ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following adverse reactions are also discussed elsewhere in the labeling:Pancreatitis [see Warnings and Precautions (5.1)] Heart Failure [see Warnings and Precautions (5.2)] Acute Renal Failure [see Warnings and Precautions (5.3)] Hypoglycemia with Concomitant Use with Insulin or Insulin Secretagogues [see Warnings and Precautions (5.4)] Hypersensitivity Reactions [see Warnings and Precautions (5.5)] Severe and Disabling Arthralgia [see Warnings and Precautions (5.6)] Bullous Pemphigoid [see Warnings and Precautions (5.7)] Pancreatitis [see Warnings and Precautions (5.1)] Heart Failure [see Warnings and Precautions (5.2)] Acute Renal Failure [see Warnings and Precautions (5.3)] Hypoglycemia with Concomitant Use with Insulin or Insulin Secretagogues [see Warnings and Precautions (5.4)] Hypersensitivity Reactions [see Warnings and Precautions (5.5)] Severe and Disabling Arthralgia [see Warnings and Precautions (5.6)] Bullous Pemphigoid [see Warnings and Precautions (5.7)] Adverse reactions reported in >=5% of patients treated with JANUVIA and more commonly than in patients treated with placebo are: upper respiratory tract infection, nasopharyngitis and headache. In the add-on to sulfonylurea and add-on to insulin studies, hypoglycemia was also more commonly reported in patients treated with JANUVIA compared to placebo. (6.1) To report SUSPECTED ADVERSE REACTIONS, contact Merck Sharp Dohme Corp., subsidiary of Merck Co., Inc., at 1-877-888-4231 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.. 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 controlled clinical studies as both monotherapy and combination therapy with metformin, pioglitazone, or rosiglitazone and metformin, the overall incidence of adverse reactions, hypoglycemia, and discontinuation of therapy due to clinical adverse reactions with JANUVIA were similar to placebo. In combination with glimepiride, with or without metformin, the overall incidence of clinical adverse reactions with JANUVIA was higher than with placebo, in part related to higher incidence of hypoglycemia (see Table 3); the incidence of discontinuation due to clinical adverse reactions was similar to placebo.Two placebo-controlled monotherapy studies, one of 18- and one of 24-week duration, included patients treated with JANUVIA 100 mg daily, JANUVIA 200 mg daily, and placebo. Five placebo-controlled add-on combination therapy studies were also conducted: one with metformin; one with pioglitazone; one with metformin and rosiglitazone; one with glimepiride (with or without metformin); and one with insulin (with or without metformin). In these trials, patients with inadequate glycemic control on stable dose of the background therapy were randomized to add-on therapy with JANUVIA 100 mg daily or placebo. The adverse reactions, excluding hypoglycemia, reported regardless of investigator assessment of causality in >=5% of patients treated with JANUVIA 100 mg daily and more commonly than in patients treated with placebo, are shown in Table for the clinical trials of at least 18 weeks duration. Incidences of hypoglycemia are shown in Table 3.Table 1: Placebo-Controlled Clinical Studies of JANUVIA Monotherapy or Add-on Combination Therapy with Pioglitazone, Metformin Rosiglitazone, or Glimepiride +/- Metformin: Adverse Reactions (Excluding Hypoglycemia) Reported in >=5% of Patients and More Commonly than in Patients Given Placebo, Regardless of Investigator Assessment of CausalityIntent-to-treat population Number of Patients (%)Monotherapy (18 or 24 weeks)JANUVIA 100 mgPlaceboN 443N 363 Nasopharyngitis23 (5.2)12 (3.3)Combination with Pioglitazone (24 weeks) JANUVIA 100 mg +Pioglitazone Placebo +PioglitazoneN 175N 178 Upper Respiratory Tract Infection11 (6.3)6 (3.4) Headache9 (5.1)7 (3.9)Combination with Metformin Rosiglitazone (18 weeks)JANUVIA 100 mg Metformin Rosiglitazone Placebo Metformin RosiglitazoneN 181N 97 Upper Respiratory Tract Infection10 (5.5)5 (5.2) Nasopharyngitis11 (6.1)4 (4.1)Combination with Glimepiride (+/- Metformin) (24 weeks)JANUVIA 100 mg Glimepiride (+/- Metformin)Placebo+ Glimepiride(+/- Metformin)N 222N 219 Nasopharyngitis14 (6.3)10 (4.6) Headache13 (5.9)5 (2.3)In the 24-week study of patients receiving JANUVIA as add-on combination therapy with metformin, there were no adverse reactions reported regardless of investigator assessment of causality in >=5% of patients and more commonly than in patients given placebo.In the 24-week study of patients receiving JANUVIA as add-on therapy to insulin (with or without metformin), there were no adverse reactions reported regardless of investigator assessment of causality in >=5% of patients and more commonly than in patients given placebo, except for hypoglycemia (see Table 3).In the study of JANUVIA as add-on combination therapy with metformin and rosiglitazone (Table 1), through Week 54 the adverse reactions reported regardless of investigator assessment of causality in >=5% of patients treated with JANUVIA and more commonly than in patients treated with placebo were: upper respiratory tract infection (JANUVIA, 15.5%; placebo, 6.2%), nasopharyngitis (11.0%, 9.3%), peripheral edema (8.3%, 5.2%), and headache (5.5%, 4.1%).In pooled analysis of the two monotherapy studies, the add-on to metformin study, and the add-on to pioglitazone study, the incidence of selected gastrointestinal adverse reactions in patients treated with JANUVIA was as follows: abdominal pain (JANUVIA 100 mg, 2.3%; placebo, 2.1%), nausea (1.4%, 0.6%), and diarrhea (3.0%, 2.3%).In an additional, 24-week, placebo-controlled factorial study of initial therapy with sitagliptin in combination with metformin, the adverse reactions reported (regardless of investigator assessment of causality) in >=5% of patients are shown in Table 2. Table 2: Initial Therapy with Combination of Sitagliptin and Metformin: Adverse Reactions Reported (Regardless of Investigator Assessment of Causality) in >=5% of Patients Receiving Combination Therapy (and Greater than in Patients Receiving Metformin alone, Sitagliptin alone, and Placebo)Intent-to-treat population. Number of Patients (%)PlaceboSitagliptin (JANUVIA)100 mg QD Metformin HCl500 or 1000 mg bidData pooled for the patients given the lower and higher doses of metformin. Sitagliptin50 mg bid +Metformin HCl500 or 1000 mg bid = 176N 179N 364 = 372 Upper Respiratory Infection9 (5.1)8 (4.5)19 (5.2)23 (6.2) Headache5 (2.8)2 (1.1)14 (3.8)22 (5.9)In 24-week study of initial therapy with JANUVIA in combination with pioglitazone, there were no adverse reactions reported (regardless of investigator assessment of causality) in >=5% of patients and more commonly than in patients given pioglitazone alone.No clinically meaningful changes in vital signs or in ECG (including in QTc interval) were observed in patients treated with JANUVIA.In pooled analysis of 19 double-blind clinical trials that included data from 10,246 patients randomized to receive sitagliptin 100 mg/day (N=5429) or corresponding (active or placebo) control (N=4817), the incidence of acute pancreatitis was 0.1 per 100 patient-years in each group (4 patients with an event in 4708 patient-years for sitagliptin and patients with an event in 3942 patient-years for control). HypoglycemiaIn the above studies (N=9), adverse reactions of hypoglycemia were based on all reports of symptomatic hypoglycemia. concurrent blood glucose measurement was not required although most (74%) reports of hypoglycemia were accompanied by blood glucose measurement <=70 mg/dL. When JANUVIA was coadministered with sulfonylurea or with insulin, the percentage of patients with at least one adverse reaction of hypoglycemia was higher than in the corresponding placebo group (Table 3).Table 3: Incidence and Rate of HypoglycemiaAdverse reactions of hypoglycemia were based on all reports of symptomatic hypoglycemia; concurrent glucose measurement was not required; intent-to-treat population. in Placebo-Controlled Clinical Studies when JANUVIA was used as Add-On Therapy to Glimepiride (with or without Metformin) or Insulin (with or without Metformin), Regardless of Investigator Assessment of CausalityAdd-On to Glimepiride (+/- Metformin) (24 weeks)JANUVIA 100 mg+ Glimepiride(+/- Metformin)Placebo+ Glimepiride(+/- Metformin)N 222N 219 Overall (%)27 (12.2)4 (1.8) Rate (episodes/patient-year)Based on total number of events (i.e., single patient may have had multiple events). 0.590.24 Severe (%)Severe events of hypoglycemia were defined as those events requiring medical assistance or exhibiting depressed level/loss of consciousness or seizure. (0.0)0 (0.0)Add-On to Insulin (+/- Metformin) (24 weeks)JANUVIA 100 mg+ Insulin(+/- Metformin)Placebo+ Insulin(+/- Metformin)N 322N 319 Overall (%)50 (15.5)25 (7.8) Rate (episodes/patient-year) 1.060.51 Severe (%) (0.6)1 (0.3)In pooled analysis of the two monotherapy studies, the add-on to metformin study, and the add-on to pioglitazone study, the overall incidence of adverse reactions of hypoglycemia was 1.2% in patients treated with JANUVIA 100 mg and 0.9% in patients treated with placebo.In the study of JANUVIA as add-on combination therapy with metformin and rosiglitazone, the overall incidence of hypoglycemia was 2.2% in patients given add-on JANUVIA and 0.0% in patients given add-on placebo through Week 18. Through Week 54, the overall incidence of hypoglycemia was 3.9% in patients given add-on JANUVIA and 1.0% in patients given add-on placebo.In the 24-week, placebo-controlled factorial study of initial therapy with JANUVIA in combination with metformin, the incidence of hypoglycemia was 0.6% in patients given placebo, 0.6% in patients given JANUVIA alone, 0.8% in patients given metformin alone, and 1.6% in patients given JANUVIA in combination with metformin.In the study of JANUVIA as initial therapy with pioglitazone, one patient taking JANUVIA experienced severe episode of hypoglycemia. There were no severe hypoglycemia episodes reported in other studies except in the study involving coadministration with insulin.In an additional, 30-week placebo-controlled, study of patients with type diabetes inadequately controlled with metformin comparing the maintenance of sitagliptin 100 mg versus withdrawal of sitagliptin when initiating basal insulin therapy, the event rate and incidence of documented symptomatic hypoglycemia (blood glucose measurement <=70 mg/dL) did not differ between the sitagliptin and placebo groups.Laboratory TestsAcross clinical studies, the incidence of laboratory adverse reactions was similar in patients treated with JANUVIA 100 mg compared to patients treated with placebo. small increase in white blood cell count (WBC) was observed due to an increase in neutrophils. This increase in WBC (of approximately 200 cells/microL vs placebo, in four pooled placebo-controlled clinical studies, with mean baseline WBC count of approximately 6600 cells/microL) is not considered to be clinically relevant. In 12-week study of 91 patients with chronic renal insufficiency, 37 patients with moderate renal insufficiency were randomized to JANUVIA 50 mg daily, while 14 patients with the same magnitude of renal impairment were randomized to placebo. Mean (SE) increases in serum creatinine were observed in patients treated with JANUVIA [0.12 mg/dL (0.04)] and in patients treated with placebo [0.07 mg/dL (0.07)]. The clinical significance of this added increase in serum creatinine relative to placebo is not known.. 6.2 Postmarketing Experience. Additional adverse reactions have been identified during postapproval use of JANUVIA as monotherapy and/or in combination with other antihyperglycemic agents. Because these reactions are reported voluntarily from population of uncertain size, it is generally not possible to reliably estimate their frequency or establish causal relationship to drug exposure.Hypersensitivity reactions including anaphylaxis, angioedema, rash, urticaria, cutaneous vasculitis, and exfoliative skin conditions including Stevens-Johnson syndrome; hepatic enzyme elevations; acute pancreatitis, including fatal and non-fatal hemorrhagic and necrotizing pancreatitis [see Indications and Usage (1) ]; worsening renal function, including acute renal failure (sometimes requiring dialysis); severe and disabling arthralgia; bullous pemphigoid; constipation; vomiting; headache; myalgia; pain in extremity; back pain; pruritus; mouth ulceration; stomatitis; rhabdomyolysis.

CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Sitagliptin is DPP-4 inhibitor, which is believed to exert its actions in patients with type diabetes mellitus by slowing the inactivation of incretin hormones. Concentrations of the active intact hormones are increased by sitagliptin, thereby increasing and prolonging the action of these hormones. Incretin hormones, including glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), are released by the intestine throughout the day, and levels are increased in response to meal. These hormones are rapidly inactivated by the enzyme, DPP-4. The incretins are part of an endogenous system involved in the physiologic regulation of glucose homeostasis. When blood glucose concentrations are normal or elevated, GLP-1 and GIP increase insulin synthesis and release from pancreatic beta cells by intracellular signaling pathways involving cyclic AMP. GLP-1 also lowers glucagon secretion from pancreatic alpha cells, leading to reduced hepatic glucose production. By increasing and prolonging active incretin levels, sitagliptin increases insulin release and decreases glucagon levels in the circulation in glucose-dependent manner. Sitagliptin demonstrates selectivity for DPP-4 and does not inhibit DPP-8 or DPP-9 activity in vitro at concentrations approximating those from therapeutic doses.. 12.2 Pharmacodynamics. GeneralIn patients with type diabetes mellitus, administration of sitagliptin led to inhibition of DPP-4 enzyme activity for 24-hour period. After an oral glucose load or meal, this DPP-4 inhibition resulted in 2- to 3-fold increase in circulating levels of active GLP-1 and GIP, decreased glucagon concentrations, and increased responsiveness of insulin release to glucose, resulting in higher C-peptide and insulin concentrations. The rise in insulin with the decrease in glucagon was associated with lower fasting glucose concentrations and reduced glucose excursion following an oral glucose load or meal.In studies with healthy subjects, sitagliptin did not lower blood glucose or cause hypoglycemia.. Sitagliptin and Metformin hydrochloride CoadministrationIn two-day study in healthy subjects, sitagliptin alone increased active GLP-1 concentrations, whereas metformin alone increased active and total GLP-1 concentrations to similar extents. Coadministration of sitagliptin and metformin had an additive effect on active GLP-1 concentrations. Sitagliptin, but not metformin, increased active GIP concentrations. It is unclear how these findings relate to changes in glycemic control in patients with type diabetes mellitus.. Cardiac ElectrophysiologyIn randomized, placebo-controlled crossover study, 79 healthy subjects were administered single oral dose of sitagliptin 100 mg, sitagliptin 800 mg (8 times the recommended dose), and placebo. At the recommended dose of 100 mg, there was no effect on the QTc interval obtained at the peak plasma concentration, or at any other time during the study. Following the 800 mg dose, the maximum increase in the placebo-corrected mean change in QTc from baseline was observed at hours postdose and was 8.0 msec. This increase is not considered to be clinically significant. At the 800 mg dose, peak sitagliptin plasma concentrations were approximately 11 times higher than the peak concentrations following 100-mg dose. In patients with type diabetes mellitus administered sitagliptin 100 mg (N=81) or sitagliptin 200 mg (N=63) daily, there were no meaningful changes in QTc interval based on ECG data obtained at the time of expected peak plasma concentration.. 12.3 Pharmacokinetics. The pharmacokinetics of sitagliptin have been extensively characterized in healthy subjects and patients with type diabetes mellitus. Following single oral 100-mg dose to healthy volunteers, mean plasma AUC of sitagliptin was 8.52 uMohr, Cmax was 950 nM, and apparent terminal half-life (t1/2) was 12.4 hours. Plasma AUC of sitagliptin increased in dose-proportional manner and increased approximately 14% following 100 mg doses at steady-state compared to the first dose. The intra-subject and inter-subject coefficients of variation for sitagliptin AUC were small (5.8% and 15.1%). The pharmacokinetics of sitagliptin was generally similar in healthy subjects and in patients with type diabetes mellitus.. AbsorptionAfter oral administration of 100 mg dose to healthy subjects, sitagliptin was rapidly absorbed with peak plasma concentrations (median Tmax) occurring to hours postdose. The absolute bioavailability of sitagliptin is approximately 87%.. Effect of FoodCoadministration of high-fat meal with sitagliptin had no effect on the pharmacokinetics of sitagliptin.. DistributionThe mean volume of distribution at steady state following single 100-mg intravenous dose of sitagliptin to healthy subjects is approximately 198 liters. The fraction of sitagliptin reversibly bound to plasma proteins is low (38%).. EliminationApproximately 79% of sitagliptin is excreted unchanged in the urine with metabolism being minor pathway of elimination. The apparent terminal t1/2 following 100 mg oral dose of sitagliptin was approximately 12.4 hours and renal clearance was approximately 350 mL/min.. MetabolismFollowing [14C]sitagliptin oral dose, approximately 16% of the radioactivity was excreted as metabolites of sitagliptin. Six metabolites were detected at trace levels and are not expected to contribute to the plasma DPP-4 inhibitory activity of sitagliptin. In vitro studies indicated that the primary enzyme responsible for the limited metabolism of sitagliptin was CYP3A4, with contribution from CYP2C8. ExcretionFollowing administration of an oral [14C]sitagliptin dose to healthy subjects, approximately 100% of the administered radioactivity was eliminated in feces (13%) or urine (87%) within one week of dosing.Elimination of sitagliptin occurs primarily via renal excretion and involves active tubular secretion. Sitagliptin is substrate for human organic anion transporter-3 (hOAT-3), which may be involved in the renal elimination of sitagliptin. The clinical relevance of hOAT-3 in sitagliptin transport has not been established. Sitagliptin is also substrate of P-glycoprotein (P-gp), which may also be involved in mediating the renal elimination of sitagliptin. However, cyclosporine, P-gp inhibitor, did not reduce the renal clearance of sitagliptin.. Specific Populations. Patients with Renal ImpairmentAn approximately 2-fold increase in the plasma AUC of sitagliptin was observed in patients with moderate renal impairment with eGFR of 30 to less than 45 mL/min/1.73 m2, and an approximately 4-fold increase was observed in patients with severe renal impairment, including patients with ESRD on hemodialysis, as compared to normal healthy control subjects.. Patients with Hepatic ImpairmentIn patients with moderate hepatic impairment (Child-Pugh score to 9), mean AUC and Cmax of sitagliptin increased approximately 21% and 13%, respectively, compared to healthy matched controls following administration of single 100-mg dose of sitagliptin. These differences are not considered to be clinically meaningful.There is no clinical experience in patients with severe hepatic impairment (Child-Pugh score >9).. Effects of Age, Body Mass Index (BMI), Gender, and RaceBased on population pharmacokinetic analysis or composite analysis of available pharmacokinetic data, BMI, gender, and race do not have clinically meaningful effect on the pharmacokinetics of sitagliptin. When the effects of age on renal function are taken into account, age alone did not have clinically meaningful impact on the pharmacokinetics of sitagliptin based on population pharmacokinetic analysis. Elderly subjects (65 to 80 years) had approximately 19% higher plasma concentrations of sitagliptin compared to younger subjects.. Drug Interaction Studies. In Vitro Assessment of Drug Interactions Sitagliptin is not an inhibitor of CYP isozymes CYP3A4, 2C8, 2C9, 2D6, 1A2, 2C19 or 2B6, and is not an inducer of CYP3A4. Sitagliptin is P-gp substrate, but does not inhibit P-gp mediated transport of digoxin. Based on these results, sitagliptin is considered unlikely to cause interactions with other drugs that utilize these pathways. Sitagliptin is not extensively bound to plasma proteins. Therefore, the propensity of sitagliptin to be involved in clinically meaningful drug-drug interactions mediated by plasma protein binding displacement is very low.. In Vivo Assessment of Drug Interactions. Effects of Sitagliptin on Other DrugsIn clinical studies, sitagliptin did not meaningfully alter the pharmacokinetics of metformin, glyburide, simvastatin, rosiglitazone, digoxin, warfarin, or an oral contraceptive (ethinyl estradiol and norethindrone) (Table 4), providing in vivo evidence of low propensity for causing drug interactions with substrates of CYP3A4, CYP2C8, CYP2C9, P-gp, and organic cationic transporter (OCT).Table 4: Effect of Sitagliptin on Systemic Exposure of Coadministered DrugsCoadministered DrugDose of Coadministered DrugAll doses administered as single dose unless otherwise specified. Dose of Sitagliptin Geometric Mean Ratio(ratio with/without sitagliptin)No Effect 1.00AUCAUC is reported as AUC0- unless otherwise specified. Cmax Digoxin0.25 mgMultiple dose. once daily for 10 days100 mg once daily for 10 daysDigoxin1.11AUC0-24hr. 1.18Glyburide1.25 mg200 mg once daily for daysGlyburide1.091.01Simvastatin20 mg200 mg once daily for daysSimvastatin0.85AUC0-last. 0.80Simvastatin Acid1.12 1.06Rosiglitazone4 mg200 mg once daily for daysRosiglitazone0.980.99Warfarin30 mg single dose on day 5200 mg once daily for 11 daysS(-) Warfarin0.950.89R(+) Warfarin0.990.89Ethinyl estradiol and norethindrone21 days once daily of 35 ug ethinyl estradiol with norethindrone 0.5 mg 7 days, 0.75 mg 7 days, 1.0 mg 7 days200 mg once daily for 21 daysEthinyl estradiol0.990.97Norethindrone1.030.98Metformin HCl1000 mg twice daily for 14 days50 mg twice daily for daysMetformin1.02AUC0-12hr. 0.97. Effects of Other Drugs on SitagliptinClinical data described below suggest that sitagliptin is not susceptible to clinically meaningful interactions by coadministered medications (Table 5).Table 5: Effect of Coadministered Drugs on Systemic Exposure of SitagliptinCoadministered DrugDose of Coadministered DrugAll doses administered as single dose unless otherwise specified. Dose of Sitagliptin Geometric Mean Ratio(ratio with/without coadministered drug)No Effect 1.00AUCAUC is reported as AUC0- unless otherwise specified. Cmax Cyclosporine600 mg once daily100 mg once dailySitagliptin1.291.68Metformin HCl1000 mgMultiple dose. twice daily for 14 days50 mg twice daily for daysSitagliptin1.02AUC0-12hr. 1.05.

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. There were approximately 5200 patients with type diabetes randomized in nine double-blind, placebo-controlled clinical safety and efficacy studies conducted to evaluate the effects of sitagliptin on glycemic control. In pooled analysis of seven of these studies, the ethnic/racial distribution was approximately 59% white, 20% Hispanic, 10% Asian, 6% black, and 6% other groups. Patients had an overall mean age of approximately 55 years (range 18 to 87 years). In addition, an active (glipizide)-controlled study of 52-weeks duration was conducted in 1172 patients with type diabetes who had inadequate glycemic control on metformin.In patients with type diabetes, treatment with JANUVIA produced clinically significant improvements in hemoglobin A1C, fasting plasma glucose (FPG) and 2-hour post-prandial glucose (PPG) compared to placebo.. 14.1 Monotherapy. total of 1262 patients with type diabetes participated in two double-blind, placebo-controlled studies, one of 18-week and another of 24-week duration, to evaluate the efficacy and safety of JANUVIA monotherapy. In both monotherapy studies, patients currently on an antihyperglycemic agent discontinued the agent, and underwent diet, exercise, and drug washout period of about weeks. Patients with inadequate glycemic control (A1C 7% to 10%) after the washout period were randomized after completing 2-week single-blind placebo run-in period; patients not currently on antihyperglycemic agents (off therapy for at least weeks) with inadequate glycemic control (A1C 7% to 10%) were randomized after completing the 2-week single-blind placebo run-in period. In the 18-week study, 521 patients were randomized to placebo, JANUVIA 100 mg, or JANUVIA 200 mg, and in the 24-week study 741 patients were randomized to placebo, JANUVIA 100 mg, or JANUVIA 200 mg. Patients who failed to meet specific glycemic goals during the studies were treated with metformin rescue, added on to placebo or JANUVIA. Treatment with JANUVIA at 100 mg daily provided significant improvements in A1C, FPG, and 2-hour PPG compared to placebo (Table 6). In the 18-week study, 9% of patients receiving JANUVIA 100 mg and 17% who received placebo required rescue therapy. In the 24-week study, 9% of patients receiving JANUVIA 100 mg and 21% of patients receiving placebo required rescue therapy. The improvement in A1C compared to placebo was not affected by gender, age, race, prior antihyperglycemic therapy, or baseline BMI. As is typical for trials of agents to treat type diabetes, the mean reduction in A1C with JANUVIA appears to be related to the degree of A1C elevation at baseline. In these 18- and 24-week studies, among patients who were not on an antihyperglycemic agent at study entry, the reductions from baseline in A1C were -0.7% and -0.8%, respectively, for those given JANUVIA, and -0.1% and -0.2%, respectively, for those given placebo. Overall, the 200 mg daily dose did not provide greater glycemic efficacy than the 100 mg daily dose. The effect of JANUVIA on lipid endpoints was similar to placebo. Body weight did not increase from baseline with JANUVIA therapy in either study, compared to small reduction in patients given placebo.Table 6: Glycemic Parameters in 18- and 24-Week Placebo-Controlled Studies of JANUVIA in Patients with Type DiabetesIntent-to-treat population using last observation on study prior to metformin rescue therapy. 18-Week Study24-Week StudyJANUVIA 100 mgPlaceboJANUVIA 100 mgPlaceboA1C (%)N 193N 103N 229N 244 Baseline (mean)8.08.18.08.0 Change from baseline (adjusted meanLeast squares means adjusted for prior antihyperglycemic therapy status and baseline value.)-0.50.1-0.60.2 Difference from placebo (adjusted mean) (95% CI)-0.6p<0.001 compared to placebo. (-0.8, -0.4)-0.8 (-1.0, -0.6) Patients (%) achieving A1C <7%69 (36%)16 (16%)93 (41%)41 (17%)FPG (mg/dL)N 201N 107N 234N 247 Baseline (mean)180184170176 Change from baseline (adjusted mean)-137-125 Difference from placebo (adjusted mean) (95% CI)-20 (-31, -9)-17 (-24, -10)2-hour PPG (mg/dL)Data not available.N 201N 204 Baseline (mean)257271 Change from baseline (adjusted mean)-49-2 Difference from placebo (adjusted mean) (95% CI)-47 (-59, -34)Additional Monotherapy StudyA multinational, randomized, double-blind, placebo-controlled study was also conducted to assess the safety and tolerability of JANUVIA in 91 patients with type diabetes and chronic renal insufficiency (creatinine clearance <50 mL/min). Patients with moderate renal insufficiency received 50 mg daily of JANUVIA and those with severe renal insufficiency or with ESRD on hemodialysis or peritoneal dialysis received 25 mg daily. In this study, the safety and tolerability of JANUVIA were generally similar to placebo. small increase in serum creatinine was reported in patients with moderate renal insufficiency treated with JANUVIA relative to those on placebo. In addition, the reductions in A1C and FPG with JANUVIA compared to placebo were generally similar to those observed in other monotherapy studies. [See Clinical Pharmacology (12.3).] 14.2 Combination Therapy. Add-on Combination Therapy with MetforminA total of 701 patients with type diabetes participated in 24-week, randomized, double-blind, placebo-controlled study designed to assess the efficacy of JANUVIA in combination with metformin. Patients already on metformin HCl (N=431) at dose of at least 1500 mg per day were randomized after completing 2-week single-blind placebo run-in period. Patients on metformin and another antihyperglycemic agent (N=229) and patients not on any antihyperglycemic agents (off therapy for at least weeks, N=41) were randomized after run-in period of approximately 10 weeks on metformin HCl (at dose of at least 1500 mg per day) in monotherapy. Patients with inadequate glycemic control (A1C 7% to 10%) were randomized to the addition of either 100 mg of JANUVIA or placebo, administered once daily. Patients who failed to meet specific glycemic goals during the studies were treated with pioglitazone rescue.In combination with metformin, JANUVIA provided significant improvements in A1C, FPG, and 2-hour PPG compared to placebo with metformin (Table 7). Rescue glycemic therapy was used in 5% of patients treated with JANUVIA 100 mg and 14% of patients treated with placebo. similar decrease in body weight was observed for both treatment groups.Table 7: Glycemic Parameters at Final Visit (24-Week Study) for JANUVIA in Add-on Combination Therapy with MetforminIntent-to-treat population using last observation on study prior to pioglitazone rescue therapy. JANUVIA 100 mg MetforminPlacebo MetforminA1C (%)N 453N 224 Baseline (mean)8.08.0 Change from baseline (adjusted meanLeast squares means adjusted for prior antihyperglycemic therapy and baseline value.)-0.7-0.0 Difference from placebo metformin (adjusted mean) (95% CI)-0.7p<0.001 compared to placebo metformin. (-0.8, -0.5) Patients (%) achieving A1C <7%213 (47%)41 (18%)FPG (mg/dL) = 454N 226 Baseline (mean) 170174 Change from baseline (adjusted mean)-179 Difference from placebo metformin (adjusted mean) (95% CI)-25 (-31, -20)2-hour PPG (mg/dL)N 387N 182 Baseline (mean) 275272 Change from baseline (adjusted mean)-62-11 Difference from placebo metformin (adjusted mean) (95% CI)-51 (-61, -41)Initial Combination Therapy with MetforminA total of 1091 patients with type diabetes and inadequate glycemic control on diet and exercise participated in 24-week, randomized, double-blind, placebo-controlled factorial study designed to assess the efficacy of sitagliptin as initial therapy in combination with metformin. Patients on an antihyperglycemic agent (N=541) discontinued the agent, and underwent diet, exercise, and drug washout period of up to 12 weeks duration. After the washout period, patients with inadequate glycemic control (A1C 7.5% to 11%) were randomized after completing 2-week single-blind placebo run-in period. Patients not on antihyperglycemic agents at study entry (N=550) with inadequate glycemic control (A1C 7.5% to 11%) immediately entered the 2-week single-blind placebo run-in period and then were randomized. Approximately equal numbers of patients were randomized to receive initial therapy with placebo, 100 mg of JANUVIA once daily, 500 mg or 1000 mg of metformin HCl twice daily, or 50 mg of sitagliptin twice daily in combination with 500 mg or 1000 mg of metformin HCl twice daily. Patients who failed to meet specific glycemic goals during the study were treated with glyburide (glibenclamide) rescue. Initial therapy with the combination of JANUVIA and metformin provided significant improvements in A1C, FPG, and 2-hour PPG compared to placebo, to metformin alone, and to JANUVIA alone (Table 8, Figure 1). Mean reductions from baseline in A1C were generally greater for patients with higher baseline A1C values. For patients not on an antihyperglycemic agent at study entry, mean reductions from baseline in A1C were: JANUVIA 100 mg once daily, -1.1%; metformin HCl 500 mg bid, -1.1%; metformin HCl 1000 mg bid, -1.2%; sitagliptin 50 mg bid with metformin HCl 500 mg bid, -1.6%; sitagliptin 50 mg bid with metformin HCl 1000 mg bid, -1.9%; and for patients receiving placebo, -0.2%. Lipid effects were generally neutral. The decrease in body weight in the groups given sitagliptin in combination with metformin was similar to that in the groups given metformin alone or placebo.Table 8: Glycemic Parameters at Final Visit (24-Week Study) for Sitagliptin and Metformin, Alone and in Combination as Initial TherapyIntent-to-treat population using last observation on study prior to glyburide (glibenclamide) rescue therapy. PlaceboSitagliptin(JANUVIA)100 mg QDMetforminHCl500 mg bidMetforminHCl1000 mg bidSitagliptin50 mg bid +MetforminHCl500 mg bidSitagliptin50 mg bid +MetforminHCl1000 mg bidA1C (%)N 165N 175N 178N 177N 183N 178 Baseline (mean)8.78.98.98.78.88.8 Change from baseline (adjusted meanLeast squares means adjusted for prior antihyperglycemic therapy status and baseline value.)0.2-0.7-0.8-1.1-1.4-1.9 Difference from placebo (adjusted mean) (95% CI)-0.8p<0.001 compared to placebo. (-1.1, -0.6)-1.0 (-1.2, -0.8)-1.3 (-1.5, -1.1)-1.6 (-1.8, -1.3)-2.1 (-2.3, -1.8) Patients (%) achieving A1C <7%15 (9%)35 (20%)41 (23%)68 (38%)79 (43%)118 (66%) Patients receiving rescue medication3221171282FPG (mg/dL) = 169N 178N 179N 179N 183N 180 Baseline (mean)196201205197204197 Change from baseline (adjusted mean)6-17-27-29-47-64 Difference from placebo (adjusted mean) (95% CI)-23 (-33, -14)-33 (-43, -24)-35 (-45, -26)-53 (-62, -43)-70 (-79, -60)2-hour PPG (mg/dL) = 129N 136N 141N 138N 147N 152 Baseline (mean)277285293283292287 Change from baseline (adjusted mean)0-52-53-78-93-117 Difference from placebo (adjusted mean) (95% CI)-52 (-67, -37)-54 (-69, -39)-78 (-93, -63)-93 (-107, -78)-117 (-131, -102)Figure 1: Mean Change from Baseline for A1C (%) over 24 Weeks with Sitagliptin and Metformin, Alone and in Combination as Initial Therapy in Patients with Type DiabetesAll Patients Treated Population: least squares means adjusted for prior antihyperglycemic therapy and baseline value. Initial combination therapy or maintenance of combination therapy may not be appropriate for all patients. These management options are left to the discretion of the health care provider. Active-Controlled Study vs Glipizide in Combination with MetforminThe efficacy of JANUVIA was evaluated in 52-week, double-blind, glipizide-controlled noninferiority trial in patients with type diabetes. Patients not on treatment or on other antihyperglycemic agents entered run-in treatment period of up to 12 weeks duration with metformin HCl monotherapy (dose of >=1500 mg per day) which included washout of medications other than metformin, if applicable. After the run-in period, those with inadequate glycemic control (A1C 6.5% to 10%) were randomized 1:1 to the addition of JANUVIA 100 mg once daily or glipizide for 52 weeks. Patients receiving glipizide were given an initial dosage of mg/day and then electively titrated over the next 18 weeks to maximum dosage of 20 mg/day as needed to optimize glycemic control. Thereafter, the glipizide dose was to be kept constant, except for down-titration to prevent hypoglycemia. The mean dose of glipizide after the titration period was 10 mg.After 52 weeks, JANUVIA and glipizide had similar mean reductions from baseline in A1C in the intent-to-treat analysis (Table 9). These results were consistent with the per protocol analysis (Figure 2). conclusion in favor of the non-inferiority of JANUVIA to glipizide may be limited to patients with baseline A1C comparable to those included in the study (over 70% of patients had baseline A1C <8% and over 90% had A1C <9%).Table 9: Glycemic Parameters in 52-Week Study Comparing JANUVIA to Glipizide as Add-On Therapy in Patients Inadequately Controlled on Metformin (Intent-to-Treat Population)The intent-to-treat analysis used the patients last observation in the study prior to discontinuation. JANUVIA 100 mg GlipizideA1C (%)N 576N 559 Baseline (mean)7.77.6 Change from baseline (adjusted meanLeast squares means adjusted for prior antihyperglycemic therapy status and baseline A1C value.)-0.5-0.6FPG (mg/dL) = 583N 568 Baseline (mean) 166164 Change from baseline (adjusted mean)-8-8Figure 2: Mean Change from Baseline for A1C (%) Over 52 Weeks in Study Comparing JANUVIA to Glipizide as Add-On Therapy in Patients Inadequately Controlled on Metformin (Per Protocol Population)The per protocol population (mean baseline A1C of 7.5%) included patients without major protocol violations who had observations at baseline and at Week 52. The incidence of hypoglycemia in the JANUVIA group (4.9%) was significantly (p<0.001) lower than that in the glipizide group (32.0%). Patients treated with JANUVIA exhibited significant mean decrease from baseline in body weight compared to significant weight gain in patients administered glipizide (-1.5 kg vs +1.1 kg).Add-on Combination Therapy with PioglitazoneA total of 353 patients with type diabetes participated in 24-week, randomized, double-blind, placebo-controlled study designed to assess the efficacy of JANUVIA in combination with pioglitazone. Patients on any oral antihyperglycemic agent in monotherapy (N=212) or on PPAR agent in combination therapy (N=106) or not on an antihyperglycemic agent (off therapy for at least weeks, N=34) were switched to monotherapy with pioglitazone (at dose of 30-45 mg per day), and completed run-in period of approximately 12 weeks in duration. After the run-in period on pioglitazone monotherapy, patients with inadequate glycemic control (A1C 7% to 10%) were randomized to the addition of either 100 mg of JANUVIA or placebo, administered once daily. Patients who failed to meet specific glycemic goals during the studies were treated with metformin rescue. Glycemic endpoints measured were A1C and fasting glucose.In combination with pioglitazone, JANUVIA provided significant improvements in A1C and FPG compared to placebo with pioglitazone (Table 10). Rescue therapy was used in 7% of patients treated with JANUVIA 100 mg and 14% of patients treated with placebo. There was no significant difference between JANUVIA and placebo in body weight change.Table 10: Glycemic Parameters at Final Visit (24-Week Study) for JANUVIA in Add-on Combination Therapy with PioglitazoneIntent-to-treat population using last observation on study prior to metformin rescue therapy. JANUVIA 100 mg PioglitazonePlacebo PioglitazoneA1C (%)N 163N 174 Baseline (mean)8.18.0 Change from baseline (adjusted meanLeast squares means adjusted for prior antihyperglycemic therapy status and baseline value.)-0.9-0.2 Difference from placebo pioglitazone (adjusted mean) (95% CI)-0.7p<0.001 compared to placebo pioglitazone. (-0.9, -0.5) Patients (%) achieving A1C <7%74 (45%)40 (23%)FPG (mg/dL) = 163N 174 Baseline (mean) 168166 Change from baseline (adjusted mean)-171 Difference from placebo pioglitazone (adjusted mean) (95% CI)-18 (-24, -11)Initial Combination Therapy with PioglitazoneA total of 520 patients with type diabetes and inadequate glycemic control on diet and exercise participated in 24-week, randomized, double-blind study designed to assess the efficacy of JANUVIA as initial therapy in combination with pioglitazone. Patients not on antihyperglycemic agents at study entry (<4 weeks cumulative therapy over the past years, and with no treatment over the prior months) with inadequate glycemic control (A1C 8% to 12%) immediately entered the 2-week single-blind placebo run-in period and then were randomized. Approximately equal numbers of patients were randomized to receive initial therapy with 100 mg of JANUVIA in combination with 30 mg of pioglitazone once daily or 30 mg of pioglitazone once daily as monotherapy. There was no glycemic rescue therapy in this study. Initial therapy with the combination of JANUVIA and pioglitazone provided significant improvements in A1C, FPG, and 2-hour PPG compared to pioglitazone monotherapy (Table 11). The improvement in A1C was generally consistent across subgroups defined by gender, age, race, baseline BMI, baseline A1C, or duration of disease. In this study, patients treated with JANUVIA in combination with pioglitazone had mean increase in body weight of 1.1 kg compared to pioglitazone alone (3.0 kg vs. 1.9 kg). Lipid effects were generally neutral.Table 11: Glycemic Parameters at Final Visit (24-Week Study) for JANUVIA in Combination with Pioglitazone as Initial Therapy Intent-to-treat population using last observation on study. JANUVIA 100 mg PioglitazonePioglitazoneA1C (%)N 251N 246 Baseline (mean)9.59.4 Change from baseline (adjusted meanLeast squares means adjusted for baseline value.)-2.4-1.5 Difference from pioglitazone (adjusted mean) (95% CI)-0.9 p<0.001 compared to placebo pioglitazone. (-1.1, -0.7) Patients (%) achieving A1C <7%151 (60%)68 (28%)FPG (mg/dL) = 256N 253 Baseline (mean) 203201 Change from baseline (adjusted mean)-63-40 Difference from pioglitazone (adjusted mean) (95% CI)-23 (-30, -15)2-hour PPG (mg/dL) = 216N 211 Baseline (mean) 283284 Change from baseline (adjusted mean)-114-69 Difference from pioglitazone (adjusted mean) (95% CI)-45 (-57, -32)Add-on Combination Therapy with Metformin and Rosiglitazone total of 278 patients with type diabetes participated in 54-week, randomized, double-blind, placebo-controlled study designed to assess the efficacy of JANUVIA in combination with metformin and rosiglitazone. Patients on dual therapy with metformin HCl >=1500 mg/day and rosiglitazone >=4 mg/day or with metformin HCl >=1500 mg/day and pioglitazone >=30 mg/day (switched to rosiglitazone >=4 mg/day) entered dose-stable run-in period of weeks. Patients on other dual therapy were switched to metformin HCl >=1500 mg/day and rosiglitazone >=4 mg/day in dose titration/stabilization run-in period of up to 20 weeks in duration. After the run-in period, patients with inadequate glycemic control (A1C 7.5% to 11%) were randomized 2:1 to the addition of either 100 mg of JANUVIA or placebo, administered once daily. Patients who failed to meet specific glycemic goals during the study were treated with glipizide (or other sulfonylurea) rescue. The primary time point for evaluation of glycemic parameters was Week 18.In combination with metformin and rosiglitazone, JANUVIA provided significant improvements in A1C, FPG, and 2-hour PPG compared to placebo with metformin and rosiglitazone (Table 12) at Week 18. At Week 54, mean reduction in A1C was -1.0% for patients treated with JANUVIA and -0.3% for patients treated with placebo in an analysis based on the intent-to-treat population. Rescue therapy was used in 18% of patients treated with JANUVIA 100 mg and 40% of patients treated with placebo. There was no significant difference between JANUVIA and placebo in body weight change. Table 12: Glycemic Parameters at Week 18 for JANUVIA in Add-on Combination Therapy with Metformin and RosiglitazoneIntent-to-treat population using last observation on study prior to glipizide (or other sulfonylurea) rescue therapy. JANUVIA 100 mg Metformin RosiglitazonePlacebo +Metformin RosiglitazoneA1C (%)N 176N 93 Baseline (mean)8.88.7 Change from baseline (adjusted meanLeast squares means adjusted for prior antihyperglycemic therapy status and baseline value.)-1.0-0.4 Difference from placebo rosiglitazone metformin (adjusted mean) (95% CI)-0.7 p<0.001 compared to placebo metformin rosiglitazone. (-0.9, -0.4) Patients (%) achieving A1C <7%39 (22%)9 (10%)FPG (mg/dL) = 179N 94 Baseline (mean) 181182 Change from baseline (adjusted mean)-30-11 Difference from placebo rosiglitazone metformin (adjusted mean) (95% CI)-18 (-26, -10)2-hour PPG (mg/dL)N 152N 80 Baseline (mean) 256248 Change from baseline (adjusted mean)-59-21 Difference from placebo rosiglitazone metformin (adjusted mean) (95% CI)-39 (-51, -26)Add-on Combination Therapy with Glimepiride, with or without MetforminA total of 441 patients with type diabetes participated in 24-week, randomized, double-blind, placebo-controlled study designed to assess the efficacy of JANUVIA in combination with glimepiride, with or without metformin. Patients entered run-in treatment period on glimepiride (>=4 mg per day) alone or glimepiride in combination with metformin HCl (>=1500 mg per day). After dose-titration and dose-stable run-in period of up to 16 weeks and 2-week placebo run-in period, patients with inadequate glycemic control (A1C 7.5% to 10.5%) were randomized to the addition of either 100 mg of JANUVIA or placebo, administered once daily. Patients who failed to meet specific glycemic goals during the studies were treated with pioglitazone rescue.In combination with glimepiride, with or without metformin, JANUVIA provided significant improvements in A1C and FPG compared to placebo (Table 13). In the entire study population (patients on JANUVIA in combination with glimepiride and patients on JANUVIA in combination with glimepiride and metformin), mean reduction from baseline relative to placebo in A1C of -0.7% and in FPG of -20 mg/dL was seen. Rescue therapy was used in 12% of patients treated with JANUVIA 100 mg and 27% of patients treated with placebo. In this study, patients treated with JANUVIA had mean increase in body weight of 1.1 kg vs. placebo (+0.8 kg vs. -0.4 kg). In addition, there was an increased rate of hypoglycemia. [See Warnings and Precautions (5.4); Adverse Reactions (6.1).] Table 13: Glycemic Parameters at Final Visit (24-Week Study) for JANUVIA as Add-On Combination Therapy with Glimepiride, with or without MetforminIntent-to-treat population using last observation on study prior to pioglitazone rescue therapy. JANUVIA 100 mg+ GlimepiridePlacebo GlimepirideJANUVIA 100 mg+ Glimepiride+ MetforminPlacebo+ Glimepiride+ MetforminA1C (%)N 102N 103N 115N 105 Baseline (mean)8.48.58.38.3 Change from baseline (adjusted meanLeast squares means adjusted for prior antihyperglycemic therapy status and baseline value.)-0.30.3-0.60.3 Difference from placebo (adjusted mean) (95% CI)-0.6p<0.001 compared to placebo. (-0.8, -0.3)-0.9 (-1.1, -0.7) Patients (%) achieving A1C <7%11 (11%)9 (9%)26 (23%)1 (1%)FPG (mg/dL) = 104N 104N 115N 109 Baseline (mean) 183185179179 Change from baseline (adjusted mean)-118-813 Difference from placebo (adjusted mean) (95% CI)-19p<0.01 compared to placebo. (-32, -7)-21 (-32, -10)Add-on Combination Therapy with Insulin (with or without Metformin)A total of 641 patients with type diabetes participated in 24-week, randomized, double-blind, placebo-controlled study designed to assess the efficacy of JANUVIA as add-on to insulin therapy (with or without metformin). The racial distribution in this study was approximately 70% white, 18% Asian, 7% black, and 5% other groups. Approximately 14% of the patients in this study were Hispanic. Patients entered 2-week, single-blind run-in treatment period on pre-mixed, long-acting, or intermediate-acting insulin, with or without metformin HCl (>=1500 mg per day). Patients using short-acting insulins were excluded unless the short-acting insulin was administered as part of pre-mixed insulin. After the run-in period, patients with inadequate glycemic control (A1C 7.5% to 11%) were randomized to the addition of either 100 mg of JANUVIA or placebo, administered once daily. Patients were on stable dose of insulin prior to enrollment with no changes in insulin dose permitted during the run-in period. Patients who failed to meet specific glycemic goals during the double-blind treatment period were to have uptitration of the background insulin dose as rescue therapy.The median daily insulin dose at baseline was 42 units in the patients treated with JANUVIA and 45 units in the placebo-treated patients. The median change from baseline in daily dose of insulin was zero for both groups at the end of the study. In combination with insulin (with or without metformin), JANUVIA provided significant improvements in A1C, FPG, and 2-hour PPG compared to placebo (Table 14). Both treatment groups had an adjusted mean increase in body weight of 0.1 kg from baseline to Week 24. There was an increased rate of hypoglycemia in patients treated with JANUVIA. [See Warnings and Precautions (5.4); Adverse Reactions (6.1).] Table 14: Glycemic Parameters at Final Visit (24-Week Study) for JANUVIA as Add-on Combination Therapy with InsulinIntent-to-treat population using last observation on study prior to rescue therapy. JANUVIA 100 mg+ Insulin(+/- Metformin)Placebo +Insulin(+/- Metformin)A1C (%)N 305N 312 Baseline (mean)8.78.6 Change from baseline (adjusted mean Least squares means adjusted for metformin use at the screening visit (yes/no), type of insulin used at the screening visit (pre-mixed vs. non-pre-mixed [intermediate- or long-acting]), and baseline value. )-0.6-0.1 Difference from placebo (adjusted mean Treatment by stratum interaction was not significant (p>0.10) for metformin stratum and for insulin stratum.) (95% CI)-0.6p<0.001 compared to placebo. (-0.7, -0.4) Patients (%) achieving A1C <7%39 (12.8%)16 (5.1%)FPG (mg/dL) = 310N 313 Baseline (mean) 176179 Change from baseline (adjusted mean)-18-4 Difference from placebo (adjusted mean) (95% CI)-15 (-23, -7)2-hour PPG (mg/dL) = 240N 257 Baseline (mean) 291292 Change from baseline (adjusted mean)-315 Difference from placebo (adjusted mean) (95% CI)-36 (-47, -25). Maintenance of JANUVIA During Initiation and Titration of Insulin GlargineA total of 746 patients with type diabetes (mean baseline HbA1C 8.8%, disease duration 10.8 years) participated in 30-week, randomized, double-blind, placebo-controlled study to assess the efficacy and safety of continuing JANUVIA during the initiation and uptitration of insulin glargine. Patients who were on stable dose of metformin HCl (>=1500 mg/day) in combination with DPP-4 inhibitor and/or sulfonylurea but with inadequate glycemic control (A1C 7.5% to 11%) were enrolled in the study. Those on metformin and JANUVIA (100 mg/day) directly entered the double-blind treatment period; those on another DPP-4 inhibitor and/or on sulfonylurea entered 4-8 week run-in period in which they were maintained on metformin and switched to JANUVIA (100 mg); other DPP-4 inhibitors and sulfonylureas were discontinued. At randomization patients were randomized either to continue JANUVIA or to discontinue JANUVIA and switch to matching placebo. On the day of randomization, insulin glargine was initiated at dose of 10 units subcutaneously in the evening. Patients were instructed to uptitrate their insulin dose in the evening based on fasting blood glucose measurements to achieve target of 72-100 mg/dL.At 30 weeks, the mean reduction in A1C was greater in the sitagliptin group than in the placebo group (Table 15). At the end of the trial, 27.3% of patients in the sitagliptin group and 27.3% in the placebo group had fasting plasma glucose (FPG) in the target range; there was no significant difference in insulin dose between arms.Table 15: Change from Baseline in A1C and FPG at Week 30 in the Maintenance of JANUVIA During Initiation and Titration of Insulin Glargine StudySitagliptin 100 mg+Metformin+ Insulin GlarginePlacebo+Metformin+ Insulin GlargineA1C (%)N 373N is the number of randomized and treated patients.N 370 Baseline (mean)8.88.8 Week 30 (mean)6.97.3 Change from baseline (adjusted mean)Analysis of Covariance including all post-baseline data regardless of rescue or treatment discontinuation. Model estimates calculated using multiple imputation to model washout of the treatment effect using placebo data for all subjects having missing Week 30 data. -1.9-1.4 Difference from placebo (adjusted mean) (95% CI) -0.4 (-0.6, -0.3)p<0.001 compared to placebo. Patients (%) with A1C <7%202 (54.2%)131 (35.4%)FPG (mg/dL)N 373N 370 Baseline (mean)199201 Week 30 (mean)118123 Change from baseline (adjusted mean) -81-76. Image of Figure 1. image of Figure 2.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. The pharmacokinetics of sitagliptin have been extensively characterized in healthy subjects and patients with type diabetes mellitus. Following single oral 100-mg dose to healthy volunteers, mean plasma AUC of sitagliptin was 8.52 uMohr, Cmax was 950 nM, and apparent terminal half-life (t1/2) was 12.4 hours. Plasma AUC of sitagliptin increased in dose-proportional manner and increased approximately 14% following 100 mg doses at steady-state compared to the first dose. The intra-subject and inter-subject coefficients of variation for sitagliptin AUC were small (5.8% and 15.1%). The pharmacokinetics of sitagliptin was generally similar in healthy subjects and in patients with type diabetes mellitus.. AbsorptionAfter oral administration of 100 mg dose to healthy subjects, sitagliptin was rapidly absorbed with peak plasma concentrations (median Tmax) occurring to hours postdose. The absolute bioavailability of sitagliptin is approximately 87%.. Effect of FoodCoadministration of high-fat meal with sitagliptin had no effect on the pharmacokinetics of sitagliptin.. DistributionThe mean volume of distribution at steady state following single 100-mg intravenous dose of sitagliptin to healthy subjects is approximately 198 liters. The fraction of sitagliptin reversibly bound to plasma proteins is low (38%).. EliminationApproximately 79% of sitagliptin is excreted unchanged in the urine with metabolism being minor pathway of elimination. The apparent terminal t1/2 following 100 mg oral dose of sitagliptin was approximately 12.4 hours and renal clearance was approximately 350 mL/min.. MetabolismFollowing [14C]sitagliptin oral dose, approximately 16% of the radioactivity was excreted as metabolites of sitagliptin. Six metabolites were detected at trace levels and are not expected to contribute to the plasma DPP-4 inhibitory activity of sitagliptin. In vitro studies indicated that the primary enzyme responsible for the limited metabolism of sitagliptin was CYP3A4, with contribution from CYP2C8. ExcretionFollowing administration of an oral [14C]sitagliptin dose to healthy subjects, approximately 100% of the administered radioactivity was eliminated in feces (13%) or urine (87%) within one week of dosing.Elimination of sitagliptin occurs primarily via renal excretion and involves active tubular secretion. Sitagliptin is substrate for human organic anion transporter-3 (hOAT-3), which may be involved in the renal elimination of sitagliptin. The clinical relevance of hOAT-3 in sitagliptin transport has not been established. Sitagliptin is also substrate of P-glycoprotein (P-gp), which may also be involved in mediating the renal elimination of sitagliptin. However, cyclosporine, P-gp inhibitor, did not reduce the renal clearance of sitagliptin.. Specific Populations. Patients with Renal ImpairmentAn approximately 2-fold increase in the plasma AUC of sitagliptin was observed in patients with moderate renal impairment with eGFR of 30 to less than 45 mL/min/1.73 m2, and an approximately 4-fold increase was observed in patients with severe renal impairment, including patients with ESRD on hemodialysis, as compared to normal healthy control subjects.. Patients with Hepatic ImpairmentIn patients with moderate hepatic impairment (Child-Pugh score to 9), mean AUC and Cmax of sitagliptin increased approximately 21% and 13%, respectively, compared to healthy matched controls following administration of single 100-mg dose of sitagliptin. These differences are not considered to be clinically meaningful.There is no clinical experience in patients with severe hepatic impairment (Child-Pugh score >9).. Effects of Age, Body Mass Index (BMI), Gender, and RaceBased on population pharmacokinetic analysis or composite analysis of available pharmacokinetic data, BMI, gender, and race do not have clinically meaningful effect on the pharmacokinetics of sitagliptin. When the effects of age on renal function are taken into account, age alone did not have clinically meaningful impact on the pharmacokinetics of sitagliptin based on population pharmacokinetic analysis. Elderly subjects (65 to 80 years) had approximately 19% higher plasma concentrations of sitagliptin compared to younger subjects.. Drug Interaction Studies. In Vitro Assessment of Drug Interactions Sitagliptin is not an inhibitor of CYP isozymes CYP3A4, 2C8, 2C9, 2D6, 1A2, 2C19 or 2B6, and is not an inducer of CYP3A4. Sitagliptin is P-gp substrate, but does not inhibit P-gp mediated transport of digoxin. Based on these results, sitagliptin is considered unlikely to cause interactions with other drugs that utilize these pathways. Sitagliptin is not extensively bound to plasma proteins. Therefore, the propensity of sitagliptin to be involved in clinically meaningful drug-drug interactions mediated by plasma protein binding displacement is very low.. In Vivo Assessment of Drug Interactions. Effects of Sitagliptin on Other DrugsIn clinical studies, sitagliptin did not meaningfully alter the pharmacokinetics of metformin, glyburide, simvastatin, rosiglitazone, digoxin, warfarin, or an oral contraceptive (ethinyl estradiol and norethindrone) (Table 4), providing in vivo evidence of low propensity for causing drug interactions with substrates of CYP3A4, CYP2C8, CYP2C9, P-gp, and organic cationic transporter (OCT).Table 4: Effect of Sitagliptin on Systemic Exposure of Coadministered DrugsCoadministered DrugDose of Coadministered DrugAll doses administered as single dose unless otherwise specified. Dose of Sitagliptin Geometric Mean Ratio(ratio with/without sitagliptin)No Effect 1.00AUCAUC is reported as AUC0- unless otherwise specified. Cmax Digoxin0.25 mgMultiple dose. once daily for 10 days100 mg once daily for 10 daysDigoxin1.11AUC0-24hr. 1.18Glyburide1.25 mg200 mg once daily for daysGlyburide1.091.01Simvastatin20 mg200 mg once daily for daysSimvastatin0.85AUC0-last. 0.80Simvastatin Acid1.12 1.06Rosiglitazone4 mg200 mg once daily for daysRosiglitazone0.980.99Warfarin30 mg single dose on day 5200 mg once daily for 11 daysS(-) Warfarin0.950.89R(+) Warfarin0.990.89Ethinyl estradiol and norethindrone21 days once daily of 35 ug ethinyl estradiol with norethindrone 0.5 mg 7 days, 0.75 mg 7 days, 1.0 mg 7 days200 mg once daily for 21 daysEthinyl estradiol0.990.97Norethindrone1.030.98Metformin HCl1000 mg twice daily for 14 days50 mg twice daily for daysMetformin1.02AUC0-12hr. 0.97. Effects of Other Drugs on SitagliptinClinical data described below suggest that sitagliptin is not susceptible to clinically meaningful interactions by coadministered medications (Table 5).Table 5: Effect of Coadministered Drugs on Systemic Exposure of SitagliptinCoadministered DrugDose of Coadministered DrugAll doses administered as single dose unless otherwise specified. Dose of Sitagliptin Geometric Mean Ratio(ratio with/without coadministered drug)No Effect 1.00AUCAUC is reported as AUC0- unless otherwise specified. Cmax Cyclosporine600 mg once daily100 mg once dailySitagliptin1.291.68Metformin HCl1000 mgMultiple dose. twice daily for 14 days50 mg twice daily for daysSitagliptin1.02AUC0-12hr. 1.05.

SPL MEDGUIDE SECTION.

Medication GuideJANUVIA(R) (jah-NEW-vee-ah)(sitagliptin)tablets, for oral useThis Medication Guide has been approved by the U.S. Food and Drug Administration.Revised: 12/2020Read this Medication Guide carefully before you start taking JANUVIA and each time you get refill. There may be new information. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about JANUVIA, ask your doctor or pharmacist.What is the most important information should know about JANUVIAJANUVIA can cause serious side effects, including:Inflammation of the pancreas (pancreatitis) which may be severe and lead to death. Certain medical problems make you more likely to get pancreatitis.Before you start taking JANUVIA, tell your doctor if you have ever had:pancreatitishigh blood triglyceride levelsstones in your gallbladder (gallstones)kidney problemsa history of alcoholismStop taking JANUVIA and call your doctor right away if you have pain in your stomach area (abdomen) that is severe and will not go away. The pain may be felt going from your abdomen through to your back. The pain may happen with or without vomiting. These may be symptoms of pancreatitis.Heart failure. Heart failure means your heart does not pump blood well enough.Before you start taking JANUVIA, tell your doctor if you have ever had heart failure or have problems with your kidneys. Contact your doctor right away if you have any of the following symptoms: increasing shortness of breath or trouble breathing, especially when you lie downswelling or fluid retention, especially in the feet, ankles or legsan unusually fast increase in weightunusual tirednessThese may be symptoms of heart failure. What is JANUVIAJANUVIA is prescription medicine used along with diet and exercise to lower blood sugar in adults with type diabetes.JANUVIA is not for people with type diabetes.If you have had pancreatitis (inflammation of the pancreas) in the past, it is not known if you have higher chance of getting pancreatitis while you take JANUVIA.The safety and effectiveness of JANUVIA have not been established in pediatric patients.Who should not take JANUVIA Do not take JANUVIA if:you are allergic to any of the ingredients in JANUVIA. See the end of this Medication Guide for complete list of ingredients in JANUVIA.Symptoms of serious allergic reaction to JANUVIA may include rash, raised red patches on your skin (hives), or swelling of the face, lips, tongue, and throat that may cause difficulty in breathing or swallowing.What should tell my doctor before taking JANUVIA Before you take JANUVIA, tell your doctor about all of your medical conditions, including if you:have or have had inflammation of your pancreas (pancreatitis).have kidney problems.have heart failure.are pregnant or plan to become pregnant. It is not known if JANUVIA will harm your unborn baby. If you are pregnant, talk with your doctor about the best way to control your blood sugar while you are pregnant. Pregnancy Registry: If you take JANUVIA at any time during your pregnancy, talk with your doctor about how you can join the JANUVIA pregnancy registry. The purpose of this registry is to collect information about the health of you and your baby. You can enroll in this registry by calling 1-800-986-8999.are breastfeeding or plan to breastfeed. It is not known if JANUVIA will pass into your breast milk. Talk with your doctor about the best way to feed your baby if you are taking JANUVIA.Tell your doctor about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Know the medicines you take. Keep list of your medicines and show it to your doctor and pharmacist when you get new medicine.How should take JANUVIA Take JANUVIA time each day exactly as your doctor tells you.You can take JANUVIA with or without food.Your doctor will do blood tests to check how well your kidneys are working before and during your treatment with JANUVIA.Your doctor may tell you to take JANUVIA along with other diabetes medicines. Low blood sugar can happen more often when JANUVIA is taken with certain other diabetes medicines. See What are the possible side effects of JANUVIA.If you miss dose, take it as soon as you remember. If you do not remember until it is time for your next dose, skip the missed dose and go back to your regular schedule. Do not take two doses of JANUVIA at the same time.If you take too much JANUVIA, call your doctor or local Poison Control Center right away.When your body is under some types of stress, such as fever, trauma (such as car accident), infection or surgery, the amount of diabetes medicine that you need may change. Tell your doctor right away if you have any of these conditions and follow your doctors instructions.Check your blood sugar as your doctor tells you to.Stay on your prescribed diet and exercise program while taking JANUVIA.Talk to your doctor about how to prevent, recognize and manage low blood sugar (hypoglycemia), high blood sugar (hyperglycemia), and problems you have because of your diabetes.Your doctor will check your diabetes with regular blood tests, including your blood sugar levels and your hemoglobin A1C.What are the possible side effects of JANUVIA JANUVIA may cause serious side effects, including:See What is the most important information should know about JANUVIA.Kidney problems, sometimes requiring dialysis.Low blood sugar (hypoglycemia). If you take JANUVIA with another medicine that can cause low blood sugar, such as sulfonylurea or insulin, your risk of getting low blood sugar is higher. The dose of your sulfonylurea medicine or insulin may need to be lowered while you use JANUVIA. Signs and symptoms of low blood sugar may include:headachedrowsinessirritabilityhungerdizzinessconfusionsweatingfeeling jitteryweaknessfast heart beatSerious allergic reactions. If you have any symptoms of serious allergic reaction, stop taking JANUVIA and call your doctor right away or get emergency medical help. See Who should not take JANUVIA. Your doctor may give you medicine for your allergic reaction and prescribe different medicine for your diabetes.Joint pain. Some people who take medicines called DPP-4 inhibitors like JANUVIA, may develop joint pain that can be severe. Call your doctor if you have severe joint pain.Skin reaction. Some people who take medicines called DPP-4 inhibitors like JANUVIA may develop skin reaction called bullous pemphigoid that can require treatment in hospital. Tell your doctor right away if you develop blisters or the breakdown of the outer layer of your skin (erosion). Your doctor may tell you to stop taking JANUVIA.The most common side effects of JANUVIA include upper respiratory infection, stuffy or runny nose and sore throat, and headache. JANUVIA may have other side effects, including stomach upset and diarrhea, swelling of the hands or legs, when JANUVIA is used with metformin and rosiglitazone (Avandia). Rosiglitazone is another type of diabetes medicine.Tell your doctor if you have any side effect that bothers you or does not go away.These are not all the possible side effects of JANUVIA. 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 JANUVIAStore JANUVIA at room temperature, between 68F to 77F (20C to 25C). Keep JANUVIA and all medicines out of the reach of children. General information about the safe and effective use of JANUVIA.Medicines are sometimes prescribed for purposes other than those listed in Medication Guide. Do not use JANUVIA for condition for which it was not prescribed. Do not give JANUVIA to other people, even if they have the same symptoms you have. It may harm them. This Medication Guide summarizes the most important information about JANUVIA. If you would like to know more information, talk with your doctor. You can ask your doctor or pharmacist for information about JANUVIA that is written for health professionals. What are the ingredients in JANUVIAActive ingredient: sitagliptin Inactive ingredients: microcrystalline cellulose, anhydrous dibasic calcium phosphate, croscarmellose sodium, magnesium stearate, and sodium stearyl fumarate. The tablet film coating contains the following inactive ingredients: polyvinyl alcohol, polyethylene glycol, talc, titanium dioxide, red iron oxide, and yellow iron oxide. Distributed by: Merck Sharp Dohme Corp., subsidiary of MERCK CO., INC., Whitehouse Station, NJ 08889, USA For more information, go to www.JANUVIA.com or call 1-800-622-4477.For patent information: www.merck.com/product/patent/home.html. The trademarks depicted herein are owned by their respective companies. Copyright (C) 2010-2020 Merck Sharp Dohme Corp., subsidiary of Merck Co., Inc. All rights reserved. usmg-mk0431-t-2012r017. Inflammation of the pancreas (pancreatitis) which may be severe and lead to death. Certain medical problems make you more likely to get pancreatitis.Before you start taking JANUVIA, tell your doctor if you have ever had:. pancreatitis. high blood triglyceride levels. stones in your gallbladder (gallstones). kidney problems. history of alcoholism. Heart failure. Heart failure means your heart does not pump blood well enough.Before you start taking JANUVIA, tell your doctor if you have ever had heart failure or have problems with your kidneys. Contact your doctor right away if you have any of the following symptoms: increasing shortness of breath or trouble breathing, especially when you lie down. swelling or fluid retention, especially in the feet, ankles or legs. an unusually fast increase in weight. unusual tiredness. JANUVIA is prescription medicine used along with diet and exercise to lower blood sugar in adults with type diabetes.. JANUVIA is not for people with type diabetes.. If you have had pancreatitis (inflammation of the pancreas) in the past, it is not known if you have higher chance of getting pancreatitis while you take JANUVIA.. The safety and effectiveness of JANUVIA have not been established in pediatric patients.. you are allergic to any of the ingredients in JANUVIA. See the end of this Medication Guide for complete list of ingredients in JANUVIA.. have or have had inflammation of your pancreas (pancreatitis).. have kidney problems.. have heart failure.. are pregnant or plan to become pregnant. It is not known if JANUVIA will harm your unborn baby. If you are pregnant, talk with your doctor about the best way to control your blood sugar while you are pregnant. Pregnancy Registry: If you take JANUVIA at any time during your pregnancy, talk with your doctor about how you can join the JANUVIA pregnancy registry. The purpose of this registry is to collect information about the health of you and your baby. You can enroll in this registry by calling 1-800-986-8999.. are breastfeeding or plan to breastfeed. It is not known if JANUVIA will pass into your breast milk. Talk with your doctor about the best way to feed your baby if you are taking JANUVIA.. Take JANUVIA time each day exactly as your doctor tells you.. You can take JANUVIA with or without food.. Your doctor will do blood tests to check how well your kidneys are working before and during your treatment with JANUVIA.. Your doctor may tell you to take JANUVIA along with other diabetes medicines. Low blood sugar can happen more often when JANUVIA is taken with certain other diabetes medicines. See What are the possible side effects of JANUVIA.. If you miss dose, take it as soon as you remember. If you do not remember until it is time for your next dose, skip the missed dose and go back to your regular schedule. Do not take two doses of JANUVIA at the same time.. If you take too much JANUVIA, call your doctor or local Poison Control Center right away.. When your body is under some types of stress, such as fever, trauma (such as car accident), infection or surgery, the amount of diabetes medicine that you need may change. Tell your doctor right away if you have any of these conditions and follow your doctors instructions.. Check your blood sugar as your doctor tells you to.. Stay on your prescribed diet and exercise program while taking JANUVIA.. Talk to your doctor about how to prevent, recognize and manage low blood sugar (hypoglycemia), high blood sugar (hyperglycemia), and problems you have because of your diabetes.. Your doctor will check your diabetes with regular blood tests, including your blood sugar levels and your hemoglobin A1C.. See What is the most important information should know about JANUVIA.. Kidney problems, sometimes requiring dialysis.. Low blood sugar (hypoglycemia). If you take JANUVIA with another medicine that can cause low blood sugar, such as sulfonylurea or insulin, your risk of getting low blood sugar is higher. The dose of your sulfonylurea medicine or insulin may need to be lowered while you use JANUVIA. Signs and symptoms of low blood sugar may include:. headache. drowsiness. irritability. hunger. dizziness. confusion. sweating. feeling jittery. weakness. fast heart beat. Serious allergic reactions. If you have any symptoms of serious allergic reaction, stop taking JANUVIA and call your doctor right away or get emergency medical help. See Who should not take JANUVIA. Your doctor may give you medicine for your allergic reaction and prescribe different medicine for your diabetes.. Joint pain. Some people who take medicines called DPP-4 inhibitors like JANUVIA, may develop joint pain that can be severe. Call your doctor if you have severe joint pain.. Skin reaction. Some people who take medicines called DPP-4 inhibitors like JANUVIA may develop skin reaction called bullous pemphigoid that can require treatment in hospital. Tell your doctor right away if you develop blisters or the breakdown of the outer layer of your skin (erosion). Your doctor may tell you to stop taking JANUVIA.

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. 8.1 Pregnancy. Pregnancy Exposure RegistryThere is pregnancy exposure registry that monitors pregnancy outcomes in women exposed to JANUVIA during pregnancy. Health care providers are encouraged to report any prenatal exposure to JANUVIA by calling the Pregnancy Registry at 1-800-986-8999.. Risk SummaryThe limited available data with JANUVIA in pregnant women are not sufficient to inform drug-associated risk for major birth defects and miscarriage. There are risks to the mother and fetus associated with poorly controlled diabetes in pregnancy [see Clinical Considerations]. No adverse developmental effects were observed when sitagliptin was administered to pregnant rats and rabbits during organogenesis at oral doses up to 30-times and 20-times, respectively, the 100 mg clinical dose, based on AUC [see Data].The estimated background risk of major birth defects is 6-10% in women with pre-gestational diabetes with Hemoglobin A1c >7% and has been reported to be as high as 20-25% in women with Hemoglobin A1c >10%. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.. Clinical Considerations. Disease-Associated Maternal and/or Embryo/Fetal RiskPoorly controlled diabetes in pregnancy increases the maternal risk for diabetic ketoacidosis, pre-eclampsia, spontaneous abortions, preterm delivery, and delivery complications. Poorly controlled diabetes increases the fetal risk for major birth defects, still birth, and macrosomia related morbidity.. Data. Animal DataIn embryo-fetal development studies, sitagliptin administered to pregnant rats and rabbits during organogenesis (gestation day to 20) did not adversely affect developmental outcomes at oral doses up to 250 mg/kg (30-times the 100 mg clinical dose) and 125 mg/kg (20-times the 100 mg clinical dose), respectively, based on AUC. Higher doses in rats associated with maternal toxicity increased the incidence of rib malformations in offspring at 1000 mg/kg, or approximately 100-times the clinical dose, based on AUC. Placental transfer of sitagliptin was observed in pregnant rats and rabbits.Sitagliptin administered to female rats from gestation day to lactation day 21 caused no functional or behavioral toxicity in offspring of rats at doses up to 1000 mg/kg.. 8.2 Lactation. Risk SummaryThere is no information regarding the presence of JANUVIA in human milk, the effects on the breastfed infant, or the effects on milk production. Sitagliptin is present in rat milk and therefore possibly present in human milk [see Data]. The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for JANUVIA and any potential adverse effects on the breastfed infant from JANUVIA or from the underlying maternal condition.. DataSitagliptin is secreted in the milk of lactating rats at milk to plasma ratio of 4:1.. 8.4 Pediatric Use. The safety and effectiveness of JANUVIA have not been established in pediatric patients.Three 20-week double-blind, placebo-controlled studies each with 34-week extensions were conducted to evaluate the efficacy and safety of sitagliptin in 410 pediatric patients aged 10 to 17 years with inadequately controlled type diabetes, with or without insulin therapy (HbA1c 6.5-10% for patients not on insulin, HbA1c 7-10% for patients on insulin). At study entry, patients in study were not treated with oral antihyperglycemic agents; patients in studies and were on maximally tolerated metformin therapy. The primary efficacy endpoint was the change from baseline in HbA1c after 20 weeks of therapy. The pre-specified primary efficacy analyses included data from study and pooled data from studies and 3, regardless of glycemic rescue or treatment discontinuation. In both efficacy analyses, the effect of treatment with sitagliptin was not significantly different from placebo. In study 1, the mean baseline HbA1c was 7.5%, and 12% of patients were on insulin therapy. At week 20, the change from baseline in HbA1c in patients treated with JANUVIA (N=95) was 0.06% compared to 0.23% in patients treated with placebo (N=95), difference of -0.17% (95% CI: -0.62, 0.28). In studies and 3, the mean baseline HbA1c was 8.0%, 15% of patients were on insulin and 72% were on metformin HCl doses of greater than 1,500 mg daily. At week 20, the change from baseline in HbA1c in patients treated with sitagliptin (N=107) was -0.23% compared to 0.09% in patients treated with placebo (N=113), difference of -0.33% (95% CI: -0.70, 0.05).. 8.5 Geriatric Use. Of the total number of subjects (N=3884) in pre-approval clinical safety and efficacy studies of JANUVIA, 725 patients were 65 years and over, while 61 patients were 75 years and over. No overall differences in safety or effectiveness were observed between subjects 65 years and over and younger subjects. While this and other reported clinical experience have not identified differences in responses between the elderly and younger patients, greater sensitivity of some older individuals cannot be ruled out. Because sitagliptin is substantially excreted by the kidney, and because aging can be associated with reduced renal function, renal function should be assessed more frequently in elderly patients [see Dosage and Administration (2.2), Warnings and Precautions (5.3)].. 8.6Renal Impairment. Sitagliptin is excreted by the kidney, and sitagliptin exposure is increased in patients with renal impairment. Lower dosages are recommended in patients with eGFR less than 45 mL/min/1.73 m2 (moderate and severe renal impairment, as well as in ESRD patients requiring dialysis). [See Dosage and Administration (2.2); Clinical Pharmacology (12.3).].

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. Pancreatitis: There have been postmarketing reports of acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis. If pancreatitis is suspected, promptly discontinue JANUVIA. (5.1)Heart failure: Heart failure has been observed with two other members of the DPP-4 inhibitor class. Consider risks and benefits of JANUVIA in patients who have known risk factors for heart failure. Monitor patients for signs and symptoms. (5.2)Acute Renal Failure: Has been reported postmarketing, sometimes requiring dialysis. Assessment of renal function is recommended prior to initiating JANUVIA and periodically thereafter. (5.3)Hypoglycemia with Concomitant Use with Insulin or Insulin Secretagogues: Increased risk of hypoglycemia when used in combination with insulin and/or an insulin secretagogue. Lower dose of insulin or insulin secretagogue may be required. (5.4, 7.1)Hypersensitivity Reactions: There have been postmarketing reports of serious allergic and hypersensitivity reactions in patients treated with JANUVIA such as anaphylaxis, angioedema, and exfoliative skin conditions including Stevens-Johnson syndrome. Promptly stop JANUVIA, assess for other potential causes, institute appropriate monitoring and treatment. (5.5, 6.2)Severe and Disabling Arthralgia: Has been reported in patients taking DPP-4 inhibitors. Consider as possible cause for severe joint pain and discontinue drug if appropriate. (5.6)Bullous Pemphigoid: There have been postmarketing reports requiring hospitalization in patients taking DPP-4 inhibitors. Tell patients to report development of blisters or erosions. If bullous pemphigoid is suspected, discontinue JANUVIA. (5.7). Pancreatitis: There have been postmarketing reports of acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis. If pancreatitis is suspected, promptly discontinue JANUVIA. (5.1). Heart failure: Heart failure has been observed with two other members of the DPP-4 inhibitor class. Consider risks and benefits of JANUVIA in patients who have known risk factors for heart failure. Monitor patients for signs and symptoms. (5.2). Acute Renal Failure: Has been reported postmarketing, sometimes requiring dialysis. Assessment of renal function is recommended prior to initiating JANUVIA and periodically thereafter. (5.3). Hypoglycemia with Concomitant Use with Insulin or Insulin Secretagogues: Increased risk of hypoglycemia when used in combination with insulin and/or an insulin secretagogue. Lower dose of insulin or insulin secretagogue may be required. (5.4, 7.1). Hypersensitivity Reactions: There have been postmarketing reports of serious allergic and hypersensitivity reactions in patients treated with JANUVIA such as anaphylaxis, angioedema, and exfoliative skin conditions including Stevens-Johnson syndrome. Promptly stop JANUVIA, assess for other potential causes, institute appropriate monitoring and treatment. (5.5, 6.2). Severe and Disabling Arthralgia: Has been reported in patients taking DPP-4 inhibitors. Consider as possible cause for severe joint pain and discontinue drug if appropriate. (5.6). Bullous Pemphigoid: There have been postmarketing reports requiring hospitalization in patients taking DPP-4 inhibitors. Tell patients to report development of blisters or erosions. If bullous pemphigoid is suspected, discontinue JANUVIA. (5.7). 5.1 Pancreatitis. There have been postmarketing reports of acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis, in patients taking JANUVIA. After initiation of JANUVIA, patients should be observed carefully for signs and symptoms of pancreatitis. If pancreatitis is suspected, JANUVIA should promptly be discontinued and appropriate management should be initiated. It is unknown whether patients with history of pancreatitis are at increased risk for the development of pancreatitis while using JANUVIA.. 5.2Heart Failure. An association between dipeptidyl peptidase-4 (DPP-4) inhibitor treatment and heart failure has been observed in cardiovascular outcomes trials for two other members of the DPP-4 inhibitor class. These trials evaluated patients with type diabetes mellitus and atherosclerotic cardiovascular disease.Consider the risks and benefits of JANUVIA prior to initiating treatment in patients at risk for heart failure, such as those with prior history of heart failure and history of renal impairment, and observe these patients for signs and symptoms of heart failure during therapy. Advise patients of the characteristic symptoms of heart failure and to immediately report such symptoms. If heart failure develops, evaluate and manage according to current standards of care and consider discontinuation of JANUVIA.. 5.3Acute Renal Failure. There have been postmarketing reports of worsening renal function, including acute renal failure, sometimes requiring dialysis. subset of these reports involved patients with renal impairment, some of whom were prescribed inappropriate doses of sitagliptin. return to baseline levels of renal impairment has been observed with supportive treatment and discontinuation of potentially causative agents. Consideration can be given to cautiously reinitiating JANUVIA if another etiology is deemed likely to have precipitated the acute worsening of renal function.Assessment of renal function is recommended prior to initiating JANUVIA and periodically thereafter. dosage adjustment is recommended in patients with moderate or severe renal impairment and in patients with ESRD requiring hemodialysis or peritoneal dialysis. [See Dosage and Administration (2.2); Use in Specific Populations (8.6).] 5.4Hypoglycemia with Concomitant Use with Insulin or Insulin Secretagogues. When JANUVIA was used in combination with insulin or insulin secretagogues (e.g., sulfonylurea), medications known to cause hypoglycemia, the incidence of hypoglycemia was increased over that of placebo used in combination with sulfonylurea or with insulin. [See Adverse Reactions (6.1).] Therefore, lower dose of sulfonylurea or insulin may be required to reduce the risk of hypoglycemia. [See Drug Interactions (7.1).] 5.5 Hypersensitivity Reactions. There have been postmarketing reports of serious hypersensitivity reactions in patients treated with JANUVIA. These reactions include anaphylaxis, angioedema, and exfoliative skin conditions including Stevens-Johnson syndrome. Onset of these reactions occurred within the first months after initiation of treatment with JANUVIA, with some reports occurring after the first dose. If hypersensitivity reaction is suspected, discontinue JANUVIA, assess for other potential causes for the event, and institute alternative treatment for diabetes. [See Adverse Reactions (6.2).] Angioedema has also been reported with other DPP-4 inhibitors. Use caution in patient with history of angioedema with another DPP-4 inhibitor because it is unknown whether such patients will be predisposed to angioedema with JANUVIA.. 5.6 Severe and Disabling Arthralgia. There have been postmarketing reports of severe and disabling arthralgia in patients taking DPP-4 inhibitors. The time to onset of symptoms following initiation of drug therapy varied from one day to years. Patients experienced relief of symptoms upon discontinuation of the medication. subset of patients experienced recurrence of symptoms when restarting the same drug or different DPP-4 inhibitor. Consider DPP-4 inhibitors as possible cause for severe joint pain and discontinue drug if appropriate.. 5.7 Bullous Pemphigoid. Postmarketing cases of bullous pemphigoid requiring hospitalization have been reported with DPP-4 inhibitor use. In reported cases, patients typically recovered with topical or systemic immunosuppressive treatment and discontinuation of the DPP-4 inhibitor. Tell patients to report development of blisters or erosions while receiving JANUVIA. If bullous pemphigoid is suspected, JANUVIA should be discontinued and referral to dermatologist should be considered for diagnosis and appropriate treatment.