Icandra (previously Vildagliptin / metformin hydrochloride Novartis)

Evrópusambandið - enska - EMA (European Medicines Agency)

Kauptu það núna

Upplýsingar fylgiseðill PIL
Vara einkenni SPC
Opinber matsskýrsla PAR
Virkt innihaldsefni:
vildagliptin, metformin hydrochloride
Fáanlegur frá:
Novartis Europharm Limited
ATC númer:
A10BD08
INN (Alþjóðlegt nafn):
vildagliptin / metformin
Meðferðarhópur:
Drugs used in diabetes, , Combinations of oral blood glucose lowering drugs
Lækningarsvæði:
Diabetes Mellitus, Type 2
Ábendingar:
Icandra is indicated in the treatment of type-2 diabetes mellitus:Icandra is indicated in the treatment of adult patients who are unable to achieve sufficient glycaemic control at their maximally tolerated dose of oral metformin alone or who are already treated with the combination of vildagliptin and metformin as separate tablets.Icandra is indicated in combination with a sulphonylurea (i.e. triple combination therapy) as an adjunct to diet and exercise in patients inadequately controlled with metformin and a sulphonylurea.Icandra is indicated in triple combination therapy with insulin as an adjunct to diet and exercise to improve glycaemic control in patients when insulin at a stable dose and metformin alone do not provide adequate glycaemic control.
Vörulýsing:
Revision: 20
Leyfisstaða:
Authorised
Leyfisnúmer:
EMEA/H/C/001050
Leyfisdagur:
2008-11-30
EMEA númer:
EMEA/H/C/001050

Skjöl

Opinber matsskýrsla Opinber matsskýrsla - búlgarska
Opinber matsskýrsla Opinber matsskýrsla - tékkneska
Opinber matsskýrsla Opinber matsskýrsla - eistneska
Opinber matsskýrsla Opinber matsskýrsla - lettneska
Opinber matsskýrsla Opinber matsskýrsla - litháíska
Opinber matsskýrsla Opinber matsskýrsla - ungverska
Opinber matsskýrsla Opinber matsskýrsla - maltneska
Opinber matsskýrsla Opinber matsskýrsla - hollenska
Opinber matsskýrsla Opinber matsskýrsla - portúgalska
Opinber matsskýrsla Opinber matsskýrsla - rúmenska
Opinber matsskýrsla Opinber matsskýrsla - slóvakíska
Opinber matsskýrsla Opinber matsskýrsla - slóvenska
Samantekt á eiginleikum vöru Samantekt á eiginleikum vöru - norskt bókmál

B. PACKAGE LEAFLET

Package leaflet: Information for the user

Icandra 50 mg/850 mg film-coated tablets

Icandra 50 mg/1000 mg film-coated tablets

vildagliptin/metformin hydrochloride

Read all of this leaflet carefully before you start taking this medicine because it contains

important information for you.

Keep this leaflet. You may need to read it again.

If you have any further questions, ask your doctor, pharmacist or nurse.

This medicine has been prescribed for you only. Do not pass it on to others. It may harm them,

even if their signs of illness are the same as yours.

If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible

side effects not listed in this leaflet. See section 4.

What is in this leaflet

What Icandra is and what it is used for

What you need to know before you take Icandra

How to take Icandra

Possible side effects

How to store Icandra

Contents of the pack and other information

1.

What Icandra is and what it is used for

The active substances of Icandra, vildagliptin and metformin, belong to a group of medicines called

“oral antidiabetics”.

Icandra is used to treat adult patients with type 2 diabetes. This type of diabetes is also known as non-

insulin-dependent diabetes mellitus.

Type 2 diabetes develops if the body does not make enough insulin or if the insulin that the body

makes does not work as well as it should. It can also develop if the body produces too much glucagon.

Both insulin and glucagon are made in the pancreas. Insulin helps to lower the level of sugar in the

blood, especially after meals. Glucagon triggers the liver to make sugar, causing the blood sugar level

to rise.

How Icandra works

Both active substances, vildagliptin and metformin, help to control the level of sugar in the blood. The

substance vildagliptin works by making the pancreas produce more insulin and less glucagon. The

substance metformin works by helping the body to make better use of insulin. This medicine has been

shown to reduce blood sugar, which may help to prevent complications from your diabetes.

2.

What you need to know before you take Icandra

Do not take Icandra

if you are allergic to vildagliptin, metformin or any of the other ingredients of this medicine

(listed in section 6). If you think you may be allergic to any of these, talk to your doctor before

taking Icandra.

if you have uncontrolled diabetes, with, for example, severe hyperglycaemia (high blood

glucose), nausea, vomiting, diarrhoea, rapid weight loss, lactic acidosis (see “Risk of lactic

acidosis” below) or ketoacidosis. Ketoacidosis is a condition in which substances called ketone

bodies accumulate in the blood and which can lead to diabetic pre-coma. Symptoms include

stomach pain, fast and deep breathing, sleepiness or your breath developing an unusual fruity

smell.

if you have recently had a heart attack or if you have heart failure or serious problems with your

blood circulation or difficulties in breathing which could be a sign of heart problems.

if you have severely reduced kidney function.

if you have a severe infection or are seriously dehydrated (have lost a lot of water from your

body).

if you are going to have a contrast x-ray (a specific type of x-ray involving an injectable dye).

Please also see information about this in section “Warnings and precautions”.

if you have liver problems.

if you drink alcohol excessively (whether every day or only from time to time).

if you are breast-feeding (see also “Pregnancy and breast-feeding”).

Warnings and precautions

Risk of lactic acidosis

Icandra may cause a very rare, but very serious side effect called lactic acidosis, particularly if your

kidneys are not working properly. The risk of developing lactic acidosis is also increased with

uncontrolled diabetes, serious infections, prolonged fasting or alcohol intake, dehydration (see further

information below), liver problems and any medical conditions in which a part of the body has a

reduced supply of oxygen (such as acute severe heart disease).

If any of the above apply to you, talk to your doctor for further instructions.

Stop taking Icandra

for a short time if you have a condition that may be associated with

dehydration

(significant loss of body fluids) such as severe vomiting, diarrhoea, fever, exposure to

heat or if you drink less fluid than normal. Talk to your doctor for further instructions.

Stop taking Icandra

and contact a doctor or the nearest hospital immediately if you experience

some of the symptoms of lactic acidosis

, as this condition may lead to coma.

Symptoms of lactic acidosis include:

vomiting

stomach ache (abdominal pain)

muscle cramps

a general feeling of not being well with severe tiredness

difficulty in breathing

reduced body temperature and heartbeat

Lactic acidosis is a medical emergency and must be treated in a hospital.

Icandra is not a substitute for insulin. Therefore, you should not receive Icandra for the treatment of

type 1 diabetes.

Talk to your doctor, pharmacist or nurse before taking Icandra if you have or have had a disease of the

pancreas.

Talk to your doctor, pharmacist or nurse before taking Icandra if you are taking an anti-diabetic

medicine known as a sulphonylurea. Your doctor may want to reduce your dose of the sulphonylurea

when you take it together with Icandra in order to avoid low blood glucose (hypoglycaemia).

If you have previously taken vildagliptin but had to stop taking it because of liver disease, you should

not take this medicine.

Diabetic skin lesions are a common complication of diabetes. You are advised to follow the

recommendations for skin and foot care that you are given by your doctor or nurse. You are also

advised to pay particular attention to new onset of blisters or ulcers while taking Icandra. Should these

occur, you should promptly consult your doctor.

If you need to have major surgery you must stop taking Icandra during and for some time after the

procedure. Your doctor will decide when you must stop and when to restart your treatment with

Icandra.

A test to determine your liver function will be performed before the start of Icandra treatment, at

three-month intervals for the first year and periodically thereafter. This is so that signs of increased

liver enzymes can be detected as early as possible.

During treatment with Icandra, your doctor will check your kidney function at least once a year or

more frequently if you are elderly and/or have worsening renal function.

Your doctor will test your blood and urine for sugar regularly.

Children and adolescents

The use of Icandra in children and adolescents up to 18 years of age is not recommended.

Other medicines and Icandra

If you need to have an injection of a contrast medium that contains iodine into your bloodstream, for

example in the context of an X-ray or scan, you must stop taking Eucreas before or at the time of the

injection. Your doctor will decide when you must stop and when to restart your treatment with

Eucreas.

Tell your doctor if you are taking, have recently taken or might take any other medicines. You may

need more frequent blood glucose and kidney function tests or your doctor may need to adjust the

dosage of Icandra. It is especially important to mention the following:

glucocorticoids generally used to treat inflammation

beta-2 agonists generally used to treat respiratory disorders

other medicines used to treat diabetes

medicines which increase urine production (diuretics)

medicines used to treat pain and inflammation (NSAID and COX-2-inhibitors, such as

ibuprofen and celecoxib)

certain medicines for the treatment of high blood pressure (ACE inhibitors and angiotensin II

receptor antagonists)

certain medicines affecting the thyroid, or

certain medicines affecting the nervous system.

Icandra with alcohol

Avoid excessive alcohol intake while taking Icandra since this may increase the risk of lactic acidosis

(please see section “Warnings and precautions”).

Pregnancy and breast-feeding

If you are pregnant, think you may be pregnant or are planning to have a baby, ask your doctor

for advice before taking this medicine. Your doctor will discuss with you the potential risk of

taking Icandra during pregnancy.

Do not use Icandra if you are pregnant or breast-feeding (see also “Do not take Icandra”).

Ask your doctor or pharmacist for advice before taking any medicine.

Driving and using machines

If you feel dizzy while taking Icandra, do not drive or use any tools or machines.

3.

How to take Icandra

The amount of Icandra that people have to take varies depending on their condition. Your doctor will

tell you exactly the dose of Icandra to take.

Always take this medicine exactly as your doctor has told you. Check with your doctor or pharmacist

if you are not sure.

The recommended dose is one film-coated tablet of either 50 mg/850 mg or 50 mg/1000 mg taken

twice a day.

If you have reduced kidney function, your doctor may prescribe a lower dose. Also if you are taking

an anti-diabetic medicine known as a sulphonylurea your doctor may prescribe a lower dose.

Your doctor may prescribe this medicine alone or with certain other medicines that lower the level of

sugar in your blood.

When and how to take Icandra

Swallow the tablets whole with a glass of water,

Take one tablet in the morning and the other in the evening with or just after food. Taking the

tablet just after food will lower the risk of an upset stomach.

Continue to follow any advice about diet that your doctor has given you. In particular, if you are

following a diabetic weight control diet, continue with this while you are taking Icandra.

If you take more Icandra than you should

If you take too many Icandra tablets, or if someone else takes your tablets,

talk to a doctor or

pharmacist immediately

. Medical attention may be necessary. If you have to go to a doctor or

hospital, take the pack and this leaflet with you.

If you forget to take Icandra

If you forget to take a tablet, take it with your next meal unless you are due to take one then anyway.

Do not take a double dose (two tablets at once) to make up for a forgotten tablet.

If you stop taking Icandra

Continue to take this medicine as long as your doctor prescribes it so that it can continue to control

your blood sugar. Do not stop taking Icandra unless your doctor tells you to. If you have any questions

about how long to take this medicine, talk to your doctor.

If you have any further questions on the use of this medicine, ask your doctor, pharmacist or nurse.

4.

Possible side effects

Like all medicines, this medicine can cause side effects, although not everybody gets them.

You should

stop taking Icandra and see your doctor immediately

if you experience the following

side effects:

Lactic acidosis

(very rare: may affect up to 1 user in 10,000):

Icandra may cause a very rare, but very serious side effect called lactic acidosis (see section

“Warnings and precautions”). If this happens you must

stop taking Icandra and contact a

doctor or the nearest hospital immediately

, as lactic acidosis may lead to coma.

Angioedema (rare: may affect up to 1 in 1,000 people): Symptoms include swollen face, tongue

or throat, difficulty swallowing, difficulty breathing, sudden onset of rash or hives, which may

indicate a reaction called “angioedema”.

Liver disease (hepatitis) (rare): Symptoms include yellow skin and eyes, nausea, loss of appetite

or dark-coloured urine, which may indicate liver disease (hepatitis).

Inflammation of the pancreas (pancreatitis) (frequency not known): Symptoms include severe

and persistent pain in the abdomen (stomach area), which might reach through to your back as

well as nausea and vomiting.

Other side effects

Some patients have experienced the following side effects while taking Icandra:

Very common (may affect more than 1 in 10 people): nausea, vomiting, diarrhoea, pain in and

around the stomach (abdominal pain), loss of appetite.

Common (may affect up to 1 in 10 people): dizziness, headache, trembling that cannot be

controlled, metallic taste, low blood glucose.

Uncommon (may affect up to 1 in 100 people): joint pain, tiredness, constipation, swollen

hands, ankle or feet (oedema).

Very rare (may affect up to 1 in 10,000 people): sore throat, runny nose, fever; signs of a high

level of lactic acid in the blood (known as lactic acidosis) such as drowsiness or dizziness,

severe nausea or vomiting, abdominal pain, irregular heart beat or deep, rapid breathing;

redness of the skin, itching; decreased vitamin B12 levels (paleness, tiredness, mental

symptoms such as confusion or memory disturbances).

Some patients have experienced the following side effects while taking Icandra and a sulphonylurea:

Common: dizziness, tremor, weakness, low blood glucose, excessive sweating.

Some patients have had the following side effects while taking Icandra and insulin:

Common: headache, chills, nausea (feeling sick),

low blood glucose, heartburn.

Uncommon: diarrhoea, flatulence.

Since this product has been marketed, the following side effects have also been reported:

Frequency not known (cannot be estimated from the available data):

itchy rash, inflammation of

the pancreas, localised peeling of skin or blisters, muscle pain.

Reporting of side effects

If you get any side effects, talk to your doctor, pharmacist or nurse. This includes any possible side

effects not listed in this leaflet. You can also report side effects directly via the national reporting

system listed in Appendix V. By reporting side effects you can help provide more information on the

safety of this medicine.

5.

How to store Icandra

Keep this medicine out of the sight and reach of children.

Do not use this medicine after the expiry date which is stated on the blister and carton after

“EXP”. The expiry date refers to the last day of that month.

Do not store above 30

Store in the original package (blister) in order to protect from moisture.

6.

Contents of the pack and other information

What Icandra contains

The active substances are vildagliptin and metformin hydrochloride.

Each Icandra 50 mg/850 mg film-coated tablet contains 50 mg vildagliptin and 850 mg

metformin hydrochloride (corresponding to 660 mg of metformin).

Each Icandra 50 mg/1000 mg film-coated tablet contains 50 mg vildagliptin and 1000 mg

metformin hydrochloride (corresponding to 780 mg of metformin).

The other ingredients are: Hydroxypropylcellulose, magnesium stearate, hypromellose, titanium

dioxide (E 171), yellow iron oxide (E 172), macrogol 4000 and talc.

What Icandra looks like and contents of the pack

Icandra 50 mg/850 mg film-coated tablets are yellow, oval tablets with “NVR” on one side and

“SEH” on the other.

Icandra 50 mg/1000 mg film-coated tablets are dark yellow, oval tablets with “NVR” on one side and

“FLO” on the other.

Icandra is available in packs containing 10, 30, 60, 120, 180 or 360 film-coated tablets and in multi-

packs containing 120 (2x60), 180 (3x60) or 360 (6x60) film-coated tablets. Not all pack sizes and

tablet strengths may be available in your country.

Marketing Authorisation Holder

Novartis Europharm Limited

Vista Building

Elm Park, Merrion Road

Dublin 4

Ireland

Manufacturer

Lek d.d, PE PROIZVODNJA LENDAVA

Trimlini 2D

Lendava, 9220

Slovenia

Novartis Pharma GmbH

Roonstraße 25

D-90429 Nuremberg

Germany

For any information about this medicine, please contact the local representative of the Marketing

Authorisation Holder:

België/Belgique/Belgien

Novartis Pharma N.V.

Tél/Tel: +32 2 246 16 11

Lietuva

SIA „Novartis Baltics“ Lietuvos filialas

Tel: +370 5 269 16 50

България

Novartis Bulgaria EOOD

Тел.: +359 2 489 98 28

Luxembourg/Luxemburg

Novartis Pharma N.V.

Tél/Tel: +32 2 246 16 11

Česká republika

Novartis s.r.o.

Tel: +420 225 775 111

Magyarország

Novartis Hungária Kft.

Tel.: +36 1 457 65 00

Danmark

Novartis Healthcare A/S

Tlf: +45 39 16 84 00

Malta

Novartis Pharma Services Inc.

Tel: +356 2122 2872

Deutschland

Apontis Pharma GmbH & Co. KG

Tel: +49 2173 48 4949

Nederland

Novartis Pharma B.V.

Tel: +31 26 37 82 111

Eesti

SIA Novartis Baltics Eesti filiaal

Tel: +372 66 30 810

Norge

Novartis Norge AS

Tlf: +47 23 05 20 00

Ελλάδα

Novartis (Hellas) A.E.B.E.

Τηλ: +30 210 281 17 12

Österreich

Novartis Pharma GmbH

Tel: +43 1 86 6570

España

Mylan Pharmaceuticals, S.L.

Tel: +34 93 378 64 00

Polska

Novartis Poland Sp. z o.o.

Tel.: +48 22 375 4888

France

Novartis Pharma S.A.S.

Tél: +33 1 55 47 66 00

Portugal

Merck, S.A.

Tel. +351 21 3613 500

Hrvatska

Novartis Hrvatska d.o.o.

Tel. +385 1 6274 220

România

Novartis Pharma Services Romania SRL

Tel: +40 21 31299 01

Ireland

Novartis Ireland Limited

Tel: +353 1 260 12 55

Slovenija

Novartis Pharma Services Inc.

Tel: +386 1 300 75 50

Ísland

Vistor hf.

Sími: +354 535 7000

Slovenská republika

Novartis Slovakia s.r.o.

Tel: +421 2 5542 5439

Italia

Novartis Farma S.p.A.

Tel: +39 02 96 54 1

Suomi/Finland

Novartis Finland Oy

Puh/Tel: +358 (0)10 6133 200

Κύπρος

Novartis Pharma Services Inc.

Τηλ: +357 22 690 690

Sverige

Novartis Sverige AB

Tel: +46 8 732 32 00

Latvija

SIA “Novartis Baltics”

Tel: +371 67 887 070

United Kingdom

Novartis Pharmaceuticals UK Ltd.

Tel: +44 1276 698370

This leaflet was last revised in

Other sources of information

Detailed information on this medicine is available on the European Medicines Agency website:

http://www.ema.europa.eu

ANNEX I

SUMMARY OF PRODUCT CHARACTERISTICS

1.

NAME OF THE MEDICINAL PRODUCT

Icandra 50 mg/850 mg film-coated tablets

Icandra 50 mg/1000 mg film-coated tablets

2.

QUALITATIVE AND QUANTITATIVE COMPOSITION

Icandra 50 mg/850 mg film-coated tablets

Each film-coated tablet contains 50 mg of vildagliptin and 850 mg of metformin hydrochloride

(corresponding to 660 mg of metformin).

Icandra 50 mg/1000 mg film-coated tablets

Each film-coated tablet contains 50 mg of vildagliptin and 1000 mg of metformin hydrochloride

(corresponding to 780 mg of metformin).

For the full list of excipients, see section 6.1.

3.

PHARMACEUTICAL FORM

Film-coated tablet.

Icandra 50 mg/850 mg film-coated tablets

Yellow, ovaloid film-coated tablet with bevelled edge, imprinted with “NVR” on one side and “SEH”

on the other side.

Icandra 50 mg/1000 mg film-coated tablets

Dark yellow, ovaloid film-coated tablet with bevelled edge, imprinted with “NVR” on one side and

“FLO” on the other side.

4.

CLINICAL PARTICULARS

4.1

Therapeutic indications

Icandra is indicated in the treatment of type 2 diabetes mellitus:

Icandra is indicated in the treatment of adult patients who are unable to achieve sufficient

glycaemic control at their maximally tolerated dose of oral metformin alone or who are already

treated with the combination of vildagliptin and metformin as separate tablets.

Icandra is indicated in combination with a sulphonylurea (i.e. triple combination therapy) as an

adjunct to diet and exercise in adult patients inadequately controlled with metformin and a

sulphonylurea.

Icandra is indicated in triple combination therapy with insulin as an adjunct to diet and exercise

to improve glycaemic control in adult patients when insulin at a stable dose and metformin

alone do not provide adequate glycaemic control.

4.2

Posology and method of administration

Posology

Adults with normal renal function (

GFR ≥ 90 ml/min

)

The dose of antihyperglycaemic therapy with Icandra should be individualised on the basis of the

patient’s current regimen, effectiveness and tolerability while not exceeding the maximum

recommended daily dose of 100 mg vildagliptin. Icandra may be initiated at either the 50 mg/850 mg

or 50 mg/1000 mg tablet strength twice daily, one tablet in the morning and the other in the evening.

For patients inadequately controlled at their maximal tolerated dose of metformin monotherapy:

The starting dose of Icandra should provide vildagliptin as 50 mg twice daily (100 mg total daily

dose) plus the dose of metformin already being taken.

For patients switching from co-administration of vildagliptin and metformin as separate tablets:

Icandra should be initiated at the dose of vildagliptin and metformin already being taken.

For patients inadequately controlled on dual combination with metformin and a sulphonylurea:

The doses of Icandra should provide vildagliptin as 50 mg twice daily (100 mg total daily dose) and a

dose of metformin similar to the dose already being taken. When Icandra is used in combination with

a sulphonylurea, a lower dose of the sulphonylurea may be considered to reduce the risk of

hypoglycaemia.

For patients inadequately controlled on dual combination therapy with insulin and the maximal

tolerated dose of metformin:

The dose of Icandra should provide vildagliptin dosed as 50 mg twice daily (100 mg total daily dose)

and a dose of metformin similar to the dose already being taken.

The safety and efficacy of vildagliptin and metformin as triple oral therapy in combination with a

thiazolidinedione have not been established.

Special populations

Elderly (≥ 65 years)

As metformin is excreted via the kidney, and elderly patients have a tendency to decreased renal

function, elderly patients taking Icandra should have their renal function monitored regularly (see

sections 4.4 and 5.2).

Renal impairment

A GFR should be assessed before initiation of treatment with metformin-containing products and at

least annually thereafter. In patients at increased risk of further progression of renal impairment and in

the elderly, renal function should be assessed more frequently, e.g. every 3-6 months.

The maximum daily dose of metformin should preferably be divided into 2-3 daily doses. Factors that

may increase the risk of lactic acidosis (see section 4.4) should be reviewed before considering

initiation of metformin in patients with GFR<60 ml/min.

If no adequate strength of Icandra is available, individual monocomponents should be used instead of

the fixed dose combination.

GFR ml/min

Metformin

Vildagliptin

60-89

Maximum daily dose is 3000 mg.

Dose reduction may be considered in

relation to declining renal function.

No dose adjustment.

45-59

Maximum daily dose is 2000 mg.

The starting dose is at most half of the

maximum dose.

Maximal daily dose is 50 mg.

30-44

Maximum daily dose is 1000 mg.

The starting dose is at most half of the

maximum dose.

<30

Metformin is contraindicated.

Hepatic impairment

Icandra should not be used in patients with hepatic impairment, including those with pre-treatment

alanine aminotransferase (ALT) or aspartate aminotransferase (AST) > 3 times the upper limit of

normal (ULN) (see sections 4.3, 4.4 and 4.8).

Paediatric population

Icandra is not recommended for use in children and adolescents (< 18 years). The safety and efficacy

of Icandra in children and adolescents (< 18 years) have not been established. No data are available.

Method of administration

Oral use.

Taking Icandra with or just after food may reduce gastrointestinal symptoms associated with

metformin (see also section 5.2).

4.3

Contraindications

Hypersensitivity to the active substances or to any of the excipients listed in section 6.1

Any type of acute metabolic acidosis (such as lactic acidosis, diabetic ketoacidosis)

Diabetic pre-coma

Severe renal failure (GFR < 30 ml/min) (see section 4.4)

Acute conditions with the potential to alter renal function, such as:

dehydration,

severe infection,

shock,

intravascular administration of iodinated contrast agents (see section 4.4).

Acute or chronic disease which may cause tissue hypoxia, such as:

cardiac or respiratory failure,

recent myocardial infarction,

shock.

Hepatic impairment (see sections 4.2, 4.4 and 4.8)

Acute alcohol intoxication, alcoholism

Breast-feeding (see section 4.6)

4.4

Special warnings and precautions for use

General

Icandra is not a substitute for insulin in insulin-requiring patients and should not be used in patients

with type 1 diabetes.

Lactic acidosis

Lactic acidosis, a very rare but serious metabolic complication, most often occurs at acute worsening

of renal function, or cardiorespiratory illness or sepsis. Metformin accumulation occurs at acute

worsening of renal function and increases the risk of lactic acidosis.

In case of dehydration (severe diarrhoea or vomiting, fever or reduced fluid intake), metformin should

be temporarily discontinued and contact with a health care professional is recommended.

Medicinal products that can acutely impair renal function (such as antihypertensives, diuretics and

NSAIDs) should be initiated with caution in metformin-treated patients. Other risk factors for lactic

acidosis are excessive alcohol intake, hepatic insufficiency, inadequately controlled diabetes, ketosis,

prolonged fasting and any conditions associated with hypoxia, as well as concomitant use of

medicinal products that may cause lactic acidosis (see sections 4.3 and 4.5).

Patients and/or care-givers should be informed of the risk of lactic acidosis. Lactic acidosis is

characterised by acidotic dyspnoea, abdominal pain, muscle cramps, asthenia and hypothermia

followed by coma. In case of suspected symptoms, the patient should stop taking metformin and seek

immediate medical attention. Diagnostic laboratory findings are decreased blood pH (< 7.35),

increased plasma lactate levels (> 5 mmol/l) and an increased anion gap and lactate/pyruvate ratio.

Administration of iodinated contrast agents

Intravascular administration of iodinated contrast agents may lead to contrast-induced nephropathy,

resulting in metformin accumulation and increased risk of lactic acidosis. Metformin should be

discontinued prior to or at the time of the imaging procedure and not restarted until at least 48 hours

after, provided that renal function has been re-evaluated and found to be stable (see sections 4.2 and

4.5).

Renal function

GFR should be assessed before treatment initiation and regularly thereafter (see section 4.2).

Metformin is contraindicated in patients with GFR < 30 ml/min and should be temporarily

discontinued in the presence of conditions that alter renal function (see section 4.3).

Hepatic impairment

Patients with hepatic impairment, including those with pre-treatment ALT or AST > 3x ULN, should

not be treated with Icandra (see sections 4.2, 4.3 and 4.8).

Liver enzyme monitoring

Rare cases of hepatic dysfunction (including hepatitis) have been reported with vildagliptin. In these

cases, the patients were generally asymptomatic without clinical sequelae and liver function tests

(LFTs) returned to normal after discontinuation of treatment. LFTs should be performed prior to the

initiation of treatment with Icandra in order to know the patient’s baseline value. Liver function

should be monitored during treatment with Icandra at three-month intervals during the first year and

periodically thereafter. Patients who develop increased transaminase levels should be monitored with

a second liver function evaluation to confirm the finding and be followed thereafter with frequent

LFTs until the abnormality(ies) return(s) to normal. Should an increase in AST or in ALT of 3x ULN

or greater persist, withdrawal of Icandra therapy is recommended. Patients who develop jaundice or

other signs suggestive of liver dysfunction should discontinue Icandra.

Following withdrawal of treatment with Icandra and LFT normalisation, treatment with Icandra

should not be re-initiated.

Skin disorders

Skin lesions, including blistering and ulceration have been reported with vildagliptin in extremities of

monkeys in non-clinical toxicology studies (see section 5.3). Although skin lesions were not observed

at an increased incidence in clinical trials, there was limited experience in patients with diabetic skin

complications. Furthermore, there have been post-marketing reports of bullous and exfoliative skin

lesions. Therefore, in keeping with routine care of the diabetic patient, monitoring for skin disorders,

such as blistering or ulceration, is recommended.

Acute pancreatitis

Use of vildagliptin has been associated with a risk of developing acute pancreatitis. Patients should be

informed of the characteristic symptom of acute pancreatitis.

If pancreatitis is suspected, vildagliptin should be discontinued; if acute pancreatitis is confirmed,

vildagliptin should not be restarted. Caution should be exercised in patients with a history of acute

pancreatitis.

Hypoglycaemia

Sulphonylureas are known to cause hypoglycaemia. Patients receiving vildagliptin in combination

with a sulphonylurea may be at risk for hypoglycaemia. Therefore, a lower dose of sulphonylurea may

be considered to reduce the risk of hypoglycaemia.

Surgery

Metformin must be discontinued at the time of surgery under general, spinal or epidural anaesthesia.

Therapy may be restarted no earlier than 48 hours following surgery or resumption of oral nutrition

and provided that renal function has been re-evaluated and found to be stable.

4.5

Interaction with other medicinal products and other forms of interaction

There have been no formal interaction studies for Icandra. The following statements reflect the

information available on the individual active substances.

Vildagliptin

Vildagliptin has a low potential for interactions with co-administered medicinal products. Since

vildagliptin is not a cytochrome P (CYP) 450 enzyme substrate and does not inhibit or induce CYP

450 enzymes, it is not likely to interact with active substances that are substrates, inhibitors or

inducers of these enzymes.

Results from clinical trials conducted with the oral antidiabetics pioglitazone, metformin and

glyburide in combination with vildagliptin have shown no clinically relevant pharmacokinetic

interactions in the target population.

Drug-drug interaction studies with digoxin (P-glycoprotein substrate) and warfarin (CYP2C9

substrate) in healthy subjects have shown no clinically relevant pharmacokinetic interactions after co-

administration with vildagliptin.

Drug-drug interaction studies in healthy subjects were conducted with amlodipine, ramipril, valsartan

and simvastatin. In these studies, no clinically relevant pharmacokinetic interactions were observed

after co-administration with vildagliptin. However, this has not been established in the target

population.

Combination with ACE inhibitors

There may be an increased risk of angioedema in patients concomitantly taking ACE inhibitors.(see

section 4.8).

As with other oral antidiabetic medicinal products the hypoglycaemic effect of vildagliptin may be

reduced by certain active substances, including thiazides, corticosteroids, thyroid products and

sympathomimetics.

Metformin

Combinations not recommended

Alcohol

Alcohol intoxication is associated with an increased risk of lactic acidosis, particularly in cases of

fasting, malnutrition or hepatic impairment.

Iodinated contrast agents

Metformin must be discontinued prior to or at the time of the imaging procedure and not restarted

until at least 48 hours after, provided that renal function has been re-evaluated and found to be stable

(see sections 4.2 and 4.4).

Cationic active substances

Cationic active substances that are eliminated by renal tubular secretion (e.g. cimetidine) may interact

with metformin by competing for common renal tubular transport systems and hence delay the

elimination of metformin, which may increase the risk of lactic acidosis. A study in healthy volunteers

showed that cimetidine, administered as 400 mg twice daily, increased metformin systemic exposure

(AUC) by 50%. Therefore, close monitoring of glycaemic control, dose adjustment within the

recommended posology and changes in diabetic treatment should be considered when cationic

medicinal products that are eliminated by renal tubular secretion are co-administered (see section 4.4).

Combinations requiring precautions for use

Some medicinal products can adversely affect renal function which may increase the risk of lactic

acidosis, e.g. NSAIDs, including selective cyclo-oxygenase (COX) II inhibitors, ACE inhibitors,

angiotensin II receptor antagonists and diuretics, especially loop diuretics. When starting or using

such products in combination with metformin, close monitoring of renal function is necessary.

Glucocorticoids, beta-2-agonists, and diuretics have intrinsic hyperglycaemic activity. The patient

should be informed and more frequent blood glucose monitoring performed, especially at the

beginning of treatment. If necessary, the dosage of Icandra may need to be adjusted during

concomitant therapy and on its discontinuation.

Angiotensin converting enzyme (ACE) inhibitors may decrease the blood glucose levels. If necessary,

the dosage of the antihyperglycaemic medicinal product should be adjusted during therapy with the

other medicinal product and on its discontinuation.

4.6

Fertility, pregnancy and lactation

Pregnancy

There are no adequate data from the use of Icandra in pregnant women. For vildagliptin studies in

animals have shown reproductive toxicity at high doses. For metformin, studies in animals have not

shown reproductive toxicity. Studies in animals performed with vildagliptin and metformin have not

shown evidence of teratogenicity, but foetotoxic effects at maternotoxic doses (see section 5.3). The

potential risk for humans is unknown. Icandra should not be used during pregnancy.

Breast-feeding

Studies in animals have shown excretion of both metformin and vildagliptin in milk. It is unknown

whether vildagliptin is excreted in human milk, but metformin is excreted in human milk in low

amounts. Due to both the potential risk of neonate hypoglycaemia related to metformin and the lack of

human data with vildagliptin, Icandra should not be used during breast-feeding (see section 4.3).

Fertility

No studies on the effect on human fertility have been conducted for Icandra (see section 5.3).

4.7

Effects on ability to drive and use machines

No studies on the effects on the ability to drive and use machines have been performed. Patients who

may experience dizziness as an adverse reaction should avoid driving vehicles or using machines.

4.8

Undesirable effects

There have been no therapeutic clinical trials conducted with Icandra. However, bioequivalence of

Icandra with co-administered vildagliptin and metformin has been demonstrated (see section 5.2). The

data presented here relate to the co-administration of vildagliptin and metformin, where vildagliptin

has been added to metformin. There have been no studies of metformin added to vildagliptin.

Summary of the safety profile

The majority of adverse reactions were mild and transient, not requiring treatment discontinuations.

No association was found between adverse reactions and age, ethnicity, duration of exposure or daily

dose.

Rare cases of hepatic dysfunction (including hepatitis) have been reported with vildagliptin. In these

cases, the patients were generally asymptomatic without clinical sequelae and liver function returned

to normal after discontinuation of treatment. In data from controlled monotherapy and add-on therapy

trials of up to 24 weeks in duration, the incidence of ALT or AST elevations ≥ 3x ULN (classified as

present on at least 2 consecutive measurements or at the final on-treatment visit) was 0.2%, 0.3% and

0.2% for vildagliptin 50 mg once daily, vildagliptin 50 mg twice daily and all comparators,

respectively. These elevations in transaminases were generally asymptomatic, non-progressive in

nature and not associated with cholestasis or jaundice.

Rare cases of angioedema have been reported on vildagliptin at a similar rate to controls. A greater

proportion of cases were reported when vildagliptin was administered in combination with an ACE

inhibitor. The majority of events were mild in severity and resolved with ongoing vildagliptin

treatment.

Tabulated list of adverse reactions

Adverse reactions reported in patients who received vildagliptin in double-blind studies as

monotherapy and add-on therapies are listed below by system organ class and absolute frequency.

Adverse reactions listed in Table 5 are based on information available from the metformin Summary

of Product Characteristics available in the EU. Frequencies are defined as very common (≥1/10);

common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to <1/1,000); very rare

(<1/10,000), not known (cannot be estimated from the available data). Within each frequency

grouping, adverse reactions are presented in order of decreasing seriousness.

Table 1

Adverse reactions reported in patients who received vildagliptin 100 mg daily as

add-on therapy to metformin compared to placebo plus metformin in double-blind

studies (N=208)

Metabolism and nutrition disorders

Common

Hypoglycaemia

Nervous system disorders

Common

Tremor

Common

Headache

Common

Dizziness

Uncommon

Fatigue

Gastrointestinal disorders

Common

Nausea

Description of selected adverse reactions

In controlled clinical trials with the combination of vildagliptin 100 mg daily plus metformin, no

withdrawal due to adverse reactions was reported in either the vildagliptin 100 mg daily plus

metformin or the placebo plus metformin treatment groups.

In clinical trials, the incidence of hypoglycaemia was common in patients receiving vildagliptin in

combination with metformin (1%) and uncommon in patients receiving placebo + metformin (0.4%).

No severe hypoglycaemic events were reported in the vildagliptin arms.

In clinical trials, weight did not change from baseline when vildagliptin 100 mg daily was added to

metformin (+0.2 kg and -1.0 kg for vildagliptin and placebo, respectively).

Clinical trials of up to more than 2 years’ duration did not show any additional safety signals or

unforeseen risks when vildagliptin was added on to metformin.

Combination with a sulphonylurea

Table 2

Adverse reactions reported in patients who received vildagliptin 50 mg twice daily

in combination with metformin and a sulphonylurea (N=157)

Metabolism and nutritional disorders

Common

Hypoglycaemia

Nervous system disorders

Common

Dizziness, tremor

Skin and subcutaneous tissue disorders

Common

Hyperhidrosis

General disorders and administration site conditions

Common

Asthenia

Description of selected adverse reactions

There were no withdrawals due to adverse reactions reported in the vildagliptin + metformin +

glimepiride treatment group versus 0.6% in the placebo + metformin + glimepiride treatment group.

The incidence of hypoglycaemia was common in both treatment groups (5.1% for the vildagliptin +

metformin + glimepiride group versus 1.9% for the placebo + metformin + glimepiride group). One

severe hypoglycaemic event was reported in the vildagliptin group.

At the end of the study, effect on mean body weight was neutral (+0.6 kg in the vildagliptin group and

-0.1 kg in the placebo group).

Combination with insulin

Table 3

Adverse reactions reported in patients who received vildagliptin 100 mg daily in

combination with insulin (with or without metformin) in double-blind studies

(N=371)

Metabolism and nutrition disorders

Common

Decreased blood glucose

Nervous system disorders

Common

Headache, chills

Gastrointestinal disorders

Common

Nausea, gastro-oesophageal reflux disease

Uncommon

Diarrhoea, flatulence

Description of selected adverse reactions

In controlled clinical trials using vildagliptin 50 mg twice daily in combination with insulin, with or

without concomitant metformin, the overall incidence of withdrawals due to adverse reactions was

0.3% in the vildagliptin treatment group and there were no withdrawals in the placebo group.

The incidence of hypoglycaemia was similar in both treatment groups (14.0% in the vildagliptin

group vs 16.4% in the placebo group). Two patients reported severe hypoglycaemic events in the

vildagliptin group, and 6 patients in the placebo group.

At the end of the study, effect on mean body weight was neutral (+0.6 kg change from baseline in the

vildagliptin group and no weight change in the placebo group).

Additional information on the individual active substances of the fixed combination

Vildagliptin

Table 4

Adverse reactions reported in patients who received vildagliptin 100 mg daily as

monotherapy in double-blind studies (N=1855)

Infections and infestations

Very rare

Upper respiratory tract infection

Very rare

Nasopharyngitis

Metabolism and nutrition disorders

Uncommon

Hypoglycaemia

Nervous system disorders

Common

Dizziness

Uncommon

Headache

Vascular disorders

Uncommon

Oedema peripheral

Gastrointestinal disorders

Uncommon

Constipation

Musculoskeletal and connective tissue disorders

Uncommon

Arthralgia

Description of selected adverse reactions

The overall incidence of withdrawals from controlled monotherapy trials due to adverse reactions was

no greater for patients treated with vildagliptin at doses of 100 mg daily (0.3%) than for placebo

(0.6%) or comparators (0.5%).

In comparative controlled monotherapy studies, hypoglycaemia was uncommon, reported in 0.4% (7

of 1,855) of patients treated with vildagliptin 100 mg daily compared to 0.2% (2 of 1,082) of patients

in the groups treated with an active comparator or placebo, with no serious or severe events reported.

In clinical trials, weight did not change from baseline when vildagliptin 100 mg daily was

administered as monotherapy (-0.3 kg and -1.3 kg for vildagliptin and placebo, respectively).

Clinical trials of up to 2 years’ duration did not show any additional safety signals or unforeseen risks

with vildagliptin monotherapy.

Metformin

Table 5

Adverse reactions for metformin component

Metabolism and nutrition disorders

Very Rare

Decrease of vitamin B

absorption and lactic acidosis*

Nervous system disorders

Common

Metallic taste

Gastrointestinal disorders

Very common

Nausea, vomiting, diarrhoea, abdominal pain and loss of appetite

Hepatobiliary disorders

Very rare

Liver function test abnormalities or hepatitis**

Skin and subcutaneous tissue disorders

Very rare

Skin reactions such as erythema, pruritus and urticaria

*A decrease in vitamin B12 absorption with decrease in serum levels has been very rarely observed

in patients treated long-term with metformin. Consideration of such aetiology is recommended if a

patient presents with megaloblastic anaemia.

**Isolated cases of liver function test abnormalities or hepatitis resolving upon metformin

discontinuation have been reported.

Gastrointestinal adverse reactions occur most frequently during initiation of therapy and resolve

spontaneously in most cases. To prevent them, it is recommended that metformin be taken in 2 daily

doses during or after meals. A slow increase in the dose may also improve gastrointestinal tolerability.

Post-marketing experience

Table 6

Post-marketing adverse reactions

Gastrointestinal disorders

Not known

Pancreatitis

Hepatobiliary disorders

Not known

Hepatitis (reversible upon discontinuation of the medicinal product)

Abnormal liver function tests (reversible upon discontinuation of the

medicinal product)

Musculoskeletal and connective tissue disorders

Not known

Myalgia

Skin and subcutaneous tissue disorders

Not known

Urticaria

Exfoliative and bullous skin lesions, including bullous pemphigoid

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It

allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare

professionals are asked to report any suspected adverse reactions via the national reporting system

listed in Appendix V.

4.9

Overdose

No data are available with regard to overdose of Icandra.

Vildagliptin

Information regarding overdose with vildagliptin is limited.

Symptoms

Information on the likely symptoms of overdose with vildagliptin was taken from a rising dose

tolerability study in healthy subjects given vildagliptin for 10 days. At 400 mg, there were three cases

of muscle pain, and individual cases of mild and transient paraesthesia, fever, oedema and a transient

increase in lipase levels. At 600 mg, one subject experienced oedema of the feet and hands, and

increases in creatine phosphokinase (CPK), AST, C-reactive protein (CRP) and myoglobin levels.

Three other subjects experienced oedema of the feet, with paraesthesia in two cases. All symptoms

and laboratory abnormalities resolved without treatment after discontinuation of the study medicinal

product.

Metformin

A large overdose of metformin (or co-existing risk of lactic acidosis) may lead to lactic acidosis,

which is a medical emergency and must be treated in hospital.

Management

The most effective method of removing metformin is haemodialysis. However, vildagliptin cannot be

removed by haemodialysis, although the major hydrolysis metabolite (LAY 151) can. Supportive

management is recommended.

5.

PHARMACOLOGICAL PROPERTIES

5.1

Pharmacodynamic properties

Pharmacotherapeutic group: Drugs used in diabetes, combinations of oral blood glucose lowering

drugs, ATC code: A10BD08

Mechanism of action

Icandra combines two antihyperglycaemic agents with complimentary mechanisms of action to

improve glycaemic control in patients with type 2 diabetes: vildagliptin, a member of the islet

enhancer class, and metformin hydrochloride, a member of the biguanide class.

Vildagliptin, a member of the islet enhancer class, is a potent and selective dipeptidyl-peptidase-4

(DPP-4) inhibitor. Metformin acts primarily by decreasing endogenous hepatic glucose production.

Pharmacodynamic effects

Vildagliptin

Vildagliptin acts primarily by inhibiting DPP-4, the enzyme responsible for the degradation of the

incretin hormones GLP-1 (glucagon-like peptide-1) and GIP (glucose-dependent insulinotropic

polypeptide).

The administration of vildagliptin results in a rapid and complete inhibition of DPP-4 activity

resulting in increased fasting and postprandial endogenous levels of the incretin hormones GLP-1 and

GIP.

By increasing the endogenous levels of these incretin hormones, vildagliptin enhances the sensitivity

of beta cells to glucose, resulting in improved glucose-dependent insulin secretion. Treatment with

vildagliptin 50-100 mg daily in patients with type 2 diabetes significantly improved markers of beta

cell function including HOMA-

(Homeostasis Model Assessment–

), proinsulin to insulin ratio and

measures of beta cell responsiveness from the frequently-sampled meal tolerance test. In non-diabetic

(normal glycaemic) individuals, vildagliptin does not stimulate insulin secretion or reduce glucose

levels.

By increasing endogenous GLP-1 levels, vildagliptin also enhances the sensitivity of alpha cells to

glucose, resulting in more glucose-appropriate glucagon secretion.

The enhanced increase in the insulin/glucagon ratio during hyperglycaemia due to increased incretin

hormone levels results in a decrease in fasting and postprandial hepatic glucose production, leading to

reduced glycaemia.

The known effect of increased GLP-1 levels delaying gastric emptying is not observed with

vildagliptin treatment.

Metformin

Metformin is a biguanide with antihyperglycaemic effects, lowering both basal and postprandial

plasma glucose. It does not stimulate insulin secretion and therefore does not produce hypoglycaemia

or increased weight gain.

Metformin may exert its glucose-lowering effect via three mechanisms:

by reduction of hepatic glucose production through inhibition of gluconeogenesis and

glycogenolysis;

in muscle, by modestly increasing insulin sensitivity, improving peripheral glucose uptake and

utilisation;

by delaying intestinal glucose absorption.

Metformin stimulates intracellular glycogen synthesis by acting on glycogen synthase and increases

the transport capacity of specific types of membrane glucose transporters (GLUT-1 and GLUT-4).

In humans, independently of its action on glycaemia, metformin has favourable effects on lipid

metabolism. This has been shown at therapeutic doses in controlled, medium-term or long-term

clinical studies: metformin reduces serum levels of total cholesterol, LDL cholesterol and

triglycerides.

The prospective randomised UKPDS (UK Prospective Diabetes Study) study has established the long-

term benefit of intensive blood glucose control in type 2 diabetes. Analysis of the results for

overweight patients treated with metformin after failure of diet alone showed:

a significant reduction in the absolute risk of any diabetes-related complication in the

metformin group (29.8 events/1,000 patient-years) versus diet alone (43.3 events/1,000 patient-

years), p=0.0023, and versus the combined sulphonylurea and insulin monotherapy groups

(40.1 events/1,000 patient-years), p=0.0034;

a significant reduction in the absolute risk of diabetes-related mortality: metformin

7.5 events/1,000 patient-years, diet alone 12.7 events/1,000 patient-years, p=0.017;

a significant reduction in the absolute risk of overall mortality: metformin

13.5 events/1,000 patient-years versus diet alone 20.6 events/1,000 patient-years (p=0.011), and

versus the combined sulphonylurea and insulin monotherapy groups 18.9 events/1,000 patient-

years (p=0.021);

a significant reduction in the absolute risk of myocardial infarction: metformin

11 events/1,000 patient-years, diet alone 18 events/1,000 patient-years (p=0.01).

Clinical efficacy and safety

Vildagliptin added to patients whose glycaemic control was not satisfactory despite treatment with

metformin monotherapy resulted after 6-month treatment in additional statistically significant mean

reductions in HbA

compared to placebo (between group differences of -0.7% to -1.1% for

vildagliptin 50 mg and 100 mg, respectively). The proportion of patients who achieved a decrease in

of ≥ 0.7% from baseline was statistically significantly higher in both vildagliptin plus

metformin groups (46% and 60%, respectively) versus the metformin plus placebo group (20%).

In a 24-week trial, vildagliptin (50 mg twice daily) was compared to pioglitazone (30 mg once daily)

in patients inadequately controlled with metformin (mean daily dose: 2020 mg). Mean reductions

from baseline HbA

of 8.4% were -0.9% with vildagliptin added to metformin and -1.0% with

pioglitazone added to metformin. A mean weight gain of +1.9 kg was observed in patients receiving

pioglitazone added to metformin compared to +0.3 kg in those receiving vildagliptin added to

metformin.

In a clinical trial of 2 years’ duration, vildagliptin (50 mg twice daily) was compared to glimepiride

(up to 6 mg/day – mean dose at 2 years: 4.6 mg) in patients treated with metformin (mean daily dose:

1894 mg). After 1 year mean reductions in HbA

were -0.4% with vildagliptin added to metformin

and -0.5% with glimepiride added to metformin, from a mean baseline HbA

of 7.3%. Body weight

change with vildagliptin was -0.2 kg vs +1.6 kg with glimepiride. The incidence of hypoglycaemia

was significantly lower in the vildagliptin group (1.7%) than in the glimepiride group (16.2%). At

study endpoint (2 years), the HbA

was similar to baseline values in both treatment groups and the

body weight changes and hypoglycaemia differences were maintained.

In a 52-week trial, vildagliptin (50 mg twice daily) was compared to gliclazide (mean daily dose:

229.5 mg) in patients inadequately controlled with metformin (metformin dose at baseline

1928 mg/day). After 1 year, mean reductions in HbA

were -0.81% with vildagliptin added to

metformin (mean baseline HbA

8.4%) and -0.85% with gliclazide added to metformin (mean

baseline HbA

8.5%); statistical non-inferiority was achieved (95% CI -0.11 – 0.20). Body weight

change with vildagliptin was +0.1 kg compared to a weight gain of +1.4 kg with gliclazide.

In a 24-week trial the efficacy of the fixed dose combination of vildagliptin and metformin (gradually

titrated to a dose of 50 mg/500 mg twice daily or 50 mg/1000 mg twice daily) as initial therapy in

drug-naïve patients was evaluated. Vildagliptin/metformin 50 mg/1000 mg twice daily reduced HbA

by -1.82%, vildagliptin/metformin 50 mg/500 mg twice daily by -1.61%, metformin 1000 mg twice

daily by -1.36% and vildagliptin 50 mg twice daily by -1.09% from a mean baseline HbA

of 8.6%.

The decrease in HbA

observed in patients with a baseline ≥10.0% was greater.

A 24-week randomised, double-blind, placebo-controlled trial was conducted in 318 patients to

evaluate the efficacy and safety of vildagliptin (50 mg twice daily) in combination with metformin

(≥1500 mg daily) and glimepiride (≥4 mg daily). Vildagliptin in combination with metformin and

glimepiride significantly decreased HbA

compared with placebo. The placebo-adjusted mean

reduction from a mean baseline HbA

of 8.8% was -0.76%.

A 24-week randomised, double-blind, placebo-controlled trial was conducted in 449 patients to

evaluate the efficacy and safety of vildagliptin (50 mg twice daily) in combination with a stable dose

of basal or premixed insulin (mean daily dose 41 units), with concomitant use of metformin (N=276)

or without concomitant metformin (N=173). Vildagliptin in combination with insulin significantly

decreased HbA

compared with placebo. In the overall population, the placebo-adjusted mean

reduction from a mean baseline HbA

8.8% was -0.72%. In the subgroups treated with insulin with or

without concomitant metformin the placebo-adjusted mean reduction in HbA

was -0.63% and

-0.84%, respectively. The incidence of hypoglycaemia in the overall population was 8.4% and 7.2%

in the vildagliptin and placebo groups, respectively. Patients receiving vildagliptin experienced no

weight gain (+0.2 kg) while those receiving placebo experienced weight reduction (-0.7 kg).

In another 24-week study in patients with more advanced type 2 diabetes not adequately controlled on

insulin (short and longer acting, average insulin dose 80 IU/day), the mean reduction in HbA

when

vildagliptin (50 mg twice daily) was added to insulin was statistically significantly greater than with

placebo plus insulin (0.5% vs. 0.2%). The incidence of hypoglycaemia was lower in the vildagliptin

group than in the placebo group (22.9% vs. 29.6%).

Cardiovascular risk

A meta-analysis of independently and prospectively adjudicated cardiovascular events from 37 phase

III and IV monotherapy and combination therapy clinical studies of up to more than 2 years duration

(mean exposure 50 weeks for vildagliptin and 49 weeks for comparators) was performed and showed

that vildagliptin treatment was not associated with an increase in cardiovascular risk versus

comparators. The composite endpoint of adjudicated major adverse cardiovascular events (MACE)

including acute myocardial infarction, stroke or cardiovascular death was similar for vildagliptin

versus combined active and placebo comparators [Mantel–Haenszel risk ratio (M-H RR) 0.82 (95%

CI 0.61-1.11)]. A MACE occurred in 83 out of 9,599 (0.86%) vildagliptin-treated patients and in 85

out of 7,102 (1.20%) comparator-treated patients. Assessment of each individual MACE component

showed no increased risk (similar M-H RR). Confirmed heart failure (HF) events defined as HF

requiring hospitalisation or new onset of HF were reported in 41 (0.43%) vildagliptin-treated patients

and 32 (0.45%) comparator-treated patients with M-H RR 1.08 (95% CI 0.68-1.70).

Paediatric population

The European Medicines Agency has waived the obligation to submit the results of studies with

vildagliptin in combination with metformin in all subsets of the paediatric population with type 2

diabetes mellitus (see section 4.2 for information on paediatric use).

5.2

Pharmacokinetic properties

Icandra

Absorption

Bioequivalence has been demonstrated between Icandra at three dose strengths (50 mg/500 mg,

50 mg/850 mg and 50 mg/1000 mg) versus free combination of vildagliptin and metformin

hydrochloride tablets at the corresponding doses.

Food does not affect the extent and rate of absorption of vildagliptin from Icandra. The rate and extent

of absorption of metformin from Icandra 50 mg/1000 mg were decreased when given with food as

reflected by the decrease in C

by 26%, AUC by 7% and delayed T

(2.0 to 4.0 h).

The following statements reflect the pharmacokinetic properties of the individual active substances of

Icandra.

Vildagliptin

Absorption

Following oral administration in the fasting state, vildagliptin is rapidly absorbed with peak plasma

concentrations observed at 1.7 hours. Food slightly delays the time to peak plasma concentration to

2.5 hours, but does not alter the overall exposure (AUC). Administration of vildagliptin with food

resulted in a decreased C

(19%) compared to dosing in the fasting state. However, the magnitude of

change is not clinically significant, so that vildagliptin can be given with or without food. The

absolute bioavailability is 85%.

Distribution

The plasma protein binding of vildagliptin is low (9.3%) and vildagliptin distributes equally between

plasma and red blood cells. The mean volume of distribution of vildagliptin at steady-state after

intravenous administration (V

) is 71 litres, suggesting extravascular distribution.

Biotransformation

Metabolism is the major elimination pathway for vildagliptin in humans, accounting for 69% of the

dose. The major metabolite (LAY 151) is pharmacologically inactive and is the hydrolysis product of

the cyano moiety, accounting for 57% of the dose, followed by the amide hydrolysis product (4% of

dose). DPP-4 contributes partially to the hydrolysis of vildagliptin based on an

in vivo

study using

DPP-4 deficient rats. Vildagliptin is not metabolised by CYP 450 enzymes to any quantifiable extent,

and accordingly the metabolic clearance of vildagliptin is not anticipated to be affected by co-

medications that are CYP 450 inhibitors and/or inducers.

In vitro

studies demonstrated that

vildagliptin does not inhibit/induce CYP 450 enzymes. Therefore, vildagliptin is not likely to affect

metabolic clearance of co-medications metabolised by CYP 1A2, CYP 2C8, CYP 2C9, CYP 2C19,

CYP 2D6, CYP 2E1 or CYP 3A4/5.

Elimination

Following oral administration of [

C] vildagliptin, approximately 85% of the dose was excreted into

the urine and 15% of the dose was recovered in the faeces. Renal excretion of the unchanged

vildagliptin accounted for 23% of the dose after oral administration. After intravenous administration

to healthy subjects, the total plasma and renal clearances of vildagliptin are 41 and 13 l/h,

respectively. The mean elimination half-life after intravenous administration is approximately 2 hours.

The elimination half-life after oral administration is approximately 3 hours.

Linearity/non-linearity

The C

for vildagliptin and the area under the plasma concentrations versus time curves (AUC)

increased in an approximately dose proportional manner over the therapeutic dose range.

Characteristics in patients

Gender: No clinically relevant differences in the pharmacokinetics of vildagliptin were observed

between male and female healthy subjects within a wide range of age and body mass index (BMI).

DPP-4 inhibition by vildagliptin is not affected by gender.

Age: In healthy elderly subjects (≥ 70 years), the overall exposure of vildagliptin (100 mg once daily)

was increased by 32%, with an 18% increase in peak plasma concentration as compared to young

healthy subjects (18-40 years). These changes are not considered to be clinically relevant, however.

DPP-4 inhibition by vildagliptin is not affected by age.

Hepatic impairment: In subjects with mild, moderate or severe hepatic impairment (Child-Pugh A-C)

there were no clinically significant changes (maximum ~30%) in exposure to vildagliptin.

Renal impairment: In subjects with mild, moderate, or severe renal impairment, systemic exposure to

vildagliptin was increased (C

8-66%; AUC 32-134%) and total body clearance was reduced

compared to subjects with normal renal function.

Ethnic group: Limited data suggest that race does not have any major influence on vildagliptin

pharmacokinetics.

Metformin

Absorption

After an oral dose of metformin, the maximum plasma concentration (C

) is achieved after about

2.5 h. Absolute bioavailability of a 500 mg metformin tablet is approximately 50-60% in healthy

subjects. After an oral dose, the non-absorbed fraction recovered in faeces was 20-30%.

After oral administration, metformin absorption is saturable and incomplete. It is assumed that the

pharmacokinetics of metformin absorption are non-linear. At the usual metformin doses and dosing

schedules, steady state plasma concentrations are reached within 24-48 h and are generally less than

1 µg/ml. In controlled clinical trials, maximum metformin plasma levels (C

) did not exceed

4 µg/ml, even at maximum doses.

Food slightly delays and decreases the extent of the absorption of metformin. Following

administration of a dose of 850 mg, the plasma peak concentration was 40% lower, AUC was

decreased by 25% and time to peak plasma concentration was prolonged by 35 minutes. The clinical

relevance of this decrease is unknown.

Distribution

Plasma protein binding is negligible. Metformin partitions into erythrocytes. The mean volume of

distribution (V

) ranged between 63-276 litres.

Biotransformation

Metformin is excreted unchanged in the urine. No metabolites have been identified in humans.

Elimination

Metformin is eliminated by renal excretion. Renal clearance of metformin is > 400 ml/min, indicating

that metformin is eliminated by glomerular filtration and tubular secretion. Following an oral dose,

the apparent terminal elimination half-life is approximately 6.5 h. When renal function is impaired,

renal clearance is decreased in proportion to that of creatinine and thus the elimination half-life is

prolonged, leading to increased levels of metformin in plasma.

5.3

Preclinical safety data

Animal studies of up to 13-week duration have been conducted with the combined substances in

Icandra. No new toxicities associated with the combination were identified. The following data are

findings from studies performed with vildagliptin or metformin individually.

Vildagliptin

Intra-cardiac impulse conduction delays were observed in dogs with a no-effect dose of 15 mg/kg (7-

fold human exposure based on C

Accumulation of foamy alveolar macrophages in the lung was observed in rats and mice. The no-

effect dose in rats was 25 mg/kg (5-fold human exposure based on AUC) and in mice 750 mg/kg (142-

fold human exposure).

Gastrointestinal symptoms, particularly soft faeces, mucoid faeces, diarrhoea and, at higher doses,

faecal blood were observed in dogs. A no-effect level was not established.

Vildagliptin was not mutagenic in conventional

in vitro

in vivo

tests for genotoxicity.

A fertility and early embryonic development study in rats revealed no evidence of impaired fertility,

reproductive performance or early embryonic development due to vildagliptin. Embryofoetal toxicity

was evaluated in rats and rabbits. An increased incidence of wavy ribs was observed in rats in

association with reduced maternal body weight parameters, with a no-effect dose of 75 mg/kg (10-fold

human exposure). In rabbits, decreased foetal weight and skeletal variations indicative of

developmental delays were noted only in the presence of severe maternal toxicity, with a no-effect

dose of 50 mg/kg (9-fold human exposure). A pre- and postnatal development study was performed in

rats. Findings were only observed in association with maternal toxicity at ≥ 150 mg/kg and included a

transient decrease in body weight and reduced motor activity in the F1 generation.

A two-year carcinogenicity study was conducted in rats at oral doses up to 900 mg/kg (approximately

200 times human exposure at the maximum recommended dose). No increases in tumour incidence

attributable to vildagliptin were observed. Another two-year carcinogenicity study was conducted in

mice at oral doses up to 1000 mg/kg. An increased incidence of mammary adenocarcinomas and

haemangiosarcomas was observed with a no-effect dose of 500 mg/kg (59-fold human exposure) and

100 mg/kg (16-fold human exposure), respectively. The increased incidence of these tumours in mice

is considered not to represent a significant risk to humans based on the lack of genotoxicity of

vildagliptin and its principal metabolite, the occurrence of tumours only in one species, and the high

systemic exposure ratios at which tumours were observed.

In a 13-week toxicology study in cynomolgus monkeys, skin lesions have been recorded at doses

≥ 5 mg/kg/day. These were consistently located on the extremities (hands, feet, ears and tail). At

5 mg/kg/day (approximately equivalent to human AUC exposure at the 100 mg dose), only blisters

were observed. They were reversible despite continued treatment and were not associated with

histopathological abnormalities. Flaking skin, peeling skin, scabs and tail sores with correlating

histopathological changes were noted at doses ≥ 20 mg/kg/day (approximately 3 times human AUC

exposure at the 100 mg dose). Necrotic lesions of the tail were observed at ≥ 80 mg/kg/day. Skin

lesions were not reversible in the monkeys treated at 160 mg/kg/day during a 4-week recovery period.

Metformin

Non-clinical data on metformin reveal no special hazard for humans based on conventional studies of

safety pharmacology, repeated dose toxicity, genotoxicity, carcinogenic potential and toxicity to

reproduction.

6.

PHARMACEUTICAL PARTICULARS

6.1

List of excipients

Tablet core

Hydroxypropylcellulose

Magnesium stearate

Film-coating

Hypromellose

Titanium dioxide (E 171)

Iron oxide, yellow (E 172)

Macrogol 4000

Talc

6.2

Incompatibilities

Not applicable.

6.3

Shelf life

PA/Alu/PVC/Alu 2 years

PCTFE/PVC/Alu 18 months

6.4

Special precautions for storage

Do not store above 30

Store in the original package (blister) in order to protect from moisture.

6.5

Nature and contents of container

Aluminium/Aluminium (PA/Alu/PVC/Alu) blister

Available in packs containing 10, 30, 60, 120,180 or 360 film-coated tablets and in multi-packs

containing 120 (2 packs of 60), 180 (3 packs of 60) or 360 (6 packs of 60) film-coated tablets.

Polychlorotrifluoroethylene (PCTFE)/PVC/Alu blister

Available in packs containing 10, 30, 60, 120, 180 or 360 film-coated tablets and in multi-packs

containing 120 (2 packs of 60), 180 (3 packs of 60) or 360 (6 packs of 60) film-coated tablets.

Not all pack sizes and tablet strengths may be marketed.

6.6

Special precautions for disposal

No special requirements.

7.

MARKETING AUTHORISATION HOLDER

Novartis Europharm Limited

Vista Building

Elm Park, Merrion Road

Dublin 4

Ireland

8.

MARKETING AUTHORISATION NUMBER(S)

Icandra 50 mg/850 mg film-coated tablets

EU/1/08/484/001-006

EU/1/08/484/013-015

EU/1/08/484/019–024

EU/1/08/484/031–033

Icandra 50 mg/1000 mg film-coated tablets

EU/1/08/484/007-012

EU/1/08/484/016-018

EU/1/08/484/025–030

EU/1/08/484/034–036

9.

DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of first authorisation: 01 December 2008

Date of latest renewal: 31 July 2013

10.

DATE OF REVISION OF THE TEXT

Detailed information on this medicinal product is available on the website of the European Medicines

Agency http://www.ema.europa.eu

EMA/760451/2012

EMEA/H/C/001050

EPAR summary for the public

Icandra

Vildagliptin / metformin hydrochloride

This is a summary of the European public assessment report (EPAR) for Icandra. It explains how the

Committee for Medicinal Products for Human Use (CHMP) assessed the medicine to reach its opinion in

favour of granting a marketing authorisation and its recommendations on the conditions of use for

Icandra.

What is Icandra?

Icandra is a medicine that contains the active substances vildagliptin and metformin hydrochloride. It

is available as tablets (50 mg/850 mg and 50 mg/1,000 mg).

This medicine is the same as Eucreas, which is already authorised in the European Union (EU). The

company that makes Eucreas has agreed that its scientific data can be used for Icandra.

What is Icandra used for?

Icandra is used to treat adults with type 2 diabetes. It is used in the following ways:

in patients whose disease is insufficiently controlled with the maximum tolerated dose of metformin

taken alone;

in patients who are already taking the combination of vildagliptin and metformin as separate

tablets;

in combination with a sulphonylurea (another type of anti-diabetes medicine) together with diet

and exercise, in patients whose diabetes is not satisfactorily controlled on metformin and a

sulphonylurea.

in combination with insulin together with diet and exercise, in patients whose diabetes is

insufficiently controlled with insulin at a stable dose and metformin.

The medicine can only be obtained with a prescription.

7 Westferry Circus

Canary Wharf

London E14 4HB

United Kingdom

An agency of the European Union

Telephone

+44 (0)20 7418 8400

Facsimile

+44 (0)20 7418 8416

E-mail

info@ema.europa.eu

Website

www.ema.europa.eu

© European Medicines Agency, 2012. Reproduction is authorised provided the source is acknowledged.

How is Icandra used?

The recommended dose of Icandra is one tablet twice a day, with one tablet taken in the morning and

one in the evening. The choice of tablet strength to start with depends on the patient’s current

treatment and the expected effects of Icandra, but it is recommended to provide a dose of metformin

similar to the dose already being taken. Patients already taking vildagliptin and metformin should

switch to Icandra containing the same amounts of each active substance. Doses of vildagliptin above

100 mg are not recommended.

Taking Icandra with or just after food may reduce any stomach problems caused by metformin.

Icandra should not be used in patients who have moderate or severe problems with their kidneys or

who have problems with their liver. Elderly patients taking Icandra should have their kidney function

monitored regularly.

How does Icandra work?

Type 2 diabetes is a disease in which the pancreas does not make enough insulin to control the level of

glucose (sugar) in the blood or when the body is unable to use insulin effectively. Icandra contains two

active substances, which each have a different mode of action. Vildagliptin, which is a dipeptidyl

peptidase 4 (DPP-4) inhibitor, works by blocking the breakdown of ‘incretin’ hormones in the body.

These hormones are released after a meal and stimulate the pancreas to produce insulin. By increasing

levels of incretin hormones in the blood, vildagliptin stimulates the pancreas to produce more insulin

when blood glucose levels are high. Vildagliptin does not work when the blood glucose is low.

Vildagliptin also reduces the amount of glucose made by the liver, by increasing insulin levels and

decreasing the levels of the hormone glucagon. Metformin works mainly by inhibiting glucose

production and reducing its absorption in the gut. As a result of the action of both substances, the

blood glucose is reduced and this helps to control type 2 diabetes.

How has Icandra been studied?

Vildagliptin on its own was approved by the EU in September 2007 under the name Galvus, and

metformin has been available in the EU since 1959. Vildagliptin can be used with metformin in type 2

diabetes patients who are not satisfactorily controlled on metformin alone. The studies with Galvus as

an add-on to metformin, metformin and a sulphonylurea, or metformin and insulin have been used to

support the use of Icandra in the same indications. The studies compared Galvus with placebo and

measured the levels of a substance in the blood called glycosylated haemoglobin (HbA1c), which gives

an indication of how well the blood glucose is controlled.

The applicant also presented the results of two studies showing that the active substances in the two

strengths of Icandra were absorbed in the body in the same way as when they were taken as separate

tablets.

What benefit has Icandra shown during the studies?

Vildagliptin has been shown to be more effective than placebo (a dummy treatment) at reducing HbA1c

levels when it was added to metformin. Patients adding vildagliptin had a fall in HbA1c levels of 0.88

percentage points after 24 weeks from a starting level of 8.38%. In contrast, patients adding placebo

had smaller changes in HbA1c levels, with a rise of 0.23 percentage points from a starting level of

8.3%. In other studies, vildagliptin in combination with metformin has been shown to be more

effective than placebo when used with a sulphonylurea or insulin.

Icandra

EMA/760451/2012

Page 2/3

What is the risk associated with Icandra?

The most common side effects with Icandra (seen in more than 1 patient in 10) are nausea (feeling

sick), vomiting, diarrhoea, abdominal (tummy) pain and loss of appetite. For the full list of all side

effects reported with Icandra, see the package leaflet.

Icandra should not be used in people who may be hypersensitive (allergic) to vildagliptin, metformin or

any of the other ingredients. It must not be used in patients who have diabetic ketoacidosis (high

levels of ketones and acids in the blood), diabetic pre-coma, problems with their kidneys or liver,

conditions that may affect the kidneys, or a disease that causes a reduced supply of oxygen to the

tissues such as failure of the heart or lungs or a recent heart attack. It must also not be used in

patients with alcohol intoxication (excessive alcohol consumption) or alcoholism, or during breast-

feeding. For the full list of restrictions, see the package leaflet.

Why has Icandra been approved?

The CHMP concluded that vildagliptin taken with metformin reduces blood glucose levels and the

combination of the two active substances in one tablet may help patients to stick to their treatment.

The CHMP also noted that the combination of vildagliptin and metformin was effective as an add-on to

a sulphonylurea or insulin. Therefore, the Committee decided that the benefits of Icandra are greater

than its risks and recommended that it be given marketing authorisation.

Other information about Icandra

The European Commission granted a marketing authorisation valid throughout the European Union for

Vildagliptin/Metformin Hydrochloride on 1 December 2008. The name of the medicine was changed to

Icandra on 6 February 2009.

The full EPAR for Icandra can be found on the Agency’s website ema.europa.eu/Find medicine/Human

medicines/European Public Assessment Reports. For more information about treatment with Icandra,

read the package leaflet (also part of the EPAR) or contact your doctor or pharmacist.

This summary was last updated in 11-2012.

Icandra

EMA/760451/2012

Page 3/3

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