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Victoza(liraglutide[rDNA origin] injection)

2013-02-06 18:46:49  作者:新特药房  来源:互联网  浏览次数:647  文字大小:【】【】【
简介: 利拉鲁肽说明书更新包括数据显示当与西他列汀比较时疗效较优2012年4月6日Novo Nordisk 公司接到美国食品药品监督管理局(FDA)批准Victoza(利拉鲁肽[重组DNA来源]注射剂)使用说明书。其中包括数据显示当与 ...

英文药名:Victoza(liraglutide [rDNA origin] injection)

中文药名:利拉鲁肽注射液

生产厂家:诺和诺德公司
药品介绍
美国食品药品管理局(FDA)近日批准Victoza (liraglutide,利拉鲁肽)注射剂用于部分成年患者2型糖尿病的治疗。Victoza属胰高血糖素样肽1(GLP-1)类似物药物(注射剂,每日注射一次),能够在患者进食后促使其胰腺分泌更多胰岛素,对于没有进行适当的饮食控制和运动的患者,Victoza不被推荐单独用于糖尿病的初期治疗。
FDA药品审评与研究中心新陈代谢与内分泌室主任、医学博士Mary Parks说,“糖尿病是引起死亡和致残的一个主要原因,每年新诊断出的糖尿病患者超过了1500万人。对于预防或控制长期的糖尿病并发症来看,控制血糖水平是非常重要的,Victoza为部分2型糖尿病患者提供了控制血糖水平的备选方案。”
Victoza最常见的不良反应包括头痛、恶心和腹泻。其他不良反应包括荨麻疹等过敏样反应。有3900位患者参加的5个临床试验结果显示,使用Victoza的患者发生胰腺炎(胰腺的一种炎症)的可能性要大于使用其他治疗药物的患者。当患者出现严重腹痛,伴随或未伴随恶心、呕吐时,应停止使用Victoza,当确诊为胰腺炎后,不应再次使用Victoza进行治疗。有胰腺炎病史的患者应慎用。动物试验显示,Victoza会引起大鼠和小鼠出现甲状腺瘤。因此,尚不能确认是否会引起人甲状腺瘤或癌,为此,在继续进行研究以证明可以扩大使用之前,Victoza不能作为治疗2型糖尿病的一线药物,也不能用于治疗已患甲状腺髓样癌的患者。
Victoza® (利拉鲁肽[liraglutide][rDNA来源]注射剂),为皮下注射溶液
美国初次批准:
2010年
作用机制
利拉鲁肽是一种酰化人胰高血糖素-样肽-1(GLP-1)受体激动剂有97%氨基酸序列同源于内源性人GLP-1(7-37)。GLP-1(7-37)代表<20%的总循环内源性GLP-1。像GLP-1(7-37)一样,利拉鲁肽活化GLP-1受体,一种膜-结合细胞表面受体耦合至腺苷酸环化酶刺激在胰腺β细胞内G-蛋白Gs。有葡萄糖浓度升高时,利拉鲁肽增加细胞内环一磷酸腺苷酸(cAMP)导致胰岛素释放。当血糖浓度降低时,胰岛素分泌消退和接近正常血糖。利拉鲁肽还以依赖葡萄糖方式减低胰高血糖素分泌。血糖降低机制还涉及胃排空延后。
GLP-1(7-37)由于被无处不在的内源性酶,二肽肽酶IV(DPP-IV)和中性内肽酶(NEP)降解,半衰期仅1.5-2分钟。利拉鲁肽和天然GLP-1不一样,对两种肽酶代谢酶降解都稳定和皮下给药后血浆半衰期13小时。利拉鲁肽的药代动力学图形使之适于每天1次给药,是自身伴延缓吸收,血浆蛋白结合和对DPP-IV和NEP代谢降解稳定性的结果。
适应证和用途
利拉鲁肽是一种胰高血糖素样肽-1(GLP-1)受体激动剂适用于在2型糖尿病成年中辅助饮食和运动治疗改善血糖控制。
重要使用限制
(1)对用膳食和运动控制不佳患者建议不作为一线治疗。
(2)有胰腺炎史患者数据有限。
(3)不是为1型糖尿病或糖尿病酮症酸中毒治疗。
(4)尚未研究与餐前胰岛素联用。
剂量和给药方法
(1)在任何时间与进餐无关,每天给药1次。
(2)在腹部,大腿或上臂皮下注射。
(3)可改变注射部位和时间不调整剂量。
(4)初始每天0.6mg共1周。初始期为减轻胃肠道症状又不影响血糖控制调整剂量。一周后,增加剂量至1.2mg。如1.2mg剂量未造成可接受的血糖控制,剂量可增至1.8mg。
剂型和规格
为皮下注射溶液,预装,多次给药笔输送剂量0.6mg,1.2mg或1.8mg(6mg/mL,3mL)。
禁忌证
甲状腺髓样癌(MTC)个人或家族史或2型多发性内分泌肿瘤综合征(MEN 2)患者禁用。
如对利拉鲁肽或产品任何组分严重超敏性史不要使用。
警告和注意事项
(1)在动物中甲状腺C-细胞肿瘤:忠告患者关于髓性甲状腺癌的风险和甲状腺肿瘤症状.
(2)胰腺炎:在临床试验中,利拉鲁肽-治疗患者中比对比药-治疗患者胰腺炎病例更多。如怀疑胰腺炎,应终止利拉鲁肽和其它潜在怀疑药物。如确证胰腺炎不应再次开始利拉鲁肽。有胰腺炎史患者慎用。
(3)严重低血糖:当利拉鲁肽与一种胰岛素促分泌素(如一种磺脲类[sulfonylurea])或胰岛素可能发生。考虑降低胰岛素促分泌素或胰岛素剂量以减少低血糖风险。
(4)肾受损:上市后曾报道,通常伴随恶心,呕吐,腹泻,或脱水有时可能需要血液透析。在有肾受损患者中当开始或扩增利拉鲁肽剂量时慎用。
(5)超敏性: 上市后严重超敏性反应(如,过敏反应和血管水肿)。患者应终止利拉鲁肽和其它怀疑药物和及时求医。
(6)大血管结局:尚无研究确定用利拉鲁肽或任何其它抗糖尿病药物减低大血管风险的结论性证据。
不良反应
(1)用利拉鲁肽治疗患者最常见不良反应,报道≥5%和比用安慰剂治疗患者更常见是:头痛,恶心,腹泻和抗-利拉鲁肽抗体形成.
(2)在临床试验中,免疫原性-相关事件,包括荨麻疹,是利拉鲁肽-治疗患者(0.8%)比对比药-治疗患者(0.4%)更常见。
药物相互作用
(1)利拉鲁肽延迟胃排空。可能影响同时给予口服药物的吸收。谨慎使用。
特殊人群中使用
(1)有肾或肝受损患者数据有限。
如何供应/贮存和处置
1)如何供应
可得到以下包装大小的利拉鲁肽含可遗弃的,预装,多剂量笔。每种个体笔输送剂量0.6mg,1.2mg,或1.8mg(6mg/mL,3mL)。
2x利拉鲁肽笔NDC 0169-4060-12
3x利拉鲁肽笔NDC 0169-4060-13
各种利拉鲁肽笔是为单一患者使用。一支利拉鲁肽笔应永远不要在患者间分享使用,即使更换针头。
2)建议贮存
首次使用前,利拉鲁肽应倍贮存在冰箱内36ºF至46ºF(2ºC至8ºC)间(表14)。不要在冻结盒或柜内贮存或直接邻近冰箱制冷元件。不要冻结利拉鲁肽和如利拉鲁肽曾冻结不要使用。
利拉鲁肽笔初始使用后,笔可在控制室温(59°F至86°F;15°C 至30°C)或在冰箱内(36°F至46°F;2°C至8°C)贮存30天。当不使用是盖上笔帽。应保护利拉鲁肽避免过热和防阳光。每次注射后总是移去和安全遗弃针头和贮存利拉鲁肽笔无注射针头附着。这将减少污染,感染,和泄漏潜在可能而也确保剂量准确。


Victoza 6mg/ml solution for injection in pre-filled pen
1. Name of the medicinal product
Victoza 6 mg/ml solution for injection in pre-filled pen
2. Qualitative and quantitative composition
One 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.
For the full list of excipients, see section 6.1.
3. Pharmaceutical form
Solution for injection.
Clear, colourless or almost colourless, isotonic solution; pH=8.15.
4. Clinical particulars
4.1 Therapeutic indications
Victoza is indicated for treatment of adults with type 2 diabetes mellitus to achieve glycaemic control in combination with oral glucose-lowering medicinal products and/or basal insulin when these, together with diet and exercise, do not provide adequate glycaemic control (see sections 4.4 and 5.1 for available data on the different combinations).
4.2 Posology and method of administration
Posology
To improve gastro-intestinal tolerability, the starting dose is 0.6 mg liraglutide daily. After at least one week, the dose should be increased to 1.2 mg. Some patients are expected to benefit from an increase in dose from 1.2 mg to 1.8 mg and based on clinical response, after at least one week, the dose can be increased to 1.8 mg to further improve glycaemic control. Daily doses higher than 1.8 mg are not recommended.
Victoza can be added to existing metformin or to a combination of metformin and thiazolidinedione therapy. The current dose of metformin and thiazolidinedione can be continued unchanged.
Victoza can be added to existing sulphonylurea or to a combination of metformin and sulphonylurea therapy or a basal insulin. When Victoza is added to sulphonylurea therapy or basal insulin, a reduction in the dose of sulphonylurea or basal insulin should be considered to reduce the risk of hypoglycaemia (see section 4.4).
Self-monitoring of blood glucose is not needed in order to adjust the dose of Victoza. However, when initiating treatment with Victoza in combination with a sulphonylurea or a basal insulin, blood glucose self-monitoring may become necessary to adjust the dose of the sulphonylurea or the basal insulin.
Special population
Elderly patients (>65 years old)
No dose adjustment is required based on age. Therapeutic experience in patients ≥75 years of age is limited (see section 5.2).
Patients with renal impairment
No dose adjustment is required for patients with mild renal impairment (creatinine clearance 60-90 ml/min). There is very limited therapeutic experience in patients with moderate renal impairment (creatinine clearance of 30-59 ml/min) and no therapeutic experience in patients with severe renal impairment (creatinine clearance below 30 ml/min). Victoza can currently not be recommended for use in patients with moderate and severe renal impairment including patients with end-stage renal disease (see section 5.2).
Patients with 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 section 5.2).
Paediatric population
The safety and efficacy of Victoza in children and adolescents below age 18 have not been established (see section 5.1). No data are available.
Method of administration
Victoza must not be administered intravenously or intramuscularly.
Victoza is administered once daily at any time, independent of meals, and can be injected subcutaneously in the abdomen, in the thigh or in the upper arm. The injection site and timing can be changed without dose adjustment. However, it is preferable that Victoza is injected around the same time of the day, when the most convenient time of the day has been chosen. For further instructions on administration, see section 6.6.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
4.4 Special warnings and precautions for use
Liraglutide should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis.
Liraglutide is not a substitute for insulin.
There is limited experience in patients with congestive heart failure New York Heart Association (NYHA) class I-II and liraglutide should therefore be used with caution. There is no experience in patients with congestive heart failure NYHA class III-IV and liraglutide is therefore not recommended in these patients.
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
Use of GLP-1 analogues has been associated with the risk of pancreatitis. There have been few reported events of acute pancreatitis. Patients should be informed of the characteristic symptom of acute pancreatitis: persistent, severe abdominal pain. If pancreatitis is suspected, Victoza and other potentially suspect medicinal products should be discontinued.
Thyroid disease
Thyroid adverse events, including increased blood calcitonin, goitre and thyroid neoplasm have been reported in clinical trials in particular in patients with pre-existing thyroid disease and liraglutide should therefore be used with caution.
Hypoglycaemia
Patients receiving liraglutide in combination with a sulphonylurea or a basal insulin may have an increased risk of hypoglycaemia (see section 4.8). The risk of hypoglycaemia can be lowered by a reduction in the dose of sulphonylurea or basal insulin.
Dehydration
Signs and symptoms of dehydration, including renal impairment and acute renal failure have been reported in patients treated with liraglutide. 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.
4.5 Interaction with other medicinal products and other forms of interaction
In vitro, liraglutide has shown very low potential to be involved in pharmacokinetic interactions with other active substances related to cytochrome P450 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. 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 with 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 INR (International Normalised Ratio) is recommended.
Paracetamol
Liraglutide did not change the overall exposure of paracetamol following a single dose of 1000 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 to a clinically relevant degree 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 adjustment of digoxin dose 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 ethinyloestradiol 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 ethinyloestradiol or levonorgestrel. The contraceptive effect is therefore anticipated to be unaffected when co-administered with liraglutide.
Insulin
No pharmacokinetic or pharmacodynamic interactions were observed between liraglutide and insulin detemir when administering a single dose of insulin detemir 0.5 U/kg with liraglutide 1.8 mg at steady state in patients with type 2 diabetes.
4.6 Fertility, pregnancy and lactation
Pregnancy
There are no adequate data from the use of liraglutide in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3). The potential risk for humans is unknown.
Liraglutide should not be used during pregnancy, and the use of insulin is recommended instead. If a patient wishes to become pregnant, or pregnancy occurs, treatment with Victoza 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 section 5.3). Because of lack of experience, Victoza 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.
4.7 Effects on ability to drive and use machines
Victoza has no or negligible influence on the ability to drive and use machines.
Patients should be advised to take precautions to avoid hypoglycaemia while driving and using machines, in particular when Victoza is used in combination with a sulphonylurea or a basal insulin.
4.8 Undesirable effects
Summary of the safety profile
In five large long-term clinical trials over 2,500 patients have received treatment with Victoza alone or in combination with metformin, a sulphonylurea (with or without metformin) or metformin plus rosiglitazone.
The most frequently reported adverse reactions during clinical trials were gastrointestinal disorders: nausea and diarrhoea were very common, whereas vomiting, constipation, abdominal pain, and dyspepsia were common. At the beginning of the therapy, these gastrointestinal adverse reactions may occur more frequently. These reactions usually diminish within a few days or weeks on continued treatment. Headache and nasopharyngitis were also common. Furthermore, hypoglycaemia was common, and very common when liraglutide is used in combination with a sulphonylurea. Major hypoglycaemia has primarily been observed when combined with a sulphonylurea.
Tabulated list of adverse reactions
Table 1 lists adverse reactions reported in long term phase 3 controlled trials and spontaneous (postmarketing) reports. Frequencies for related spontaneous reports (postmarketing) have been calculated based on their incidence in phase 3 clinical trials.
Frequencies 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); not known (cannot be estimated from the available data). Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.
Table 1 Adverse reactions from long-term controlled phase 3 trials and spontaneous (postmarketing) reports

MedDRA system organ classes

Very common

Common

Uncommon

Rare

Very rare

Infections and infestations

 

Nasopharyngitis

Bronchitis

     

Immune system disorders

     

Anaphylactic reactions

 

Metabolism and nutrition disorders

 

Hypoglycaemia

Anorexia

Appetite decreased

Dehydration

   

Nervous system disorders

 

Headache

Dizziness

     

Cardiac disorders

 

Increased heart rate

     

Gastrointestinal disorders

Nausea

Diarrhoea

Vomiting

Dyspepsia

Abdominal pain upper

Constipation

Gastritis

Flatulence

Abdominal distension

Gastroesophageal reflux disease

Abdominal discomfort

Toothache

 

Intestinal obstruction

Pancreatitis (including necrotising pancreatitis)

Skin and subcutaneous tissue disorder

 

Rash

Urticaria

Pruritus

   

Renal and urinary disorders

   

Renal impairment

Renal failure acute

   

General disorders and administration site conditions

 

Fatigue

Injection site reactions

Malaise


Description of selected adverse reactions
In a clinical trial with liraglutide as monotherapy, rates of hypoglycaemia reported with liraglutide were lower than rates reported for patients treated with active comparator (glimepiride). The most frequently reported adverse reactions were gastrointestinal disorders, infections and infestations.
Hypoglycaemia
Most episodes of confirmed hypoglycaemia in clinical trials were minor. No episodes of major hypoglycaemia were observed in the trial with liraglutide used as monotherapy. Major hypoglycaemia may occur uncommonly and has primarily been observed when liraglutide is combined with a sulphonylurea (0.02 events/subject year). Very few episodes (0.001 events/subject year) were observed with administration of liraglutide in combination with oral antidiabetics other than sulphonylureas. The risk of hypoglycaemia is low with combined use of basal insulin and liraglutide (1.0 events per subject year, see section 5.1).
Gastrointestinal adverse reactions
When combining liraglutide with metformin, 20.7% of patients reported at least one episode of nausea, and 12.6% of patients reported at least one episode of diarrhoea. When combining liraglutide with a sulphonylurea, 9.1% of patients reported at least one episode of nausea and 7.9% of patients reported at least one episode of diarrhoea. Most episodes were mild to moderate and occurred in a dose-dependent fashion. With continued therapy, the frequency and severity decreased in most patients who initially experienced nausea.
Patients >70 years may experience more gastrointestinal effects when treated with liraglutide.
Patients with mild renal impairment (creatinine clearance 60-90 ml/min) may experience more gastrointestinal effects when treated with liraglutide.
Withdrawal
The incidence of withdrawal due to adverse reactions was 7.8% for liraglutide-treated patients and 3.4% for comparator-treated patients in the long-term controlled trials (26 weeks or longer). The most frequent adverse reactions leading to withdrawal for liraglutide-treated patients were nausea (2.8% of patients) and vomiting (1.5%).
Injection site reactions
Injection site reactions have been reported in approximately 2% of patients receiving Victoza in long-term (26 weeks or longer) controlled trials. These reactions have usually been mild.
Pancreatitis
Few cases (<0.2%) of acute pancreatitis have been reported during long-term clinical trials with Victoza. Pancreatitis was also reported post-marketing.
Allergic reactions
Allergic reactions including urticaria, rash and pruritus have been reported from marketed use of Victoza.
Few cases of anaphylactic reactions with additional symptoms such as hypotension, palpitations, dyspnoea and oedema have been reported with marketed use of Victoza. Few cases (0.05%) of angioedema have been reported during all long-term clinical trials with Victoza.
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:
Ireland
Pharmacovigilance Section
Irish Medicines Board
Kevin O'Malley House
Earlsfort Centre
Earlsfort Terrace
IRL - Dublin 2
Tel: +353 1 6764971
Fax: +353 1 67625177836
Website: www.imb.ie
e-mail: imbpharmacovigilance@imb.ie
United Kingdom
Yellow Card Scheme
Website: www.mhra.gov.uk/yellowcard
4.9 Overdose
From clinical trials and marketed use, overdoses have been reported of up to 40 times (72 mg) the recommended maintenance dose. Events reported included severe nausea and severe vomiting. 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.
5. Pharmacological properties
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: Drugs used in diabetes, other blood glucose lowering drugs, excl. insulins. ATC code: A10BX07
Mechanism of action
Liraglutide is a GLP-1 analogue with 97% sequence homology to human GLP-1 that binds to and activates the GLP-1 receptor. The GLP-1 receptor is the target for native GLP-1, an endogenous incretin hormone that potentiates glucose-dependent insulin secretion from the pancreatic beta cells. Unlike native GLP-1, liraglutide has a pharmacokinetic and pharmacodynamic profile in humans suitable for once daily administration. Following subcutaneous administration, the protracted action profile is based on three mechanisms: self-association, which results in slow absorption; binding to albumin; and higher enzymatic stability towards the dipeptidyl peptidase -4 (DPP-4) and neutral endopeptidase (NEP) enzymes, resulting in a long plasma half-life.
Liraglutide action is mediated via a specific interaction with GLP-1 receptors, leading to an increase in cyclic adenosine monophosphate (cAMP). Liraglutide stimulates insulin secretion in a glucose-dependent manner. Simultaneously, liraglutide lowers inappropriately high glucagon secretion, also in a glucose-dependent manner. Thus, when blood glucose is high, insulin secretion is stimulated and glucagon secretion is inhibited. Conversely, during hypoglycaemia liraglutide diminishes insulin secretion and does not impair glucagon secretion. The mechanism of blood glucose lowering also involves a minor delay in gastric emptying. Liraglutide reduces body weight and body fat mass through mechanisms involving reduced hunger and lowered energy intake.
Pharmacodynamic effects
Liraglutide has 24-hour duration of action and improves glycaemic control by lowering fasting and postprandial blood glucose in patients with type 2 diabetes mellitus.
Clinical efficacy and safety
Five double-blind, randomised, controlled clinical trials were conducted to evaluate the effects of liraglutide on glycaemic control. Treatment with liraglutide produced clinically and statistically significant improvements in glycosylated haemoglobin A1c (HbA1c), fasting plasma glucose and postprandial glucose compared with placebo.
These trials included 3,978 exposed patients with type 2 diabetes (2,501 patients treated with Victoza), 53.7% men and 46.3% women, 797 patients (508 treated with liraglutide) were ≥65 years of age and 113 patients (66 treated with liraglutide) were ≥75 years of age.
• Glycaemic control
Combination with oral antidiabetics
Liraglutide in combination therapy, for 26 weeks, with metformin, glimepiride or metformin and rosiglitazone resulted in statistically significant (p<0.0001) and sustained reductions in HbA1c compared with patients receiving placebo (Tables 2 to 5).
Combination with metformin
Table 2 Victoza in combination with metformin (26 weeks)

Metformin add-on therapy

1.8 mg liraglutide + metformin3

1.2 mg liraglutide + metformin3

Placebo + metformin3

Glimepiride2 + metformin3

N

242

240

121

242

Mean HbA1c (%)

Baseline

Change from baseline

8.4 

-1.00

8.3 

-0.97

8.4 

0.09

8.4 

-0.98

Patients (%) achieving HbA1c <7%

All patients

Previous OAD monotherapy

 

42.4 

66.3

 

35.3 

52.8

 

10.8 

22.5

 

36.3 

56.0

Mean body weight (kg)

Baseline

Change from baseline

88.0

-2.79

88.5

-2.58

91.0

-1.51

89.0

0.95


Combination with sulphonylurea
Table 3 Victoza in combination with glimepiride (26 weeks)

Glimepiride add-on therapy

1.8 mg liraglutide + glimepiride2

1.2 mg liraglutide + glimepiride2

Placebo + glimepiride2

Rosiglitazone1 + glimepiride2

N

234

228

114

231

Mean HbA1c (%)

Baseline

Change from baseline

8.5 

-1.13

8.5 

-1.08

8.4 

0.23

8.4 

-0.44

Patients (%) achieving HbA1c <7%

All patients

Previous OAD monotherapy

41.6 

55.9

34.5 

57.4

7.5 

11.8

21.9 

36.1

Mean body weight (kg)

Baseline

Change from baseline

83.0

-0.23

80.0

0.32

81.9

-0.10

80.6

2.11


1 Rosiglitazone 4 mg/day; 2 glimepiride 4 mg/day; 3 metformin 2000 mg/day
Combination with thiazolidinedione and metformin
Table 4 Victoza in combination with metformin + rosiglitazone (26 weeks)

Metformin + rosiglitazone add-on therapy

1.8 mg liraglutide + metformin2 + rosiglitazone3

1.2 mg liraglutide + metformin2 + rosiglitazone3

Placebo + metformin2 + rosiglitazone3

N/A

N

178

177

175

 

Mean HbA1c (%)

Baseline

Change from baseline

8.56 

-1.48

8.48 

-1.48

8.42 

-0.54

 

Patients (%) achieving HbA1c <7%

All patients

53.7 

57.5  

28.1  

 

Mean body weight (kg)

Baseline

Change from baseline

94.9

-2.02

95.3

-1.02

98.5

0.60


Combination with sulphonylurea and metformin
Table 5 Victoza in combination with glimepiride + metformin (26 weeks)

Metformin + glimepiride add-on therapy

1.8 mg liraglutide + metformin2 + glimepiride4

N/A

Placebo + metformin2 + glimepiride4

Insulin glargine 1 + metformin2 + glimepiride4

N

230

 

114

232

Mean HbA1c (%)

Baseline

Change from baseline

8.3 

-1.33

 

8.3 

-0.24

8.1 

-1.09

Patients (%) achieving HbA1c <7%

All patients

53.1 

 

15.3 

45.8 

Mean body weight (kg)

Baseline

Change from baseline

85.8

-1.81

 

85.4

-0.42

85.2

1.62

1 The dosing of insulin glargine was open-labelled and was applied according to the following titration guideline. Titration of the insulin glargine dose was managed by the patient after instruction by the investigator. 2 Metformin 2,000 mg/day; 3 rosiglitazone 4 mg twice daily; 4 glimepiride 4 mg/day.
Guideline for titration of insulin glargine

Self-measured FPG

Increase in insulin glargine dose (IU)

≤5.5 mmol/l (≤100 mg/dl) Target

No adjustment

>5.5 and <6.7 mmol/l (>100 and <120 mg/dl)

0–2 IUa

≥6.7 mmol/l (≥120 mg/dl)

2 IU


a According to the individualised recommendation by the investigator at the previous visit, for example depending on whether the patient has experienced hypoglycaemia.
Combination with insulin
In a 104-week clinical trial, 57% of patients with type 2 diabetes treated with insulin degludec in combination with metformin achieved a target HbA1c <7% and the remaining patients continued in a 26-week open label trial and were randomised to add liraglutide or a single dose of insulin aspart (with the largest meal). In the insulin degludec + liraglutide arm, the insulin dose was reduced by 20% in order to minimize the risk of hypoglycaemia. Addition of liraglutide resulted in a statistically significantly greater reduction of HbA1c (-0.73% for liraglutide vs -0.40% for comparator) and body weight (-3.03 vs 0.72 kg). The rate of hypoglycaemic episodes (per patient year of exposure) was statistically significantly lower when adding liraglutide compared to adding a single dose of insulin aspart (1.0 vs 8.15; ratio: 0.13; 95% CI: 0.08 to 0.21).
In a 52-week clinical trial, the addition of insulin detemir to liraglutide 1.8 mg and metformin in patients not achieving glycaemic targets on liraglutide and metformin alone resulted in a HbA1c decrease from baseline of 0.54%, compared to 0.20% in the liraglutide 1.8 mg and metformin control group. Weight loss was sustained. There was a small increase in the rate of minor hypoglycaemic episodes (0.23 versus 0.03 events per subject years).
• Proportion of patients achieving reductions in HbA1c
Liraglutide in combination with metformin, glimepiride, or metformin and rosiglitazone resulted in a statistically significant (p≤0.0001) greater proportion of patients achieving an HbA1c≤6.5% at 26 weeks compared with patients receiving these agents alone.
• Fasting plasma glucose
Treatment with liraglutide alone or in combination with one or two oral antidiabetic drugs resulted in a reduction in fasting plasma glucose of 13-43.5 mg/dl (0.72-2.42 mmol/l). This reduction was observed within the first two weeks of treatment.
• Postprandial glucose
Liraglutide reduces postprandial glucose across all three daily meals by 31-49 mg/dl (1.68-2.71 mmol/l).
• Beta-cell function
Clinical trials with liraglutide indicate improved beta-cell function based on measures such as the homeostasis model assessment for beta-cell function (HOMA-B) and the proinsulin to insulin ratio. Improved first and second phase insulin secretion after 52 weeks treatment with liraglutide was demonstrated in a subset of patients with type 2 diabetes (N=29).
• Body weight
Liraglutide in combination with metformin, metformin and glimepiride or metformin and rosiglitazone was associated with sustained weight reduction over the duration of trials in a range from 1.0 kg to 2.8 kg.
Larger weight reduction was observed with increasing body mass index (BMI) at baseline.
• Cardiovascular evaluation
Blood pressure
Over the duration of the trials, liraglutide decreased the systolic blood pressure on average of 2.3 to 6.7 mmHg from baseline and compared to active comparator the decrease was 1.9 to 4.5 mmHg.
Post-hoc analysis of serious major adverse cardiovascular events (cardiovascular death, myocardial infarction, stroke) from all intermediate and long-term phase 2 and 3 trials (ranging from 26 and up to 100 weeks duration) including 5,607 patients (3,651 exposed to liraglutide), showed no increase in cardiovascular risk (incidence ratio of 0.75 (95% CI 0.35; 1.63) for the composite endpoint for liraglutide versus all comparators (metformin, glimepiride, rosiglitazone, insulin glargine, placebo)). High-risk cardiovascular patients were excluded from the trials and the incidence rates of serious major cardiovascular events in the trials were low (6.02 per 1,000 patient years in liraglutide-treated patients and 10.45 in all-comparator-treated patients), precluding firm conclusions.
Immunogenicity
Consistent with the potentially immunogenic properties of medicinal products containing proteins or peptides, patients may develop anti-liraglutide antibodies following treatment with liraglutide. On average, 8.6% of patients developed antibodies. Antibody formation has not been associated with reduced efficacy of liraglutide.
Paediatric population
The European Medicines Agency has deferred the obligation to submit the results of studies with Victoza in one or more subsets of the paediatric population in type 2 diabetes mellitus (see section 4.2 for information on paediatric use).
Other clinical data
In an open label trial comparing the efficacy and safety of liraglutide (1.2 mg and 1.8 mg) and sitagliptin (a DPP-4 inhibitor, 100 mg) in patients inadequately controlled on metformin therapy (mean HbA1c 8.5%), liraglutide at both doses was statistically superior to sitagliptin treatment in reducing HbA1c after 26 weeks (-1.24%, -1.50% vs -0.90%, p<0.0001). Patients treated with liraglutide had a significant decrease in body weight compared to that of patients treated with sitagliptin (-2.9 kg and -3.4 kg vs -1.0 kg, p<0.0001). Greater proportions of patients treated with liraglutide experienced transient nausea vs patients treated with sitagliptin (20.8% and 27.1% for liraglutide vs. 4.6% for sitagliptin). The reductions in HbA1c and superiority vs sitagliptin observed after 26 weeks of liraglutide treatment (1.2 mg and 1.8 mg) were sustained after 52 weeks of treatment (-1.29% and -1.51% vs -0.88%, p<0.0001). Switching patients from sitagliptin to liraglutide after 52 weeks of treatment resulted in additional and statistically significant reduction in HbA1c (-0.24% and -0.45%, 95% CI: -0.41 to -0.07 and -0.67 to -0.23 ) at week 78, but a formal control group was not available.
In an open label trial comparing the efficacy and safety of liraglutide 1.8 mg once daily and exenatide 10 mcg twice daily in patients inadequately controlled on metformin and/or sulphonylurea therapy (mean HbA1c 8.3%), liraglutide was statistically superior to exenatide treatment in reducing HbA1c after 26 weeks (-1.12% vs -0.79%; estimated treatment difference: -0.33; 95% CI: -0.47 to -0.18). Significantly more patients achieved HbA1c below 7% with liraglutide compared with exenatide (54.2% vs 43.4%, p=0.0015). Both treatments resulted in mean body weight loss of approximately 3 kg. Switching patients from exenatide to liraglutide after 26 weeks of treatment resulted in an additional and statistically significant reduction in HbA1c (-0.32%, 95% CI: -0.41 to -0.24) at week 40, but a formal control group was not available. During the 26 weeks, there were 12 serious events in 235 patients (5.1%) using liraglutide, whereas there were 6 serious adverse events in 232 patients (2.6%) using exenatide. There was no consistent pattern with respect to system organ class of events.
5.2 Pharmacokinetic properties
Absorption
The absorption of liraglutide following subcutaneous administration is slow, reaching maximum concentration 8-12 hours post dosing. Estimated maximum liraglutide concentration was 9.4 nmol/l for a subcutaneous single dose of liraglutide 0.6 mg. At 1.8 mg liraglutide, the average steady state concentration of liraglutide (AUC/24) reached approximately 34 nmol/l. Liraglutide exposure increased proportionally with dose. The intra-subject coefficient of variation for liraglutide AUC was 11% following single dose administration.
Absolute bioavailability of liraglutide following subcutaneous administration is approximately 55%.
Distribution
The apparent volume of distribution after subcutaneous administration is 11-17 l. The mean volume of distribution after intravenous administration of liraglutide is 0.07 l/kg. Liraglutide is extensively bound to plasma proteins (>98%).
Biotransformation
During 24 hours following administration of a single radiolabelled [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). Liraglutide is metabolised in a similar manner to large proteins without a specific organ having been identified as major route of elimination.
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 a single dose liraglutide is approximately 1.2 l/h with an elimination half-life of approximately 13 hours.
Special populations
Elderly patients:
Age had no clinically relevant effect on the pharmacokinetics of liraglutide based on the results from a pharmacokinetic study in healthy subjects and population pharmacokinetic data analysis of patients (18 to 80 years).
Gender:
Gender had no clinically meaningful effect on the pharmacokinetics of liraglutide based on the results of population pharmacokinetic data analysis of male and female patients and a pharmacokinetic study in healthy subjects.
Ethnic origin:
Ethnic origin had no clinically relevant effect on the pharmacokinetics of liraglutide based on the results of population pharmacokinetic analysis which included patients of White, Black, Asian and Hispanic groups.
Obesity:
Population pharmacokinetic analysis suggests that body mass index (BMI) has no significant effect on the pharmacokinetics of liraglutide.
Hepatic impairment:
The pharmacokinetics of liraglutide was evaluated in patients with varying degree of hepatic impairment in a single-dose trial. 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. Liraglutide exposure was lowered by 33%, 14%, 27% and 28%, 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.
5.3 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 2-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 Victoza 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 Victoza, 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.
Following intra-arterial injection of liraglutide to rabbits, slight to moderate haemorrhage, erythema and swelling at the injection site were observed.
6. Pharmaceutical particulars
6.1 List of excipients
Disodium phosphate dihydrate
Propylene glycol
Phenol
Water for injections
6.2 Incompatibilities
Substances added to Victoza may cause degradation of liraglutide. In the absence of compatibility studies, this medicinal product must not be mixed with other medicinal products.
6.3 Shelf life
30 months.
After first use: 1 month.
6.4 Special precautions for 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). Do not freeze.
Keep the cap on the pen in order to protect from light.
6.5 Nature and contents of container
Cartridge (type 1 glass) with a plunger (bromobutyl) and a stopper (bromobutyl/polyisoprene) contained in a pre-filled multidose disposable pen made of polyolefin and polyacetal.
Each pen contains 3 ml solution, delivering 30 doses of 0.6 mg, 15 doses of 1.2 mg or 10 doses of 1.8 mg.
Pack sizes of 1, 2, 3, 5 or 10 pre-filled pens.
Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
Victoza should not be used if it does not appear clear and colourless, or almost colourless.
Victoza should not be used if it has been frozen.
Victoza can be administered with needles up to a length of 8 mm and as thin as 32G. The pen is designed to be used with NovoFine or NovoTwist disposable needles.
Needles are not included.
The patient should be advised to discard the injection needle in accordance with local requirements 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.
7. Marketing authorisation holder

Novo Nordisk A/S
Novo Allé
DK-2880 Bagsværd
Denmark
8. Marketing authorisation number(s)
EU/1/09/529/001-005
9. Date of first authorisation/renewal of the authorisation
Date of first authorisation: 30/06/2009
Date of last renewal:
10. Date of revision of the text
04/2014
Detailed information on this medicinal product is available on the website of the European Medicines Agency http://www.ema.europa.eu.

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