failure was observed in the saxagliptin treated patients compared to placebo, although a causal relationship has not been established. Additional analysis did not indicate a differential effect among NYHA classes (see Adverse Reactions - Cardiovascular safety). Caution is warranted if QTERN is used in patients who have known risk factors for hospitalisation for heart failure or moderate to severe renal impairment. Patients should be advised of the characteristic symptoms of heart failure, and to immediately report such symptoms.
Dapagliflozin: Experience in NYHA class I-II is limited, and there is no experience in clinical studies with dapagliflozin in NYHA class III-IV.
Arthralgia: Joint pain, which may be severe, has been reported in postmarketing reports for DPP4 inhibitors. Patients experienced relief of symptoms after discontinuation of the medication and some experienced recurrence of symptoms with reintroduction of the same or another DPP4 inhibitor. Onset of symptoms following initiation of drug therapy may be rapid or may occur after longer periods of treatment. If a patient presents with severe joint pain, continuation of drug therapy should be individually assessed (see Adverse Reactions).
Combinations not studied: QTERN has not been studied in combination with glucagon like peptide 1 (GLP-1) analogues, insulin and insulin secretagogues, such as sulfonylureas.
Use in patients treated with pioglitazone: While a causal relationship between dapagliflozin and bladder cancer is unlikely (see Adverse Reactions), as a precautionary measure, QTERN is not recommended for use in patients concomitantly treated with pioglitazone. Available epidemiological data for pioglitazone suggest a small increased risk of bladder cancer in diabetic patients treated with pioglitazone.
Immunocompromised patients: Immunocompromised patients, such as patients who have undergone organ transplantation or patients diagnosed with human immunodeficiency syndrome have not been studied in the saxagliptin clinical program. The efficacy and safety profile of QTERN in these patients has not been established.
Lower limb amputations: Dapagliflozin: In one long-term clinical study with another SGLT2 inhibitor, an increase in cases of lower limb amputation (primarily of the toe) has been observed. The medicine in that study is not dapagliflozin. However, it is unknown whether this constitutes a class effect. It is important to regularly examine the feet and counsel all diabetic patients on routine preventative footcare.
Genotoxicity: Saxagliptin: The mutagenic and clastogenic potential of saxagliptin was tested at high concentrations and exposures in a battery of genetic toxicity studies including an in vitro Ames bacterial assay, an in vitro cytogenetics assay in primary human lymphocytes, an in vivo oral micronucleus assay in rats, an in vivo oral DNA repair study in rats and an oral in vivo/in vitro cytogenetics study in rat peripheral blood lymphocytes. Saxagliptin was not mutagenic or clastogenic based on the combined outcomes of these studies. The major metabolite was not mutagenic in an in vitro Ames bacterial assay.
Dapagliflozin: Dapagliflozin was positive in an in vitro clastogenicity assay in the presence of metabolic activation. However, dapagliflozin was negative in the Ames mutagenicity assay and in a series of in vivo clastogenicity studies evaluating micronuclei or DNA repair in rats at exposure multiples at least 2100 times the human exposure at the MRHD. The weight of evidence from these studies, along with the absence of tumour findings in the rat and mouse carcinogenicity studies, support that dapagliflozin is not genotoxic.
Carcinogenicity: No carcinogenicity studies have been conducted with saxagliptin and dapagliflozin in combination.
Saxagliptin: Two-year carcinogenicity studies were conducted in mice and rats. Saxagliptin did not induce tumours in mice treated at up to 600 mg/kg/day, producing exposure 1123-times that of humans at the recommended clinical dose. In rats, no increase in tumours was observed in males treated with saxagliptin at up to 150 mg/kg/day and females at up to 300 mg/kg/day (relative exposure at the highest doses, approximately 400 and 2465, respectively.
Dapagliflozin: Dapagliflozin did not induce tumours in two-year carcinogenicity studies in mice or rats at oral doses up to 40 mg/kg/day and 10 mg/kg/day respectively. These doses correspond to AUC exposure levels at least 78 times the human AUC at the MRHD of 10 mg/day.
Effect on laboratory tests: Saxagliptin: Across clinical studies, the incidence of laboratory adverse events was similar in patients treated with saxagliptin 5 mg alone or in combination compared to patients treated with placebo.
A small decrease in absolute lymphocyte count was observed. From a baseline mean absolute lymphocyte count of approximately 2.2 x 109 c/L, a mean decrease of approximately 0.1 x 109 c/L relative to placebo was observed in a pooled analysis of five placebo-controlled clinical studies. Mean absolute lymphocyte counts remained stable and within the normal limits with daily dosing up to 102 weeks in duration. The decreases in lymphocyte count were not associated with clinically relevant adverse reactions.
In the SAVOR trial, decreased lymphocyte counts were reported in 0.5% of saxagliptin-treated patients and 0.4% of placebo-treated patients.
Dapagliflozin: Interference with 1,5-anhydroglucitol (1,5-AG) Assay: Monitoring glycaemic control with 1,5-AG assay is not recommended as measurements of 1,5-AG are unreliable in assessing glycaemic control in patients taking SGLT2 inhibitors. Use alternative methods to monitor glycaemic control.
Haematocrit: In the short-term placebo-controlled studies, at Week 24, marked laboratory abnormalities of increased haematocrit values >55% were reported at in 0.4% of placebo-treated patients and 1.3% of dapagliflozin 10 mg-treated patients. In placebo-controlled studies with long-term data, at Week 102, results for haematocrit values >55% were similar to Week 24. Most patients with marked abnormalities of elevated haematocrit or haemoglobin had elevations measured a single time that resolved at subsequent visits.
Serum Inorganic Phosphorus: In short-term placebo-controlled studies, higher proportions of patients with marked laboratory abnormalities of hyperphosphataemia were reported on dapagliflozin at Week-24 (0.9% versus 1.7% for placebo and dapagliflozin 10 mg, respectively).
In placebo-controlled studies with long-term data, at Week-102, hyperphosphataemia were reported in a higher proportion of patients in the dapagliflozin group compared to placebo (3.0% vs. 1.6%, respectively). The clinical relevance of these findings is unknown.
Lipids: In short-term placebo-controlled studies, small changes from baseline in mean lipid values were reported at Week-24 in dapagliflozin 10 mg treated patients compared with placebo. Mean percent change from baseline at Week-24 for dapagliflozin 10 mg vs. placebo, respectively was as follows: total cholesterol 2.5% vs. 0.0%; HDL cholesterol 6.0% vs. 2.7%; LDL cholesterol 2.9% vs. -1.0%; triglycerides -2.7% vs. -0.7%. The ratio between LDL cholesterol and HDL cholesterol decreased for both treatment groups at week 24.
In the placebo-controlled studies with short-term and long-term data, the mean percent change from baseline at Week-102 were of a similar magnitude as at week 24.
Liver Function Tests: In the 21-study active and placebo-controlled pool (see Adverse Reactions), there was no imbalance across treatment groups in the incidence of elevations of ALT or AST. ALT >3 x ULN was reported in 1.2% of patients treated with dapagliflozin 10 mg and 1.6% treated with comparator. ALT or AST >3 x ULN and bilirubin >2 x ULN was reported in 0.1% of patients on any dose of dapagliflozin, 0.2% of patients on dapagliflozin 10 mg, and 0.1% of patients on comparator.
Effects on ability to drive and use machines: No studies on the effects on the ability to drive and use machines have been performed. However, when driving or operating machines, it should be taken into account that dizziness has been reported with saxagliptin. Patients should be alerted to the risk of hypoglycaemia when QTERN is used in combination with a sulphonylurea or insulin.
Use in renal impairment: The glycaemic efficacy of dapagliflozin is dependent on renal function.
QTERN should not be used in patients with an eGFR persistently < 45 ml/min/1.73 m2 by MDRD or end-stage renal disease (ESRD). QTERN has not been studied in patients with severe renal impairment (eGFR < 30 ml/min/1.73 m2 by MDRD) or end-stage renal disease (ESRD) and, therefore, should not be used in these populations. Renal function should be evaluated prior to initiation of QTERN and periodically thereafter (see Dosage & Administration).
Use in hepatic impairment: Dapagliflozin exposure is increased in patients with severe hepatic impairment. Due to limited clinical experience in patients with hepatic impairment, QTERN should not be used in patients with severe hepatic impairment (see Dosage & Administration and Pharmacology under Actions).
Effects on fertility: No studies on the effect on fertility have been conducted with saxagliptin and dapagliflozin in combination
Saxagliptin: In a rat fertility study, males were treated with oral gavage doses of 100, 200, and 400 mg/kg/day for two weeks prior to mating, during mating, and up to scheduled termination (approximately four weeks total) and females were treated with oral gavage doses of 125, 300, and 750 mg/kg/day for two weeks prior to mating through gestation day 7. No adverse effects on fertility were observed at 200 mg/kg/day (males) or 125 mg/kg/day (females) resulting in respective exposures (AUC) of approximately 670 (males) and 865 (females) times human exposure at the recommended clinical dose. At higher, maternally toxic doses (300 and 750 mg/kg/day), increased foetal resorptions were observed (approximately 2300 and 6810 times the recommended clinical dose). Additional effects on oestrous cycling, fertility, ovulation, and implantation were observed at 750 mg/kg/day (approximately 6810 times the recommended clinical dose).
Dapagliflozin: In a study of fertility in rats, no effects on mating, fertility, or early embryonic development were seen when males received oral doses up to 210 mg/kg/day or when females received oral doses up to 75 mg/kg/day (yielding plasma AUC values at least 1000 times the clinical exposure at the maximum recommended human dose [MRHD] of 10 mg/day). However, at 210 mg/kg/day, a dose associated with profound toxicity (including mortality), seminal vesicle and epididymal weights were reduced; sperm motility and sperm counts were reduced; and there were increased numbers of morphologically abnormal sperm. No adverse effects on sperm or male reproductive organs were seen at 75 mg/kg/day (700 times the clinical exposure at the MRHD).
Use in pregnancy - Category D: Saxagliptin/dapagliflozin combination: There are no adequate and well-controlled studies of QTERN or its mono-components in pregnant women. Animal studies with the individual active components have identified adverse effects on embryofoetal development, most particularly with regard to dapagliflozin on the kidney. No animal developmental studies with saxagliptin and dapagliflozin in combination have been conducted. QTERN should not be used during pregnancy. If pregnancy is detected, treatment with QTERN should be discontinued.
Saxagliptin: Saxagliptin was not teratogenic at any dose evaluated in rats or rabbits. At high doses in rats, saxagliptin caused a minor developmental delay in ossification of the foetal pelvis at ≥240 mg/kg/day (≥1670 times the human exposure [AUC] at the recommended clinical dose). Maternal toxicity and reduced foetal body weights were observed at 900 mg/kg/day (>8860 times the recommended clinical dose). In rabbits, the effects of saxagliptin were limited to minor skeletal variations observed only at maternally toxic doses (200 mg/kg/day, exposures 1520 times the recommended clinical dose).
Saxagliptin administered to female rats from gestation day 6 to lactation day 20 resulted in decreased body weights in male and female offspring only at maternally toxic doses (≥250 mg/kg/day, exposures ≥1810 times the recommended clinical dose). No functional or behavioural toxicity was observed in the offspring of rats administered saxagliptin at any dose.
Saxagliptin and/or its metabolites cross the placenta into the foetus following dosing in pregnant rats.
Dapagliflozin: There are no data from the use of dapagliflozin in pregnant women. Studies in rats have shown toxicity to the developing kidney in the time period corresponding to the second and third trimesters of human pregnancy (see Precautions). Therefore, dapagliflozin must not be used during the second and third trimesters of pregnancy. When pregnancy is detected, treatment with dapagliflozin should be discontinued.
In conventional studies of embryofoetal development in rats and rabbits, dapagliflozin was administered for intervals coinciding with the period of organogenesis in humans. An increased incidence of embryofoetal lethality, decreased foetal weight and an increased incidence of foetal visceral and skeletal anomalies were seen in rats at maternotoxic doses (oral doses greater than or equal to 150 mg/kg/day). The no observed effect level for embryofoetal effects in rats was an oral dose of 75 mg/kg/day (1530 times the exposure in patients at the maximum recommended human dose [MRHD]).
No developmental toxicities were observed in rabbits at oral doses up to 180 mg/kg/day (1265 times the exposure in patients at the MRHD).
Use in lactation: Saxagliptin/dapagliflozin combination: It is not known whether QTERN or its mono-components and/or their metabolites are excreted in human milk. QTERN must not be used by a breastfeeding woman.
Saxagliptin: Saxagliptin and/or its metabolites are secreted in the milk of lactating rats.
Dapagliflozin: Studies in rats have shown excretion of dapagliflozin in milk. Direct and indirect exposure of dapagliflozin to weanling juvenile rats and during late pregnancy are each associated with increased incidence and/or severity of renal pelvic and tubular dilatations in progeny, although the long-term functional consequences of these effects are unknown. These periods of exposure coincide with a critical window of renal maturation in rats. As functional maturation of the kidneys in humans continues in the first 2 years of life, dapagliflozin-associated dilated renal pelvis and tubules noted in juvenile rats could constitute potential risk for human renal maturation during the first 2 years of life. Additionally, the negative effects on body-weight gain associated with lactational exposure in weanling juvenile rats suggest that dapagliflozin must be avoided during the first 2 years of life.
Use in Children: Safety and effectiveness of QTERN in paediatric patients have not been established. Delayed growth and metabolic acidosis in rats were observed in both sexes at higher doses of dapagliflozin (greater than or equal to 15 mg/kg/day). The developmental age of animals in this study approximately correlates to 2 to 16 years in humans.
Use in elderly: Elderly patients are more likely to have impaired renal function, and/or to be treated with anti hypertensive medicinal products that may cause changes in renal function such as angiotensin converting enzyme inhibitors (ACE-I) and angiotensin II type 1 receptor blockers (ARB). The same recommendations for renal function apply to elderly patients as to all patients (see Use in Patients with Renal Impairment as previously mentioned and Dosage & Administration).
Due to limited therapeutic experience with dapagliflozin in patients 75 years and older, the initiation of QTERN therapy in this population is not recommended (see Adverse Reactions, Pharmacology: Pharmacokinetics under Actions and Dosage & Administration).
Saxagliptin: Of the 16,492 patients randomised in the SAVOR trial, 8561 (51.9%) patients were ≥65 years and 2330 (14.1%) were ≥75 years.
Of the 4148 subjects in 6, double-blind, controlled clinical safety and efficacy studies of saxagliptin, (15.3%) patients were ≥65 years, (1.4%) patients were ≥75 years.
No overall differences in safety profile or efficacy were observed between subjects ≥65 years of age and younger subjects.
Saxagliptin and its major metabolite are eliminated in part by the kidney. Because elderly patients are more likely to have decreased renal function, care should be taken in the elderly based on renal function (see Dosage & Administration).
Dapagliflozin: In patients ≥65 years of age, a higher proportion of patients treated with dapagliflozin had events related to renal impairment or failure compared with placebo. The most commonly reported adverse events related to function was increased blood serum creatinine increases, the majority of which were transient and reversible (See Pharmacology: Pharmacokinetics under Actions and Dosage & Administration).
Elderly patients may be at a greater risk for volume depletion and are more likely to be treated with diuretics. In subjects ≥65 years of age, a higher proportion of subjects treated with dapagliflozin had adverse reactions events related to volume depletion (see Adverse Reactions).
Use In Pregnancy & Lactation
Effects on fertility: No studies on the effect on fertility have been conducted with saxagliptin and dapagliflozin in combination
Saxagliptin: In a rat fertility study, males were treated with oral gavage doses of 100, 200, and 400 mg/kg/day for two weeks prior to mating, during mating, and up to scheduled termination (approximately four weeks total) and females were treated with oral gavage doses of 125, 300, and 750 mg/kg/day for two weeks prior to mating through gestation day 7. No adverse effects on fertility were observed at 200 mg/kg/day (males) or 125 mg/kg/day (females) resulting in respective exposures (AUC) of approximately 670 (males) and 865 (females) times human exposure at the recommended clinical dose. At higher, maternally toxic doses (300 and 750 mg/kg/day), increased foetal resorptions were observed (approximately 2300 and 6810 times the recommended clinical dose). Additional effects on oestrous cycling, fertility, ovulation, and implantation were observed at 750 mg/kg/day (approximately 6810 times the recommended clinical dose).
Dapagliflozin: In a study of fertility in rats, no effects on mating, fertility, or early embryonic development were seen when males received oral doses up to 210 mg/kg/day or when females received oral doses up to 75 mg/kg/day (yielding plasma AUC values at least 1000 times the clinical exposure at the maximum recommended human dose [MRHD] of 10 mg/day). However, at 210 mg/kg/day, a dose associated with profound toxicity (including mortality), seminal vesicle and epididymal weights were reduced; sperm motility and sperm counts were reduced; and there were increased numbers of morphologically abnormal sperm. No adverse effects on sperm or male reproductive organs were seen at 75 mg/kg/day (700 times the clinical exposure at the MRHD).
Use in pregnancy - Category D: Saxagliptin/dapagliflozin combination: There are no adequate and well-controlled studies of QTERN or its mono-components in pregnant women. Animal studies with the individual active components have identified adverse effects on embryofoetal development, most particularly with regard to dapagliflozin on the kidney. No animal developmental studies with saxagliptin and dapagliflozin in combination have been conducted. QTERN should not be used during pregnancy. If pregnancy is detected, treatment with QTERN should be discontinued.
Saxagliptin: Saxagliptin was not teratogenic at any dose evaluated in rats or rabbits. At high doses in rats, saxagliptin caused a minor developmental delay in ossification of the foetal pelvis at ≥240 mg/kg/day (≥1670 times the human exposure [AUC] at the recommended clinical dose). Maternal toxicity and reduced foetal body weights were observed at 900 mg/kg/day (>8860 times the recommended clinical dose). In rabbits, the effects of saxagliptin were limited to minor skeletal variations observed only at maternally toxic doses (200 mg/kg/day, exposures 1520 times the recommended clinical dose).
Saxagliptin administered to female rats from gestation day 6 to lactation day 20 resulted in decreased body weights in male and female offspring only at maternally toxic doses (≥250 mg/kg/day, exposures ≥1810 times the recommended clinical dose). No functional or behavioural toxicity was observed in the offspring of rats administered saxagliptin at any dose.
Saxagliptin and/or its metabolites cross the placenta into the foetus following dosing in pregnant rats.
Dapagliflozin: There are no data from the use of dapagliflozin in pregnant women. Studies in rats have shown toxicity to the developing kidney in the time period corresponding to the second and third trimesters of human pregnancy (see Precautions). Therefore, dapagliflozin must not be used during the second and third trimesters of pregnancy. When pregnancy is detected, treatment with dapagliflozin should be discontinued.
In conventional studies of embryofoetal development in rats and rabbits, dapagliflozin was administered for intervals coinciding with the period of organogenesis in humans. An increased incidence of embryofoetal lethality, decreased foetal weight and an increased incidence of foetal visceral and skeletal anomalies were seen in rats at maternotoxic doses (oral doses greater than or equal to 150 mg/kg/day). The no observed effect level for embryofoetal effects in rats was an oral dose of 75 mg/kg/day (1530 times the exposure in patients at the maximum recommended human dose [MRHD]). No developmental toxicities were observed in rabbits at oral doses up to 180 mg/kg/day (1265 times the exposure in patients at the MRHD).
Use in lactation: Saxagliptin/dapagliflozin combination: It is not known whether QTERN or its mono-components and/or their metabolites are excreted in human milk. QTERN must not be used by a breastfeeding woman.
Saxagliptin: Saxagliptin and/or its metabolites are secreted in the milk of lactating rats.
Dapagliflozin: Studies in rats have shown excretion of dapagliflozin in milk. Direct and indirect exposure of dapagliflozin to weanling juvenile rats and during late pregnancy are each associated with increased incidence and/or severity of renal pelvic and tubular dilatations in progeny, although the long-term functional consequences of these effects are unknown. These periods of exposure coincide with a critical window of renal maturation in rats. As functional maturation of the kidneys in humans continues in the first 2 years of life, dapagliflozin-associated dilated renal pelvis and tubules noted in juvenile rats could constitute potential risk for human renal maturation during the first 2 years of life. Additionally, the negative effects on body-weight gain associated with lactational exposure in weanling juvenile rats suggest that dapagliflozin must be avoided during the first 2 years of life.
Adverse Reactions
Significant adverse events are also described in the PRECAUTIONS section. The adverse events with QTERN are consistent with the adverse events for each component. For further information on adverse effects associated with the saxagliptin and dapagliflozin refer to the appropriate individual Product Information document.
Clinical trials: Saxagliptin/dapagliflozin fixed-dose combination has been demonstrated to be bioequivalent with co-administered saxagliptin and dapagliflozin. In therapeutic clinical trials, saxagliptin and dapagliflozin were administered as individual tablets.
The safety of combined use of 5 mg saxagliptin and 10 mg dapagliflozin has been evaluated in 1169 adult subjects with type 2 diabetes (T2DM) in an integrated safety pool of three phase 3 active/placebo controlled short-term and long-term clinical trials for up to 52 weeks. The median exposure for the saxagliptin plus dapagliflozin plus metformin group was 359 days. At least 235 subjects in the saxagliptin plus dapagliflozin plus metformin group received saxagliptin/dapagliflozin for >360 days. The pooled safety analysis is comprised of 3 treatment groups: saxagliptin plus dapagliflozin plus metformin (492 subjects; data pooled from the concomitant therapy with saxagliptin and dapagliflozin study and the 2 sequential combination use studies); saxagliptin plus metformin (336 subjects data pooled from the concomitant therapy with saxagliptin and dapagliflozin and the dapagliflozin added to saxagliptin and metformin studies); and dapagliflozin plus metformin (341 subjects data pooled from the concomitant therapy with saxagliptin and dapagliflozin and the saxagliptin added to dapagliflozin and metformin studies). The safety profile of the combined use of saxagliptin plus dapagliflozin in these trials was comparable to the individual monocomponents (see Table 3). The incidence of hypoglycaemia was low (1.4%). No episodes of major hypoglycaemia were reported, and no subject discontinued the study treatment due to hypoglycaemia. (See Table 3.)

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Additional adverse reactions occurring at frequency of ≥2% and more than ≥1% more frequently compared to placebo in the mono-component clinical programs for saxagliptin and dapagliflozin included gastroenteritis, vomiting and polyuria.
Diabetic ketoacidosis was identified with a frequency of rare ( ≥1/10,000 to < 1/1000), based on annual rate, in a large cardiovascular outcomes study with dapagliflozin in patients with type 2 diabetes.
Description of selected adverse events: The information as follows provides additional information regarding adverse events reported for the saxagliptin/dapagliflozin combination.
Hypoglycaemia: Saxagliptin/dapagliflozin combination The overall incidence of hypoglycaemia for the pooled safety data patients was low (1.4%) in the saxagliptin plus dapagliflozin plus metformin group, 0.3% in the saxagliptin plus metformin group, and 1.8% in dapagliflozin plus metformin group. No episodes of major hypoglycaemia were reported, and no subject discontinued the study treatment due to hypoglycaemia.
Urinary Tract Infections: Saxagliptin/dapagliflozin combination: In the pooled safety analysis, urinary tract infections were balanced across the 3 treatment groups: 5.7% in the saxagliptin plus dapagliflozin plus metformin group, 7.4% in the saxagliptin plus metformin group and 5.6% in the dapagliflozin plus metformin group. The majority of the urinary tract infection adverse events were reported in females (81% of subjects with urinary tract infection), and were mild or moderate in intensity, of single occurrence, and most patients continued on therapy.
Genital Infections: Saxagliptin/dapagliflozin combination: The reported adverse events of vulvovaginitis, balanitis and related genital infections from pooled safety analysis were reflective of the safety profile with dapagliflozin. Adverse events of genital infection were reported in 3.0% in the saxagliptin plus dapagliflozin plus metformin group, 0.9% of saxagliptin plus metformin group and 5.9% of subjects in the dapagliflozin plus metformin group. The majority of the genital infections were reported in females (84% of subjects with a genital infection), and were mild or moderate in intensity, of single occurrence and most patients continued on therapy.
Diabetic ketoacidosis (DKA): Dapagliflozin: In a large cardiovascular outcomes study with dapagliflozin in patients with type 2 diabetes, where 8574 patients received dapagliflozin 10 mg and 8569 patients received placebo, with a median exposure time of 48 months, events of DKA were reported in 27 patients in the dapagliflozin 10 mg group and 12 patients in the placebo group. The events occurred evenly distributed over the study period. Of the 27 patients with DKA events in the dapagliflozin group, 22 had concomitant insulin treatment at the time of the event. Precipitating factors for DKA were as expected in a type 2 diabetes mellitus population (see PRECAUTIONS).
Volume depletion: Saxagliptin/dapagliflozin combination: Events related to volume depletion (hypotension, dehydration, and hypovolemia) were reflective of the adverse events with dapagliflozin and were reported in two subjects (0.4%) in the saxagliptin plus dapagliflozin plus metformin group (SAE of syncope and an adverse event of urine output decreased), and 3 subjects (0.9%) in the dapagliflozin plus metformin group (2 adverse events of syncope and 1 of hypotension).
Events Related to Decreased Renal Function: Saxagliptin/dapagliflozin combination: In the pooled safety analysis, the incidence of adverse events related to decreased renal function was 2.0% of subjects in the saxagliptin plus dapagliflozin plus metformin group, 1.8% of subjects in the saxagliptin plus metformin group, and 0.6% of subjects in the dapagliflozin plus metformin group. Subjects with adverse events of renal impairment had lower mean eGFR values at baseline of 61.8 mL/min/1.73 m2 compared to 93.6 mL/min/1.73 m2 in overall population. The majority of events were considered non-serious, mild or moderate in intensity, and resolved.
Dapagliflozin: In the 13 study, short-term, placebo controlled dapagliflozin study pool, adverse events related to increased creatinine were grouped (e.g. decreased renal creatinine clearance, renal impairment, increased blood creatinine and decreased glomerular filtration rate). This grouping of events was reported in 3.2% and 1.8% of patients who received dapagliflozin 10 mg and placebo, respectively.
In patients with normal renal function or mild renal impairment (baseline eGFR ≥60 mL/min/1.73 m2) this grouping of events were reported in 1.3% and 0.8% of patients who received dapagliflozin 10 mg and placebo, respectively. These events were more common in patients with baseline eGFR ≥30 and <60 mL/min/1.73 m2 (18.5% dapagliflozin 10 mg vs 9.3% placebo).
Further evaluation of patients who had renal-related adverse events showed that most had serum creatinine changes of ≤44 μmol/L from baseline. The increases in creatinine were generally transient during continuous treatment or reversible after discontinuation of treatment.
Cardiovascular Safety: Saxagliptin/dapagliflozin combination: CV events that were adjudicated and confirmed as CV events were reported in a total of 1.0% of subjects in the saxagliptin plus dapagliflozin plus metformin group, 0.6% in the saxagliptin plus metformin group, and 0.9% in the dapagliflozin plus metformin group.
Saxagliptin: In the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus-Thrombolysis in Myocardial Infarction (SAVOR) Trial, the effect of ONGLYZA (saxagliptin) on the occurrence of major cardiovascular disease (CVD) events was assessed in 16,492 adult patients with type 2 diabetes who had either established CVD or multiple risk factors for vascular disease. Patients were randomly assigned to placebo (n=8212) or saxagliptin (5 mg or 2.5 mg for patients with moderate or severe renal insufficiency) once daily (n=8280). The demographics and baseline characteristics of subjects were balanced between the saxagliptin and placebo groups. Subjects were followed for a mean duration of 2 (median=2.0) years.
The primary safety and efficacy endpoint was a composite endpoint consisting of the time-to-first occurrence of any of the following major adverse CV events (MACE): CV death, non-fatal myocardial infarction, or non-fatal ischaemic stroke.
Saxagliptin did not increase the CV risk (CV death, nonfatal myocardial infarction, or nonfatal ischemic stroke) in patients with T2DM compared to placebo when added to current background therapy (HR 1.00; 95% CI: 0.89, 1.12; P<0.001 for non-inferiority).
One component of the secondary composite endpoint, hospitalisation for heart failure, occurred at a greater rate in the saxagliptin group (3.5%) compared with the placebo group (2.8%), with nominal statistical significance favouring placebo [HR = 1.27; 95% CI 1.07, 1.51); p=0.007].
Dapagliflozin: A meta-analysis of adjudicated cardiovascular events in the clinical program (21 Phase 2b and 3 studies) was performed. In the clinical program, 34.4% of subjects had a history of cardiovascular disease (excluding hypertension) at baseline and 67.9% had hypertension. The hazard ratio comparing dapagliflozin to comparator was 0.79 (95 % CI: 0.58, 1.07), indicating that in this analysis dapagliflozin is not associated with an increase in cardiovascular risk in patients with type 2 diabetes mellitus. Cardiovascular death, MI and stroke were observed with a hazard ratio of 0.77 (95 % CI: 0.54, 1.10).
Malignancies: Saxagliptin/dapagliflozin combination: Malignant and unspecified neoplasms were reported in 3 subjects included in the short-term combination pooled safety data. They included adverse events of gastric neoplasm, pancreatic cancer with hepatic metastases, and invasive ductal breast carcinoma in the saxagliptin plus dapagliflozin plus metformin group. Considering the short latency between first drug exposure and tumour diagnosis, a causal relationship to any specific tumour type is considered unlikely.
Dapagliflozin: During clinical trials, the overall proportion of subjects with malignant or unspecified tumours was similar between those treated with dapagliflozin (1.50%) and placebo/comparator (1.50%), and there was no carcinogenicity or mutagenicity signal in animal data (see Precautions). When considering the cases of tumours occurring in the different organ systems, the relative risk associated with dapagiflozin was above 1 for some tumours (bladder, prostate, breast) and below 1 for others (e.g. blood and lymphatic, ovary, renal tract), not resulting in an overall increased tumour risk associated with dapagliflozin. The increased/decreased risk was not statistically significant in any of the organ systems. Considering the lack of tumour findings in non-clinical studies as well as the short latency between first drug exposure and tumour diagnosis, a causal relationship is considered unlikely. Since the numerical imbalance of breast, bladder and prostate tumours must be considered with caution, it will be further investigated in post-authorisation studies.
Vital signs: Saxagliptin/dapagliflozin combination: Mean change from baseline in the heart rates across the 3 treatment groups were similar. Consistent with its mild diuretic effects, the dapagliflozin-containing treatments were associated with decreases in systolic and diastolic blood pressure. The small effects on blood pressure were consistent over time. A similar proportion of subjects in each of the three treatment groups achieved systolic blood pressure <130 mmHg and diastolic blood pressure <80 mmHg.
Peripheral Oedema: Saxagliptin: In a saxagliptin add-on to TZD study, the incidence of peripheral oedema was higher for saxagliptin 5 mg plus TZD versus placebo plus TZD (8.1% versus 4.3%). However, in saxagliptin monotherapy the overall incidence of peripheral oedema was similar to placebo. In the SAVOR study, the overall incidence of adverse reactions of peripheral oedema observed in patients treated with saxagliptin was similar to those treated with placebo (3.9% versus 4% respectively).
Hypersensitivity reactions: Saxagliptin: A grouping of hypersensitivity-related events in the saxagliptin 5-study pooled analysis up to Week 24 showed an incidence of 1.5% and 0.4% in patients who received saxagliptin 5 mg and placebo, respectively. None of these events in patients who received saxagliptin required hospitalisation or were reported to be life-threatening by the investigators.
Laboratory Findings: Saxagliptin/dapagliflozin combination: The frequency of marked abnormalities in laboratory tests results in the pooled safety analysis was low and similar across the treatment groups (see Precautions-Effect on laboratory tests).
Post-marketing experience: The following post-marketing case reports have been reported during post-approval use of the monocomponents. Because these cases are reported voluntarily from a population of an unknown size, it is not always possible to reliably estimate their frequency.
Dapagliflozin: Metabolism and nutrition disorders - Ketoacidosis.
Infections and infestations - Serious urinary tract infections such as pyelonephritis, urosepsis, necrotising fasciitis of the perineum (Fournier's gangrene).
Skin and subcutaneous tissue disorders - Rash.
Saxagliptin: Gastrointestinal disorders - Acute pancreatitis.
Musculoskeletal and connective tissue disorders - Arthralgia.
Immune system disorders - Hypersensitivity reactions, including anaphylaxis, angioedema, rash, and urticaria.
Skin and subcutaneous tissue disorders - bullous pemphigoid.
Drug Interactions
Saxagliptin and dapagliflozin: The lack of pharmacokinetic interaction between saxagliptin and dapagliflozin was demonstrated in a drug-drug interaction study between saxagliptin and dapagliflozin. No dose adjustment of either saxagliptin or dapagliflozin is needed when the two drugs are co administered either separately or as the QTERN fixed-dose combination.
See saxagliptin and dapagliflozin subsections for drug interactions. In summary, there are no clinically meaningful drug interactions expected for either saxagliptin or dapagliflozin or the QTERN fixed-dose combination.
Saxagliptin: The metabolism of saxagliptin is primarily mediated by cytochrome P450 3A4/5 (CYP3A4/5) which converts it to an active metabolite. Therefore, drugs which inhibit the activity of this enzyme system may increase plasma concentrations of saxagliptin but reduce those of its metabolite, whereas CYP3A inducers will tend to do the opposite. However, the overall biological effect of saxagliptin is unaffected by coadministration with inhibitors or inducers of CYP3A4/5.
In in vitro studies, saxagliptin and its major metabolite neither inhibited CYP1A2, 2A6, 2B6, 2C8, 2C9, 2C19, 2D6, 2E1, or 3A4, nor induced CYP1A2, 2B6, 2C9, or 3A4, nor inhibited UGT1A9. Therefore, saxagliptin is not expected to alter the metabolic clearance of coadministered drugs that are metabolised by these enzymes. Saxagliptin is neither a significant inhibitor of P-glycoprotein (P-gp) nor an inducer of P-gp.
The in vitro protein binding of saxagliptin and its major metabolite in human serum is below measurable levels. Thus, protein binding would not have a meaningful influence on the pharmacokinetics of saxagliptin or other drugs.
In studies conducted in healthy subjects, the pharmacokinetics of saxagliptin, its major metabolite, were altered by some drugs which affect the CYP3A4/5 system. However, total exposure to the total active components of saxagliptin (parent+metabolite), were not meaningfully altered by metformin, glibenclamide, pioglitazone, digoxin, simvastatin, diltiazem, ketoconazole, rifampicin, omeprazole, aluminum hydroxide+magnesium hydroxide+simethicone combination, or famotidine. Saxagliptin also did not meaningfully alter the pharmacokinetics of metformin, glibenclamide, pioglitazone, digoxin, simvastatin, diltiazem, ketoconazole or an estrogen/progestin combined oral contraceptive.
Other interactions: The effects of smoking, diet, herbal products, and alcohol use on the pharmacokinetics of saxagliptin have not been specifically studied.
The safety and efficacy of saxagliptin in combination with alpha-glucosidase inhibitors or orlistat has not been established.
Dapagliflozin: The metabolism of dapagliflozin is primarily mediated by UGT1A9-dependent glucuronide conjugation. The major metabolite, dapagliflozin 3-O-glucuronide, is not an SGLT2 inhibitor.
In in vitro studies, dapagliflozin and dapagliflozin 3-O-glucuronide neither inhibited CYP1A2, 2A6, 2B6, 2C8, 2C9, 2C19, 2D6, 3A4, nor induced CYP1A2, 2B6 or 3A4. Therefore, dapagliflozin is not expected to alter the metabolic clearance of coadministered drugs that are metabolised by these enzymes, and drugs that inhibit or induce these enzymes are not expected to alter the metabolic clearance of dapagliflozin. Dapagliflozin is a weak substrate of the P-glycoprotein (P-gp) active transporter and dapagliflozin 3-O-glucuronide is a substrate for the OAT3 active transporter. Dapagliflozin or dapagliflozin 3-O-glucuronide did not meaningfully inhibit P-gp, OCT2, OAT1, or OAT3 active transporters. Overall, dapagliflozin is unlikely to affect the pharmacokinetics of concurrently administered medications that are P-gp, OCT2, OAT1, or OAT3 substrates.
In studies conducted in healthy subjects, the pharmacokinetics of dapagliflozin were not altered by metformin, pioglitazone (a CYP2C8 [major] and CYP3A4 [minor] substrate), sitagliptin (an hOAT-3 substrate, and P-glycoprotein substrate), glimepiride, hydrochlorothiazide, bumetanide, valsartan, simvastatin, digoxin or warfarin. Following coadministration of dapagliflozin with rifampicin (an inducer of various active transporters and drug-metabolizing enzymes) or mefenamic acid (an inhibitor of UGT1A9), a 22% decrease and a 51% increase, respectively, in dapagliflozin systemic exposure was seen, but with no clinically meaningful effect on 24-hour urinary glucose excretion in either case. No dose adjustment of dapagliflozin is recommended when dapagliflozin is coadministered with either rifampicin or mefenamic acid.
Other interactions: The effects of smoking, diet, herbal products, and alcohol use on the pharmacokinetics of dapagliflozin have not been specifically studied.
Storage
Store below 30°C.
MIMS Class
ATC Classification
A10BD21 - saxagliptin and dapagliflozin ; Belongs to the class of combinations of oral blood glucose lowering drugs. Used in the treatment of diabetes.
Presentation/Packing
FC tab (light brown to brown, biconvex, round, with "5/10" printed on one side, and "1122" printed on the other side, in blue ink) 28's.
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