Saxenda

Saxenda

liraglutide

Manufacturer:

Novo Nordisk

Distributor:

Zuellig Pharma
Full Prescribing Info
Contents
Liraglutide.
Description
1 ml of solution contains 6 mg of liraglutide*. One pre-filled pen contains 18 mg liraglutide in 3 ml.
*human glucagon-like peptide-1 (GLP-1) analogue produced by recombinant DNA technology in Saccharomyces cerevisiae.
Excipients/Inactive Ingredients: Disodium phosphate dihydrate, propylene glycol, 5.5mg/ml phenol (as preservative), hydrochloric acid (for pH adjustment), sodium hydroxide (for pH adjustment), water for injections.
Action
Pharmacotherapeutic Group: Drugs used in diabetes, glucagon-like peptide-1 (GLP-1) analogues. ATC Code: A10BJ02.
Pharmacology: Pharmacodynamics: Mechanism of action: Liraglutide is an acylated human glucagon-like peptide-1 (GLP-1) analogue with 97% amino acid sequence homology to endogenous human GLP-1. Liraglutide binds to and activates the GLP-1 receptor (GLP-1R). GLP-1 is a physiological regulator of appetite and food intake, but the exact mechanism of action is not entirely clear. In animal studies, peripheral administration of liraglutide led to uptake in specific brain regions involved in regulation of appetite, where liraglutide, via specific activation of the GLP-1R, increased key satiety and decreased key hunger signals, thereby leading to lower body weight.
GLP-1 receptors are also expressed in specific locations in the heart, vasculature, immune system, and kidneys. In mouse models of atherosclerosis, liraglutide prevented aortic plaque progression and reduced inflammation in the plaque. In addition, liraglutide had a beneficial effect on plasma lipids. Liraglutide did not reduce the plaque size of already established plaques.
Pharmacodynamic effects: Liraglutide lowers body weight in humans mainly through loss of fat mass with relative reductions in visceral fat being greater than for subcutaneous fat loss. Liraglutide regulates appetite by increasing feelings of fullness and satiety, while lowering feelings of hunger and prospective food consumption, thereby leading to reduced food intake. Liraglutide does not increase energy expenditure compared to placebo.
Liraglutide stimulates insulin secretion and lowers glucagon secretion in a glucose-dependent manner which results in a lowering of fasting and post-prandial glucose. The glucose lowering effect is more pronounced in patients with pre-diabetes and diabetes compared to patients with normoglycaemia. Clinical trials suggest that liraglutide improves and sustains beta-cell function, according to HOMA-B, and the proinsulin-toinsulin ratio.
Clinical efficacy and safety: The efficacy and safety of liraglutide for weight management in conjunction with reduced calorie intake and increased physical activity were studied in four phase 3 randomised, double-blind, placebo-controlled trials which included a total of 5,358 patients.
Trial 1 (SCALE Obesity & Pre-Diabetes - 1839): A total of 3,731 patients with obesity (BMI ≥30 kg/m2), or with overweight (BMI ≥27 kg/m2) with dyslipidaemia and/or hypertension were stratified according to pre-diabetes status at screening and BMI at baseline (≥30 kg/m2 or <30 kg/m2). All 3,731 patients were randomised to 56 weeks of treatment and the 2,254 patients with pre-diabetes at screening were randomised to 160 weeks of treatment. Both treatment periods were followed by a 12-week off drug/placebo observational follow-up period. Lifestyle intervention in the form of an energy-restricted diet and exercise counselling was background therapy for all patients.
The 56 week part of trial 1 assessed body weight loss in all the 3,731 randomised patients (2,590 completers).
The 160 week part of trial 1 assessed time to onset of type 2 diabetes in the 2,254 randomised patients with pre-diabetes (1,128 completers).
Trial 2 (SCALE Diabetes - 1922): A 56-week trial assessing body weight loss in 846 randomised (628 completers) obese and overweight patients with insufficiently controlled type 2 diabetes mellitus (HbA1c range 7-10%). The background treatment at trial start was either diet and exercise alone, metformin, a sulfonylurea, a glitazone as single agents or any combination hereof.
Trial 3 (SCALE Sleep Apnoea - 3970): A 32-week trial assessing sleep apnoea severity and body weight loss in 359 randomised (276 completers) obese patients with moderate or severe obstructive sleep apnoea.
Trial 4 (SCALE Maintenance - 1923): A 56-week trial assessing body weight maintenance and weight loss in 422 randomised (305 completers) obese and overweight patients with hypertension or dyslipidaemia after a preceding weight loss of ≥5% induced by a low-calorie diet.
Body weight: Superior weight loss was achieved with liraglutide compared to placebo in obese/overweight patients in all groups studied. Across the trial populations, greater proportions of the patients achieved ≥5% and >10% weight loss with liraglutide than with placebo (Tables 1-3). In the 160 weeks part of trial 1, the weight loss occurred mainly in the first year, and was sustained throughout 160 weeks. In trial 4, more patients maintained the weight loss achieved prior to treatment initiation with liraglutide than with placebo (81.4% and 48.9%, respectively). Specific data on weight loss, responders, time course and cumulative distribution of weight change (%) for trials 1-4 are presented in Tables 1-5 and Figures 1, 2, and 3.
Weight loss response after 12 weeks with liraglutide (3.0 mg) treatment: Early responders were defined as patients who achieved ≥5% weight loss after 12 weeks on treatment dose of liraglutide (4 weeks of dose escalation and 12 weeks on treatment dose). In the 56 week part of trial 1, 67.5% achieved ≥5% weight loss after 12 weeks. In trial 2, 50.4% achieved ≥5% weight loss after 12 weeks. With continued treatment with liraglutide, 86.2% of these early responders are predicted to achieve a weight loss of ≥5% and 51% are predicted to achieve a weight loss of ≥10% after 1 year of treatment. The predicted mean weight loss in early responders who complete 1 year of treatment is 11.2% of their baseline body weight (9.7% for males and 11.6% for females). For patients who have achieved a weight loss of <5% after 12 weeks on treatment dose of liraglutide, the proportion of patients not reaching a weight loss of ≥10% after 1 year is 93.4%.
Glycaemic control: Treatment with liraglutide significantly improved glycaemic parameters across sub-populations with normoglycaemia, pre-diabetes and type 2 diabetes mellitus. In the 56 week part of trial 1, fewer patients treated with liraglutide had developed type 2 diabetes mellitus compared to patients treated with placebo (0.2% vs 1.1%). More patients with pre-diabetes at baseline had reversed their pre-diabetes diabetes compared to patients treated with placebo (69.2% vs. 32.7%). In the 160 week part of trial 1 the primary efficacy endpoint was the proportion of patients with onset of type 2 diabetes mellitus evaluated as time to onset. At week 160, while on treatment, 3% treated with Saxenda and 11% treated with placebo were diagnosed with type 2 diabetes mellitus. The estimated time to onset of type 2 diabetes mellitus for patients treated with liraglutide 3.0 mg was 2.7 times longer (with a 95% confidence interval of [1.9, 3.9]), and the hazard ratio for risk of developing type 2 diabetes mellitus was 0.2 for liraglutide versus placebo.
Cardiometabolic risk factors: Treatment with liraglutide significantly improved systolic blood pressure and waist circumference compared with placebo (Tables 1, 2 and 3).
Apnoea-Hypopnoea Index (AHI): Treatment with liraglutide significantly reduced the severity of obstructive sleep apnoea as assessed by change from baseline in the AHI compared with placebo (Table 4). (See Tables 1, 2, 3, 4 and 5 and Figures 1, 2 and 3.)

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Before week 0 patients were only treated with low-calorie diet and exercise. At week 0 patients were randomised to receive either Saxenda or placebo.
Immunogenicity: Consistent with the potentially immunogenic properties of protein and peptide pharmaceuticals, patients may develop anti-liraglutide antibodies following treatment with liraglutide. In clinical trials, 2.5% of patients treated with liraglutide developed anti-liraglutide antibodies. Antibody formation has not been associated with reduced efficacy of liraglutide.
Cardiovascular evaluation: Major adverse cardiovascular events (MACE) were adjudicated by an external independent group of experts and defined as non-fatal myocardial infarction, non-fatal stroke and cardiovascular death. In all the long-term clinical trials with Saxenda, there were 6 MACE for patients treated with liraglutide and 10 MACE for placebo treated patients. The hazard ratio and 95% CI is 0.33 [0.12; 0.90] for liraglutide versus placebo. A mean increase in heart rate from baseline of 2.5 beats per minute (ranging across trials from 1.6 to 3.6 beats per minute) has been observed with liraglutide in clinical phase 3 trials. The heart rate peaked after approximately 6 weeks. The long-term clinical impact of this mean increase in heart rate has not been established. The change in heart rate was reversible upon discontinuation of liraglutide (see Precautions).
The Liraglutide Effect and Action in Diabetes Evaluation of Cardiovascular Outcomes Results (LEADER) trial included 9,340 patients with insufficiently controlled type 2 diabetes. The vast majority of these had established cardiovascular disease. Patients were randomly allocated to either liraglutide on a daily dose of up to 1.8 mg (4,668) or placebo (4,672), both on a background of standard of care.
The duration of exposure was between 3.5 and 5 years. The mean age was 64 years and the mean BMI was 32.5 kg/m2. Mean baseline HbA1c was 8.7 and had improved after 3 years by 1.2 % in patients assigned to liraglutide and by 0.8 % in patients assigned to placebo. The primary endpoint was the time from randomisation to first occurrence of any major adverse cardiovascular events (MACE): cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke.
Liraglutide significantly reduced the rate of major adverse cardiovascular events (primary endpoint events, MACE) vs. placebo (3.41 vs. 3.90 per 100 patient years of observation in the liraglutide and placebo groups, respectively) with a risk reduction of 13%, HR 0.87, [0.78, 0.97] [95% CI]) (p=0.005) (see Figure 4).

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Pharmacokinetics: Absorption: The absorption of liraglutide following subcutaneous administration was slow, reaching maximum concentration approximately 11 hours post dosing. The average liraglutide steady state concentration (AUCτ/24) reached approximately 31 nmol/l in obese (BMI 30-40 kg/m2) patients following administration of 3 mg liraglutide. Liraglutide exposure increased proportionally with dose. Absolute bioavailability of liraglutide following subcutaneous administration is approximately 55%.
Distribution: The mean apparent volume of distribution after subcutaneous administration is 20-25 l (for a person weighing approximately 100 kg). Liraglutide is extensively bound to plasma protein (>98%).
Biotransformation: During 24 hours following administration of a single [3H]-liraglutide dose to healthy subjects, the major component in plasma was intact liraglutide. Two minor plasma metabolites were detected (≤9% and ≤5% of total plasma radioactivity exposure).
Elimination:
Liraglutide is endogenously metabolised in a similar manner to large proteins without a specific organ as major route of elimination. Following a [3H]-liraglutide dose, intact liraglutide was not detected in urine or faeces. Only a minor part of the administered radioactivity was excreted as liraglutide-related metabolites in urine or faeces (6% and 5%, respectively). The urine and faeces radioactivity was mainly excreted during the first 6-8 days, and corresponded to three minor metabolites, respectively.
The mean clearance following subcutaneous administration of liraglutide is approximately 0.9-1.4 l/h with an elimination half-life of approximately 13 hours.
Special populations: Elderly: Age had no clinically relevant effect on the pharmacokinetics of liraglutide based on the results from a population pharmacokinetic analysis of data from overweight and obese patients (18 to 82 years). No dosage adjustment is required based on age.
Gender: Based on the results of population pharmacokinetic analysis, females have 24% lower weight adjusted clearance of liraglutide compared to males. Based on the exposure response data, no dose adjustment is necessary based on gender.
Ethnic origin: Ethnic origin had no clinically relevant effect on the pharmacokinetics of liraglutide based on the results of population pharmacokinetic analysis which included overweight and obese patients of White, Black, Asian and Hispanic/non-Hispanic groups.
Body weight: The exposure of liraglutide decreases with an increase in baseline body weight. The 3.0 mg daily dose of liraglutide provided adequate systemic exposures over the body weight range of 60-234 kg evaluated for exposure response in the clinical trials. Liraglutide exposure was not studied in patients with body weight >234 kg.
Hepatic impairment: The pharmacokinetics of liraglutide was evaluated in patients with varying degree of hepatic impairment in a single-dose trial (0.75 mg). Liraglutide exposure was decreased by 13-23% in patients with mild to moderate hepatic impairment compared to healthy subjects. Exposure was significantly lower (44%) in patients with severe hepatic impairment (Child Pugh score >9).
Renal impairment: Liraglutide exposure was reduced in patients with renal impairment compared to individuals with normal renal function in a single-dose trial (0.75 mg). Liraglutide exposure was lowered by 33%, 14%, 27% and 26%, respectively, in patients with mild (creatinine clearance, CrCl 50-80 ml/min), moderate (CrCl 30-50 ml/min), and severe (CrCl <30 ml/min) renal impairment and in end-stage renal disease requiring dialysis.
Paediatric population: Saxenda has not been studied in paediatric patients.
Toxicology: Preclinical safety data: Non-clinical data reveal no special hazards for humans based on conventional studies of safety pharmacology, repeat-dose toxicity, or genotoxicity.
Non-lethal thyroid C-cell tumours were seen in two year carcinogenicity studies in rats and mice. In rats, a no observed adverse effect level (NOAEL) was not observed. These tumours were not seen in monkeys treated for 20 months. These findings in rodents are caused by a non-genotoxic, specific GLP-1 receptor-mediated mechanism to which rodents are particularly sensitive. The relevance for humans is likely to be low but cannot be completely excluded. No other treatment related tumours have been found.
Animal studies did not indicate direct harmful effects with respect to fertility but slightly increased early embryonic deaths at the highest dose. Dosing with liraglutide during mid-gestation caused a reduction in maternal weight and foetal growth with equivocal effects on ribs in rats and skeletal variation in the rabbit. Neonatal growth was reduced in rats while exposed to liraglutide, and persisted in the post-weaning period in the high dose group. It is unknown whether the reduced pup growth is caused by reduced pup milk intake due to a direct GLP-1 effect or reduced maternal milk production due to decreased caloric intake.
Indications/Uses
Saxenda is indicated as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adult patients with an initial Body Mass Index (BMI) of ≥ 30 kg/m2 (obese), or ≥ 27 kg/m2 to < 30 kg/m2(overweight) in the presence of at least one weight-related comorbidity such as dysglycaemia (pre-diabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea.
Treatment with Saxenda should be discontinued after 12 weeks on the 3.0 mg/day dose if patients have not lost at least 5% of their initial body weight.
Dosage/Direction for Use
The starting dose is 0.6 mg once daily. The dose should be increased to 3.0 mg once daily in increments of 0.6 mg with at least one week intervals to improve gastro-intestinal tolerability (see Table 6). If escalation to the next dose step is not tolerated for two consecutive weeks, consider discontinuing treatment. Daily doses higher than 3.0 mg are not recommended. (See Table 6.)

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Patients with type 2 diabetes mellitus: Saxenda should not be used in combination with another GLP-1 receptor agonist.
When initiating Saxenda, consider reducing the dose of concomitantly administered insulin or insulin secretagogues (such as sulfonylureas) to reduce the risk of hypoglycaemia.
Special populations: Elderly (≥65 years old): No dose adjustment is required based on age. Therapeutic experience in patients ≥75 years of age is limited and use in these patients is not recommended (see Precautions and Pharmacology: Pharmacokinetics under Actions).
Renal impairment: No dose adjustment is required for patients with mild or moderate renal impairment (creatinine clearance ≥30 ml/min). Saxenda is not recommended for use in patients with severe renal impairment (creatinine clearance <30 ml/min) including patients with end-stage renal disease (see Precautions, Adverse Reactions and Pharmacology: Pharmacokinetics under Actions).
Hepatic impairment: The therapeutic experience in patients with all degrees of hepatic impairment is currently too limited to recommend the use in patients with mild, moderate, or severe hepatic impairment (see Precautions and Pharmacology: Pharmacokinetics under Actions).
Paediatric population: The safety and efficacy of Saxenda in children and adolescents below 18 years of age have not been established (see Pharmacology: Pharmacodynamics under Actions). No data are available. This medicinal product is not recommended for use in paediatric patients.
Method of administration: Saxenda is for subcutaneous use only. It must not be administered intravenously or intramuscularly.
Saxenda is administered once daily at any time, independent of meals. It should be injected in the abdomen, thigh or upper arm. The injection site and timing can be changed without dose adjustment. However, it is preferable that Saxenda is injected around the same time of the day, when the most convenient time of the day has been chosen.
If a dose is missed within 12 hours from when it is usually taken, the patient should take the dose as soon as possible. If there is less than 12 hours to the next dose, the patient should not take the missed dose and resume the once-daily regimen with the next scheduled dose. An extra dose or increase in dose should not be taken to make up for the missed dose. For further instructions on administration, see Special precautions for disposal and other handling under Cautions for Usage.
Overdosage
From clinical trials and post-marketing use of liraglutide overdoses have been reported up to 72 mg (24 times the recommended dose for weight management). Events reported included severe nausea and severe vomiting which are also the expected symptoms of an overdose with liraglutide. None of the reports included severe hypoglycaemia. All patients recovered without complications.
In the event of overdose, appropriate supportive treatment should be initiated according to the patient's clinical signs and symptoms. The patient should be observed for clinical signs of dehydration and blood glucose should be monitored.
Contraindications
Hypersensitivity to liraglutide or to any of the excipients listed in Description.
Special Precautions
In patients with diabetes mellitus Saxenda must not be used as a substitute for insulin.
There is no clinical experience in patients with congestive heart failure New York Heart Association (NYHA) class IV and liraglutide is therefore not recommended for use in these patients.
The safety and efficacy of liraglutide for weight management have not been established in patients: aged 75 years or more, treated with other products for weight management, with obesity secondary to endocrinological or eating disorders or to treatment with medicinal products that may cause weight gain, with severe renal impairment, with hepatic impairment.
Use in these patients is not recommended (see Dosage & Administration).
There is limited experience in patients with inflammatory bowel disease and diabetic gastroparesis. Use of liraglutide is not recommended in these patients since it is associated with transient gastrointestinal adverse reactions, including nausea, vomiting and diarrhoea.
Pancreatitis: Acute Pancreatitis has been observed with the use of GLP-1 receptor agonists. Patients should be informed of the characteristic symptoms of acute pancreatitis. If pancreatitis is suspected, liraglutide should be discontinued; if acute pancreatitis is confirmed, liraglutide should not be restarted.
Cholelithiasis and cholecystitis: In clinical trials for weight management, a higher rate of cholelithiasis and cholecystitis was observed in patients treated with liraglutide than in patients on placebo. The fact that substantial weight loss can increase the risk of cholelithiasis and thereby cholecystitis only partially explained the higher rate with liraglutide. Cholelithiasis and cholecystitis may lead to hospitalisation and cholecystectomy. Patients should be informed of the characteristic symptoms of cholelithiasis and cholecystitis.
Thyroid disease: In clinical trials in type 2 diabetes, thyroid adverse events, such as goitre have been reported in particular in patients with pre-existing thyroid disease. Liraglutide should therefore be used with caution in patients with thyroid disease.
Risk of Thyroid C-Cell Tumours: Liraglutide causes dose-dependent and treatment-duration-dependent thyroid C-cell tumours (adenomas and/or carcinomas) at clinically relevant exposures in both genders of rats and mice. Malignant thyroid C-cell carcinomas were detected in rats and mice. A statistically significant increase in cancer was observed in rats receiving liraglutide at 8-times clinical exposure compared to controls. It is unknown whether Saxenda will cause thyroid C-cell tumours, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of liraglutide-induced rodent thyroid C-cell tumours could not be determined by clinical or nonclinical studies.
In the clinical trials, there was one reported case of thyroid C-cell hyperplasia among Saxenda-treated patients and no cases in placebo-treated patients. In the case of the thyroid C-cell hyperplasia, the patient had elevated blood calcitonin level at screening. There were no cases of MTC in Saxenda-treated patients and one case in placebo-treated patients.
Counsel patients regarding the potential risk for MTC and the symptoms of thyroid tumours (e.g. a mass in the neck, dysphagia, dyspnoea, persistent hoarseness). It is unknown whether monitoring with serum calcitonin or thyroid ultrasound will mitigate the potential risk of MTC, and such monitoring may increase the risk of unnecessary procedures, due to low test specificity for serum calcitonin and a high background incidence of thyroid disease. Patients with thyroid nodules noted on physical examination or neck imaging obtained for other reasons should be referred to an endocrinologist for further evaluation. Although routine monitoring of serum calcitonin is of uncertain value in patients treated with liraglutide if serum calcitonin is measured and found to be elevated, the patient should be referred to an endocrinologist for further evaluation.
Heart rate: An increase in heart rate was observed with liraglutide in clinical trials (see Pharmacology: Pharmacodynamics under Actions). Heart rate should be monitored at regular intervals consistent with usual clinical practice. Patients should be informed of the symptoms of increased heart rate (palpitations or feelings of a racing heartbeat while at rest). For patients who experience a clinically relevant sustained increase in resting heart rate, treatment with liraglutide should be discontinued.
Dehydration: Signs and symptoms of dehydration, including renal impairment and acute renal failure, have been reported in patients treated with GLP-1 receptor agonists. Patients treated with liraglutide should be advised of the potential risk of dehydration in relation to gastrointestinal side effects and take precautions to avoid fluid depletion.
Hypoglycaemia in patients with type 2 diabetes mellitus: Patients with type 2 diabetes mellitus receiving liraglutide in combination with a sulfonylurea may have an increased risk of hypoglycaemia. The risk of hypoglycaemia may be lowered by a reduction in the dose of sulfonylurea. The addition of Saxenda in patients treated with insulin has not been evaluated.
Suicidal Behaviour and Ideation: In Saxenda clinical trials, 6 (0.2%) of 3384 Saxenda-treated patients and none of the 1941 placebo-treated patients reported suicidal ideation; one of the Saxenda-treated patients attempted suicide. Patients treated with Saxenda should be monitored for the emergence or worsening of depression, suicidal thoughts or behaviour, and/or any unusual changes in mood or behaviour. Discontinue Saxenda in patients who experience suicidal thoughts or behaviours. Avoid Saxenda in patients with a history of suicidal attempts or active suicidal ideation.
Effects on ability to drive and use machines: Saxenda has no or negligible influence on the ability to drive and use machines.
Use In Pregnancy & Lactation
Pregnancy: There are limited data from the use of liraglutide in pregnant women. Studies in animals have shown reproductive toxicity (see Pharmacology: Toxicology: Preclinical safety data under Actions). The potential risk for humans is unknown.
Liraglutide should not be used during pregnancy. If a patient wishes to become pregnant, or pregnancy occurs, treatment with liraglutide should be discontinued.
Breast-feeding: It is not known whether liraglutide is excreted in human milk. Animal studies have shown that the transfer of liraglutide and metabolites of close structural relationship into milk is low. Non-clinical studies have shown a treatment related reduction of neonatal growth in suckling rat pups (see Pharmacology: Toxicology: Preclinical safety data under Actions). Because of lack of experience, Saxenda should not be used during breast-feeding.
Fertility: Apart from a slight decrease in the number of live implants, animal studies did not indicate harmful effects with respect to fertility (see Pharmacology: Toxicology: Preclinical safety data under Actions).
Adverse Reactions
Summary of the safety profile: Saxenda was evaluated for safety in 5 double- blind, placebo controlled trials that enrolled 5,813 obese patients or overweight patients with at least one weight-related comorbidity. Overall, gastrointestinal reactions were the most frequently reported adverse reactions during treatment with Saxenda (see Description of Selected Adverse Reactions as follows).
Tabulated list of adverse reactions: Table 7 lists adverse reactions reported in long term phase 2 and phase 3 controlled trials. Adverse reactions are listed by system organ class and frequency. Frequency categories are defined as: very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare (<1/10,000). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness. (See Table 7.)

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Description of selected adverse reactions: Hypoglycaemia in patients without type 2 diabetes mellitus: In clinical trials in overweight or obese patients without type 2 diabetes mellitus treated with Saxenda in combination with diet and exercise no severe hypoglycaemic events (requiring third party assistance) were reported. Symptoms of hypoglycaemic events were reported by 1.6 % of patients treated with Saxenda and 1.1% of patients treated with placebo; however, these events were not confirmed by blood glucose measurements. The majority of events were mild.
Hypoglycaemia in patients with type 2 diabetes mellitus: In a clinical trial in overweight or obese patients with type 2 diabetes mellitus treated with Saxenda in combination with diet and exercise, severe hypoglycaemia (requiring third party assistance) was reported by 0.7% of patients treated with Saxenda and only in patients concomitantly treated with sulfonylurea. Also, in these patients documented symptomatic hypoglycaemia was reported by 43.6% of patients treated with Saxenda and in 27.3% of patients treated with placebo. Among patients not concomitantly treated with sulfonylurea, 15.7% of patients treated with Saxenda and 7.6% of patients treated with placebo reported documented symptomatic hypoglycaemic events (defined as plasma glucose ≤3.9 mmol/l accompanied by symptoms).
Gastrointestinal adverse reactions: Most episodes of gastrointestinal events were mild to moderate, transient and the majority did not lead to discontinuation of therapy. The reactions usually occurred during the first weeks of treatment and diminished within a few days or weeks on continued treatment.
Patients ≥65 years of age may experience more gastrointestinal effects when treated with Saxenda.
Patients with mild or moderate renal impairment (creatinine clearance ≥30 ml/min) may experience more gastrointestinal effects when treated with Saxenda.
Acute renal failure: In patients treated with GLP-1 receptor agonists, there have been reports of acute renal failure. A majority of the reported events occurred in patients who had experienced nausea, vomiting, or diarrhoea leading to volume depletion (see Precautions).
Allergic reactions: Few cases of anaphylactic reactions with symptoms such as hypotension, palpitations, dyspnoea and oedema have been reported with marketed use of liraglutide. Anaphylactic reactions may potentially be life threatening. If an anaphylactic reaction is suspected, liraglutide should be discontinued and treatment should not be restarted (see Contraindications).
Injection site reactions: Injection site reactions have been reported in patients treated with Saxenda. These reactions were usually mild and transitory and majority disappeared during continued treatment.
Tachycardia: In clinical trials, tachycardia was reported in 0.6% of patients treated with Saxenda and in 0.1% of patients treated with placebo. The majority of events were mild or moderate. Events were isolated and majority resolved during continued treatment with Saxenda.
Breast Cancer: In Saxenda clinical trials, breast cancer confirmed by adjudication was reported in 14 (0.6%) of 2379 Saxenda-treated women compared with 3 (0.2%) of 1300 placebo-treated women, including invasive cancer (11 Saxenda-treated and 2 placebo-treated women) and ductal carcinoma in situ (3 Saxenda- and 1 placebo-treated woman). The majority of cancers were estrogen- and progesterone-receptor positive. There were too few cases to determine whether these cases were related to Saxenda. In addition, there are insufficient data to determine whether Saxenda has an effect on pre-existing breast neoplasia.
Drug Interactions
In vitro, liraglutide has shown very low potential to be involved in pharmacokinetic interactions with other active substances related to cytochrome P450 (CYP) and plasma protein binding.
The small delay of gastric emptying with liraglutide may influence absorption of concomitantly administered oral medicinal products. Interaction studies did not show any clinically relevant delay of absorption and therefore no dose adjustment is required.
Interaction studies have been performed with 1.8 mg liraglutide. The effect on rate of gastric emptying was equivalent between liraglutide 1.8 mg and 3.0 mg, (paracetamol AUC0-300 min). Few patients treated with liraglutide reported at least one episode of severe diarrhoea. Diarrhoea may affect the absorption of concomitant oral medicinal products.
Warfarin and other coumarin derivatives: No interaction study has been performed. A clinically relevant interaction with active substances with poor solubility or narrow therapeutic index such as warfarin cannot be excluded. Upon initiation of liraglutide treatment in patients on warfarin or other coumarin derivatives more frequent monitoring of International Normalised Ratio (INR) is recommended.
Paracetamol (Acetaminophen): Liraglutide did not change the overall exposure of paracetamol following a single dose of 1,000 mg.
Paracetamol Cmax was decreased by 31% and median tmax was delayed up to 15 min. No dose adjustment for concomitant use of paracetamol is required.
Atorvastatin: Liraglutide did not change the overall exposure of atorvastatin following single dose administration of atorvastatin 40 mg. Therefore, no dose adjustment of atorvastatin is required when given with liraglutide. Atorvastatin Cmax was decreased by 38% and median tmax was delayed from 1 h to 3 h with liraglutide.
Griseofulvin: Liraglutide did not change the overall exposure of griseofulvin following administration of a single dose of griseofulvin 500 mg. Griseofulvin Cmax increased by 37% while median tmax did not change. Dose adjustments of griseofulvin and other compounds with low solubility and high permeability are not required.
Digoxin: A single dose administration of digoxin 1 mg with liraglutide resulted in a reduction of digoxin AUC by 16%; Cmax decreased by 31%. Digoxin median tmax was delayed from 1 h to 1.5 h. No dose adjustment of digoxin is required based on these results.
Lisinopril: A single dose administration of lisinopril 20 mg with liraglutide resulted in a reduction of lisinopril AUC by 15%; Cmax decreased by 27%. Lisinopril median tmax was delayed from 6 h to 8 h with liraglutide. No dose adjustment of lisinopril is required based on these results.
Oral contraceptives: Liraglutide lowered ethinylestradiol and levonorgestrel Cmax by 12% and 13%, respectively, following administration of a single dose of an oral contraceptive product. tmax was delayed by 1.5 h with liraglutide for both compounds. There was no clinically relevant effect on the overall exposure of either ethinylestradiol or levonorgestrel. The contraceptive effect is therefore anticipated to be unaffected when co-administered with liraglutide.
Caution For Usage
Instructions on how to use Saxenda 6 mg/ml solution for injection in pre-filled pen: Read these instructions carefully before using Saxenda pre-filled pen.
Do not use the pen without proper training from a doctor or nurse.
Start by checking the pen to make sure that it contains Saxenda 6 mg/ml.
If the patient is blind or have poor eyesight and cannot read the dose counter on the pen, do not use this pen without help. Get help from a person with good eyesight who is trained to use the Saxenda pre-filled pen.
The pen is a pre-filled dial-a-dose pen. It contains 18 mg of liraglutide, and delivers doses of 0.6 mg, 1.2 mg, 1.8 mg, 2.4 mg and 3.0 mg. The pen is designed to be used with NovoFine or NovoTwist disposable needles up to a length of 8 mm and as thin as 32G.
Needles are not included in the pack.
Important information: Pay special attention to these notes, as they are important for safe use of the pen.
1. Prepare the pen with a new needle: Check the name and coloured label of the pen, to make sure that it contains Saxenda. This is especially important if the patient takes more than one type of injectable medicine. Using the wrong medicine could be harmful to patient's health.
Pull off the pen cap.
Check that the solution in the pen is clear and colourless. Look through the pen window. If the solution looks cloudy, do not use the pen.
Take a new needle and tear off the paper tab.
Push the needle straight onto the pen. Turn until it is on tight.
Pull off the outer needle cap and keep it for later. The patient will need it after the injection, to safely remove the needle from the pen.
Pull off the inner needle cap and throw it away. If the patient tries to put it back on, patient may accidentally stick themselves with the needle. A drop of solution may appear at the needle tip. This is normal, but the patient must still check the flow, if the patient uses a new pen for the first time.
Do not attach a new needle to the pen until the patient is ready to take injection.
Always use a new needle for each injection.
This may prevent blocked needles, contamination, infection and inaccurate dosing.
Never use a bent or damaged needle.
2. Check the flow: Before the first injection with each new pen, check the flow. If the pen is already in use, go to step 3 Select dose.
Turn the dose selector until the dose counter shows the flow check symbol. Hold the pen with the needle pointing up.
Press and hold in the dose button until the dose counter returns to 0. The 0 must line up with the dose pointer.
A drop of solution should appear at the needle tip.
A small drop may remain at the needle tip, but it will not be injected.
If no drop appears, repeat step 2 Check the flow up to 6 times. If there is still no drop, change the needle and repeat step 2 Check the flow once more.
If a drop still does not appear, dispose of the pen and use a new one.
Always make sure that a drop appears at the needle tip before using a new pen for the first time. This makes sure that the solution flows.
If no drop appears, the patient will not inject any medicine, even though the dose counter may move. This may indicate a blocked or damaged needle.
If the patient does not check the flow before the first injection with each new pen, the patient may not get the prescribed dose and the intended effect of Saxenda.
3. Select the dose: Turn the dose selector until the dose counter shows the dose (0.6 mg, 1.2 mg, 1.8 mg, 2.4 mg or 3.0 mg).
If the patient selects the wrong dose, the patient can turn the dose selector forwards or backwards to the correct dose.
The pen can dial up to a maximum of 3.0 mg.
The dose selector changes the dose. Only the dose counter and dose pointer will show how many mg the patient selects per dose.
The patient can select up to 3.0 mg per dose. When the pen contains less than 3.0 mg, the dose counter stops before 3.0 is shown.
The dose selector clicks differently when turned forwards, backwards or past the number of mg left. Do not count the pen clicks.
Always use the dose counter and the dose pointer to see how many mg have selected before injecting this medicine.
Do not count the pen clicks.
Do not use the pen scale. It only shows approximately how much solution is left in the pen. Only doses of 0.6 mg, 1.2 mg, 1.8 mg, 2.4 mg or 3.0 mg must be selected with the dose selector.
The selected dose must line up precisely with the dose pointer to ensure that the patient get a correct dose.
How much solution is left: The pen scale shows approximately how much solution is left in the pen.
To see precisely how much solution is left, use the dose counter: Turn the dose selector until the dose counter stops.
If it shows 3.0, at least 3.0 mg are left in the pen. If the dose counter stops before 3.0 mg, there is not enough solution left for a full dose of 3.0 mg.
If the patient needs more medicine than what is left in the pen: Only if trained or advised by doctor or nurse, the patient may split the dose between the current pen and a new pen. Use a calculator to plan the doses as instructed by the doctor or nurse.
Be very careful to calculate correctly.
If the patient is not sure how to split the dose using two pens, then select and inject the dose needs with a new pen.
4. Inject the dose: Insert the needle into the patient's skin as the doctor or nurse has shown the patient.
Make sure the patient can see the dose counter. Do not cover it with fingers. This could interrupt the injection.
Press and hold down the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. The patient may then hear or feel a click.
Keep the needle in the skin after the dose counter has returned to 0 and count slowly to 6.
If the needle is removed earlier, the patient may see a stream of solution coming from the needle tip. If so, the full dose will not be delivered.
Remove the needle from the skin.
If blood appears at the injection site, press lightly. Do not rub the area.
The patient may see a drop of solution at the needle tip after injecting. This is normal and does not affect the dose.
Always watch the dose counter to know how many mg the patient injects. Hold the dose button down until the dose counter shows 0.
How to identify a blocked or damaged needle: If 0 does not appear in the dose counter after continuously pressing the dose button, the patient may have used a blocked or damaged needle.
In this case, the patient has not received any medicine even though the dose counter has moved from the original dose that the patient has set.
How to handle a blocked needle: Change the needle as described in step 5 After injection and repeat all steps starting with step 1 Prepare the pen with a new needle. Make sure the patient select the full dose needed.
Never touch the dose counter when injecting. This can interrupt the injection.
5. After the injection: Lead the needle tip into the outer needle cap on a flat surface without touching the needle or the outer needle cap.
Once the needle is covered, carefully push the outer needle cap completely on.
Unscrew the needle and dispose of it carefully.
Put the pen cap on the pen after each use to protect the solution from light.
Always dispose of the needle after each injection to ensure convenient injections and prevent blocked needles. If the needle is blocked, the patient will not inject any medicine.
When the pen is empty, throw it away without a needle on as instructed by the doctor, nurse, pharmacist or local authorities.
Never try to put the inner needle cap back on the needle. The patient may stick themselves with the needle.
Always remove the needle from the pen after each injection.
This may prevent blocked needles, contamination, infection, leakage of solution and inaccurate dosing.
Further important information: Always keep the pen and needles out of the sight and reach of others, especially children.
Never share the pen or the needles with other people.
Caregivers must be very careful when handling used needles to prevent needle injury and cross-infection.
Caring for the pen: Do not leave the pen in a car or another place where it can get too hot or too cold.
Do not inject Saxenda which has been frozen. If the patient does that, the patient may not get the intended effect of this medicine.
Do not expose the pen to dust, dirt or liquid.
Do not wash, soak or lubricate the pen. If necessary, clean it with a mild detergent on a moistened cloth.
Do not drop the pen or knock it against hard surfaces. If the patient drops it or suspect a problem, attach a new needle and check the flow before the patient injects.
Do not try to refill the pen. Once empty, it must be disposed of.
Do not try to repair the pen or pull it apart.
Special precautions for disposal and other handling: The solution should not be used if it does not appear clear, colourless or almost colourless.
Saxenda should not be used if it has been frozen.
The pen is designed to be used with NovoFine or NovoTwist disposable needles up to a length of 8 mm and as thin as 32G. Needles are not included in the pack.
The patient should be advised to discard the injection needle after each injection and store the pen without an injection needle attached. This prevents contamination, infection and leakage. It also ensures that the dosing is accurate.
Any unused medicinal product or waste material should be disposed in accordance with local requirements.
Incompatibilities: Substances added to Saxenda may cause degradation of liraglutide. In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.
Storage
Store in a refrigerator (2°C - 8°C). Do not freeze. Store away from the freezer compartment.
After first use: Store below 30°C or store in a refrigerator (2°C - 8°C). The product should be discarded 1 month after first use.
Keep the cap on the pen in order to protect from light.
ATC Classification
A10BJ02 - liraglutide ; Belongs to the class of glucagon-like peptide-1 (GLP-1) analogues. Used in the treatment of diabetes.
Presentation/Packing
Soln for inj (pre-filled pen) 6 mg/mL (clear, colourless or almost colourless isotonic; pH 8.15) x 3 mL x 1's.
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