Glimepiride 2 Mg Tablets
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Glimepiride 2 mg tablets
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Each tablet contains 2 mg glimepiride.
Excipients
Each tablet contains 139.4 mg lactose monohydrate.
For the full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Tablet
Mottled green, round tablet, bisected on both sides. One side of the tablet debossed with “9” on one side of score and “3” on the other. The other side of the tablets debossed with “72” on one side of score and “55” on the other.
The tablet can be divided into equal halves.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
Glimepiride is indicated for the treatment of type 2 diabetes mellitus, when diet, physical exercise and weight reduction alone are not adequate.
4.2 Posology and method of administration
Posology
The basis for successful treatment of diabetes is a good diet, regular physical activity, as well as routine checks of blood and urine. Tablets or insulin cannot compensate if the patient does not keep to the recommended diet.
Dosage is determined by the results of blood and urinary glucose determinations.
The starting dose is 1 mg glimepiride per day. If good control is achieved this dosage should be used for maintenance therapy.
For the different dosage regimens appropriate strengths are available.
If control is unsatisfactory the dosage should be increased, based on the glycaemic control, in a stepwise manner with an interval of about 1 to 2 weeks between each step, to 2, 3 or 4 mg glimepiride per day.
A dosage of more than 4 mg glimepiride per day gives better results only in exceptional cases. The maximum recommended dose is 6 mg glimepiride per day.
In patients not adequately controlled with the maximum daily dose of metformin, concomitant glimepiride therapy can be initiated. While maintaining the metformin dose, glimepiride therapy is started with a low dose, and is then titrated up depending on the desired level of metabolic control up to the maximum daily dose. The combination therapy should be initiated under close medical supervision.
In patients not adequately controlled with the maximum daily dose of glimepiride, concomitant insulin therapy can be initiated if necessary. While maintaining the glimepiride dose, insulin treatment is started at low dose and titrated up depending on the desired level of metabolic control. The combination therapy should be initiated under close medical supervision.
Normally a single daily dose of glimepiride is sufficient. It is recommended that this dose be taken shortly before or during a substantial breakfast or - if none is taken - shortly before or during the first main meal.
If a dose is forgotten, this should not be corrected by increasing the next dose. Tablets should be swallowed whole with some liquid.
If a patient has a hypoglycaemic reaction on 1 mg glimepiride daily, this indicates that they can be controlled by diet alone.
In the course of treatment, as an improvement in control of diabetes is associated with higher insulin sensitivity, glimepiride requirements may fall. To avoid hypoglycaemia timely dose reduction or cessation of therapy must therefore be considered. Change in dosage may also be necessary, if there are changes in weight or lifestyle of the patient, or other factors that increase the risk of hypo- or hyperglycaemia.
Switch-over from other oral hypoglycaemic agents to glimepiride:
A switch-over from other oral hypoglycaemic agents to glimepiride can generally be done. For the switch-over to glimepiride the strength and the halflife of the previous medicinal product has to be taken into account. In some cases, especially in antidiabetics with a long half-life (e.g. chlorpropamide), a wash-out period of a few days is advisable in order to minimise the risk of hypoglycaemic reactions due to the additive effect.
The recommended starting dose is 1 mg glimepiride per day. Based on the response, the glimepiride dosage may be increased stepwise, as indicated earlier.
Switch-over from insulin to glimepiride:
In exceptional cases, where type 2 diabetic patients are regulated on insulin, a change-over to glimepiride may be indicated. The change-over should be undertaken under close medical supervision.
Patient with renal or hepatic impairment:
See section 4.3.
Paediatric population :
There are no data available on the use of glimepiride in patients under 8 years of age. For children aged 8 to 17 years, there are limited data on glimepiride as monotherapy (see sections 5.1 and 5.2).
The available data on safety and efficacy are insufficient in the paediatric population and therefore such use is not recommended.
Method of administration For oral administration.
4.3 Contraindications
Glimepiride is contraindicated in patients with the following conditions:
- hypersensitivity to glimepiride, other sulfonylureas or sulfonamides or to any of the excipients listed in section 6.1.
- insulin-dependent diabetes,
- diabetic coma,
- ketoacidosis,
- severe renal or hepatic function disorders.
In case of severe renal or hepatic function disorders, a change-over to insulin is required.
4.4 Special warnings and precautions for use
Glimepiride must be taken shortly before or during a meal.
When meals are taken at irregular hours or skipped altogether, treatment with glimepiride may lead to hypoglycaemia. Possible symptoms of hypoglycaemia include headache, ravenous hunger, nausea, vomiting, lassitude, sleepiness, disordered sleep, restlessness, aggressiveness, impaired concentration, alertness and reaction time, depression, confusion, speech and visual disorders, aphasia, tremor, paresis, sensory disturbances, dizziness, helplessness, loss of self-control, delirium, cerebral convulsions, somnolence and loss of consciousness up to and including coma, shallow respiration and bradycardia. In addition, signs of adrenergic counter-regulation may be present such as sweating, clammy skin, anxiety, tachycardia, hypertension, palpitations, angina pectoris and cardiac arrhythmias.
The clinical picture of a severe hypoglycaemic attack may resemble that of a stroke.
Symptoms can almost always be promptly controlled by immediate intake of carbohydrates (sugar). Artificial sweeteners have no effect.
It is known from other sulfonylureas that, despite initially successful countermeasures, hypoglycaemia may recur.
Severe hypoglycaemia or prolonged hypoglycaemia, only temporarily controlled by the usual amounts of sugar, requires immediate medical treatment and occasionally hospitalisation.
Factors favouring hypoglycaemia include:
- unwillingness or (more commonly in older patients) incapacity of the patient to cooperate,
- undernutrition, irregular mealtimes or missed meals or periods of fasting,
- alterations in diet,
- imbalance between physical exertion and carbohydrate intake,
- consumption of alcohol, especially in combination with skipped meals,
- impaired renal function,
- serious liver dysfunction,
- overdosage with glimepiride,
- certain uncompensated disorders of the endocrine system affecting carbohydrate metabolism or counter-regulation of hypoglycaemia (as for example in certain disorders of thyroid function and in anterior pituitary or adrenocortical insufficiency), concurrent administration of certain other medicinal products (see section 4.5).
Treatment with glimepiride requires regular monitoring of glucose levels in
blood and urine.
In addition determination of the proportion of glycosylated haemoglobin is recommended.
Regular hepatic and haematological monitoring (especially leucocytes and thrombocytes) are required during treatment with glimepiride.
In stress situations (e.g. accidents, acute operations, infections with fever, etc.) a temporary switch to insulin may be indicated.
No experience has been gained concerning the use of glimepiride in patients with severe impairment of liver function or dialysis patients. In patients with severe impairment of renal or liver function change-over to insulin is indicated.
Treatment of patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency with sulfonylurea agents can lead to haemolytic anaemia. Since glimepiride belongs to the class of sulfonylurea agents, caution should be used in patients with G6PD-deficiency and a non-sulfonylurea alternative should be considered.
Glimepiride tablets contain lactose monohydrate. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.
4.5 Interaction with other medicinal products and other forms of interaction
If glimepiride is taken simultaneously with certain other medicinal products, both undesired increases and decreases in the hypoglycaemic action of glimepiride can occur. For this reason, other medicinal products should only be taken with the knowledge (or at the prescription) of the doctor.
Glimepiride is metabolised by cytochrome P450 2C9 (CYP2C9). Its metabolism is known to be influenced by concomitant administration of CYP2C9 inducers (e.g. rifampicin) or inhibitors (e.g. fluconazole).
Results from an in vivo interaction study reported in the literature show that the glimepiride AUC is increased approximately 2-fold by fluconazole, one of the most potent CYP2C9 inhibitors.
Based on the experience with glimepiride and with other sulfonylureas the following interactions have to be mentioned.
Potentiation of the blood-glucose-lowering effect and, thus, in some instances hypoglycaemia, may occur when one of the following medicinal products is taken, for example:
- phenylbutazone, azapropazon and oxyfenbutazone
- insulin and oral antidiabetic medicinal products, such as metformin
- salicylates and p-amino-salicylic acid
- anabolic steroids and male sex hormones
- chloramphenicol
- certain long-acting sulfonamides
- tetracyclines
- quinolone antibiotics
- clarithromycin
- coumarin anticoagulants
- disopyramide
- fenfluramine
- fibrates
- ACE inhibitors
- fluoxetine
- MAO inhibitors
- allopurinol
- probenecid
- sulfinpyrazone
- sympatholytics
- cyclophosphamide, trophosphamide and iphosphamides
- miconazole
- fluconazole
- pentoxifylline (high dose parenteral)
- tritoqualine
Weakening of the blood-glucose-lowering effect and thus, raised blood glucose levels, may occur when one of the following medicinal products is taken, for example:
- oestrogens and progestogens,
- saluretics, thiazide diuretics,
- thyroid-stimulating agents, glucocorticoids,
- phenothiazine derivatives, chlorpromazine,
- adrenaline and sympathomimetics,
- nicotinic acid (high dosages) and nicotinic acid derivatives,
- laxatives (long term use),
- phenytoin, diazoxide,
- glucagon, barbiturates and rifampicin,
- acetazolamide.
H2 antagonists, betablockers, clonidine and reserpine may lead to either potentiation or weakening of the blood-glucose-lowering effect.
Under the influence of sympatholytic medicinal products such as betablockers, clonidine, guanethidine and reserpine, the signs of adrenergic counterregulation to hypoglycaemia may be reduced or absent.
Alcohol intake may potentiate or weaken the hypoglycaemic action of glimepiride in an unpredictable fashion.
Glimepiride may either potentiate or weaken the effects of coumarin derivatives.
4.6 Fertility, pregnancy and lactation
Pregnancy
Risk related to diabetes
Abnormal blood glucose levels during pregnancy are associated with a higher incidence of congenital abnormalities and perinatal mortality. So the blood glucose level must be closely monitored during pregnancy in order to avoid the teratogenic risk. The use of insulin is required under such circumstances. Patients who consider pregnancy should inform their physician.
Risk related to glimepiride
There are no adequate data from the use of glimepiride in pregnant women. Animal studies have shown reproductive toxicity, which likely was related to the pharmacological action (hypoglycaemia) of glimepiride (see section 5.3). Consequently, glimepiride should not be used during the whole pregnancy.
In case of treatment by glimepiride, if the patient plans to become pregnant or if a pregnancy is discovered, the treatment should be switched as soon as possible to insulin therapy.
Breast-feeding
The excretion in human milk is unknown. Glimepiride is excreted in rat milk. As other sulfonylureas are excreted in human milk and because there is a risk of hypoglycaemia in nursing infants, breast-feeding is advised against during treatment with glimepiride.
4.7 Effects on ability to drive and use machines
No studies on the effects on the ability to drive and use machines have been performed.
The patient's ability to concentrate and react may be impaired as a result of hypoglycaemia or hyperglycaemia or, for example, as a result of visual impairment. This may constitute a risk in situations where these abilities are of special importance (e.g. driving a car or operating machinery).
Patients should be advised to take precautions to avoid hypoglycaemia whilst driving. This is particularly important in those who have reduced or absent awareness of the warning symptoms of hypoglycaemia or have frequent episodes of hypoglycaemia. It should be considered whether it is advisable to drive or operate machinery in these circumstances.
4.8 Undesirable effects
The following adverse reactions from clinical investigations were based on experience with glimepiride and other sulfonylureas, are listed below by system organ class and in order of decreasing incidence: 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), not known (cannot be estimated from the available data).:
Blood and lymphatic system disorders
Rare: thrombocytopenia, leukopenia, granulocytopenia, agranulocytosis, erythropenia, haemolytic anaemia and pancytopenia, which are in general reversible upon discontinuation of medication.
Not known: Severe thrombocytopenia with platelet count less than 10,000/pl and thrombocytopenic purpura.
Immune system disorders
Very rare: leukocytoclastic vasculitis, mild hypersensitivity reactions that may develop into serious reactions with dyspnoea, fall in blood pressure and sometimes shock.
Not known: Cross-allergenicity with sulfonylureas, sulfonamides or related substances is possible.
Metabolism and nutrition disorders Rare: hypoglycaemia
These hypoglycaemic reactions mostly occur immediately, may be severe and are not always easy to correct. The occurrence of such reactions depends, as with other hypoglycaemic therapies, on individual factors such as dietary habits and the dosage (see further under section 4.4).
Eye disorders
Not known: Visual disturbances, transient, may occur especially on initiation of treatment, due to changes in blood glucose levels.
Gastrointestinal disorders
Very rare: nausea, vomiting, diarrhoea, abdominal distention, abdominal discomfort and abdominal pain, which seldom lead to discontinuation of therapy.
Hepato-biliary disorders
Very rare: hepatic function abnormal (e.g. with cholestasis and jaundice), hepatitis and liver failure.
Not known: Hepatic enzymes increased.
Skin and subcutaneous tissue disorders
Not known: Hypersensitivity reactions of the skin may occur such as pruritus, rash, urticaria and photosensitivity.
Investigations
Very rare: blood sodium decrease Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
4.9 Overdose
Symptoms
After ingestion of an overdosage hypoglycaemia may occur, lasting from 12 to 72
hours, and may recur after an initial recovery. Symptoms may be not present for up to 24 hours after ingestion. In general observation in hospital is recommended. Nausea, vomiting and epigastric pain may occur. The hypoglycaemia may in general be accompanied by neurological symptoms like restlessness, tremor, visual disturbances, co-ordination problems, sleepiness, coma and convulsions.
Management
Treatment primarily consists of preventing absorption of glimepiride by inducing vomiting and then drinking water or lemonade with activated charcoal (adsorbent) and sodium-sulphate (laxative). If large quantities have been ingested, gastric lavage is indicated, followed by activated charcoal and sodium-sulphate. In case of (severe) overdosage hospitalisation in an intensive care department is indicated. Start the administration of glucose as soon as possible, if necessary by a bolus intravenous injection of 50 ml of a 50% solution, followed by an infusion of a 10% solution with strict monitoring of blood glucose. Further treatment should be symptomatic.
Paediatric population
In particular when treating hypoglycaemia due to accidental intake of glimepiride in infants and young children, the dose of glucose given must be carefully controlled to avoid the possibility of producing dangerous hyperglycaemia. Blood glucose should be closely monitored.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Oral blood-glucose-lowering drugs: Sulfonamides, urea derivatives.
ATC code: A10B B12
Glimepiride is an orally active hypoglycaemic substance belonging to the sulfonylurea group. It may be used in non-insulin-dependent diabetes mellitus.
Mechanism of action
Glimepiride acts mainly by stimulating insulin release from pancreatic beta cells. As with other sulfonylureas this effect is based on an increase of responsiveness of the pancreatic beta cells to the physiological glucose stimulus. In addition, glimepiride seems to have pronounced extrapancreatic effects also postulated for other sulfonylureas.
Insulin release
Sulfonylureas regulate insulin secretion by closing the ATP-sensitive potassium channel in the beta cell membrane. Closing the potassium channel induces depolarisation of the beta cell and results - by opening of calcium channels - in an increased influx of calcium into the cell.
This leads to insulin release through exocytosis.
Glimepiride binds with a high exchange rate to a beta cell membrane protein which is associated with the ATP-sensitive potassium channel but which is different from the usual sulfonylurea binding site.
Extrapancreatic activity
The extrapancreatic effects are for example an improvement of the sensitivity of the peripheral tissue for insulin and a decrease of the insulin uptake by the liver.
The uptake of glucose from blood into peripheral muscle and fat tissues occurs via special transport proteins, located in the cell membrane. The transport of glucose in these tissues is the rate-limiting step in the use of glucose. Glimepiride increases very rapidly the number of active glucose transport molecules in the plasma membranes of muscle and fat cells, resulting in stimulated glucose uptake.
Glimepiride increases the activity of the glycosyl-phosphatidylinositol-specific phospholipase C which may be correlated with the drug-induced lipogenesis and glycogenesis in isolated fat and muscle cells. Glimepiride inhibits glucose production in the liver by increasing the intracellular concentration of fructose-2,6-bisphosphate, which in its turn inhibits the gluconeogenesis.
Pharmacodynamic effects
In healthy persons, the minimum effective oral dose is approximately 0.6 mg. The effect of glimepiride is dose-dependent and reproducible. The physiological response to acute physical exercise, reduction of insulin secretion, is still present under glimepiride.
There was no significant difference in effect regardless of whether the medicinal product was given 30 minutes or immediately before a meal. In diabetic patients, good metabolic control over 24 hours can be achieved with a single daily dose.
Although the hydroxy metabolite of glimepiride caused a small but significant decrease in serum glucose in healthy persons, it accounts for only a minor part of the total drug effect.
Combination therapy with metformin
Improved metabolic control for concomitant glimepiride therapy compared to metformin alone in patients not adequately controlled with the maximum dosage of metformin has been shown in one study.
Combination therapy with insulin
Data for combination therapy with insulin are limited. In patients not adequately controlled with the maximum dosage of glimepiride, concomitant insulin therapy can be initiated. In two studies, the combination achieved the same improvement in metabolic control as insulin alone. However, a lower average dose of insulin was required in combination therapy.
Special populations
Paediatric population
An active controlled clinical trial (glimepiride up to 8 mg daily or metformin up to 2,000 mg daily) of 24 weeks duration was performed in 285 children (817 years of age) with type 2 diabetes.
Both glimepiride and metformin exhibited a significant decrease from baseline in HbA1c (glimepiride -0.95 (se 0.41); metformin -1.39 (se 0.40)). However, glimepiride did not achieve the criteria of non-inferiority to metformin in mean change from baseline of HbA1c. The difference between treatments was 0.44% in favour of metformin. The upper limit (1.05) of the 95% confidence interval for the difference was not below the 0.3% non-inferiority margin.
Following glimepiride treatment, there were no new safety concerns noted in children compared to adult patients with type 2 diabetes mellitus. No longterm efficacy and safety data are available in paediatric patients.
5.2 Pharmacokinetic properties
Absorption
The bioavailability of glimepiride after oral administration is complete. Food intake has no relevant influence on absorption, only absorption rate is slightly diminished. Maximum serum concentrations (Cmax) are reached approx. 2.5 hours after oral intake (mean 0.3 pg/ml during multiple dosing of 4 mg daily) and there is a linear relationship between dose and both Cmax and AUC (area under the time/concentration curve).
Distribution
Glimepiride has a very low distribution volume (approx. 8.8 litres) which is roughly equal to the albumin distribution space, high protein binding (>99%), and a low clearance (approx. 48 ml/min). In animals, glimepiride is excreted in milk. Glimepiride is transferred to the placenta. Passage of the blood brain barrier is low.
Biotransformation and elimination
Mean dominant serum half-life, which is of relevance for the serum concentrations under multiple-dose conditions, is about 5 to 8 hours. After high doses, slightly longer half-lives were noted.
After a single dose of radiolabelled glimepiride, 58% of the radioactivity was recovered in the urine, and 35% in the faeces. No unchanged substance was detected in the urine. Two metabolites - most probably resulting from hepatic metabolism (major enzyme is CYP2C9) - were identified both in urine and faeces: the hydroxy derivative and the carboxy derivative. After oral administration of glimepiride, the terminal half-lives of these metabolites were 3 to 6 and 5 to 6 hours respectively.
Comparison of single and multiple once-daily dosing revealed no significant differences in pharmacokinetics, and the intraindividual variability was very low. There was no relevant accumulation.
Special populations
Pharmacokinetics were similar in males and females, as well as in young and elderly (above 65 years) patients. In patients with low creatinine clearance, there was a tendency for glimepiride clearance to increase and for average serum concentrations to decrease, most probably resulting from a more rapid elimination because of lower protein binding. Renal elimination of the two metabolites was impaired. Overall no additional risk of accumulation is to be assumed in such patients.
Pharmacokinetics in five non-diabetic patients after bile duct surgery were similar to those in healthy persons.
Paediatric population
A fed study investigating the pharmacokinetics, safety, and tolerability of a 1 mg single dose of glimepiride in 30 paediatric patients (4 children aged 10-12 years and 26 children aged 12-17 years) with type 2 diabetes showed mean AUC(0-last) , Cmax and t1/2 similar to that previously observed in adults.
5.3 Preclinical safety data
Preclinical effects observed occurred at exposures sufficiently in excess of the maximum human exposure as to indicate little relevance to clinical use, or were due to the pharmacodynamic action (hypoglycaemia) of the compound. This finding is based on conventional safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenicity, and reproduction toxicity studies. In the latter (covering embryotoxicity, teratogenicity and developmental toxicity), adverse effects observed were considered to be secondary to the hypoglycaemic effects induced by the compound in dams and in offspring.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Lactose monohydrate Sodium starch glycolate type A Povidone K-30 Microcrystalline cellulose Magnesium stearate Iron oxide yellow (E172)
Indigo carmine aluminium lake (E132)
6.2 Incompatibilities
Not applicable.
6.3 Shelf life 2 years
6.4 Special precautions for storage
Do not store above 25°C.
6.5 Nature and contents of container
PVC/PVdC aluminium blisters.
Pack sizes: 20, 28, 30 50, 60, 90, 120 and 200 tablets.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal
No special requirements
7 MARKETING AUTHORISATION HOLDER
TEVA UK Limited Brampton Road Hampden Park, Eastbourne East Sussex, BN22 9AG
8 MARKETING AUTHORISATION NUMBER(S)
PL 00289/0944
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
10/09/2010
10 DATE OF REVISION OF THE TEXT
19/01/2014