HOW SUPPLIED SECTION.

16 HOW SUPPLIED/STORAGE AND HANDLING. How Supplied Nateglinide tablets, USP60 mg Pink, circular, biconvex tablet with WPI debossed on one side and 3354 on the other.Bottles of 100 NDC 0591-3354-01120 mg Pink, capsule-shaped, biconvex tablet with WPI debossed on one side and 3355 on the other.Bottles of 100 NDC 0591-3355-01Storage and HandlingStore at 20 to 25C (68 to 77F) [See USP Controlled Room Temperature].Dispense in tight container, USP.

INDICATIONS & USAGE SECTION.

1 INDICATIONS AND USAGE. Nateglinide tablets are indicated as an adjunct to diet and exercise to improve glycemic control in adults with type diabetes mellitus.Limitations of Use: Nateglinide should not be used in patients with type diabetes mellitus or for the treatment of diabetic ketoacidosis.. Nateglinide is glinide indicated as an adjunct to diet and exercise to improve glycemic control in adults with type diabetes mellitus. (1)Limitations of use: Not for treating type diabetes mellitus or diabetes ketoacidosis (1).

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following serious adverse reaction is also described elsewhere in the labeling:Hypoglycemia [see Warnings and Precautions (5.1)] Table 1. Adverse Reactions other than Hypoglycemia (%) occurring >= 2% in Nateglinide-Treated Patients from Pool of 12 to 64 week Placebo Controlled TrialsPlaceboNateglinideN=458N=1441Preferred TermUpper Respiratory Infection8.110.5Back Pain3.74.0Flu Symptoms2.63.6Dizziness2.23.6Arthropathy2.23.3Diarrhea3.13.2Accidental Trauma1.72.9Bronchitis2.62.7Coughing2.22.4HypoglycemiaEpisodes of severe hypoglycemia (plasma glucose less than 36 mg/dL) were reported in two patients treated with nateglinide. Non-severe hypoglycemia occurred in 2.4 of nateglinide treated patients and 0.4 of placebo treated patients [see Warnings and Precautions (5.1)].Weight GainPatients treated with nateglinide had statistically significant mean increases in weight compared to placebo. In clinical trials, the mean weight increases with nateglinide 60 mg (3 times daily) and nateglinide 120 mg (3 times daily) compared to placebo were 1.0 kg and 1.6 kg respectively.Laboratory TestIncreases in Uric Acid: There were increases in mean uric acid levels for patients treated with nateglinide alone, nateglinide in combination with metformin, metformin alone, and glyburide alone. The respective differences from placebo were 0.29 mg/dL, 0.45 mg/dL, 0.28 mg/dL, and 0.19 mg/dL.. Common adverse reactions associated with nateglinide (3% or greater incidence) were upper respiratory tract infection, back pain, flu symptoms, dizziness, arthropathy, diarrhea. (6.1)To report SUSPECTED ADVERSE REACTIONS, contact Actavis at 1-800-272-5525 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. Common adverse reactions associated with nateglinide (3% or greater incidence) were upper respiratory tract infection, back pain, flu symptoms, dizziness, arthropathy, diarrhea. (6.1). 6.1 Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. In clinical trials, approximately 2,600 patients with type diabetes mellitus were treated with nateglinide. Of these, approximately 1,335 patients were treated for months or longer and approximately 190 patients for one year or longer. Table shows the most common adverse reactions associated with nateglinide.. 6.2 Postmarketing Experience. The following adverse reactions have been identified during post-approval use of nateglinide. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure.Hypersensitivity reactions: Rash, itching, and urticariaHepatobiliary Disorders: Jaundice, cholestatic hepatitis, and elevated liver enzymes. Hypersensitivity reactions: Rash, itching, and urticaria. Hepatobiliary Disorders: Jaundice, cholestatic hepatitis, and elevated liver enzymes.

CARCINOGENESIS & MUTAGENESIS & IMPAIRMENT OF FERTILITY SECTION.

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. Carcinogenicity: Nateglinide did not increase tumors in two year carcinogenicity studies conducted in mice and rats. Oral doses of Nateglinide up to 900 mg/kg in rats and 400 mg/kg in mice were tested, which produced exposures in rats approximately 30 to 40 times and in mice 10 to 30 times the human therapeutic exposure of nateglinide at dose of 120 mg three times daily, based on AUC.Mutagenesis: Nateglinide was not genotoxic in the in vitro Ames test, mouse lymphoma assay, chromosome aberration assay or in the in vivo mouse micronucleus test.Impairment of Fertility: Fertility was unaffected by administration of nateglinide to rats at doses up to 600 mg/kg (approximately 16 times the human therapeutic exposure with recommended nateglinide dose of 120 mg three times daily before meals).

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Nateglinide lowers blood glucose levels by stimulating insulin secretion from the pancreas. This action is dependent upon functioning beta-cells in the pancreatic islets. Nateglinide interacts with the ATP-sensitive potassium (K+ATP) channel on pancreatic beta-cells. The subsequent depolarization of the beta cell opens the calcium channel, producing calcium influx and insulin secretion. The extent of insulin release is glucose dependent and diminishes at low glucose levels. Nateglinide is highly tissue selective with low affinity for heart and skeletal muscle.. 12.2 Pharmacodynamics. Nateglinide stimulates pancreatic insulin secretion within 20 minutes of oral administration. When nateglinide is dosed before meals, the peak rise in plasma insulin occurs approximately hour after dosing and falls to baseline by hours after dosing.. 12.3 Pharmacokinetics. In patients with Type diabetes, multiple dose administration of nateglinide over the dosage range of 60 mg to 240 mg shows linear pharmacokinetics for both AUC and Cmax. In patients with Type diabetes, there is no apparent accumulation of nateglinide upon multiple dosing of up to 240 mg three times daily for days.AbsorptionAbsolute bioavailability of nateglinide is approximately 73%. Plasma profiles are characterized by multiple plasma concentration peaks when nateglinide is administered under fasting conditions. This effect is diminished when nateglinide is taken prior to meal. Following oral administration immediately prior to meal, the mean peak plasma nateglinide concentrations (Cmax) generally occur within hour (Tmax) after dosing. Tmax is independent of dose.The pharmacokinetics of nateglinide are not affected by the composition of meal (high protein, fat, or carbohydrate). However, peak plasma levels are significantly reduced when nateglinide is administered 10 minutes prior to liquid meal as compared to solid meal. When given with or after meals, the extent of nateglinide absorption (AUC) remains unaffected. However, there is delay in the rate of absorption characterized by decrease in Cmax and delay in time to peak plasma concentration (Tmax).Nateglinide did not have any effect on gastric emptying in healthy subjects as assessed by acetaminophen testing. DistributionFollowing intravenous (IV) administration of nateglinide, the steady-state volume of distribution of nateglinide is estimated to be approximately 10 in healthy subjects. Nateglinide is extensively bound (98%) to serum proteins, primarily serum albumin, and to lesser extent acid glycoprotein. The extent of serum protein binding is independent of drug concentration over the test range of 0.1 to 10 mcg/mL.EliminationIn healthy volunteers and patients with type diabetes mellitus, nateglinide plasma concentrations declined with an average elimination half-life of approximately 1.5 hours.MetabolismIn vitro drug metabolism studies indicate that nateglinide is predominantly metabolized by the cytochrome P450 isozyme CYP2C9 (70%) and to lesser extent CYP3A4 (30%).The major routes of metabolism are hydroxylation followed by glucuronide conjugation. The major metabolites are less potent antidiabetic agents than nateglinide. The isoprene minor metabolite possesses potency similar to that of the parent compound nateglinide.ExcretionNateglinide and its metabolites are rapidly and completely eliminated following oral administration. Eighty-three percent of the 14C-nateglinide was excreted in the urine with an additional 10% eliminated in the feces. Approximately 16% of the 14C-nateglinide was excreted in the urine as parent compound.Specific PopulationsRenal ImpairmentNo pharmacokinetic data are available in subjects with mild renal impairment (CrCl 60 to 89 mL/min). Compared to healthy matched subjects, patients with type diabetes mellitus and moderate and severe renal impairment (CrCl 15 to 50 mL/min) not on dialysis displayed similar apparent clearance, AUC, and Cmax. Patients with type diabetes and renal failure on dialysis exhibited reduced overall drug exposure (Cmax decreased by 49%; not statistically significant). However, hemodialysis patients also experienced reductions in plasma protein binding compared to the matched healthy volunteers.Hepatic ImpairmentIn patients with mild hepatic impairment, the mean increase in Cmax and AUC of nateglinide were 37% and 30 respectively, as compared to healthy matched control subjects. There is no data on pharmacokinetics of nateglinide in patients with moderate-to-severe hepatic impairment.GenderNo clinically significant differences in nateglinide pharmacokinetics were observed between men and women.RaceResults of population pharmacokinetic analysis including subjects of Caucasian, Black, and other ethnic origins suggest that race has little influence on the pharmacokinetics of nateglinide.AgeAge does not influence the pharmacokinetic properties of nateglinide.Drug Interactions:In vitro assessment of drug interactionsNateglinide is potential inhibitor of the CYP2C9 isoenzyme in vivo as indicated by its ability to inhibit the in vitro metabolism of tolbutamide. Inhibition of CYP3A4 metabolic reactions was not detected in in vitro experiments.In vitro displacement studies with highly protein-bound drugs such as furosemide, propranolol, captopril, nicardipine, pravastatin, glyburide, warfarin, phenytoin, acetylsalicylic acid, tolbutamide, and metformin showed no influence on the extent of nateglinide protein binding. Similarly, nateglinide had no influence on the serum protein binding of propranolol, glyburide, nicardipine, warfarin, phenytoin, acetylsalicylic acid, and tolbutamide in vitro. However, prudent evaluation of individual cases is warranted in the clinical setting.In vivo assessment of drug interactions The effect of coadministered drugs on the pharmacokinetics of nateglinide and the effect of nateglinide on pharmacokinetics of coadministered drugs are shown in Tables and 4. No clinically relevant change in pharmacokinetic parameters of either agent was reported when nateglinide was coadministered with glyburide, metformin, digoxin, warfarin, and diclofenac.Table 3. Effect of Coadministered drugs on Pharmacokinetics of NateglinideCoadministered drugDosing regimen of coadministered drugDosing regimen of nateglinideChange in Cmax Change in AUCGlyburide10 mg once daily for weeks120 mg three times day, single dose8.78% 3.53% Metformin500 mg three times aday for weeks120 mg three times day, single doseAM: 7.14% PM: 11.4% AM: 1.51% PM: 5.97% Digoxin1 mg, single dose120 mg three times day, single doseAM: 2.17% PM: 3.19% AM: 7.62% PM: 2.22% Warfarin30 mg, single dose120 mg three times day for days2.65% 3.72% Diclofenac75 mg, single dose120 mg twice daily,single doseAM: 13.23% PM: 3.76% AM: 2.2% PM: 7.5% AM: after morning dose; PM: after evening dose; after second dose; increase in the parameter; decrease in the parameterTable 4. Effect of Nateglinide on Pharmacokinetics of Coadministered DrugsCoadministered drugDosing regimen of coadministered drugDosing regimen of nateglinideChange in Cmax Change in AUCGlyburide10 mg once daily for weeks120 mg three times day, single dose3.18% 7.34% Metformin500 mg three times day for weeks120 mg three times day, single doseAM: 10.7% PM: 0.40% AM: 13.3% PM: 2.27% Digoxin1 mg, single dose120 mg three times day, single dose5.41% 6.58% Warfarin30 mg, single dose120 mg three times day for daysR-warfarin: 1.03% S-warfarin: 0.85% R-warfarin: 0.74% S-warfarin: 7.23% Diclofenac75 mg, single dose120 mg twice daily, single dose2.19% 7.97% AM: after morning dose; PM: after evening dose; SD: single dose; increase in the parameter; decrease in the parameter.

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. 14.1 Monotherapy. In 24-week, double-blind, placebo-controlled study, patients with type diabetes were randomized to receive either nateglinide (60 mg or 120 mg three times daily before meals) or placebo. Patients previously treated with antidiabetic medications were required to discontinue that medication for at least months before randomization. At Week 24, treatment with nateglinide before meals resulted in statistically significant reductions in mean HbA1C and mean fasting plasma glucose (FPG) compared to placebo (see Table 5). The reductions in HbA1C and FPG were similar for patients naive to, and those previously exposed to, antidiabetic medications.Table 5. Endpoint results for 24-week, fixed dose study of nateglinide monotherapyHbA 1C (%)PlaceboN=168Nateglinide 60 mg three times daily before mealsN=167Nateglinide 120 mg three times daily before mealsN=168Baseline (mean)Change from baseline (mean)Difference from placebo (mean)FPG (mg/dL)8.0+0.2N=1727.9-0.3-0.5 N=1718.1-0.5-0.7 N=169Baseline (mean)Change from baseline (mean)Difference from placebo (mean) 167.9+9.1161.0+0.4-8.7 166.5-4.5-13.6 a p-value <= 0.004. 14.2 MonotherapyCompared to Glyburide. In 24-week, double-blind, active-controlled trial, patients with type diabetes who had been on sulfonylurea for or more months and who had baseline HbA1C greater than or equal to 6.5% were randomized to receive nateglinide (60 mg or 120 mg three times daily before meals) or glyburide 10 mg once daily. Patients randomized to nateglinide had significant increases in mean HbA1C and mean FPG at endpoint compared to patients randomized to glyburide.Table 6. Endpoint results for 24-week study of nateglinide monotherapy compared to glyburideGlyburide10 mgOnce dailyNateglinide60 mgthree times dailybefore mealsNateglinide120 mgthree times dailybefore mealsHbA1C (%)N=183N=178N=179Baseline (mean)7.88.07.9Change from baseline (mean)0.31.31.1Difference from glyburide1.0 0.9 FPG (mmol/L)N=184N=182N=180Baseline (mean)9.449.679.61Change from baseline (mean)0.193.062.84Difference from glyburide2.87 2.66 a p-value <0.001. 14.3 Monotherapy and in Combination withMetformin. In 24-week, double-blind, active- and placebo-controlled study, patients with type diabetes were randomized to receive either nateglinide alone (120 mg three times daily before meals), metformin alone (500 mg three times daily), combination of nateglinide 120 mg (three times daily before meals) and metformin (500 mg three times daily), or placebo. Fifty-seven percent of patients were previously untreated with oral antidiabetic therapy. Patients previously treated with antidiabetic medications were required to discontinue medication for at least months before randomization.At Week 24, statistically significant reductions in mean HbA1c and FPG were observed with metformin monotherapy compared to nateglinide monotherapy, and the combination of nateglinide and metformin compared to either nateglinide or metformin monotherapy (see Table 7).Compared to placebo, nateglinide monotherapy was associated with statistically significant increase in mean body weight, while no significant change in body weight was observed with metformin monotherapy or combination of nateglinide and metformin therapy (see Table 7). Among the subset of patients previously treated with other antidiabetic agents, primarily glyburide, HbA1C in the nateglinide monotherapy group increased slightly from baseline, whereas HbA1C was reduced in the metformin monotherapy group (see Table 7).Table 7. Endpoint results for 24-week study of nateglinide monotherapy and combination with metforminHbA1C (%)AllPlaceboN=160Nateglinide120 mgthree times dailybefore mealsN=171Metformin500 mgthree times dailyN=172Nateglinide120 mgbefore meals plus MetforminN=162Baseline (mean)8.38.38.48.4Change from baseline (mean)+0.4-0.4 bc -0.8 -1.5Difference from placebo-0.8 -1.2 -1.9 NaiveN=98N=99N=98N=81Baseline (mean)8.28.18.38.2Change from baseline (mean)+0.3-0.7 -0.8 -1.6Difference from placebo-1.0 -1.1 -1.9 Non-NaiveN=62N=72N=74N=81Baseline (mean)8.38.58.78.7Change from baseline (mean) +0.6+0.004 bc -0.8 -1.4Difference from placebo-0.6 -1.4 -2.0 FPG (mg/dL) AllN=166N=173N=174N=167Baseline (mean)194.0196.5196.0197.7Change from baseline (mean) +8.0-13.1 bc -30.0 -44.9Difference from placebo-21.1 -38.0 -52.9 a p-value <= 0.05 vs. placebo p-value <= 0.03 vs. metformin p-value <= 0.05 vs. combination Metformin was administered three times dailyIn another 24-week, double-blind, placebo-controlled trial, patients with type diabetes with HbA1C greater than or equal to 6.8% after treatment with metformin (greater than or equal to 1500 mg daily for at least month) were first entered into four week run-in period of metformin monotherapy (2000 mg daily) and then randomized to receive either nateglinide (60 mg or 120 mg three times daily before meals) or placebo as add-on to metformin. At the end of treatment, nateglinide 60 mg and 120 mg three times daily resulted in statistically significantly greater reductions in HbA1C compared to placebo when added to metformin (-0.4% and -0.6% for nateglinide 60 mg and nateglinide 120 mg plus metformin, respectively).Table 8. Endpoint results for 24-week study of nateglinide monotherapy as add-on to metforminPlacebo metforminNateglinide 60 mg metforminNateglinide 120 mg metforminHbA1C (%) N=150N=152N=154Baseline (mean)8.28.08.2Change from baseline (mean)0.01-0.4-0.6Difference from metformin-0.4 -0.6 a p-value 0.003 vs. metforminb p-value 0.001 vs. metforminAll nateglinide/placebo taken three times daily before meals; all metformin 1000 mg twice daily. 14.4 Add-On Combination Therapy withRosiglitazone. 24-week, double blind, multicenter, placebo-controlled trial was performed in patients with type diabetes not adequately controlled on rosiglitazone mg daily. The addition of nateglinide (120 mg three times per day with meals) was associated with statistically significantly greater reductions in HbA1C compared to placebo as add-on to rosiglitazone. The mean change in weight from baseline was +3 kg for patients treated with nateglinide compared to +1 kg for patients treated with placebo when added to rosiglitazone.Table 9. Endpoint results for 24-week study of the effect of adding nateglinide or placebo to rosiglitazonePlacebo rosiglitazone mg once dailyNateglinide 120 mg before meals rosiglitazone mg once dailyHbA1C (%)N=191N=194Baseline (mean)8.48.3Change from baseline (mean)0.03-0.7Difference from rosiglitazone (mean)-0.7 a p-value <= 0.0001. 14.5 Add-On Combination Therapy with Glyburide. In 12-week study of patients with type diabetes inadequately controlled on glyburide 10 mg once daily, the addition of nateglinide (60 mg or 120 mg three times daily before meals) did not produce any additional benefit.Table 10. Endpoint results for 12-week study of the effect of adding nateglinide or placebo to glyburidePlacebo glyburide 10 mg once dailyNateglinide 60 mg before meals glyburide 10 mg once dailyNateglinide 120 mg before meals glyburide 10 mg once dailyHbA1C (%)N=58N=55N=54Baseline (mean)8.78.78.7Change from baseline (mean)0.30.2-0.02Difference from glyburide (mean)-0.1 -0.3 Placebo or nateglinide given 10 minutes prior to breakfast, lunch, and dinner; glyburide given with the breakfast dose of nateglinide or placebo.a p-value 0.6959b p-value 0.1246.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. Nateglinide is contraindicated in patients with history of hypersensitivity to nateglinide or its active ingredients.. History of hypersensitivity to nateglinide inactive ingredients (4). History of hypersensitivity to nateglinide inactive ingredients (4).

DESCRIPTION SECTION.

11 DESCRIPTION. Nateglinide, USP is an oral blood glucose-lowering drug of the glinide class. Nateglinide, (-)-N-[(trans-4-isopropylcyclohexane)carbonyl]-D-phenylalanine, is structurally unrelated to the oral sulfonylurea insulin secretagogues. The structural formula is as shown:Nateglinide, USP is white powder with molecular weight of 317.43. It is freely soluble in methanol, ethanol, and chloroform, soluble in ether, sparingly soluble in acetonitrile and octanol, and practically insoluble in water. Nateglinide biconvex tablets contain 60 mg, or 120 mg, of nateglinide, USP for oral administration.Inactive Ingredients: colloidal silicon dioxide, fumaric acid, hypromellose, iron oxide (black and red), lactose monohydrate, alpha-lactose monohydrate, magnesium stearate, polysorbate 80, sodium starch glycolate, starch (maize), titanium dioxide, and FD&C red No. 40 aluminum lake.. 1.

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. The recommended dose of nateglinide tablets is 120 mg orally three times daily before meals.The recommended dose of nateglinide tablets is 60 mg orally three times daily before meals in patients who are near glycemic goal when treatment is initiated.Instruct patients to take nateglinide tablets to 30 minutes before meals. In patients who skip meals, instruct patients to skip the scheduled dose of nateglinide tablets to reduce the risk of hypoglycemia [see Warnings and Precautions (5.1)].. Recommended dose is 120 mg three times daily.In patients who are near glycemic goal when treatment is initiated, 60 mg three times daily may be administered. (2)Administer to 30 minutes before meals. (2)If meal is skipped, skip the scheduled dose to reduce the risk of hypoglycemia. (2, 5.1). Recommended dose is 120 mg three times daily.. In patients who are near glycemic goal when treatment is initiated, 60 mg three times daily may be administered. (2). Administer to 30 minutes before meals. (2). If meal is skipped, skip the scheduled dose to reduce the risk of hypoglycemia. (2, 5.1).

DOSAGE FORMS & STRENGTHS SECTION.

3 DOSAGE FORMS AND STRENGTHS. 60 mg tablets: pink, circular, biconvex tablet with WPI debossed on one side and 3354 on the other.120 mg tablets: pink, capsule-shaped, biconvex tablet with WPI debossed on one side and 3355 on the other.. 60 mg tablets: pink, circular, biconvex tablet with WPI debossed on one side and 3354 on the other.. 120 mg tablets: pink, capsule-shaped, biconvex tablet with WPI debossed on one side and 3355 on the other.. Tablets: 60 mg and 120 mg (3).

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. Table includes list of drugs with clinically important drug interactions when concomitantly administered or withdrawn with nateglinide and instructions for managing or preventing them.Table 2. Clinically Significant Drug Interactions with NateglinideDrugs That May Increase the Blood-Glucose-Lowering Effect of Nateglinide and Susceptibility to HypoglycemiaDrugs:Nonsteroidal anti-inflammatory drugs (NSAIDs), salicylates, monoamine oxidase inhibitors, non-selective beta-adrenergic-blocking agents, anabolic hormones (e.g. methandrostenolone), guanethidine, gymnema sylvestre, glucomannan, thioctic acid, and inhibitors of CYP2C9 (e.g. amiodarone, fluconazole, voriconazole, sulfinpyrazone), alcohol.Intervention:Dose reductions and increased frequency of glucose monitoring may be required when nateglinide is coadministered with these drugs.Drugs and Herbals That May Reduce the Blood-Glucose-Lowering Effect of Nateglinide and Increase Susceptibility to HyperglycemiaDrugs:Thiazides, corticosteroids, thyroid products, sympathomimetics, somatropin, somatostatin analogues (e.g. lanreotide, octreotide), and CYP inducers (e.g. rifampin, phenytoin and St Johns Wort).Intervention:Dose increases and increased frequency of glucose monitoring may be required when nateglinide is coadministered with these drugs.Drugs That May Blunt Signs and Symptoms of HypoglycemiaDrugs:beta-blockers, clonidine, guanethidine, and reserpineIntervention:Increased frequency of glucose monitoring may be required when nateglinide is coadministered with these drugs.. Drugs That May Increase the Potential for Hypoglycemia: Nateglinide dose reductions and increased frequency of glucose monitoring may be required when coadministered (7)Drugs That May Increase the Potential for Hyperglycemia: Nateglinide dose increases and increased frequency of glucose monitoring may be required when coadministered (7)Drugs That May Blunt Signs and Symptoms of Hypoglycemia: Increased frequency of glucose monitoring may be required when coadministered (7). Drugs That May Increase the Potential for Hypoglycemia: Nateglinide dose reductions and increased frequency of glucose monitoring may be required when coadministered (7). Drugs That May Increase the Potential for Hyperglycemia: Nateglinide dose increases and increased frequency of glucose monitoring may be required when coadministered (7). Drugs That May Blunt Signs and Symptoms of Hypoglycemia: Increased frequency of glucose monitoring may be required when coadministered (7).

GERIATRIC USE SECTION.

8.5 Geriatric Use. 436 patients 65 years and older, and 80 patients 75 years and older were exposed to nateglinide in clinical studies. No differences were observed in safety or efficacy of nateglinide between patients age 65 and over, and those under age 65. However, greater sensitivity of some older individuals to nateglinide therapy cannot be ruled out.

INFORMATION FOR PATIENTS SECTION.

17 PATIENT COUNSELING INFORMATION. AdministrationInstruct patients to take nateglinide to 30 minutes before meals. Instruct patients that skip meals to skip their dose of nateglinide [see Dosage and Administration (2)].HypoglycemiaInform patients that nateglinide can cause hypoglycemia and instruct patients and their caregivers on self-management procedures including glucose monitoring and management of hypoglycemia. Inform patients that their ability to concentrate and react may be impaired as result of hypoglycemia. In patients at higher risk for hypoglycemia and patients who have reduced symptomatic awareness of hypoglycemia, increased frequency of blood glucose monitoring is recommended [see Warnings and Precautions (5.1)].Drug InteractionsDiscuss potential drug interactions with patients and inform them of potential drug-drug interactions with nateglinide.Manufactured by: Cipla Ltd. Verna Goa, INDIADistributed by: Actavis Pharma, Inc. Parsippany, NJ 07054 USA Revised: March 2017.

MECHANISM OF ACTION SECTION.

12.1 Mechanism of Action. Nateglinide lowers blood glucose levels by stimulating insulin secretion from the pancreas. This action is dependent upon functioning beta-cells in the pancreatic islets. Nateglinide interacts with the ATP-sensitive potassium (K+ATP) channel on pancreatic beta-cells. The subsequent depolarization of the beta cell opens the calcium channel, producing calcium influx and insulin secretion. The extent of insulin release is glucose dependent and diminishes at low glucose levels. Nateglinide is highly tissue selective with low affinity for heart and skeletal muscle.

NONCLINICAL TOXICOLOGY SECTION.

13 NONCLINICAL TOXICOLOGY. 13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility. Carcinogenicity: Nateglinide did not increase tumors in two year carcinogenicity studies conducted in mice and rats. Oral doses of Nateglinide up to 900 mg/kg in rats and 400 mg/kg in mice were tested, which produced exposures in rats approximately 30 to 40 times and in mice 10 to 30 times the human therapeutic exposure of nateglinide at dose of 120 mg three times daily, based on AUC.Mutagenesis: Nateglinide was not genotoxic in the in vitro Ames test, mouse lymphoma assay, chromosome aberration assay or in the in vivo mouse micronucleus test.Impairment of Fertility: Fertility was unaffected by administration of nateglinide to rats at doses up to 600 mg/kg (approximately 16 times the human therapeutic exposure with recommended nateglinide dose of 120 mg three times daily before meals).

NURSING MOTHERS SECTION.

8.3 Nursing Mothers. It is not known whether nateglinide is excreted in human milk. Nateglinide is excreted in rat milk. Offspring of rats exposed to 1,000 mg/kg nateglinide (approximately 27 times the human therapeutic exposure of 120 mg three times daily, based on body surface area) had lower body weight. Because the potential for hypoglycemia in nursing infants may exist, decision should be made as to whether nateglinide should be discontinued in nursing mothers, or if mothers should discontinue nursing.

OVERDOSAGE SECTION.

10 OVERDOSAGE. There have been no instances of overdose with nateglinide in clinical trials. However, an overdose may result in an exaggerated glucose-lowering effect with the development of hypoglycemic symptoms. Hypoglycemic symptoms without loss of consciousness or neurological findings should be treated with oral glucose and adjustments in dosage and/or meal patterns. Severe hypoglycemic reactions with coma, seizure, or other neurological symptoms should be treated with intravenous glucose. As nateglinide is highly protein bound, dialysis is not an efficient means of removing it from the blood.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL.

PACKAGE LABEL.PRINCIPAL DISPLAY PANEL. NDC 0591-3354-01Nateglinide Tablets, USP60 mg100 TabletsActavisRx Only. 1.

PEDIATRIC USE SECTION.

8.4 Pediatric Use. The safety and effectiveness of nateglinide have not been established in pediatric patients.

PHARMACODYNAMICS SECTION.

12.2 Pharmacodynamics. Nateglinide stimulates pancreatic insulin secretion within 20 minutes of oral administration. When nateglinide is dosed before meals, the peak rise in plasma insulin occurs approximately hour after dosing and falls to baseline by hours after dosing.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. In patients with Type diabetes, multiple dose administration of nateglinide over the dosage range of 60 mg to 240 mg shows linear pharmacokinetics for both AUC and Cmax. In patients with Type diabetes, there is no apparent accumulation of nateglinide upon multiple dosing of up to 240 mg three times daily for days.AbsorptionAbsolute bioavailability of nateglinide is approximately 73%. Plasma profiles are characterized by multiple plasma concentration peaks when nateglinide is administered under fasting conditions. This effect is diminished when nateglinide is taken prior to meal. Following oral administration immediately prior to meal, the mean peak plasma nateglinide concentrations (Cmax) generally occur within hour (Tmax) after dosing. Tmax is independent of dose.The pharmacokinetics of nateglinide are not affected by the composition of meal (high protein, fat, or carbohydrate). However, peak plasma levels are significantly reduced when nateglinide is administered 10 minutes prior to liquid meal as compared to solid meal. When given with or after meals, the extent of nateglinide absorption (AUC) remains unaffected. However, there is delay in the rate of absorption characterized by decrease in Cmax and delay in time to peak plasma concentration (Tmax).Nateglinide did not have any effect on gastric emptying in healthy subjects as assessed by acetaminophen testing. DistributionFollowing intravenous (IV) administration of nateglinide, the steady-state volume of distribution of nateglinide is estimated to be approximately 10 in healthy subjects. Nateglinide is extensively bound (98%) to serum proteins, primarily serum albumin, and to lesser extent acid glycoprotein. The extent of serum protein binding is independent of drug concentration over the test range of 0.1 to 10 mcg/mL.EliminationIn healthy volunteers and patients with type diabetes mellitus, nateglinide plasma concentrations declined with an average elimination half-life of approximately 1.5 hours.MetabolismIn vitro drug metabolism studies indicate that nateglinide is predominantly metabolized by the cytochrome P450 isozyme CYP2C9 (70%) and to lesser extent CYP3A4 (30%).The major routes of metabolism are hydroxylation followed by glucuronide conjugation. The major metabolites are less potent antidiabetic agents than nateglinide. The isoprene minor metabolite possesses potency similar to that of the parent compound nateglinide.ExcretionNateglinide and its metabolites are rapidly and completely eliminated following oral administration. Eighty-three percent of the 14C-nateglinide was excreted in the urine with an additional 10% eliminated in the feces. Approximately 16% of the 14C-nateglinide was excreted in the urine as parent compound.Specific PopulationsRenal ImpairmentNo pharmacokinetic data are available in subjects with mild renal impairment (CrCl 60 to 89 mL/min). Compared to healthy matched subjects, patients with type diabetes mellitus and moderate and severe renal impairment (CrCl 15 to 50 mL/min) not on dialysis displayed similar apparent clearance, AUC, and Cmax. Patients with type diabetes and renal failure on dialysis exhibited reduced overall drug exposure (Cmax decreased by 49%; not statistically significant). However, hemodialysis patients also experienced reductions in plasma protein binding compared to the matched healthy volunteers.Hepatic ImpairmentIn patients with mild hepatic impairment, the mean increase in Cmax and AUC of nateglinide were 37% and 30 respectively, as compared to healthy matched control subjects. There is no data on pharmacokinetics of nateglinide in patients with moderate-to-severe hepatic impairment.GenderNo clinically significant differences in nateglinide pharmacokinetics were observed between men and women.RaceResults of population pharmacokinetic analysis including subjects of Caucasian, Black, and other ethnic origins suggest that race has little influence on the pharmacokinetics of nateglinide.AgeAge does not influence the pharmacokinetic properties of nateglinide.Drug Interactions:In vitro assessment of drug interactionsNateglinide is potential inhibitor of the CYP2C9 isoenzyme in vivo as indicated by its ability to inhibit the in vitro metabolism of tolbutamide. Inhibition of CYP3A4 metabolic reactions was not detected in in vitro experiments.In vitro displacement studies with highly protein-bound drugs such as furosemide, propranolol, captopril, nicardipine, pravastatin, glyburide, warfarin, phenytoin, acetylsalicylic acid, tolbutamide, and metformin showed no influence on the extent of nateglinide protein binding. Similarly, nateglinide had no influence on the serum protein binding of propranolol, glyburide, nicardipine, warfarin, phenytoin, acetylsalicylic acid, and tolbutamide in vitro. However, prudent evaluation of individual cases is warranted in the clinical setting.In vivo assessment of drug interactions The effect of coadministered drugs on the pharmacokinetics of nateglinide and the effect of nateglinide on pharmacokinetics of coadministered drugs are shown in Tables and 4. No clinically relevant change in pharmacokinetic parameters of either agent was reported when nateglinide was coadministered with glyburide, metformin, digoxin, warfarin, and diclofenac.Table 3. Effect of Coadministered drugs on Pharmacokinetics of NateglinideCoadministered drugDosing regimen of coadministered drugDosing regimen of nateglinideChange in Cmax Change in AUCGlyburide10 mg once daily for weeks120 mg three times day, single dose8.78% 3.53% Metformin500 mg three times aday for weeks120 mg three times day, single doseAM: 7.14% PM: 11.4% AM: 1.51% PM: 5.97% Digoxin1 mg, single dose120 mg three times day, single doseAM: 2.17% PM: 3.19% AM: 7.62% PM: 2.22% Warfarin30 mg, single dose120 mg three times day for days2.65% 3.72% Diclofenac75 mg, single dose120 mg twice daily,single doseAM: 13.23% PM: 3.76% AM: 2.2% PM: 7.5% AM: after morning dose; PM: after evening dose; after second dose; increase in the parameter; decrease in the parameterTable 4. Effect of Nateglinide on Pharmacokinetics of Coadministered DrugsCoadministered drugDosing regimen of coadministered drugDosing regimen of nateglinideChange in Cmax Change in AUCGlyburide10 mg once daily for weeks120 mg three times day, single dose3.18% 7.34% Metformin500 mg three times day for weeks120 mg three times day, single doseAM: 10.7% PM: 0.40% AM: 13.3% PM: 2.27% Digoxin1 mg, single dose120 mg three times day, single dose5.41% 6.58% Warfarin30 mg, single dose120 mg three times day for daysR-warfarin: 1.03% S-warfarin: 0.85% R-warfarin: 0.74% S-warfarin: 7.23% Diclofenac75 mg, single dose120 mg twice daily, single dose2.19% 7.97% AM: after morning dose; PM: after evening dose; SD: single dose; increase in the parameter; decrease in the parameter.

PREGNANCY SECTION.

8.1 Pregnancy. Pregnancy Category CThere are no adequate and well-controlled studies of nateglinide in pregnant women. It is unknown whether nateglinide can cause fetal harm when administered to pregnant woman. Nateglinide should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.In the rabbit, embryonic development was adversely affected and the incidence of gall bladder agenesis or small gallbladder was increased at dose of 500 mg/kg (approximately 27 times the human therapeutic exposure of 120 mg three times daily, based on body surface area). Nateglinide was not teratogenic in rats at doses up to 1,000 mg/kg (approximately 27 times the human therapeutic exposure based on body surface area).

SPL UNCLASSIFIED SECTION.

5.1 Hypoglycemia. All glinides, including nateglinide, can cause hypoglycemia [see Adverse Reactions (6.1)]. Severe hypoglycemia can cause seizures, may be life-threatening, or cause death. Hypoglycemia can impair concentration ability and reaction time; this may place an individual and others at risk in situations where these abilities are important (e.g., driving or operating other machinery).Hypoglycemia can happen suddenly and symptoms may differ in each individual and change over time in the same individual. Symptomatic awareness of hypoglycemia may be less pronounced in patients with longstanding diabetes, in patients with diabetic neuropathy (nerve disease), in patients using medications that block the sympathetic nervous system (e.g., beta-blockers) [see Drug Interactions (7)], or in patients who experience recurrent hypoglycemia.Factors which may increase the risk of hypoglycemia include changes in meal pattern (e.g., macronutrient content), changes in level of physical activity, changes to coadministered medication [see Drug Interactions (7)], and concomitant use with other antidiabetic agents. Patients with renal or hepatic impairment may be at higher risk of hypoglycemia [see Use in Specific Populations (8.6, 8.7)].Patients should take nateglinide before meals and be instructed to skip the dose of nateglinide if meal is skipped [see Dosage and Administration (2)]. Patients and caregivers must be educated to recognize and manage hypoglycemia. Self- monitoring of blood glucose plays an essential role in the prevention and management of hypoglycemia. In patients at higher risk for hypoglycemia and patients who have reduced symptomatic awareness of hypoglycemia, increased frequency of blood glucose monitoring is recommended.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. Nursing mothers: Discontinue nateglinide or nursing (8.3). Nursing mothers: Discontinue nateglinide or nursing (8.3). 8.1 Pregnancy. Pregnancy Category CThere are no adequate and well-controlled studies of nateglinide in pregnant women. It is unknown whether nateglinide can cause fetal harm when administered to pregnant woman. Nateglinide should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.In the rabbit, embryonic development was adversely affected and the incidence of gall bladder agenesis or small gallbladder was increased at dose of 500 mg/kg (approximately 27 times the human therapeutic exposure of 120 mg three times daily, based on body surface area). Nateglinide was not teratogenic in rats at doses up to 1,000 mg/kg (approximately 27 times the human therapeutic exposure based on body surface area).. 8.3 Nursing Mothers. It is not known whether nateglinide is excreted in human milk. Nateglinide is excreted in rat milk. Offspring of rats exposed to 1,000 mg/kg nateglinide (approximately 27 times the human therapeutic exposure of 120 mg three times daily, based on body surface area) had lower body weight. Because the potential for hypoglycemia in nursing infants may exist, decision should be made as to whether nateglinide should be discontinued in nursing mothers, or if mothers should discontinue nursing.. 8.4 Pediatric Use. The safety and effectiveness of nateglinide have not been established in pediatric patients.. 8.5 Geriatric Use. 436 patients 65 years and older, and 80 patients 75 years and older were exposed to nateglinide in clinical studies. No differences were observed in safety or efficacy of nateglinide between patients age 65 and over, and those under age 65. However, greater sensitivity of some older individuals to nateglinide therapy cannot be ruled out.. 8.6 Renal Impairment. No dosage adjustment is recommended in patients with mild to severe renal impairment [see Clinical Pharmacology (12.3)].. 8.7 Hepatic Impairment. No dose adjustment is recommended for patients with mild hepatic impairment. Use of nateglinide in patients with moderate-to-severe hepatic impairment has not been studied and therefore, should be used with caution in these patients [see Clinical Pharmacology (12.3)].

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Hypoglycemia: nateglinide may cause hypoglycemia. Administer before meals to reduce the risk of hypoglycemia. Skip the scheduled dose of nateglinide if meal is skipped to reduce the risk of hypoglycemia. (5.1)Macrovascular outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with nateglinide. (5.2). Hypoglycemia: nateglinide may cause hypoglycemia. Administer before meals to reduce the risk of hypoglycemia. Skip the scheduled dose of nateglinide if meal is skipped to reduce the risk of hypoglycemia. (5.1). Macrovascular outcomes: There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with nateglinide. (5.2). 5.1 Hypoglycemia. All glinides, including nateglinide, can cause hypoglycemia [see Adverse Reactions (6.1)]. Severe hypoglycemia can cause seizures, may be life-threatening, or cause death. Hypoglycemia can impair concentration ability and reaction time; this may place an individual and others at risk in situations where these abilities are important (e.g., driving or operating other machinery).Hypoglycemia can happen suddenly and symptoms may differ in each individual and change over time in the same individual. Symptomatic awareness of hypoglycemia may be less pronounced in patients with longstanding diabetes, in patients with diabetic neuropathy (nerve disease), in patients using medications that block the sympathetic nervous system (e.g., beta-blockers) [see Drug Interactions (7)], or in patients who experience recurrent hypoglycemia.Factors which may increase the risk of hypoglycemia include changes in meal pattern (e.g., macronutrient content), changes in level of physical activity, changes to coadministered medication [see Drug Interactions (7)], and concomitant use with other antidiabetic agents. Patients with renal or hepatic impairment may be at higher risk of hypoglycemia [see Use in Specific Populations (8.6, 8.7)].Patients should take nateglinide before meals and be instructed to skip the dose of nateglinide if meal is skipped [see Dosage and Administration (2)]. Patients and caregivers must be educated to recognize and manage hypoglycemia. Self- monitoring of blood glucose plays an essential role in the prevention and management of hypoglycemia. In patients at higher risk for hypoglycemia and patients who have reduced symptomatic awareness of hypoglycemia, increased frequency of blood glucose monitoring is recommended.. 5.2 MacrovascularOutcomes. There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with nateglinide.

LACTATION SECTION.

8.2 Lactation. Risk summary There are no data on the presence of nateglinide in human milk, the effects on the breastfeeding infant, or the effects on milk production. The drug is present in animal milk. When drug is present in animal milk, it is likely that the drug will be present in human milk (see Data). Because the potential for hypoglycemia in breast-fed infants, advise women that use of nateglinide is not recommended while breastfeeding. DataIn rat reproduction studies, nateglinide and its metabolite are excreted in the milk following oral dose (300 mg/kg). The overall milk: plasma (M/P) concentration ratio of the total radioactivity was approximately 1.4 based on AUC0-48 values. The M/P ratio of unchanged nateglinide was approximately 2.2.