Table of Contents
2012年4月20日，阿斯利康及施贵宝公司2型糖尿病治疗新药达格列净（dapagliflozin，Forxiga）上市许可获欧洲药品管理局（EMA）推荐。
EMA在一份声明中指出，达格列净是一种口服药物，通过抑制钠-葡萄糖转运蛋白2（SGLT2）——肾内的一种使葡萄糖被重新吸收到血液中的蛋白质——而发挥作用。这使得多余的葡萄糖通过尿液被排除体外，从而在不增加胰岛素分泌的情况下改善血糖控制。使用这种药物要求患者的肾功能正常，中至重度肾功能不全患者禁用该药。
达格列净的疗效与二肽基肽酶抑制剂等数种新型降糖药物相当，而且可轻度降低血压和体重。该药有5 mg和10 mg两种片剂可供选择，可单独使用或与包括胰岛素在内的其他糖尿病药物联用。
美国食品药物管理局（FDA）内分泌药物顾问委员会于2011年7月因安全性顾虑而反对批准达格列净上市。临床试验显示，达格列净膀胱癌和乳腺癌风险增加有关：治疗组和对照组的膀胱癌发病率分别为0.16％和0.03％，乳腺癌发病率分别为0.4％和0.22％。EMA则认为，达格列净的收益超过其风险，但已要求生产商进行上市后流行病学研究，以澄清与使用达格列净相关的癌症和其他风险。

1. Name of the medicinal product
Forxiga▼ 5 mg film-coated tablets
Forxiga▼ 10 mg film-coated tablets
2. Qualitative and quantitative composition
5 mg:
Each tablet contains dapagliflozin propanediol monohydrate equivalent to 5 mg dapagliflozin.
Excipient with known effect:
Each tablet contains 25 mg of lactose anhydrous.
For the full list of excipients, see section 6.1.
10 mg:
Each tablet contains dapagliflozin propanediol monohydrate equivalent to 10 mg dapagliflozin.
Excipient with known effect:
Each tablet contains 50 mg of lactose anhydrous.
For the full list of excipients, see section 6.1.
3. Pharmaceutical form
 Film-coated tablet (tablet).
5 mg:
Yellow, biconvex, 0.7 cm diameter round, film-coated tablets with “5” engraved on one side and “1427” engraved on the other side.
10 mg:
Yellow, biconvex, approximately 1.1 x 0.8 cm diagonally diamond-shaped, film-coated tablets with “10” engraved on one side and “1428” engraved on the other side.
4. Clinical particulars
4.1 Therapeutic indications
Forxiga is indicated in adults aged 18 years and older with type 2 diabetes mellitus to improve glycaemic control as:
Monotherapy
When diet and exercise alone do not provide adequate glycaemic control in patients for whom use of metformin is considered inappropriate due to intolerance.
Add-on combination therapy
In combination with other glucose-lowering medicinal products including insulin, when these, together with diet and exercise, do not provide adequate glycaemic control (see sections 4.4, 4.5 and 5.1 for available data on different combinations).
4.2 Posology and method of administration
 Posology
Monotherapy and add-on combination therapy
The recommended dose is 10 mg dapagliflozin once daily for monotherapy and add-on combination therapy with other glucose-lowering medicinal products including insulin. When dapagliflozin is used in combination with insulin or an insulin secretagogue, such as a sulphonylurea, a lower dose of insulin or insulin secretagogue may be considered to reduce the risk of hypoglycaemia (see sections 4.5 and 4.8).
Special populations
Renal impairment
The efficacy of dapagliflozin is dependent on renal function, and efficacy is reduced in patients who have moderate renal impairment and likely absent in patients with severe renal impairment. Forxiga is not recommended for use in patients with moderate to severe renal impairment (patients with creatinine clearance [CrCl] < 60 ml/min or estimated glomerular filtration rate [eGFR] < 60 ml/min/1.73 m2, see sections 4.4, 4.8, 5.1 and 5.2).
No dosage adjustment is indicated in patients with mild renal impairment.
Hepatic impairment
No dosage adjustment is necessary for patients with mild or moderate hepatic impairment. In patients with severe hepatic impairment, a starting dose of 5 mg is recommended. If well tolerated, the dose may be increased to 10 mg (see sections 4.4 and 5.2).
Elderly (≥ 65 years)
In general, no dosage adjustment is recommended based on age. Renal function and risk of volume depletion should be taken into account (see sections 4.4 and 5.2). Due to the limited therapeutic experience in patients 75 years and older, initiation of dapagliflozin therapy is not recommended.
Paediatric population
The safety and efficacy of dapagliflozin in children aged 0 to < 18 years have not yet been established. No data are available.
Method of administration
Forxiga can be taken orally once daily at any time of day with or without food. Tablets are to be swallowed whole.
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
 General
Forxiga should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis.
Use in patients with renal impairment
The efficacy of dapagliflozin is dependent on renal function, and efficacy is reduced in patients who have moderate renal impairment and likely absent in patients with severe renal impairment (see section 4.2). In subjects with moderate renal impairment (patients with CrCl < 60 ml/min or eGFR < 60 ml/min/1.73 m2), a higher proportion of subjects treated with dapagliflozin had adverse reactions of increase in creatinine, phosphorus, parathyroid hormone (PTH) and hypotension, compared with placebo. Forxiga is not recommended for use in patients with moderate to severe renal impairment (patients with CrCl < 60 ml/min or eGFR < 60 ml/min/1.73 m2). Forxiga has not been studied in severe renal impairment (CrCl < 30 ml/min or eGFR < 30 ml/min/1.73 m2) or end-stage renal disease (ESRD).
Monitoring of renal function is recommended as follows:
• Prior to initiation of dapagliflozin and at least yearly, thereafter (see sections 4.2, 4.8, 5.1 and 5.2)
• Prior to initiation of concomitant medicinal products that may reduce renal function and periodically thereafter
• For renal function approaching moderate renal impairment, at least 2 to 4 times per year. If renal function falls below CrCl < 60 ml/min or eGFR < 60 ml/min/1.73 m2, dapagliflozin treatment should be discontinued.
Use in patients with hepatic impairment
There is limited experience in clinical trials in patients with hepatic impairment. Dapagliflozin exposure is increased in patients with severe hepatic impairment (see sections 4.2 and 5.2).
Use in patients at risk for volume depletion, hypotension and/or electrolyte imbalances
Due to its mechanism of action, dapagliflozin increases diuresis associated with a modest decrease in blood pressure (see section 5.1), which may be more pronounced in patients with very high blood glucose concentrations.
Dapagliflozin is not recommended for use in patients receiving loop diuretics (see section 4.5) or who are volume depleted, e.g. due to acute illness (such as gastrointestinal illness).
Caution should be exercised in patients for whom a dapagliflozin-induced drop in blood pressure could pose a risk, such as patients with known cardiovascular disease, patients on anti-hypertensive therapy with a history of hypotension or elderly patients.
For patients receiving dapagliflozin, in case of intercurrent conditions that may lead to volume depletion, careful monitoring of volume status (e.g. physical examination, blood pressure measurements, laboratory tests including haematocrit) and electrolytes is recommended. Temporary interruption of treatment with dapagliflozin is recommended for patients who develop volume depletion until the depletion is corrected (see section 4.8).
Urinary tract infections
Urinary tract infections were more frequently reported for dapagliflozin 10 mg compared to placebo in a pooled analysis up to 24 weeks (see section 4.8). Pyelonephritis was uncommon and occurred at a similar frequency to control. Urinary glucose excretion may be associated with an increased risk of urinary tract infection; therefore, temporary interruption of dapagliflozin should be considered when treating pyelonephritis or urosepsis.
Elderly patients
Elderly patients are more likely to have impaired renal function, and/or to be treated with anti-hypertensive medicinal products that may cause changes in renal function such as angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin II type 1 receptor blockers (ARB). The same recommendations for renal function apply to elderly patients as to all patients (see sections 4.2, 4.4, 4.8 and 5.1).
In subjects ≥ 65 years of age, a higher proportion of subjects treated with dapagliflozin had adverse reactions related to renal impairment or failure compared with placebo. The most commonly reported adverse reaction related to renal function was serum creatinine increases, the majority of which were transient and reversible (see section 4.8).
Elderly patients may be at a greater risk for volume depletion and are more likely to be treated with diuretics. In subjects ≥ 65 years of age, a higher proportion of subjects treated with dapagliflozin had adverse reactions related to volume depletion (see section 4.8).
Therapeutic experience in patients 75 years and older is limited. Initiation of dapagliflozin therapy in this population is not recommended (see sections 4.2 and 5.2).
Cardiac failure
Experience in NYHA class I-II is limited, and there is no experience in clinical studies with dapagliflozin in NYHA class III-IV.
Use in patients treated with pioglitazone
While a causal relationship between dapagliflozin and bladder cancer is unlikely (see sections 4.8 and 5.3), as a precautionary measure, dapagliflozin is not recommended for use in patients concomitantly treated with pioglitazone. Available epidemiological data for pioglitazone suggest a small increased risk of bladder cancer in diabetic patients treated with pioglitazone.
Elevated haematocrit
Haematocrit increase was observed with dapagliflozin treatment (see section 4.8); therefore, caution in patients with already elevated haematocrit is warranted.
Combinations not studied
Dapagliflozin has not been studied in combination with glucagon-like peptide 1 (GLP-1) analogues.
Urine laboratory assessments
Due to its mechanism of action, patients taking Forxiga will test positive for glucose in their urine.
Lactose
The tablets contain lactose anhydrous. 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
 Pharmacodynamic interactions
Diuretics
Dapagliflozin may add to the diuretic effect of thiazide and loop diuretics and may increase the risk of dehydration and hypotension (see section 4.4).
Insulin and insulin secretagogues
Insulin and insulin secretagogues, such as sulphonylureas, cause hypoglycaemia. Therefore, a lower dose of insulin or an insulin secretagogue may be required to reduce the risk of hypoglycaemia when used in combination with dapagliflozin (see sections 4.2 and 4.8).
Pharmacokinetic interactions
The metabolism of dapagliflozin is primarily via glucuronide conjugation mediated by UDP glucuronosyltransferase 1A9 (UGT1A9).
In in vitro studies, dapagliflozin neither inhibited cytochrome P450 (CYP) 1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP3A4, nor induced CYP1A2, CYP2B6 or CYP3A4. Therefore, dapagliflozin is not expected to alter the metabolic clearance of coadministered medicinal products that are metabolised by these enzymes.
Effect of other medicinal products on dapagliflozin
Interaction studies conducted in healthy subjects, using mainly a single dose design, suggest that the pharmacokinetics of dapagliflozin are not altered by metformin, pioglitazone, sitagliptin, glimepiride, voglibose, hydrochlorothiazide, bumetanide, valsartan, or simvastatin.
Following coadministration of dapagliflozin with rifampicin (an inducer of various active transporters and drug-metabolising enzymes) a 22% decrease in dapagliflozin systemic exposure (AUC) was observed, but with no clinically meaningful effect on 24-hour urinary glucose excretion. No dose adjustment is recommended. A clinically relevant effect with other inducers (e.g. carbamazepine, phenytoin, phenobarbital) is not expected.
Following coadministration of dapagliflozin with mefenamic acid (an inhibitor of UGT1A9), a 55% increase in dapagliflozin systemic exposure was seen, but with no clinically meaningful effect on 24-hour urinary glucose excretion. No dose adjustment is recommended.
Effect of dapagliflozin on other medicinal products
In interaction studies conducted in healthy subjects, using mainly a single-dose design, dapagliflozin did not alter the pharmacokinetics of metformin, pioglitazone, sitagliptin, glimepiride, hydrochlorothiazide, bumetanide, valsartan, digoxin (a P-gp substrate) or warfarin (S-warfarin, a CYP2C9 substrate), or the anticoagulatory effects of warfarin as measured by INR. Combination of a single dose of dapagliflozin 20 mg and simvastatin (a CYP3A4 substrate) resulted in a 19% increase in AUC of simvastatin and 31% increase in AUC of simvastatin acid. The increase in simvastatin and simvastatin acid exposures are not considered clinically relevant.
Other interactions
The effects of smoking, diet, herbal products and alcohol use on the pharmacokinetics of dapagliflozin have not been studied.
Paediatric population
Interaction studies have only been performed in adults.
4.6 Fertility, pregnancy and lactation
 Pregnancy
There are no data from the use of dapagliflozin in pregnant women. Studies in rats have shown toxicity to the developing kidney in the time period corresponding to the second and third trimesters of human pregnancy (see section 5.3). Therefore, the use of dapagliflozin is not recommended during the second and third trimesters of pregnancy.
When pregnancy is detected, treatment with dapagliflozin should be discontinued.
Breast-feeding
It is unknown whether dapagliflozin and/or its metabolites are excreted in human milk. Available pharmacodynamic/toxicological data in animals have shown excretion of dapagliflozin/metabolites in milk, as well as pharmacologically-mediated effects in nursing offspring (see section 5.3). A risk to the newborns/infants cannot be excluded. Dapagliflozin should not be used while breast-feeding.
Fertility
The effect of dapagliflozin on fertility in humans has not been studied. In male and female rats, dapagliflozin showed no effects on fertility at any dose tested.
4.7 Effects on ability to drive and use machines
 Forxiga has no or negligible influence on the ability to drive and use machines. Patients should be alerted to the risk of hypoglycaemia when dapagliflozin is used in combination with a sulphonylurea or insulin.
4.8 Undesirable effects
 Summary of the safety profile
In a pre-specified pooled analysis of 12 placebo-controlled studies, 1,193 subjects were treated with dapagliflozin 10 mg and 1,393 were treated with placebo.
The overall incidence of adverse events (short-term treatment) in subjects treated with dapagliflozin 10 mg was similar to placebo. Few adverse events led to discontinuation of treatment and were balanced across study groups. The most commonly reported events leading to discontinuation in patients treated with dapagliflozin 10 mg were increased blood creatinine (0.4%), urinary tract infections (0.3%), nausea (0.2%), dizziness (0.2%), and rash (0.2%). One subject receiving dapagliflozin experienced a liver adverse event with diagnoses of drug induced hepatitis and/or autoimmune hepatitis.
The most frequently reported adverse reaction was hypoglycaemia, which depended on the type of background therapy used in each study. The frequency of minor episodes of hypoglycaemia was similar between treatment groups, including placebo, with the exceptions of studies with add-on sulphonylurea (SU) and add-on insulin therapies. Combination therapies with sulphonylurea and add-on insulin had higher rates of hypoglycaemia (see Hypoglycaemia below).
Tabulated list of adverse reactions
The following adverse reactions have been identified in the placebo-controlled clinical trials. None were found to be dose-related. Adverse reactions listed below are classified according to frequency and system organ class (SOC). Frequency categories are defined according to the following convention: 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).
Table 1. Adverse reactions in placebo-controlled studiesa
System organ class
 Very common
 Common*
 Uncommon**
Infections and infestations
   Vulvovaginitis, balanitis and related genital infectionsb,c
Urinary tract infectionb
 Vulvovaginal pruritus
Metabolism and nutrition disorders
 Hypoglycaemia (when used with SU or insulin)b
   Volume depletionb,e
Thirst
Gastrointestinal disorders
     Constipation
Skin and subcutaneous tissue disorders
     Hyperhidrosis
Musculoskeletal and connective tissue disorders
   Back pain
Renal and urinary disorders
   Dysuria
Polyuriad
 Nocturia
Investigations
   Dyslipidaemiaf
Haematocrit increasedg
 Blood creatinine increased
Blood urea increased
aThe table shows up to 24-week (short-term) data regardless of glycaemic rescue.
bSee corresponding subsection below for additional information.
cVulvovaginitis, balanitis and related genital infections includes, e.g. the predefined preferred terms: vulvovaginal mycotic infection, vaginal infection, balanitis, genital infection fungal, vulvovaginal candidiasis, vulvovaginitis, balanitis candida, genital candidiasis, genital infection, genital infection male, penile infection, vulvitis, vaginitis bacterial, vulval abscess.
dPolyuria includes the preferred terms: pollakiuria, polyuria, urine output increased.
eVolume depletion includes, e.g. the predefined preferred terms: dehydration, hypovolaemia, hypotension.
fMean percent change from baseline for dapagliflozin 10 mg versus placebo, respectively, was: total cholesterol 1.4% versus -0.4%; HDL cholesterol 5.5% versus 3.8%; LDL cholesterol 2.7% versus -1.9%; triglycerides -5.4% versus -0.7%.
gMean changes from baseline in haematocrit were 2.15% for dapagliflozin 10 mg versus 0.40% for placebo.
*Reported in ≥ 2% of subjects treated with dapagliflozin 10 mg and ≥ 1% more frequently than placebo.
**Reported in ≥ 0.2% of subjects and ≥ 0.1% more and at least 3 more subjects treated with dapagliflozin 10 mg regardless of glycaemic rescue compared to placebo.
Description of selected adverse reactions
Hypoglycaemia
The frequency of hypoglycaemia depended on the type of background therapy used in each study.
For studies of dapagliflozin in monotherapy, as add-on to metformin or as add-on to sitagliptin (with or without metformin), the frequency of minor episodes of hypoglycaemia was similar (< 5%) between treatment groups, including placebo up to 102 weeks of treatment. Across all studies, major events of hypoglycaemia were uncommon and comparable between the groups treated with dapagliflozin or placebo. Studies with add-on sulphonylurea and add-on insulin therapies had higher rates of hypoglycaemia (see section 4.5).
In an add-on to glimepiride study, minor episodes of hypoglycaemia were reported more frequently in the group treated with dapagliflozin 10 mg plus glimepiride (6.0%) than in the placebo plus glimepiride group (2.1%).
In an add-on to insulin study, episodes of major hypoglycaemia were reported in 0.5% and 1.0% of subjects treated with dapagliflozin 10 mg plus insulin at Weeks 24 and 104, respectively, and in 0.5% of subjects treated with placebo plus insulin groups at Weeks 24 and 104. At Weeks 24 and 104, minor episodes of hypoglycaemia were reported, respectively, in 40.3% and 53.1% of subjects who received dapagliflozin 10 mg plus insulin and in 34.0% and 41.6% of the subjects who received placebo plus insulin.
Volume depletion
Reactions related to volume depletion (including, reports of dehydration, hypovolaemia or hypotension) were reported in 0.8% and 0.4% of subjects who received dapagliflozin 10 mg and placebo, respectively; serious reactions occurred in < 0.2% of subjects balanced between dapagliflozin 10 mg and placebo (see section 4.4).
Vulvovaginitis, balanitis and related genital infections
Vulvovaginitis, balanitis and related genital infections were reported in 4.8% and 0.9% of subjects who received dapagliflozin 10 mg and placebo, respectively. Most infections were mild to moderate, and subjects responded to an initial course of standard treatment and rarely resulted in discontinuation from dapagliflozin treatment. These infections were more frequent in females (6.9% and 1.5% for dapagliflozin and placebo, respectively), and subjects with a prior history were more likely to have a recurrent infection.
Urinary tract infections
Urinary tract infections were more frequently reported for dapagliflozin 10 mg compared to placebo (4.3% versus 3.7%, respectively; see section 4.4). Most infections were mild to moderate, and subjects responded to an initial course of standard treatment and rarely resulted in discontinuation from dapagliflozin treatment. These infections were more frequent in females, and subjects with a prior history were more likely to have a recurrent infection.
Parathyroid hormone (PTH)
Small increases in serum PTH levels were observed with increases being larger in subjects with higher baseline PTH concentrations. Bone mineral density measurements in patients with normal or mildly impaired renal function did not indicate bone loss over a treatment period of one year.
Malignancies
During clinical trials, the overall proportion of subjects with malignant or unspecified tumours was similar between those treated with dapagliflozin (1.47%) and placebo/comparator (1.35%), and there was no carcinogenicity or mutagenicity signal in animal data (see section 5.3). When considering the cases of tumours occurring in the different organ systems, the relative risk associated with dapagliflozin was above 1 for some tumours (bladder, prostate, breast) and below 1 for others (e.g. blood and lymphatic, ovary, renal tract), not resulting in an overall increased tumour risk associated with dapagliflozin. The increased/decreased risk was not statistically significant in any of the organ systems. Considering the lack of tumour findings in non-clinical studies as well as the short latency between first drug exposure and tumour diagnosis, a causal relationship is considered unlikely. Since the numerical imbalance of breast, bladder and prostate tumours must be considered with caution, it will be further investigated in post-authorisation studies.
Special populations
Elderly patients (≥ 65 years)
In subjects ≥ 65 years of age, adverse reactions related to renal impairment or failure were reported in 2.5% of subjects treated with dapagliflozin and 1.1% of subjects treated with placebo (see section 4.4). The most commonly reported adverse reaction related to renal function was increased serum creatinine. The majority of these reactions were transient and reversible. In subjects ≥ 65 years of age, adverse reactions of volume depletion, most commonly reported as hypotension, were reported in 1.5% and 0.4% of dapagliflozin-treated subjects and placebo-treated subjects, respectively (see section 4.4).
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:
United Kingdom
Yellow Card Scheme
Website: www.mhra.gov.uk/yellowcard
Malta
ADR Reporting
The Medicines Authority
Post-Licensing Directorate
203 Level 3, Rue D'Argens
GZR-1368 Gzira
Website: www.medicinesauthority.gov.mt
e-mail: postlicensing.medicinesauthority@gov.mt
4.9 Overdose
 Dapagliflozin did not show any toxicity in healthy subjects at single oral doses up to 500 mg (50 times the maximum recommended human dose). These subjects had detectable glucose in the urine for a dose-related period of time (at least 5 days for the 500 mg dose), with no reports of dehydration, hypotension or electrolyte imbalance, and with no clinically meaningful effect on QTc interval. The incidence of hypoglycaemia was similar to placebo. In clinical studies where once-daily doses of up to 100 mg (10 times the maximum recommended human dose) were administered for 2 weeks in healthy subjects and type 2 diabetes subjects, the incidence of hypoglycaemia was slightly higher than placebo and was not dose-related. Rates of adverse events including dehydration or hypotension were similar to placebo, and there were no clinically meaningful dose-related changes in laboratory parameters, including serum electrolytes and biomarkers of renal function.
In the event of an overdose, appropriate supportive treatment should be initiated as dictated by the patient's clinical status. The removal of dapagliflozin by haemodialysis has not been studied.
5. Pharmacological properties
5.1 Pharmacodynamic properties
 Pharmacotherapeutic group: Drugs used in diabetes, Other blood glucose lowering drugs, excluding insulins, ATC code: A10BX09
Mechanism of action
Dapagliflozin is a highly potent (Ki: 0.55 nM), selective and reversible inhibitor of sodium-glucose co-transporter 2 (SGLT2).
The SGLT2 is selectively expressed in the kidney with no expression detected in more than 70 other tissues including liver, skeletal muscle, adipose tissue, breast, bladder and brain. SGLT2 is the predominant transporter responsible for reabsorption of glucose from the glomerular filtrate back into the circulation. Despite the presence of hyperglycaemia in type 2 diabetes, reabsorption of filtered glucose continues. Dapagliflozin improves both fasting and post-prandial plasma glucose levels by reducing renal glucose reabsorption leading to urinary glucose excretion. This glucose excretion (glucuretic effect) is observed after the first dose, is continuous over the 24-hour dosing interval and is sustained for the duration of treatment. The amount of glucose removed by the kidney through this mechanism is dependent upon the blood glucose concentration and GFR. Dapagliflozin does not impair normal endogenous glucose production in response to hypoglycaemia. Dapagliflozin acts independently of insulin secretion and insulin action. Improvement in homeostasis model assessment for beta cell function (HOMA beta-cell) has been observed in clinical studies with Forxiga.
Urinary glucose excretion (glucuresis) induced by dapagliflozin is associated with caloric loss and reduction in weight. Inhibition of glucose and sodium co-transport by dapagliflozin is also associated with mild diuresis and transient natriuresis.
Dapagliflozin does not inhibit other glucose transporters important for glucose transport into peripheral tissues and is > 1,400 times more selective for SGLT2 versus SGLT1, the major transporter in the gut responsible for glucose absorption.
Pharmacodynamic effects
Increases in the amount of glucose excreted in the urine were observed in healthy subjects and in subjects with type 2 diabetes mellitus following the administration of dapagliflozin. Approximately 70 g of glucose was excreted in the urine per day (corresponding to 280 kcal/day) at a dapagliflozin dose of 10 mg/day in subjects with type 2 diabetes mellitus for 12 weeks. Evidence of sustained glucose excretion was seen in subjects with type 2 diabetes mellitus given dapagliflozin 10 mg/day for up to 2 years.
This urinary glucose excretion with dapagliflozin also results in osmotic diuresis and increases in urinary volume in subjects with type 2 diabetes mellitus. Urinary volume increases in subjects with type 2 diabetes mellitus treated with dapagliflozin 10 mg were sustained at 12 weeks and amounted to approximately 375 ml/day. The increase in urinary volume was associated with a small and transient increase in urinary sodium excretion that was not associated with changes in serum sodium concentrations.
Urinary uric acid excretion was also increased transiently (for 3-7 days) and accompanied by a sustained reduction in serum uric acid concentration. At 24 weeks, reductions in serum uric acid concentrations ranged from -48.3 to -18.3 micromoles/l (-0.87 to -0.33 mg/dl).
Clinical efficacy and safety
Twelve double-blind, randomised, controlled clinical trials were conducted with 6,144 subjects with type 2 diabetes to eva luate the efficacy and safety of Forxiga; 4,164 subjects in these studies were treated with dapagliflozin. Eleven studies had a treatment period of 24 weeks duration, 6 with long-term extensions ranging from 24 to 78 weeks (up to a total study duration of 102 weeks), and one study was 52 weeks in duration with a long-term extension of 52 weeks (total study duration of 104 weeks). Mean duration of diabetes ranged from 1.4 to 16.9 years. Fifty-one percent had mild renal impairment and 11% had moderate renal impairment. Fifty-one percent (51%) of the subjects were men, 83% were White, 10% were Asian, 3% were Black and 4% were of other racial groups. Eighty percent (80%) of the subjects had a body mass index (BMI) ≥ 27.
Glycaemic control
Monotherapy
A double-blind, placebo-controlled study of 24-week duration (with an additional extension period) was conducted to eva luate the safety and efficacy of monotherapy with Forxiga in subjects with inadequately controlled type 2 diabetes mellitus. Once-daily treatment with dapagliflozin resulted in statistically significant (p < 0.0001) reductions in HbA1c compared to placebo (Table 2).
In the extension period, HbA1c reductions were sustained through Week 102 (-0.63%, and -0.18% adjusted mean change from baseline for dapagliflozin 10 mg and placebo, respectively).
Table 2. Results at Week 24 (LOCFa) of a placebo-controlled study of dapagliflozin as monotherapy
  Monotherapy
  Dapagliflozin
10 mg
 Placebo
Nb
 70
 75
HbA1c (%)
Baseline (mean)
 8.01
 7.79
Change from baselinec
 -0.89
 -0.23
Difference from placeboc
 -0.66*
(95% CI)
 (-0.96, -0.36)
Subjects (%) achieving:
HbA1c < 7%
Adjusted for baseline
 50.8§
 31.6
Body weight (kg)
Baseline (mean)
 94.13
 88.77
Change from baselinec
 -3.16
 -2.19
Difference from placeboc
 -0.97
(95% CI)
 (-2.20, 0.25) 
aLOCF: Last observation (prior to rescue for rescued subjects) carried forward
bAll randomised subjects who took at least one dose of double-blind study medication during the short-term double-blind period
cLeast squares mean adjusted for baseline value
*p-value < 0.0001 versus placebo
§ Not eva luated for statistical significance as a result of the sequential testing procedure for secondary end points
Combination therapy
In a 52-week, active-controlled non-inferiority study (with a 52-week extension period), Forxiga was eva luated as add-on therapy to metformin compared with a sulphonylurea (glipizide) as add-on therapy to metformin in subjects with inadequate glycaemic control (HbA1c > 6.5% and ≤ 10%). The results showed a similar mean reduction in HbA1c from baseline to Week 52, compared to glipizide, thus demonstrating non-inferiority (Table 3). At Week 104, adjusted mean change from baseline in HbA1c was -0.32% for dapagliflozin and -0.14% for glipizide. At 52 and 104 weeks, a significantly lower proportion of subjects in the group treated with dapagliflozin (3.5% and 4.3%, respectively) experienced at least one event of hypoglycaemia compared to the group treated with glipizide (40.8% and 47.0%, respectively). The proportion of subjects remaining in the study at Week 104 was 56.2% for the group treated with dapagliflozin and 50.0% for the group treated with glipizide.
Table 3. Results at Week 52 (LOCFa) in an active-controlled study comparing dapagliflozin to glipizide as add-on to metformin
Parameter
 Dapagliflozin + metformin
 Glipizide + metformin
Nb
 400
 401
HbA1c (%)
Baseline (mean)
 7.69
 7.74
Change from baselinec
 -0.52
 -0.52
Difference from glipizide + metforminc
 0.00d
(95% CI)
 (-0.11, 0.11)
Body weight (kg)
Baseline (mean)
 88.44
 87.60
Change from baselinec
 -3.22
 1.44
Difference from glipizide + metforminc
 -4.65*
(95% CI)
 (-5.14, -4.17)
aLOCF: Last observation carried forward
bRandomised and treated subjects with baseline and at least 1 post-baseline efficacy measurement
cLeast squares mean adjusted for baseline value
dNon-inferior to glipizide + metformin
*p-value < 0.0001
Dapagliflozin as an add-on with either metformin, glimepiride, sitagliptin (with or without metformin) or insulin resulted in statistically significant reductions in HbA1c at 24 weeks compared with subjects receiving placebo (p < 0.0001; Tables 4 and 5).
The reductions in HbA1c observed at Week 24 were sustained in add-on combination studies (glimepiride and insulin) with 48-week data (glimepiride) and up to 104-week data (insulin). At Week 48 when added to sitagliptin (with or without metformin), the adjusted mean change from baseline for dapagliflozin 10 mg and placebo was -0.30% and 0.38%, respectively. For the add-on to metformin study, HbA1c reductions were sustained through Week 102 (-0.78% and 0.02% adjusted mean change from baseline for 10 mg and placebo, respectively). At Week 104 for insulin (with or without additional oral glucose-lowering medicinal products), the HbA1c reductions were -0.71% and -0.06% adjusted mean change from baseline for dapagliflozin 10 mg and placebo, respectively. At Weeks 48 and 104, the insulin dose remained stable compared to baseline in subjects treated with dapagliflozin 10 mg at an average dose of 76 IU/day. In the placebo group there was a mean increase of 10.5 IU/day and 18.3 IU/day from baseline (mean average dose of 84 and 92 IU/day) at Weeks 48 and 104, respectively. The proportion of subjects remaining in the study at Week 104 was 72.4% for the group treated with dapagliflozin 10 mg and 54.8% for the placebo group.
Table 4. Results of 24-week (LOCFa) placebo-controlled studies of dapagliflozin in add-on combination with metformin, glimepiride or sitagliptin (with or without metformin)
  Add-on combination
Metformin1
 Sulphonylurea
(glimepiride2)
 DPP-4 Inhibitor
(sitagliptin3) ± Metformin1
  Dapagliflozin
10 mg
 Placebo
 Dapagliflozin
10 mg
 Placebo
 Dapagliflozin
10 mg
 Placebo
Nb
 135
 137
 151
 145
 223
 224
HbA1c (%)   
Baseline (mean)
 7.92
 8.11
 8.07
 8.15
 7.90
 7.97
Change from baselinec
 -0.84
 -0.30
 -0.82
 -0.13
 -0.45
 0.04
Difference from placeboc
 -0.54*
   -0.68*
   -0.48*
(95% CI)
 (-0.74, -0.34)
   (-0.86, -0.51)
   (-0.62, -0.34)
Subjects (%) achieving:
HbA1c < 7%       
Adjusted for baseline
 40.6**
 25.9
 31.7*
 13.0
Body weight (kg)      
Baseline (mean)
 86.28
 87.74
 80.56
 80.94
 91.02
 89.23
Change from baselinec
 -2.86
 -0.89
 -2.26
 -0.72
 -2.14
 -0.26
Difference from placeboc
 -1.97*
   -1.54*
   -1.89*
(95% CI)
 (-2.63, -1.31)
   (-2.17, -0.92)
   (-2.37, -1.40)
1Metformin ≥ 1500 mg/day; 2glimepiride 4 mg/day; 3sitagliptin 100 mg/day
aLOCF: Last observation (prior to rescue for rescued subjects) carried forward
bAll randomised subjects who took at least one dose of double-blind study medicinal product during the short-term double-blind period
cLeast squares mean adjusted for baseline value
*p-value < 0.0001 versus placebo + oral glucose-lowering medicinal product
**p-value < 0.05 versus placebo + oral glucose-lowering medicinal product
Table 5. Results at Week 24 (LOCFa) in a placebo-controlled study of dapagliflozin in combination with insulin (alone or with oral glucose-lowering medicinal products)
Parameter
 Dapagliflozin 10 mg + insulin
± oral glucose-lowering medicinal products2
 Placebo + insulin
± oral glucose-lowering medicinal products2
Nb
 194
 193
HbA1c (%)
Baseline (mean)
 8.58
 8.46
Change from baselinec
 -0.90
 -0.30
Difference from placeboc
 -0.60*
(95% CI)
 (-0.74, -0.45)
Body weight (kg)
Baseline (mean)
 94.63
 94.21
Change from baselinec
 -1.67
 0.02
Difference from placeboc
 -1.68*
(95% CI)
 (-2.19, -1.18)
Mean daily insulin dose (IU)1
Baseline (mean)
 77.96
 73.96
Change from baselinec
 -1.16
 5.08
Difference from placeboc
 -6.23*
(95% CI)
 (-8.84, -3.63)
Subjects with mean daily insulin dose reduction of at least 10% (%)
 19.7**
 11.0
LOCF: Last observation (prior to or on the date of the first insulin up-titration, if needed) carried forward
bAll randomised subjects who took at least one dose of double-blind study medicinal product during the short-term double-blind period
cLeast squares mean adjusted for baseline value and presence of oral glucose-lowering medicinal product
*p-value < 0.0001 versus placebo + insulin ± oral glucose-lowering medicinal product
**p-value < 0.05 versus placebo + insulin ± oral glucose-lowering medicinal product
1Up-titration of insulin regimens (including short-acting, intermediate, and basal insulin) was only allowed if subjects met pre-defined FPG criteria.
2Fifty percent of subjects were on insulin monotherapy at baseline; 50% were on 1 or 2 oral glucose-lowering medicinal product(s) in addition to insulin: Of this latter group, 80% were on metformin alone, 12% were on metformin plus sulphonylurea therapy, and the rest were on other oral glucose-lowering medicinal products.
Fasting plasma glucose
Treatment with dapagliflozin 10 mg as a monotherapy or as an add-on to either metformin, glimepiride, sitagliptin (with or without metformin) or insulin resulted in statistically significant reductions in fasting plasma glucose (-1.58 to -1.20 mmol/l [-28.5 to -21.7 mg/dl]) compared to placebo (-0.33 to 0.21 mmol/l [-6.0 to 3.8 mg/dl]). This effect was observed at Week 1 of treatment and maintained in studies extended through Week 102.
Post-prandial glucose
Treatment with dapagliflozin 10 mg as an add-on to glimepiride resulted in statistically significant reductions in 2-hour post-prandial glucose at 24 weeks that were maintained up to Week 48.
Treatment with dapagliflozin 10 mg as an add-on to sitagliptin (with or without metformin) resulted in reductions in 2-hour post-prandial glucose at 24 weeks that were maintained up to Week 48.
Body weight
Dapagliflozin 10 mg as an add-on to metformin, glimepiride, sitagliptin (with or without metformin) or insulin resulted in statistically significant body weight reduction at 24 weeks (p < 0.0001, Tables 4 and 5). These effects were sustained in longer-term trials. At 48 weeks, the difference for dapagliflozin as add-on to sitagliptin (with or without metformin) compared with placebo was -2.22 kg. At 102 weeks, the difference for dapagliflozin as add-on to metformin compared with placebo, or as add-on to insulin compared with placebo was -2.14 and -2.88 kg, respectively.
As an add-on therapy to metformin in an active-controlled non-inferiority study, dapagliflozin resulted in a statistically significant body weight reduction of -4.65 kg at 52 weeks (p < 0.0001, Table 3) that was sustained at 104 weeks (-5.06 kg) compared with glipizide.
A 24-week study in 182 diabetic subjects using dual energy X-ray absorptiometry (DXA) to eva luate body composition demonstrated reductions with dapagliflozin 10 mg plus metformin compared with placebo plus metformin, respectively, in body weight and body fat mass as measured by DXA rather than lean tissue or fluid loss. Treatment with Forxiga plus metformin showed a numerical decrease in visceral adipose tissue compared with placebo plus metformin treatment in a magnetic resonance imaging substudy.
Blood pressure
In a pre-specified pooled analysis of 12 placebo-controlled studies, treatment with dapagliflozin 10 mg resulted in a systolic blood pressure change from baseline of -4.4 mmHg and diastolic blood pressure of -2.1 mmHg versus -0.9 mmHg systolic and -0.5 mmHg diastolic blood pressure for placebo group at Week 24.
Cardiovascular safety
A meta-analysis of cardiovascular events in the clinical program was performed. In the clinical program, 36.6% of subjects had a history of cardiovascular disease (excluding hypertension) at baseline and 70.0% had hypertension. Cardiovascular episodes were adjudicated by an independent adjudication committee. The primary end point was the time-to-first event of one of the following outcomes: cardiovascular death, stroke, myocardial infarction (MI) or hospitalisation for unstable angina. Primary episodes occurred at a rate of 1.64% per patient-year in subjects treated with dapagliflozin and 1.99% in comparator-treatment subjects, per patient-year. The hazard ratio comparing dapagliflozin to comparator was 0.82 (95% Confidence interval [CI]: 0.58, 1.15), indicating that in this analysis Forxiga is not associated with an increase in cardiovascular risk in patients with type 2 diabetes mellitus. Cardiovascular death, MI and stroke were observed with a hazard ratio of 0.79 (95% CI: 0.54, 1.17).
Patients with renal impairment
Moderate renal impairment (eGFR ≥ 30 to < 60 ml/min/1.73 m2)
The efficacy of dapagliflozin was also assessed separately in a dedicated study of diabetic subjects with moderate renal impairment (252 subjects with mean eGFR 45 ml/min/1.73 m2). The mean change from baseline in HbA1c at 24 weeks was -0.44% and -0.32%, for dapagliflozin 10 mg and placebo, respectively.
Patients with baseline HbA1c ≥ 9%
In a pre-specified analysis of subjects with baseline HbA1c ≥ 9.0%, treatment with dapagliflozin 10 mg resulted in statistically significant reductions in HbA1c at Week 24 as a monotherapy (adjusted mean change from baseline: -2.04% and 0.19% for dapagliflozin 10 mg and placebo, respectively) and as an add-on to metformin (adjusted mean change from baseline: -1.32% and -0.53% for dapagliflozin and placebo, respectively).
Paediatric population
The European Medicines Agency has deferred the obligation to submit the results of studies with dapagliflozin in one or more subsets of the paediatric population in the treatment of type 2 diabetes (see section 4.2 for information on paediatric use).
5.2 Pharmacokinetic properties
Absorption
Dapagliflozin was rapidly and well absorbed after oral administration. Maximum dapagliflozin plasma concentrations (Cmax) were usually attained within 2 hours after administration in the fasted state. Geometric mean steady-state dapagliflozin Cmax and AUCτ values following once daily 10 mg doses of dapagliflozin were 158 ng/ml and 628 ng h/ml, respectively. The absolute oral bioavailability of dapagliflozin following the administration of a 10 mg dose is 78%. Administration with a high-fat meal decreased dapagliflozin Cmax by up to 50% and prolonged Tmax by approximately 1 hour, but did not alter AUC as compared with the fasted state. These changes are not considered to be clinically meaningful. Hence, Forxiga can be administered with or without food.
Distribution
Dapagliflozin is approximately 91% protein bound. Protein binding was not altered in various disease states (e.g. renal or hepatic impairment). The mean steady-state volume of distribution of dapagliflozin was 118 l.
Biotransformation
Dapagliflozin is extensively metabolised, primarily to yield dapagliflozin 3-O-glucuronide, which is an inactive metabolite. Dapagliflozin 3-O-glucuronide or other metabolites do not contribute to the glucose-lowering effects. The formation of dapagliflozin 3-O-glucuronide is mediated by UGT1A9, an enzyme present in the liver and kidney, and CYP-mediated metabolism was a minor clearance pathway in humans.
Elimination
The mean plasma terminal half-life (t1/2) for dapagliflozin was 12.9 hours following a single oral dose of dapagliflozin 10 mg to healthy subjects. The mean total systemic clearance of dapagliflozin administered intravenously was 207 ml/min. Dapagliflozin and related metabolites are primarily eliminated via urinary excretion with less than 2% as unchanged dapagliflozin. After administration of a 50 mg [14C]-dapagliflozin dose, 96% was recovered, 75% in urine and 21% in feces. In feces, approximately 15% of the dose was excreted as parent drug.
Linearity
Dapagliflozin exposure increased proportional to the increment in dapagliflozin dose over the range of 0.1 to 500 mg and its pharmacokinetics did not change with time upon repeated daily dosing for up to 24 weeks.
Special populations
Renal impairment
At steady-state (20 mg once-daily dapagliflozin for 7 days), subjects with type 2 diabetes mellitus and mild, moderate or severe renal impairment (as determined by iohexol plasma clearance) had mean systemic exposures of dapagliflozin of 32%, 60% and 87% higher, respectively, than those of subjects with type 2 diabetes mellitus and normal renal function. The steady-state 24-hour urinary glucose excretion was highly dependent on renal function and 85, 52, 18 and 11 g of glucose/day was excreted by subjects with type 2 diabetes mellitus and normal renal function or mild, moderate or severe renal impairment, respectively. The impact of hemodialysis on dapagliflozin exposure is not known.
Hepatic impairment
In subjects with mild or moderate hepatic impairment (Child-Pugh classes A and B), mean Cmax and AUC of dapagliflozin were up to 12% and 36% higher, respectively, compared to healthy matched control subjects. These differences were not considered to be clinically meaningful. In subjects with severe hepatic impairment (Child-Pugh class C) mean Cmax and AUC of dapagliflozin were 40% and 67% higher than matched healthy controls, respectively.
Elderly patients (≥ 65 years)
There is no clinically meaningful increase in exposure based on age alone in subjects up to 70 years old. However, an increased exposure due to age-related decrease in renal function can be expected. There are insufficient data to draw conclusions regarding exposure in patients > 70 years old.
Paediatric population
Pharmacokinetics in the paediatric population have not been studied.
Gender
The mean dapagliflozin AUCss in females was estimated to be about 22% higher than in males.
Race
There were no clinically relevant differences in systemic exposures between White, Black or Asian races.
Body weight
Dapagliflozin exposure was found to decrease with increased weight. Consequently, low-weight patients may have somewhat increased exposure and patients with high weight somewhat decreased exposure. However, the differences in exposure were not considered clinically meaningful.
5.3 Preclinical safety data
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential and fertility. Dapagliflozin did not induce tumours in either mice or rats at any of the doses eva luated in two-year carcinogenicity studies.
Reproductive and developmental toxicity
Direct administration of dapagliflozin to weanling juvenile rats and indirect exposure during late pregnancy (time periods corresponding to the second and third trimesters of pregnancy with respect to human renal maturation) and lactation are each associated with increased incidence and/or severity of renal pelvic and tubular dilatations in progeny.
In a juvenile toxicity study, when dapagliflozin was dosed directly to young rats from postnatal day 21 until postnatal day 90, renal pelvic and tubular dilatations were reported at all dose levels; pup exposures at the lowest dose tested were ≥ 15 times the maximum recommended human dose. These findings were associated with dose-related increases in kidney weight and macroscopic kidney enlargement observed at all doses. The renal pelvic and tubular dilatations observed in juvenile animals did not fully reverse within the approximate 1-month recovery period.
In a separate study of pre- and postnatal development, maternal rats were dosed from gestation day 6 through postnatal day 21, and pups were indirectly exposed in utero and throughout lactation. (A satellite study was conducted to assess dapagliflozin exposures in milk and pups.) Increased incidence or severity of renal pelvic dilatation was observed in adult offspring of treated dams, although only at the highest dose tested (associated maternal and pup dapagliflozin exposures were 1,415 times and 137 times, respectively, the human values at the maximum recommended human dose). Additional developmental toxicity was limited to dose-related reductions in pup body weights, and observed only at doses ≥ 15 mg/kg/day (associated with pup exposures that are ≥ 29 times the human values at the maximum recommended human dose). Maternal toxicity was evident only at the highest dose tested, and limited to transient reductions in body weight and food consumption at dose. The no observed adverse effect level (NOAEL) for developmental toxicity, the lowest dose tested, is associated with a maternal systemic exposure multiple that is approximately 19 times the human value at the maximum recommended human dose.
In additional studies of embryo-foetal development in rats and rabbits, dapagliflozin was administered for intervals coinciding with the major periods of organogenesis in each species. Neither maternal nor developmental toxicities were observed in rabbits at any dose tested; the highest dose tested is associated with a systemic exposure multiple of approximately 1,191 times the maximum recommended human dose. In rats, dapagliflozin was neither embryolethal nor teratogenic at exposures up to 1,441 times the maximum recommended human dose.
6. Pharmaceutical particulars
6.1 List of excipients
 Tablet core
Microcrystalline cellulose (E460i)
Lactose, anhydrous
Crospovidone (E1201)
Silicon dioxide (E551)
Magnesium stearate (E470b)
Film-coating
Polyvinyl alcohol (E1203)
Titanium dioxide (E171)
Macrogol 3350
Talc (E553b)
Iron oxide yellow (E172)
6.2 Incompatibilities
 Not applicable.
6.3 Shelf life
3 years
6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
6.5 Nature and contents of container
 Alu/Alu blister
Pack sizes of 14, 28 and 98 film-coated tablets in non-perforated calendar blisters
Pack sizes of 30x1 and 90x1 film-coated tablets in perforated unit dose blisters
Not all pack sizes may be marketed.
6.6 Special precautions for disposal and other handling
No special requirements.
7. Marketing authorisation holder
 Bristol-Myers Squibb/AstraZeneca EEIG
Bristol-Myers Squibb House
Uxbridge Business Park
Sanderson Road
Uxbridge
Middlesex
UB8 1DH
United Kingdom
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8. Marketing authorisation number(s)
EU/1/12/795/002
EU/1/12/795/007
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9. Date of first authorisation/renewal of the authorisation
12 November, 2012