TRIJARDY® XR

TRIJARDY® XR is a prescription medication used to treat type 2 diabetes. It contains three active ingredients: empagliflozin, linagliptin, and metformin hydrochloride. Empagliflozin and linagliptin work together to help lower blood sugar levels by increasing insulin production and reducing glucose production in the liver. Metformin hydrochloride also helps to reduce glucose production in the liver and improves the body's ability to use insulin. TRIJARDY® XR is an extended-release tablet, which means that it releases the medication slowly over time, providing consistent blood sugar control throughout the day.

Empagliflozin

Empagliflozin is an inhibitor of the sodium-glucose co-transporter 2 (SGLT2).

The chemical name of empagliflozin is D-Glucitol,1,5-anhydro-1-C-[4-chloro-3-[[4-[[(3S)-tetrahydro-3furanyl]oxy]phenyl]methyl]phenyl]-, (1S).

The molecular formula is C₂₃H₂₇ClO₇and the molecular weight is 450.91.

Empagliflozin is a white to yellowish, non-hygroscopic powder. It is very slightly soluble in water, sparingly soluble in methanol, slightly soluble in ethanol and acetonitrile, soluble in 50% acetonitrile/water, and practically insoluble in toluene.

Linagliptin

Linagliptin is an inhibitor of the dipeptidyl peptidase-4 (DPP-4) enzyme.

The chemical name of linagliptin is 1H-Purine-2,6-dione, 8-[(3R)-3-amino-1-piperidinyl]-7-(2-butyn-1-yl)-3,7dihydro-3-methyl-1-[(4-methyl-2-quinazolinyl)methyl]. The molecular formula is C₂₅H₂₈N₈O₂ and the molecular weight is 472.54.

Linagliptin is a white to yellowish, not or only slightly hygroscopic solid substance. It is very slightly soluble in water. Linagliptin is soluble in methanol, sparingly soluble in ethanol, very slightly soluble in isopropanol, and very slightly soluble in acetone.

Metformin hydrochloride Metformin hydrochloride (N,N-dimethylimidodicarbonimidic diamide hydrochloride) is a biguanide. Metformin hydrochloride is a white to off-white crystalline compound with a molecular formula of C₄H₁₁N₅•HCl and a molecular weight of 165.63. Metformin hydrochloride is freely soluble in water and is practically insoluble in acetone, ether, and chloroform. The pKa of metformin is 12.4. The pH of a 1% aqueous solution of metformin hydrochloride is 6.68.

TRIJARDY® XR (empagliflozin, linagliptin, and metformin hydrochlorideextended-release tablets)

INDICATIONS AND USAGE

TRIJARDY XR is a combination of empagliflozin, linagliptin, and metformin hydrochloride (HCl) indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.

Empagliflozin is indicated to reduce the risk of cardiovascular death in adults with type 2 diabetes mellitus and established cardiovascular disease.

Limitations of Use

TRIJARDY XR is not recommended in patients with type 1 diabetes mellitus. It may increase the risk of diabetic ketoacidosis in these patients.

TRIJARDY XR has not been studied in patients with a history of pancreatitis. It is unknown whether patients with a history of pancreatitis are at an increased risk for the development of pancreatitis while using TRIJARDY XR.

Mechanism of Action

TRIJARDY XR

TRIJARDY XR contains: empagliflozin, a sodium-glucose co-transporter 2 (SGLT2) inhibitor, linagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, and metformin, a biguanide.

Empagliflozin

Sodium-glucose co-transporter 2 (SGLT2) is the predominant transporter responsible for reabsorption of glucose from the glomerular filtrate back into the circulation. Empagliflozin is an inhibitor of SGLT2. By inhibiting SGLT2, empagliflozin reduces renal reabsorption of filtered glucose and lowers the renal threshold for glucose, and thereby increases urinary glucose excretion.

Linagliptin

Linagliptin is an inhibitor of DPP-4, an enzyme that degrades the incretin hormones glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP). Thus, linagliptin increases the concentrations of active incretin hormones, stimulating the release of insulin in a glucose-dependent manner and decreasing the levels of glucagon in the circulation. Both incretin hormones are involved in the physiological regulation of glucose homeostasis. Incretin hormones are secreted at a low basal level throughout the day and levels rise immediately after meal intake. GLP-1 and GIP increase insulin biosynthesis and secretion from pancreatic beta cells in the presence of normal and elevated blood glucose levels. Furthermore, GLP-1 also reduces glucagon secretion from pancreatic alpha cells, resulting in a reduction in hepatic glucose output.

Metformin HCl

Metformin is an antihyperglycemic agent which improves glucose tolerance in patients with type 2 diabetes mellitus, lowering both basal and postprandial plasma glucose. Metformin decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization. With metformin therapy, insulin secretion remains unchanged while fasting insulin levels and day-long plasma insulin response may decrease.

DOSAGE AND ADMINISTRATION

Recommended Dosage and Administration

Individualize the starting dose of TRIJARDY XR based on the patient’s current regimen:

In patients on metformin HCl, with or without linagliptin, switch to TRIJARDY XR containing a similar total daily dose of metformin HCl and a total daily dose of empagliflozin 10 mg and linagliptin 5 mg;
In patients on metformin HCl and any regimen containing empagliflozin, with or without linagliptin, switch to TRIJARDY XR containing a similar total daily dose of metformin HCl, the same total daily dose of empagliflozin and linagliptin 5 mg.
Monitor effectiveness and tolerability, and adjust dosing as appropriate, not to exceed the maximum recommended daily dose of empagliflozin 25 mg, linagliptin 5 mg and metformin HCl 2000 mg.

Take TRIJARDY XR orally, once daily with a meal in the morning.

Take TRIJARDY XR 10 mg/5 mg/1000 mg or TRIJARDY XR 25 mg/5 mg/1000 mg as a single tablet once daily.
Take TRIJARDY XR 5 mg/2.5 mg/1000 mg or TRIJARDY XR 12.5 mg/2.5 mg/1000 mg as two tablets together once daily.

Swallow TRIJARDY XR tablets whole. Do not split, crush, dissolve, or chew.

Dosage Recommendations in Patients with Renal Impairment

Initiation of TRIJARDY XR is not recommended in patients with an eGFR less than 45 mL/min/1.73 m², due to the metformin component.
TRIJARDY XR is contraindicated in patients with an eGFR less than 30 mL/min/1.73 m²or in patients on dialysis

Discontinuation for Iodinated Contrast Imaging Procedures

Discontinue TRIJARDY XR at the time of, or prior to, an iodinated contrast imaging procedure in patients with an eGFR less than 60 mL/min/1.73 m²; in patients with a history of liver disease, alcoholism or heart failure; or in patients who will be administered intra-arterial iodinated contrast. Re-evaluate eGFR 48 hours after the imaging procedure; restart TRIJARDY XR if renal function is stable.

CONTRAINDICATIONS

TRIJARDY XR is contraindicated in patients with:

Severe renal impairment (eGFR less than 30 mL/min/1.73 m²), end-stage renal disease, or dialysis.
Acute or chronic metabolic acidosis, including diabetic ketoacidosis.
Hypersensitivity to empagliflozin, linagliptin, metformin or any of the excipients in TRIJARDY XR, reactions such as anaphylaxis, angioedema, exfoliative skin conditions, urticaria, or bronchial hyperreactivity have occurred.

OVERDOSAGE

In the event of an overdose with TRIJARDY XR, contact the Poison Control Center.

Overdose of metformin HCl has occurred, including ingestion of amounts greater than 50 grams. Lactic acidosis has been reported in approximately 32% of metformin overdose cases. Metformin is dialyzable with a clearance of up to 170 mL/min under good hemodynamic conditions. Therefore, hemodialysis may be useful for removal of accumulated drug from patients in whom metformin overdosage is suspected.

Removal of empagliflozin by hemodialysis has not been studied, and removal of linagliptin by hemodialysis or peritoneal dialysis is unlikely.

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TRIJARDY® XR (empagliflozin, linagliptin, and metformin hydrochloride extended-release tablets)

TRIJARDY® XR