SPL MEDGUIDE SECTION.


MEDICATION GUIDE PRADAXA (pra dax a) (dabigatran etexilate mesylate) capsulesRead this Medication Guide before you start taking PRADAXA and each time you get refill. There may be new information. This Medication Guide does not take the place of talking with your doctor about your medical condition or your treatment.What is the most important information should know about PRADAXAPRADAXA can cause bleeding which can be serious, and sometimes lead to death. This is because PRADAXA is blood thinner medicine that lowers the chance of blood clots forming in your body.You may have higher risk of bleeding if you take PRADAXA and:are over 75 years oldhave kidney problemshave stomach or intestine bleeding that is recent or keeps coming back, or you have stomach ulcertake other medicines that increase your risk of bleeding, including: Tell your doctor if you take any of these medicines. Ask your doctor or pharmacist if you are not sure if your medicine is one listed above.aspirin or aspirin containing productslong-term (chronic) use of non-steroidal anti-inflammatory drugs (NSAIDs)warfarin sodium (Coumadin(R), Jantoven(R))a medicine that contains heparinclopidogrel (Plavix(R)) prasugrel (Effient(R)) PRADAXA can increase your risk of bleeding because it lessens the ability of your blood to clot. While you take PRADAXA: Call your doctor or get medical help right away if you have any of these signs or symptoms of bleeding: Take PRADAXA exactly as prescribed. Do not stop taking PRADAXA without first talking to the doctor who prescribes it for you. Stopping PRADAXA may increase your risk of stroke. PRADAXA may need to be stopped, if possible, for one or more days before any surgery, or medical or dental procedure. If you need to stop taking PRADAXA for any reason, talk to the doctor who prescribed PRADAXA for you to find out when you should stop taking it. Your doctor will tell you when to start taking PRADAXA again after your surgery or procedure. See What are the possible side effects of PRADAXA for more information about side effects. you may bruise more easilyit may take longer for any bleeding to stop What is PRADAXAPRADAXA is prescription medicine used to reduce the risk of stroke and blood clots in people who have medical condition called atrial fibrillation. With atrial fibrillation, part of the heart does not beat the way it should. This can lead to blood clots forming and increase your risk of stroke. PRADAXA is blood thinner medicine that lowers the chance of blood clots forming in your body.It is not known if PRADAXA is safe and works in children.Who should not take PRADAXADo not take PRADAXA if you:currently have certain types of abnormal bleeding. Talk to your doctor, before taking PRADAXA if you currently have unusual bleeding.have had serious allergic reaction to PRADAXA. Ask your doctor if you are not sure.What should tell my doctor before taking PRADAXA Before you take PRADAXA, tell your doctor if you:have kidney problemshave ever had bleeding problemshave ever had stomach ulcershave any other medical conditionare pregnant or plan to become pregnant. It is not known if PRADAXA will harm your unborn baby.are breastfeeding or plan to breastfeed. It is not known if PRADAXA passes into your breast milk. Tell all of your doctors and dentists that you are taking PRADAXA. They should talk to the doctor who prescribed PRADAXA for you, before you have any surgery, or medical or dental procedure. Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. Some of your other medicines may affect the way PRADAXA works. Certain medicines may increase your risk of bleeding. See What is the most important information should know about PRADAXA Especially tell your doctor if you take: Know the medicines you take. Keep list of them and show it to your doctor and pharmacist when you get new medicine.rifampin (Rifater, Rifamate, Rimactane, Rifadin) How should take PRADAXATake PRADAXA exactly as prescribed by your doctor.Do not take PRADAXA more often than your doctor tells you to.You can take PRADAXA with or without food.Swallow PRADAXA capsules whole. Do not break, chew, or empty the pellets from the capsule.If you miss dose of PRADAXA, take it as soon as you remember. If your next dose is less than hours away, skip the missed dose. Do not take two doses of PRADAXA at the same time.Your doctor will decide how long you should take PRADAXA. Do not stop taking PRADAXA without first talking with your doctor. Stopping PRADAXA may increase your risk of stroke. Do not run out of PRADAXA. Refill your prescription before you run out. If you plan to have surgery, or medical or dental procedure, tell your doctor and dentist that you are taking PRADAXA. You may have to stop taking PRADAXA for short time. See What is the most important information should know about PRADAXAIf you take too much PRADAXA, go to the nearest hospital emergency room or call your doctor or the Poison Control Center right away.What are the possible side effects of PRADAXAPRADAXA can cause serious side effects.See What is the most important information should know about PRADAXAAllergic Reactions. In some people, PRADAXA can cause symptoms of an allergic reaction, including hives, rash, and itching. Tell your doctor or get medical help right away if you get any of the following symptoms of serious allergic reaction with PRADAXA: chest pain or chest tightnessswelling of your face or tonguetrouble breathing or wheezingfeeling dizzy or faint Common side effects of PRADAXA include:indigestion, upset stomach, or burning stomach painTell your doctor if you have any side effect that bothers you or that does not go away.These are not all of the possible side effects of PRADAXA. For more information, ask your doctor or pharmacist.Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.How should store PRADAXAStore PRADAXA at room temperature between 59F to 86F (15C to 30C). After opening the bottle, use PRADAXA within 30 days. Safely throw away any unused PRADAXA after 30 days.Store PRADAXA in the original package to keep it dry. Keep the bottle tightly closed.Keep PRADAXA and all medicines out of the reach of children.General information about PRADAXAMedicines are sometimes prescribed for purposes other than those listed in Medication Guide. Do not use PRADAXA for condition for which it was not prescribed. Do not give your PRADAXA to other people, even if they have the same symptoms. It may harm them.This Medication Guide summarizes the most important information about PRADAXA. If you would like more information, talk with your doctor. You can ask your pharmacist or doctor for information about PRADAXA that is written for health professionals.For more information, go to www.PRADAXA.com or call 1-800-542-6257 or (TTY) 1-800-459-9906.What are the ingredients in PRADAXAActive ingredient: dabigatran etexilate mesylateInactive ingredients: acacia, dimethicone, hypromellose, hydroxypropyl cellulose, talc, and tartaric acid. The capsule shell is composed of carrageenan, FD&C Blue No. 2, FD&C Yellow No. 6, hypromellose, potassium chloride, titanium dioxide, and black edible ink.Distributed by: Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT 06877 USARevised: March 2011 This Medication Guide has been approved by the U.S. Food and Drug Administration.Copyright 2011 Boehringer Ingelheim Pharmaceuticals, Inc. ALL RIGHTS RESERVED75461-02 IT5060BC07201175457-02 IT5400BRepackaged by Rebel Distributors CorpThousand Oaks, CA 91320Coumadin(R) is registered trademark for Bristol-Myers Squibb Jantoven(R) is registered trademark for USL Pharma Plavix(R) is registered trademark of sanofi aventis Effient(R) is registered trademark of Eli Lilly and Company PRADAXA can cause bleeding which can be serious, and sometimes lead to death. This is because PRADAXA is blood thinner medicine that lowers the chance of blood clots forming in your body.. You may have higher risk of bleeding if you take PRADAXA and:are over 75 years oldhave kidney problemshave stomach or intestine bleeding that is recent or keeps coming back, or you have stomach ulcertake other medicines that increase your risk of bleeding, including: Tell your doctor if you take any of these medicines. Ask your doctor or pharmacist if you are not sure if your medicine is one listed above.aspirin or aspirin containing productslong-term (chronic) use of non-steroidal anti-inflammatory drugs (NSAIDs)warfarin sodium (Coumadin(R), Jantoven(R))a medicine that contains heparinclopidogrel (Plavix(R)) prasugrel (Effient(R)) are over 75 years old. have kidney problems. have stomach or intestine bleeding that is recent or keeps coming back, or you have stomach ulcer. take other medicines that increase your risk of bleeding, including: Tell your doctor if you take any of these medicines. Ask your doctor or pharmacist if you are not sure if your medicine is one listed above.aspirin or aspirin containing productslong-term (chronic) use of non-steroidal anti-inflammatory drugs (NSAIDs)warfarin sodium (Coumadin(R), Jantoven(R))a medicine that contains heparinclopidogrel (Plavix(R)) prasugrel (Effient(R)) aspirin or aspirin containing products. long-term (chronic) use of non-steroidal anti-inflammatory drugs (NSAIDs). warfarin sodium (Coumadin(R), Jantoven(R)). medicine that contains heparin. clopidogrel (Plavix(R)) prasugrel (Effient(R)). PRADAXA can increase your risk of bleeding because it lessens the ability of your blood to clot. While you take PRADAXA: Call your doctor or get medical help right away if you have any of these signs or symptoms of bleeding: Take PRADAXA exactly as prescribed. Do not stop taking PRADAXA without first talking to the doctor who prescribes it for you. Stopping PRADAXA may increase your risk of stroke. PRADAXA may need to be stopped, if possible, for one or more days before any surgery, or medical or dental procedure. If you need to stop taking PRADAXA for any reason, talk to the doctor who prescribed PRADAXA for you to find out when you should stop taking it. Your doctor will tell you when to start taking PRADAXA again after your surgery or procedure. See What are the possible side effects of PRADAXA for more information about side effects. you may bruise more easilyit may take longer for any bleeding to stop you may bruise more easily. it may take longer for any bleeding to stop. currently have certain types of abnormal bleeding. Talk to your doctor, before taking PRADAXA if you currently have unusual bleeding.. have had serious allergic reaction to PRADAXA. Ask your doctor if you are not sure.. have kidney problems. have ever had bleeding problems. have ever had stomach ulcers. have any other medical condition. are pregnant or plan to become pregnant. It is not known if PRADAXA will harm your unborn baby.. are breastfeeding or plan to breastfeed. It is not known if PRADAXA passes into your breast milk. Tell all of your doctors and dentists that you are taking PRADAXA. They should talk to the doctor who prescribed PRADAXA for you, before you have any surgery, or medical or dental procedure. Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins, and herbal supplements. Some of your other medicines may affect the way PRADAXA works. Certain medicines may increase your risk of bleeding. See What is the most important information should know about PRADAXA Especially tell your doctor if you take: Know the medicines you take. Keep list of them and show it to your doctor and pharmacist when you get new medicine.rifampin (Rifater, Rifamate, Rimactane, Rifadin) rifampin (Rifater, Rifamate, Rimactane, Rifadin). Take PRADAXA exactly as prescribed by your doctor.. Do not take PRADAXA more often than your doctor tells you to.. You can take PRADAXA with or without food.. Swallow PRADAXA capsules whole. Do not break, chew, or empty the pellets from the capsule.. If you miss dose of PRADAXA, take it as soon as you remember. If your next dose is less than hours away, skip the missed dose. Do not take two doses of PRADAXA at the same time.. Your doctor will decide how long you should take PRADAXA. Do not stop taking PRADAXA without first talking with your doctor. Stopping PRADAXA may increase your risk of stroke. Do not run out of PRADAXA. Refill your prescription before you run out. If you plan to have surgery, or medical or dental procedure, tell your doctor and dentist that you are taking PRADAXA. You may have to stop taking PRADAXA for short time. See What is the most important information should know about PRADAXA. If you take too much PRADAXA, go to the nearest hospital emergency room or call your doctor or the Poison Control Center right away.. See What is the most important information should know about PRADAXA. Allergic Reactions. In some people, PRADAXA can cause symptoms of an allergic reaction, including hives, rash, and itching. Tell your doctor or get medical help right away if you get any of the following symptoms of serious allergic reaction with PRADAXA: chest pain or chest tightnessswelling of your face or tonguetrouble breathing or wheezingfeeling dizzy or faint chest pain or chest tightness. swelling of your face or tongue. trouble breathing or wheezing. feeling dizzy or faint. indigestion, upset stomach, or burning stomach pain. Store PRADAXA at room temperature between 59F to 86F (15C to 30C). After opening the bottle, use PRADAXA within 30 days. Safely throw away any unused PRADAXA after 30 days.. Store PRADAXA in the original package to keep it dry. Keep the bottle tightly closed.

HOW SUPPLIED SECTION.


16 HOW SUPPLIED/STORAGE AND HANDLING. PRADAXA 75 mg capsules have light blue opaque cap imprinted with the Boehringer Ingelheim company symbol and cream-colored opaque body imprinted with R75. The color of the imprinting is black. The capsules are supplied in the packages listed:NDC 0597-0107-54 Unit of use bottle of 60 capsulesNDC 0597-0107-60 Blister package containing 60 capsules (10 6 capsule blister cards) PRADAXA 150 mg capsules have light blue opaque cap imprinted with the Boehringer Ingelheim company symbol and cream-colored opaque body imprinted with R150. The color of the imprinting is black. The capsules are supplied in the packages listed:NDC 0597-0135-54 Unit of use bottle of 60 capsulesNDC 0597-0135-60 Blister package containing 60 capsules (10 6 capsule blister cards) BottlesStore at 25C (77F); excursions permitted to 15-30C (59-86F). Once opened, the product must be used within 30 days. Keep the bottle tightly closed. Store in the original package to protect from moisture. BlistersStore at 25C (77F); excursions permitted to 15-30C (59-86F). Store in the original package to protect from moisture.Keep out of the reach of children.. NDC 0597-0107-54 Unit of use bottle of 60 capsules. NDC 0597-0107-60 Blister package containing 60 capsules (10 6 capsule blister cards) NDC 0597-0135-54 Unit of use bottle of 60 capsules. NDC 0597-0135-60 Blister package containing 60 capsules (10 6 capsule blister cards).

ADVERSE REACTIONS SECTION.


6 ADVERSE REACTIONS. Most common adverse reactions (>15%) are gastritis-like symptoms and bleeding (6.1) To report SUSPECTED ADVERSE REACTIONS, contact Boehringer Ingelheim Pharmaceuticals, Inc. at (800) 542-6257 or (800) 459-9906 TTY or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch .. 6.1 Clinical Trials Experience. The RE-LY study provided safety information on the use of two doses of PRADAXA and warfarin [see Clinical Studies (14)]. The numbers of patients and their exposures are described in Table 1. Limited information is presented on the 110 mg dosing arm because this dose is not approved.Table Summary of Treatment Exposure in RE-LYPRADAXA 110 mg twice dailyPRADAXA 150 mg twice dailyWarfarinTotal number treated598360595998Exposure 12 months493649395193 24 months238724052470Mean exposure (months)20.520.3 21.3 Total patient-years10,24210,26110,659Because clinical studies are conducted under widely varying conditions and over varying lengths of time, adverse reaction rates observed in the clinical studies of drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.. Drug Discontinuation in RE-LYThe rates of adverse reactions leading to treatment discontinuation were 21% for PRADAXA 150 mg and 16% for warfarin. The most frequent adverse reactions leading to discontinuation of PRADAXA were bleeding and gastrointestinal events (i.e., dyspepsia, nausea, upper abdominal pain, gastrointestinal hemorrhage, and diarrhea).. Bleeding [see Warnings and Precautions (5.1)]Table shows the number of patients experiencing serious bleeding during the treatment period in the RE-LY study, with the bleeding rate per 100 patient-years (%). Major bleeds fulfilled one or more of the following criteria: bleeding associated with reduction in hemoglobin of at least grams per deciliter or leading to transfusion of at least units of blood, or symptomatic bleeding in critical area or organ (intraocular, intracranial, intraspinal or intramuscular with compartment syndrome, retroperitoneal bleeding, intra-articular bleeding, or pericardial bleeding). life-threatening bleed met one or more of the following criteria: fatal, symptomatic intracranial bleed, reduction in hemoglobin of at least grams per deciliter, transfusion of at least units of blood, associated with hypotension requiring the use of intravenous inotropic agents, or necessitating surgical intervention. Intracranial hemorrhage included intracerebral (hemorrhagic stroke), subarachnoid, and subdural bleeds.Table Bleeding Events (per 100 Patient-Years) PRADAXA 150 mg twice daily (%)Warfarin (%)Hazard Ratio (95% CI) Patients contributed multiple events and events were counted in multiple categories. Confidence intervalRandomized patients60766022 Patient-years12,03311,794 Intracranial hemorrhage38 (0.3)90 (0.8)0.41 (0.28, 0.60) Life-threatening bleed179 (1.5)218 (1.9)0.80 (0.66, 0.98) Major bleed399 (3.3)421 (3.6)0.93 (0.81, 1.07) Any bleed1993 (16.6)2166 (18.4)0.91 (0.85, 0.96)The risk of major bleeds was similar with PRADAXA 150 mg and warfarin across major subgroups defined by baseline characteristics, with the exception of age, where there was trend towards higher incidence of major bleeding on PRADAXA (hazard ratio 1.2, 95% CI: 1.0 to 1.4) for patients >=75 years of age.There was higher rate of major gastrointestinal bleeds in patients receiving PRADAXA 150 mg than in patients receiving warfarin (1.6% vs. 1.1%, respectively, with hazard ratio vs. warfarin of 1.5, 95% CI, 1.2 to 1.9), and higher rate of any gastrointestinal bleeds (6.1% vs. 4.0%, respectively).. Gastrointestinal Adverse ReactionsPatients on PRADAXA 150 mg had an increased incidence of gastrointestinal adverse reactions (35% vs. 24% on warfarin). These were commonly dyspepsia (including abdominal pain upper, abdominal pain, abdominal discomfort, and epigastric discomfort) and gastritis-like symptoms (including GERD, esophagitis, erosive gastritis, gastric hemorrhage, hemorrhagic gastritis, hemorrhagic erosive gastritis, and gastrointestinal ulcer). Hypersensitivity ReactionsIn the RE-LY study, drug hypersensitivity (including urticaria, rash, and pruritus), allergic edema, anaphylactic reaction, and anaphylactic shock were reported in <0.1% of patients receiving PRADAXA.

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.


13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. Dabigatran was not carcinogenic when administered by oral gavage to mice and rats for up to years. The highest doses tested (200 mg/kg/day) in mice and rats were approximately 3.6 and times, respectively, the human exposure at MRHD of 300 mg/day based on AUC comparisons.Dabigatran was not mutagenic in in vitro tests, including bacterial reversion tests, mouse lymphoma assay and chromosomal aberration assay in human lymphocytes, and the in vivo micronucleus assay in rats.In the rat fertility study with oral gavage doses of 15, 70, and 200 mg/kg, males were treated for 29 days prior to mating, during mating up to scheduled termination, and females were treated 15 days prior to mating through gestation Day 6. No adverse effects on male or female fertility were observed at 200 mg/kg or to 12 times the human exposure at MRHD of 300 mg/day based on AUC comparisons. However, the number of implantations decreased in females receiving 70 mg/kg, or times the human exposure at MRHD based on AUC comparisons.

CLINICAL PHARMACOLOGY SECTION.


12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Dabigatran and its acyl glucuronides are competitive, direct thrombin inhibitors. Because thrombin (serine protease) enables the conversion of fibrinogen into fibrin during the coagulation cascade, its inhibition prevents the development of thrombus. Both free and clot-bound thrombin, and thrombin-induced platelet aggregation are inhibited by the active moieties.. 12.2 Pharmacodynamics. At recommended therapeutic doses, dabigatran etexilate prolongs the aPTT, ECT, and TT. With an oral dose of 150 mg twice daily the median peak aPTT is approximately 2x control. Twelve hours after the last dose the median aPTT is 1.5x control, with less than 10% of patients exceeding 2x control. In the RE-LY trial, the median (10th to 90th percentile) trough aPTT in patients receiving the 150 mg dose was 52 (40 to 76) seconds. The median (10th to 90th percentile) trough ECT in patients receiving the 150 mg dose was 63 (44 to 103) seconds. The INR test is relatively insensitive to the activity of dabigatran and may or may not be elevated in patients on PRADAXA. When converting patient from PRADAXA to warfarin therapy, the INR is unlikely to be useful until at least days after discontinuation of PRADAXA.. Cardiac ElectrophysiologyNo prolongation of the QTc interval was observed with dabigatran etexilate at doses up to 600 mg.. 12.3 Pharmacokinetics. Dabigatran etexilate mesylate is absorbed as the dabigatran etexilate ester. The ester is then hydrolyzed, forming dabigatran, the active moiety. Dabigatran is metabolized to four different acyl glucuronides and both the glucuronides and dabigatran have similar pharmacological activity. Pharmacokinetics described here refer to the sum of dabigatran and its glucuronides. Dabigatran displays dose-proportional pharmacokinetics in healthy subjects and patients in the range of doses from 10 to 400 mg.. AbsorptionThe absolute bioavailability of dabigatran following oral administration of dabigatran etexilate is approximately to 7%. Dabigatran etexilate is substrate of the efflux transporter P-gp. After oral administration of dabigatran etexilate in healthy volunteers, Cmax occurs at hour post-administration in the fasted state. Coadministration of PRADAXA with high-fat meal delays the time to Cmax by approximately hours but has no effect on the bioavailability of dabigatran; PRADAXA may be administered with or without food. The oral bioavailability of dabigatran etexilate increases by 75% when the pellets are taken without the capsule shell compared to the intact capsule formulation. PRADAXA capsules should therefore not be broken, chewed, or opened before administration.. DistributionDabigatran is approximately 35% bound to human plasma proteins. The red blood cell to plasma partitioning of dabigatran measured as total radioactivity is less than 0.3. The volume of distribution of dabigatran is 50 to 70 L. Dabigatran pharmacokinetics are dose proportional after single doses of 10 to 400 mg. Given twice daily, dabigatrans accumulation factor is approximately two.. EliminationDabigatran is eliminated primarily in the urine. Renal clearance of dabigatran is 80% of total clearance after intravenous administration. After oral administration of radiolabeled dabigatran, 7% of radioactivity is recovered in urine and 86% in feces. The half-life of dabigatran in healthy subjects is 12 to 17 hours.. MetabolismAfter oral administration, dabigatran etexilate is converted to dabigatran. The cleavage of the dabigatran etexilate by esterase-catalyzed hydrolysis to the active principal dabigatran is the predominant metabolic reaction. Dabigatran is not substrate, inhibitor, or inducer of CYP450 enzymes. Dabigatran is subject to conjugation forming pharmacologically active acyl glucuronides. Four positional isomers, 1-O, 2-O, 3-O, and 4-O-acylglucuronide exist, and each accounts for less than 10% of total dabigatran in plasma.. Renal ImpairmentAn open, parallel-group single-center study compared dabigatran pharmacokinetics in healthy subjects and patients with mild to moderate renal impairment receiving single dose of PRADAXA 150 mg. Based on pharmacokinetic modeling, estimated exposure to dabigatran increases with the severity of renal function impairment (Table 3). Similar findings were observed in the RE-LY trial.Table Estimated Pharmacokinetic Parameters of Dabigatran by Renal FunctionRenal FunctionCrCl (mL/min)Increase in AUCIncrease in Cmax t1/2 (h)Normal801x1x13Mild501.5x1.1x15Moderate303.2x1.7x18. Hepatic ImpairmentAdministration of PRADAXA in patients with moderate hepatic impairment (Child-Pugh B) showed large inter-subject variability, but no evidence of consistent change in exposure or pharmacodynamics.. Drug InteractionsImpact of Other Drugs on Dabigatran. P-gp Inducers Rifampin: Rifampin 600 mg once daily for days followed by single dose of dabigatran decreased its AUC and Cmax by 66% and 67%, respectively. By Day after cessation of rifampin treatment, dabigatran exposure was close to normal [see Warnings and Precautions (5.3) and Drug Interactions (7)].. P-gp Inhibitors. In studies with the P-gp inhibitors ketoconazole, amiodarone, verapamil, and quinidine, the time to peak, terminal half-life, and mean residence time of dabigatran were not affected. Any observed changes in Cmax and AUC are described below.Dronedarone: Exposure to dabigatran is higher when it is administered with dronedarone than when it is administered alone (1.7- to 2-fold).Ketoconazole: Ketoconazole increased dabigatran AUC0- and Cmax values by 138% and 135%, respectively, after single dose of 400 mg, and 153%, and 149%, respectively, after multiple daily doses of 400 mg.Verapamil: When dabigatran etexilate was coadministered with oral verapamil, the Cmax and AUC of dabigatran were increased. The extent of increase depends on the formulation of verapamil and timing of administration. If verapamil is present in the gut when dabigatran is taken, it will increase exposure to dabigatran with the greatest increase observed when single dose of immediate-release verapamil is given one hour prior to dabigatran (AUC increased by factor of 2.4). If verapamil is given hours after dabigatran, the increase in AUC is negligible. In the population pharmacokinetics study from RE-LY, no important changes in dabigatran trough levels were observed in patients who received verapamil.Amiodarone: When dabigatran etexilate was coadministered with single 600 mg oral dose of amiodarone, the dabigatran AUC and Cmax increased by 58% and 50%, respectively. The increase in exposure was mitigated by 65% increase in the renal clearance of dabigatran in the presence of amiodarone. The increase in renal clearance may persist after amiodarone is discontinued because of amiodarones long half-life. In the population pharmacokinetics study from RE-LY, no important changes in dabigatran trough levels were observed in patients who received amiodarone.Quinidine: Quinidine was given as 200 mg dose every hours up to total dose of 1000 mg. Dabigatran etexilate was given over consecutive days, the last evening dose on Day with or without quinidine pre-dosing. Concomitant quinidine administration increased dabigatrans AUC and Cmax by 53% and 56%, respectively.Clarithromycin: Coadministered clarithromycin had no impact on the exposure to dabigatran.. Other Drugs. Clopidogrel: When dabigatran etexilate was given concomitantly with loading dose of 300 mg or 600 mg clopidogrel, the dabigatran AUC and Cmax increased by approximately 30% and 40%, respectively. The concomitant administration of dabigatran etexilate and clopidogrel resulted in no further prolongation of capillary bleeding times compared to clopidogrel monotherapy. When comparing combined treatment and the respective mono-treatments, the coagulation measures for dabigatrans effect (aPTT, ECT, and TT) remained unchanged, and inhibition of platelet aggregation (IPA), measurement of clopidogrels effect, remained unchanged.Enoxaparin: Enoxaparin 40 mg given subcutaneously for days with the last dose given 24 hours before single dose of PRADAXA had no impact on the exposure to dabigatran or the coagulation measures aPTT, ECT, or TT.Diclofenac, Ranitidine, and Digoxin: None of these drugs alters exposure to dabigatran.In RE-LY, dabigatran plasma samples were also collected. The concomitant use of proton pump inhibitors, H2 antagonists, and digoxin did not appreciably change the trough concentration of dabigatran.. Impact of Dabigatran on Other DrugsIn clinical studies exploring CYP3A4, CYP2C9, P-gp and other pathways, dabigatran did not meaningfully alter the pharmacokinetics of amiodarone, atorvastatin, clarithromycin, diclofenac, clopidogrel, digoxin, pantoprazole, or ranitidine.

CLINICAL STUDIES SECTION.


14 CLINICAL STUDIES. The clinical evidence for the efficacy of PRADAXA was derived from RE-LY (Randomized Evaluation of Long-term Anticoagulant Therapy), multi-center, multi-national, randomized parallel group trial comparing two blinded doses of PRADAXA (110 mg twice daily and 150 mg twice daily) with open-label warfarin (dosed to target INR of to 3) in patients with non-valvular, persistent, paroxysmal, or permanent atrial fibrillation and one or more of the following additional risk factors:Previous stroke, transient ischemic attack (TIA), or systemic embolismLeft ventricular ejection fraction <40% Symptomatic heart failure, >= New York Heart Association Class 2Age >=75 yearsAge >=65 years and one of the following: diabetes mellitus, coronary artery disease (CAD), or hypertension The primary objective of this study was to determine if PRADAXA was non-inferior to warfarin in reducing the occurrence of the composite endpoint, stroke (ischemic and hemorrhagic) and systemic embolism. The study was designed to ensure that PRADAXA preserved more than 50% of warfarins effect as established by previous randomized, placebo-controlled trials of warfarin in atrial fibrillation. Statistical superiority was also analyzed.A total of 18,113 patients were randomized and followed for median of years. The patients mean age was 71.5 years and the mean CHADS2 score was 2.1. The patient population was 64% male, 70% Caucasian, 16% Asian, and 1% black. Twenty percent of patients had history of stroke or TIA and 50% were Vitamin antagonist (VKA) naive, defined as less than months total lifetime exposure to VKA. Thirty-two percent of the population had never been exposed to VKA. Concomitant diseases of patients in this trial included hypertension 79%, diabetes 23%, and CAD 28%. At baseline, 40% of patients were on aspirin and 6% were on clopidogrel. For patients randomized to warfarin, the mean percentage of time in therapeutic range (INR to 3) was 64%; the mean percentages of time INR measurements were greater than or less than 1.5 were 2% and 5%, respectively.Relative to warfarin and to PRADAXA 110 mg twice daily, PRADAXA 150 mg twice daily significantly reduced the primary composite endpoint of stroke and systemic embolism (see Table and Figure 1). Table First Occurrence of Stroke or Systemic Embolism in the RE-LY Study PRADAXA 150 mg twice dailyPRADAXA 110 mg twice dailyWarfarinPatients randomized607660156022Patients (%) with events 134 (2.2%)183 (3%)202 (3.4%)Hazard ratio vs. warfarin (95% CI)0.65 (0.52, 0.81)0.90 (0.74, 1.10) P-value for superiority0.00010.3 Hazard ratio vs. PRADAXA 110 mg (95% CI)0.72 (0.58, 0.90) P-value for superiority0.004 Figure Kaplan-Meier Curve Estimate of Time to First Stroke or Systemic Embolism The contributions of the components of the composite endpoint, including stroke by subtype, are shown in Table 5. The treatment effect was primarily reduction in stroke. PRADAXA 150 mg twice daily significantly reduced both ischemic and hemorrhagic strokes relative to warfarin.Table Strokes and Systemic Embolism in the RE-LY Study PRADAXA 150 mg twice dailyWarfarin Hazard ratio vs. warfarin(95% CI) Patients randomized60766022 Stroke 122 186 0.64 (0.51, 0.81) Ischemic stroke1031340.75 (0.58, 0.97) Hemorrhagic stroke12450.26 (0.14, 0.49)Systemic embolism13210.61 (0.30, 1.21)The efficacy of PRADAXA 150 mg twice daily was generally consistent across major subgroups (see Figure 2). Figure Stroke and Systemic Embolism Hazard Ratios by Baseline Characteristics Centers were ranked post hoc by the percentage of time that warfarin-treated patients were in therapeutic range (INR to 3). Findings for stroke/systemic embolism, all-cause mortality, and major bleeds are shown for centers above and below the median level of INR control in Table 6. The benefits of PRADAXA 150 mg relative to warfarin were most apparent in patients enrolled at centers with INR control below the median.Table Center INR Control in the RE-LY Study Centers with INR control below the median of 67%Centers with INR control above the median of 67%Stroke/systemic embolism0.57 (0.42, 0.76)0.76 (0.55, 1.05)All-cause mortality0.78 (0.66, 0.93)1.01 (0.84, 1.23)Major bleed0.82 (0.68, 0.99)1.08 (0.89, 1.31)The risk of myocardial infarction was numerically greater in patients who received PRADAXA (1.5% for 150 mg dose) than in those who received warfarin (1.1%).. Previous stroke, transient ischemic attack (TIA), or systemic embolism. Left ventricular ejection fraction <40% Symptomatic heart failure, >= New York Heart Association Class 2. Age >=75 years. Age >=65 years and one of the following: diabetes mellitus, coronary artery disease (CAD), or hypertension Kaplan-Meier Curve Estimate of Time to First Stroke or Systemic Embolism. Stroke and Systemic Embolism Hazard Ratios by Baseline Characteristics.

CONTRAINDICATIONS SECTION.


4 CONTRAINDICATIONS. PRADAXA is contraindicated in patients with:Active pathological bleeding [see Warnings and Precautions (5.1) and Adverse Reactions (6.1)].History of serious hypersensitivity reaction to PRADAXA (e.g., anaphylactic reaction or anaphylactic shock) [see Adverse Reactions (6.1)].. Active pathological bleeding [see Warnings and Precautions (5.1) and Adverse Reactions (6.1)].. History of serious hypersensitivity reaction to PRADAXA (e.g., anaphylactic reaction or anaphylactic shock) [see Adverse Reactions (6.1)].. Active pathological bleeding (4) History of serious hypersensitivity reaction to PRADAXA (4) Active pathological bleeding (4) History of serious hypersensitivity reaction to PRADAXA (4).

DESCRIPTION SECTION.


11 DESCRIPTION. The chemical name for dabigatran etexilate mesylate, direct thrombin inhibitor, is -Alanine, N-[[2-[[[4-[[[(hexyloxy)carbonyl]amino]iminomethyl] phenyl]amino]methyl]-1-methyl-1H-benzimidazol-5-yl]carbonyl]-N-2-pyridinyl-,ethyl ester, methanesulfonate. The empirical formula is C34H41N7O5 CH4O3S and the molecular weight is 723.86 (mesylate salt), 627.75 (free base). The structural formula is:Dabigatran etexilate mesylate is yellow-white to yellow powder. saturated solution in pure water has solubility of 1.8 mg/mL. It is freely soluble in methanol, slightly soluble in ethanol, and sparingly soluble in isopropanol.The 150 mg capsule for oral administration contains 172.95 mg dabigatran etexilate mesylate, which is equivalent to 150 mg of dabigatran etexilate, and the following inactive ingredients: acacia, dimethicone, hypromellose, hydroxypropyl cellulose, talc, and tartaric acid. The capsule shell is composed of carrageenan, FD&C Blue No. 2, FD&C Yellow No. 6, hypromellose, potassium chloride, titanium dioxide, and black edible ink. The 75 mg capsule contains 86.48 mg dabigatran etexilate mesylate, equivalent to 75 mg dabigatran etexilate, and is otherwise similar to the 150 mg capsule.. Praxada (dabigatran etexilate mesylate) structure.

DOSAGE & ADMINISTRATION SECTION.


2 DOSAGE AND ADMINISTRATION. For patients with CrCl >30 mL/min: 150 mg orally, twice daily (2.1) For patients with CrCl 15-30 mL/min: 75 mg orally, twice daily (2.1) Instruct patients not to chew, break, or open capsules (2.1) Review recommendations for converting to or from other oral or parenteral anticoagulants (2.2, 2.3) Temporarily discontinue PRADAXA before invasive or surgical procedures when possible, then restart promptly (2.4) For patients with CrCl >30 mL/min: 150 mg orally, twice daily (2.1) For patients with CrCl 15-30 mL/min: 75 mg orally, twice daily (2.1) Instruct patients not to chew, break, or open capsules (2.1) Review recommendations for converting to or from other oral or parenteral anticoagulants (2.2, 2.3) Temporarily discontinue PRADAXA before invasive or surgical procedures when possible, then restart promptly (2.4) 2.1 Recommended Dose. For patients with creatinine clearance (CrCl) >30 mL/min, the recommended dose of PRADAXA is 150 mg taken orally, twice daily, with or without food. For patients with CrCl 15-30 mL/min, the recommended dose is 75 mg twice daily [see Use in Specific Populations (8.6) and Clinical Pharmacology (12.3)]. Dosing recommendations for patients with CrCL <15 mL/min or on dialysis cannot be provided.Instruct patients to swallow the capsules whole. Breaking, chewing, or emptying the contents of the capsule can result in increased exposure [see Clinical Pharmacology (12.3)].If dose of PRADAXA is not taken at the scheduled time, the dose should be taken as soon as possible on the same day; the missed dose should be skipped if it cannot be taken at least hours before the next scheduled dose. The dose of PRADAXA should not be doubled to make up for missed dose.. 2.2 Converting from or to Warfarin. When converting patients from warfarin therapy to PRADAXA, discontinue warfarin and start PRADAXA when the international normalized ratio (INR) is below 2.0.When converting from PRADAXA to warfarin, adjust the starting time of warfarin based on creatinine clearance as follows:For CrCl >50 mL/min, start warfarin days before discontinuing PRADAXA.For CrCl 31-50 mL/min, start warfarin days before discontinuing PRADAXA.For CrCl 15-30 mL/min, start warfarin day before discontinuing PRADAXA.For CrCl <15 mL/min, no recommendations can be made.Because PRADAXA can contribute to an elevated INR, the INR will better reflect warfarins effect after PRADAXA has been stopped for at least days.. For CrCl >50 mL/min, start warfarin days before discontinuing PRADAXA.. For CrCl 31-50 mL/min, start warfarin days before discontinuing PRADAXA.. For CrCl 15-30 mL/min, start warfarin day before discontinuing PRADAXA.. For CrCl <15 mL/min, no recommendations can be made.. 2.3 Converting from or to Parenteral Anticoagulants. For patients currently receiving parenteral anticoagulant, start PRADAXA to hours before the time that the next dose of the parenteral drug was to have been administered or at the time of discontinuation of continuously administered parenteral drug (e.g., intravenous unfractionated heparin).For patients currently taking PRADAXA, wait 12 hours (CrCl >=30 mL/min) or 24 hours (CrCl <30 mL/min) after the last dose of PRADAXA before initiating treatment with parenteral anticoagulant [see Clinical Pharmacology (12.3)].. 2.4 Surgery and Interventions. If possible, discontinue PRADAXA to days (CrCl >=50 mL/min) or to days (CrCl <50 mL/min) before invasive or surgical procedures because of the increased risk of bleeding. Consider longer times for patients undergoing major surgery, spinal puncture, or placement of spinal or epidural catheter or port, in whom complete hemostasis may be required [see Use in Specific Populations (8.6) and Clinical Pharmacology (12.3)].If surgery cannot be delayed, there is an increased risk of bleeding [see Warnings and Precautions (5.1)]. This risk of bleeding should be weighed against the urgency of intervention [see Warnings and Precautions (5.2)]. Bleeding risk can be assessed by the ecarin clotting time (ECT). This test is better marker of the anticoagulant activity of dabigatran than activated partial thromboplastin time (aPTT), prothrombin time (PT)/INR, or thrombin time (TT). If ECT is not available, the aPTT test provides an approximation of PRADAXAs anticoagulant activity [see Clinical Pharmacology (12.2)].

DOSAGE FORMS & STRENGTHS SECTION.


3 DOSAGE FORMS AND STRENGTHS. Capsules with light blue opaque cap imprinted in black with the Boehringer Ingelheim company symbol and cream-colored opaque body imprinted in black with R150 (150 mg) or R75 (75 mg).. Capsules: 75 mg and 150 mg (3).

DRUG INTERACTIONS SECTION.


7 DRUG INTERACTIONS. The concomitant use of PRADAXA with P-gp inducers (e.g., rifampin) reduces exposure to dabigatran and should generally be avoided [see Clinical Pharmacology (12.3)]. P-gp inhibitors ketoconazole, verapamil, amiodarone, quinidine, and clarithromycin do not require dose adjustments. These results should not be extrapolated to other P-gp inhibitors [see Clinical Pharmacology (12.3)].

GERIATRIC USE SECTION.


8.5 Geriatric Use. Of the total number of patients in the RE-LY study, 82% were 65 and over, while 40% were 75 and over. The risk of stroke and bleeding increases with age, but the risk-benefit profile is favorable in all age groups [see Warnings and Precautions (5), Adverse Reactions (6.1), and Clinical Studies (14)].

INDICATIONS & USAGE SECTION.


1 INDICATIONS AND USAGE. PRADAXA is indicated to reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation.. PRADAXA is direct thrombin inhibitor indicated to reduce the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation (1).

INFORMATION FOR PATIENTS SECTION.


17 PATIENT COUNSELING INFORMATION. See Medication Guide. 17.1 Instructions for Patients. Tell patients to take PRADAXA exactly as prescribed.Remind patients not to discontinue PRADAXA without talking to the health care provider who prescribed it.Advise patients not to chew or break the capsules before swallowing them and not to open the capsules and take the pellets alone (e.g., sprinkled over food or into beverages).. Tell patients to take PRADAXA exactly as prescribed.. Remind patients not to discontinue PRADAXA without talking to the health care provider who prescribed it.. Advise patients not to chew or break the capsules before swallowing them and not to open the capsules and take the pellets alone (e.g., sprinkled over food or into beverages).. 17.2 Bleeding. Inform patients that they may bleed more easily, may bleed longer, and should call their health care provider for any signs or symptoms of bleeding.Instruct patients to seek emergency care right away if they have any of the following, which may be sign or symptom of serious bleeding: Unusual bruising (bruises that appear without known cause or that get bigger)Pink or brown urineRed or black, tarry stoolsCoughing up bloodVomiting blood, or vomit that looks like coffee groundsInstruct patients to call their health care provider or to get prompt medical attention if they experience any signs or symptoms of bleeding: Pain, swelling or discomfort in jointHeadaches, dizziness, or weaknessReoccurring nose bleedsUnusual bleeding from gumsBleeding from cut that takes long time to stopMenstrual bleeding or vaginal bleeding that is heavier than normal. Unusual bruising (bruises that appear without known cause or that get bigger). Pink or brown urine. Red or black, tarry stools. Coughing up blood. Vomiting blood, or vomit that looks like coffee grounds. Pain, swelling or discomfort in joint. Headaches, dizziness, or weakness. Reoccurring nose bleeds. Unusual bleeding from gums. Bleeding from cut that takes long time to stop. Menstrual bleeding or vaginal bleeding that is heavier than normal. 17.3 Gastrointestinal Adverse Reactions. Instruct patients to call their health care provider if they experience any signs or symptoms of dyspepsia or gastritis:Dyspepsia (upset stomach), burning, or nauseaAbdominal pain or discomfort Epigastric discomfort, GERD (gastric indigestion). Dyspepsia (upset stomach), burning, or nausea. Abdominal pain or discomfort Epigastric discomfort, GERD (gastric indigestion). 17.4 Invasive or Surgical Procedures. Instruct patients to inform their health care provider that they are taking PRADAXA before any invasive procedure (including dental procedures) is scheduled.. 17.5 Concomitant Medications. Ask patients to list all prescription medications, over-the-counter medications, or dietary supplements they are taking or plan to take so their health care provider knows about other treatments that may affect bleeding risk (e.g., aspirin or NSAIDs) or dabigatran exposure.. Distributed by: Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT 06877 USACopyright 2011 Boehringer Ingelheim Pharmaceuticals, Inc. ALL RIGHTS RESERVED75461-02 IT5060BC07201175457-02 IT5400B.

LABOR & DELIVERY SECTION.


8.2 Labor and Delivery. Safety and effectiveness of PRADAXA during labor and delivery have not been studied in clinical trials. Consider the risks of bleeding and of stroke in using PRADAXA in this setting [see Warnings and Precautions (5.1)].Death of offspring and mother rats during labor in association with uterine bleeding occurred during treatment of pregnant rats from implantation (gestation Day 7) to weaning (lactation Day 21) with dabigatran at dose of 70 mg/kg (about 2.6 times the human exposure at MRHD of 300 mg/day based on AUC comparisons).

MECHANISM OF ACTION SECTION.


12.1 Mechanism of Action. Dabigatran and its acyl glucuronides are competitive, direct thrombin inhibitors. Because thrombin (serine protease) enables the conversion of fibrinogen into fibrin during the coagulation cascade, its inhibition prevents the development of thrombus. Both free and clot-bound thrombin, and thrombin-induced platelet aggregation are inhibited by the active moieties.

NONCLINICAL TOXICOLOGY SECTION.


13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. Dabigatran was not carcinogenic when administered by oral gavage to mice and rats for up to years. The highest doses tested (200 mg/kg/day) in mice and rats were approximately 3.6 and times, respectively, the human exposure at MRHD of 300 mg/day based on AUC comparisons.Dabigatran was not mutagenic in in vitro tests, including bacterial reversion tests, mouse lymphoma assay and chromosomal aberration assay in human lymphocytes, and the in vivo micronucleus assay in rats.In the rat fertility study with oral gavage doses of 15, 70, and 200 mg/kg, males were treated for 29 days prior to mating, during mating up to scheduled termination, and females were treated 15 days prior to mating through gestation Day 6. No adverse effects on male or female fertility were observed at 200 mg/kg or to 12 times the human exposure at MRHD of 300 mg/day based on AUC comparisons. However, the number of implantations decreased in females receiving 70 mg/kg, or times the human exposure at MRHD based on AUC comparisons.

NURSING MOTHERS SECTION.


8.3 Nursing Mothers. It is not known whether dabigatran is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when PRADAXA is administered to nursing woman.

OVERDOSAGE SECTION.


10 OVERDOSAGE. Accidental overdose may lead to hemorrhagic complications. There is no antidote to dabigatran etexilate or dabigatran. In the event of hemorrhagic complications, initiate appropriate clinical support, discontinue treatment with PRADAXA, and investigate the source of bleeding. Dabigatran is primarily excreted in the urine; therefore, maintain adequate diuresis. Dabigatran can be dialyzed (protein binding is low), with the removal of about 60% of drug over to hours; however, data supporting this approach are limited. Consider surgical hemostasis or the transfusion of fresh frozen plasma or red blood cells. There is some experimental evidence to support the role of activated prothrombin complex concentrates (e.g., FEIBA), or recombinant Factor VIIa, or concentrates of coagulation factors II, IX or X; however, their usefulness in clinical settings has not been established. Consider administration of platelet concentrates in cases where thrombocytopenia is present or long-acting antiplatelet drugs have been used. Measurement of aPTT or ECT may help guide therapy [see Clinical Pharmacology (12.2)].

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.


Principal Display panel. Pradaxa 150mg.

PEDIATRIC USE SECTION.


8.4 Pediatric Use. Safety and effectiveness of PRADAXA in pediatric patients has not been established.

PHARMACODYNULLMICS SECTION.


12.2 Pharmacodynamics. At recommended therapeutic doses, dabigatran etexilate prolongs the aPTT, ECT, and TT. With an oral dose of 150 mg twice daily the median peak aPTT is approximately 2x control. Twelve hours after the last dose the median aPTT is 1.5x control, with less than 10% of patients exceeding 2x control. In the RE-LY trial, the median (10th to 90th percentile) trough aPTT in patients receiving the 150 mg dose was 52 (40 to 76) seconds. The median (10th to 90th percentile) trough ECT in patients receiving the 150 mg dose was 63 (44 to 103) seconds. The INR test is relatively insensitive to the activity of dabigatran and may or may not be elevated in patients on PRADAXA. When converting patient from PRADAXA to warfarin therapy, the INR is unlikely to be useful until at least days after discontinuation of PRADAXA.. Cardiac ElectrophysiologyNo prolongation of the QTc interval was observed with dabigatran etexilate at doses up to 600 mg.

PHARMACOKINETICS SECTION.


12.3 Pharmacokinetics. Dabigatran etexilate mesylate is absorbed as the dabigatran etexilate ester. The ester is then hydrolyzed, forming dabigatran, the active moiety. Dabigatran is metabolized to four different acyl glucuronides and both the glucuronides and dabigatran have similar pharmacological activity. Pharmacokinetics described here refer to the sum of dabigatran and its glucuronides. Dabigatran displays dose-proportional pharmacokinetics in healthy subjects and patients in the range of doses from 10 to 400 mg.. AbsorptionThe absolute bioavailability of dabigatran following oral administration of dabigatran etexilate is approximately to 7%. Dabigatran etexilate is substrate of the efflux transporter P-gp. After oral administration of dabigatran etexilate in healthy volunteers, Cmax occurs at hour post-administration in the fasted state. Coadministration of PRADAXA with high-fat meal delays the time to Cmax by approximately hours but has no effect on the bioavailability of dabigatran; PRADAXA may be administered with or without food. The oral bioavailability of dabigatran etexilate increases by 75% when the pellets are taken without the capsule shell compared to the intact capsule formulation. PRADAXA capsules should therefore not be broken, chewed, or opened before administration.. DistributionDabigatran is approximately 35% bound to human plasma proteins. The red blood cell to plasma partitioning of dabigatran measured as total radioactivity is less than 0.3. The volume of distribution of dabigatran is 50 to 70 L. Dabigatran pharmacokinetics are dose proportional after single doses of 10 to 400 mg. Given twice daily, dabigatrans accumulation factor is approximately two.. EliminationDabigatran is eliminated primarily in the urine. Renal clearance of dabigatran is 80% of total clearance after intravenous administration. After oral administration of radiolabeled dabigatran, 7% of radioactivity is recovered in urine and 86% in feces. The half-life of dabigatran in healthy subjects is 12 to 17 hours.. MetabolismAfter oral administration, dabigatran etexilate is converted to dabigatran. The cleavage of the dabigatran etexilate by esterase-catalyzed hydrolysis to the active principal dabigatran is the predominant metabolic reaction. Dabigatran is not substrate, inhibitor, or inducer of CYP450 enzymes. Dabigatran is subject to conjugation forming pharmacologically active acyl glucuronides. Four positional isomers, 1-O, 2-O, 3-O, and 4-O-acylglucuronide exist, and each accounts for less than 10% of total dabigatran in plasma.. Renal ImpairmentAn open, parallel-group single-center study compared dabigatran pharmacokinetics in healthy subjects and patients with mild to moderate renal impairment receiving single dose of PRADAXA 150 mg. Based on pharmacokinetic modeling, estimated exposure to dabigatran increases with the severity of renal function impairment (Table 3). Similar findings were observed in the RE-LY trial.Table Estimated Pharmacokinetic Parameters of Dabigatran by Renal FunctionRenal FunctionCrCl (mL/min)Increase in AUCIncrease in Cmax t1/2 (h)Normal801x1x13Mild501.5x1.1x15Moderate303.2x1.7x18. Hepatic ImpairmentAdministration of PRADAXA in patients with moderate hepatic impairment (Child-Pugh B) showed large inter-subject variability, but no evidence of consistent change in exposure or pharmacodynamics.. Drug InteractionsImpact of Other Drugs on Dabigatran. P-gp Inducers Rifampin: Rifampin 600 mg once daily for days followed by single dose of dabigatran decreased its AUC and Cmax by 66% and 67%, respectively. By Day after cessation of rifampin treatment, dabigatran exposure was close to normal [see Warnings and Precautions (5.3) and Drug Interactions (7)].. P-gp Inhibitors. In studies with the P-gp inhibitors ketoconazole, amiodarone, verapamil, and quinidine, the time to peak, terminal half-life, and mean residence time of dabigatran were not affected. Any observed changes in Cmax and AUC are described below.Dronedarone: Exposure to dabigatran is higher when it is administered with dronedarone than when it is administered alone (1.7- to 2-fold).Ketoconazole: Ketoconazole increased dabigatran AUC0- and Cmax values by 138% and 135%, respectively, after single dose of 400 mg, and 153%, and 149%, respectively, after multiple daily doses of 400 mg.Verapamil: When dabigatran etexilate was coadministered with oral verapamil, the Cmax and AUC of dabigatran were increased. The extent of increase depends on the formulation of verapamil and timing of administration. If verapamil is present in the gut when dabigatran is taken, it will increase exposure to dabigatran with the greatest increase observed when single dose of immediate-release verapamil is given one hour prior to dabigatran (AUC increased by factor of 2.4). If verapamil is given hours after dabigatran, the increase in AUC is negligible. In the population pharmacokinetics study from RE-LY, no important changes in dabigatran trough levels were observed in patients who received verapamil.Amiodarone: When dabigatran etexilate was coadministered with single 600 mg oral dose of amiodarone, the dabigatran AUC and Cmax increased by 58% and 50%, respectively. The increase in exposure was mitigated by 65% increase in the renal clearance of dabigatran in the presence of amiodarone. The increase in renal clearance may persist after amiodarone is discontinued because of amiodarones long half-life. In the population pharmacokinetics study from RE-LY, no important changes in dabigatran trough levels were observed in patients who received amiodarone.Quinidine: Quinidine was given as 200 mg dose every hours up to total dose of 1000 mg. Dabigatran etexilate was given over consecutive days, the last evening dose on Day with or without quinidine pre-dosing. Concomitant quinidine administration increased dabigatrans AUC and Cmax by 53% and 56%, respectively.Clarithromycin: Coadministered clarithromycin had no impact on the exposure to dabigatran.. Other Drugs. Clopidogrel: When dabigatran etexilate was given concomitantly with loading dose of 300 mg or 600 mg clopidogrel, the dabigatran AUC and Cmax increased by approximately 30% and 40%, respectively. The concomitant administration of dabigatran etexilate and clopidogrel resulted in no further prolongation of capillary bleeding times compared to clopidogrel monotherapy. When comparing combined treatment and the respective mono-treatments, the coagulation measures for dabigatrans effect (aPTT, ECT, and TT) remained unchanged, and inhibition of platelet aggregation (IPA), measurement of clopidogrels effect, remained unchanged.Enoxaparin: Enoxaparin 40 mg given subcutaneously for days with the last dose given 24 hours before single dose of PRADAXA had no impact on the exposure to dabigatran or the coagulation measures aPTT, ECT, or TT.Diclofenac, Ranitidine, and Digoxin: None of these drugs alters exposure to dabigatran.In RE-LY, dabigatran plasma samples were also collected. The concomitant use of proton pump inhibitors, H2 antagonists, and digoxin did not appreciably change the trough concentration of dabigatran.. Impact of Dabigatran on Other DrugsIn clinical studies exploring CYP3A4, CYP2C9, P-gp and other pathways, dabigatran did not meaningfully alter the pharmacokinetics of amiodarone, atorvastatin, clarithromycin, diclofenac, clopidogrel, digoxin, pantoprazole, or ranitidine.

PREGNULLNCY SECTION.


8.1 Pregnancy. Pregnancy Category C. There are no adequate and well-controlled studies in pregnant women.Dabigatran has been shown to decrease the number of implantations when male and female rats were treated at dosage of 70 mg/kg (about 2.6 to 3.0 times the human exposure at maximum recommended human dose [MRHD] of 300 mg/day based on area under the curve [AUC] comparisons) prior to mating and up to implantation (gestation Day 6). Treatment of pregnant rats after implantation with dabigatran at the same dose increased the number of dead offspring and caused excess vaginal/uterine bleeding close to parturition. Although dabigatran increased the incidence of delayed or irregular ossification of fetal skull bones and vertebrae in the rat, it did not induce major malformations in rats or rabbits.

SPL UNCLASSIFIED SECTION.


2.1 Recommended Dose. For patients with creatinine clearance (CrCl) >30 mL/min, the recommended dose of PRADAXA is 150 mg taken orally, twice daily, with or without food. For patients with CrCl 15-30 mL/min, the recommended dose is 75 mg twice daily [see Use in Specific Populations (8.6) and Clinical Pharmacology (12.3)]. Dosing recommendations for patients with CrCL <15 mL/min or on dialysis cannot be provided.Instruct patients to swallow the capsules whole. Breaking, chewing, or emptying the contents of the capsule can result in increased exposure [see Clinical Pharmacology (12.3)].If dose of PRADAXA is not taken at the scheduled time, the dose should be taken as soon as possible on the same day; the missed dose should be skipped if it cannot be taken at least hours before the next scheduled dose. The dose of PRADAXA should not be doubled to make up for missed dose.

USE IN SPECIFIC POPULATIONS SECTION.


8 USE IN SPECIFIC POPULATIONS. Geriatric use: Risk of bleeding increases with age (8.5) 8.1 Pregnancy. Pregnancy Category C. There are no adequate and well-controlled studies in pregnant women.Dabigatran has been shown to decrease the number of implantations when male and female rats were treated at dosage of 70 mg/kg (about 2.6 to 3.0 times the human exposure at maximum recommended human dose [MRHD] of 300 mg/day based on area under the curve [AUC] comparisons) prior to mating and up to implantation (gestation Day 6). Treatment of pregnant rats after implantation with dabigatran at the same dose increased the number of dead offspring and caused excess vaginal/uterine bleeding close to parturition. Although dabigatran increased the incidence of delayed or irregular ossification of fetal skull bones and vertebrae in the rat, it did not induce major malformations in rats or rabbits.. 8.2 Labor and Delivery. Safety and effectiveness of PRADAXA during labor and delivery have not been studied in clinical trials. Consider the risks of bleeding and of stroke in using PRADAXA in this setting [see Warnings and Precautions (5.1)].Death of offspring and mother rats during labor in association with uterine bleeding occurred during treatment of pregnant rats from implantation (gestation Day 7) to weaning (lactation Day 21) with dabigatran at dose of 70 mg/kg (about 2.6 times the human exposure at MRHD of 300 mg/day based on AUC comparisons).. 8.3 Nursing Mothers. It is not known whether dabigatran is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when PRADAXA is administered to nursing woman.. 8.4 Pediatric Use. Safety and effectiveness of PRADAXA in pediatric patients has not been established.. 8.5 Geriatric Use. Of the total number of patients in the RE-LY study, 82% were 65 and over, while 40% were 75 and over. The risk of stroke and bleeding increases with age, but the risk-benefit profile is favorable in all age groups [see Warnings and Precautions (5), Adverse Reactions (6.1), and Clinical Studies (14)].. 8.6 Renal Impairment. No dose adjustment of PRADAXA is recommended in patients with mild or moderate renal impairment. Reduce the dose of PRADAXA in patients with severe renal impairment (CrCl 15-30 mL/min) [see Dosage and Administration (2.1)]. Dosing recommendations for patients with CrCl <15 mL/min or on dialysis cannot be provided.

WARNINGS AND PRECAUTIONS SECTION.


5 WARNINGS AND PRECAUTIONS. Risk of bleeding: PRADAXA can cause serious and, sometimes, fatal bleeding. Promptly evaluate signs and symptoms of blood loss. (5.1) Temporary discontinuation: Avoid lapses in therapy to minimize risk of stroke (5.2) P-gp inducers and inhibitors: Avoid coadministration of rifampin with PRADAXA because of effects on dabigatran exposure (5.3) Risk of bleeding: PRADAXA can cause serious and, sometimes, fatal bleeding. Promptly evaluate signs and symptoms of blood loss. (5.1) Temporary discontinuation: Avoid lapses in therapy to minimize risk of stroke (5.2) P-gp inducers and inhibitors: Avoid coadministration of rifampin with PRADAXA because of effects on dabigatran exposure (5.3) 5.1 Risk of Bleeding. PRADAXA increases the risk of bleeding and can cause significant and, sometimes, fatal bleeding. Risk factors for bleeding include the use of drugs that increase the risk of bleeding in general (e.g., anti-platelet agents, heparin, fibrinolytic therapy, and chronic use of NSAIDs) and labor and delivery. Promptly evaluate any signs or symptoms of blood loss (e.g., drop in hemoglobin and/or hematocrit or hypotension). Discontinue PRADAXA in patients with active pathological bleeding.In the RE-LY (Randomized Evaluation of Long-term Anticoagulant Therapy) study, life-threatening bleed (bleeding that met one or more of the following criteria: fatal, symptomatic intracranial, reduction in hemoglobin of at least grams per deciliter, transfusion of at least units of blood, associated with hypotension requiring the use of intravenous inotropic agents, or necessitating surgical intervention) occurred at an annualized rate of 1.5% and 1.8% for PRADAXA 150 mg and warfarin, respectively [see Adverse Reactions (6.1)].. 5.2 Temporary Discontinuation of PRADAXA. Discontinuing anticoagulants, including PRADAXA, for active bleeding, elective surgery, or invasive procedures places patients at an increased risk of stroke. Lapses in therapy should be avoided, and if anticoagulation with PRADAXA must be temporarily discontinued for any reason, therapy should be restarted as soon as possible.. 5.3 Effect of P-gp Inducers and Inhibitors on Dabigatran Exposure. The concomitant use of PRADAXA with P-gp inducers (e.g., rifampin) reduces exposure to dabigatran and should generally be avoided [see Clinical Pharmacology (12.3)].P-gp inhibitors ketoconazole, verapamil, amiodarone, quinidine, and clarithromycin do not require dose adjustments. These results should not be extrapolated to other P-gp inhibitors [see Clinical Pharmacology (12.3)].