Limitations of Use

JARDIANCE, SYNJARDY, SYNJARDY XR, and GLYXAMBI are not recommended for patients with type 1 diabetes or for the treatment of diabetic ketoacidosis.

GLYXAMBI has not been studied in patients with a history of pancreatitis, and it is unknown if using GLYXAMBI increases the risk of developing pancreatitis in these patients.

IMPORTANT SAFETY
INFORMATION (continued)

CONTRAINDICATIONS

JARDIANCE: History of serious hypersensitivity to empagliflozin or any of the excipients in JARDIANCE; severe renal impairment, end-stage renal disease, or dialysis.

SYNJARDY and SYNJARDY XR: Moderate to severe renal impairment (eGFR <45 mL/min/1.73 m²), end-stage renal disease, or dialysis; acute or chronic metabolic acidosis, including diabetic ketoacidosis; history of serious hypersensitivity reaction to empagliflozin, metformin, or any of the excipients in SYNJARDY or SYNJARDY XR.

GLYXAMBI: Severe renal impairment, end-stage renal disease, or dialysis; history of hypersensitivity reaction to empagliflozin, linagliptin, or any of the excipients in GLYXAMBI, such as anaphylaxis, angioedema, exfoliative skin conditions, urticaria, or bronchial hyperreactivity.

WARNINGS AND PRECAUTIONS

Lactic Acidosis: SYNJARDY, SYNJARDY XR
There have been cases of metformin-associated lactic acidosis, including fatal cases.These cases had a subtle onset and were accompanied by nonspecific symptoms such as malaise, myalgias, abdominal pain, respiratory distress, or increased somnolence; however, hypothermia, hypotension, and resistant bradyarrhythmias have occurred with severe acidosis. Additional findings included elevated blood lactate concentrations (>5 mmol/L), anion gap acidosis (without evidence of ketonuria or ketonemia), and an increased lactate: pyruvate ratio, metformin plasma levels generally >5 mcg/mL.

If lactic acidosis is suspected, immediately discontinue SYNJARDY or SYNJARDY XR and institute general supportive measures promptly in a hospital setting. Prompt hemodialysis is recommended to correct the acidosis.

Educate patients and their families about the symptoms of lactic acidosis and, if these symptoms occur, instruct them to discontinue SYNJARDY or SYNJARDY XR and promptly notify their healthcare provider.

Recommendations to reduce the risk include:

• Renal Impairment: Obtain eGFR prior to initiating and annually or more frequently in patients at increased risk of developing renal impairment.
• Drug Interactions: More frequent monitoring is recommended when administered with drugs that impair renal function, result in hemodynamic change, interfere with acid-base balance, or increase metformin accumulation.
• Age 65 or Greater: Assess renal function more frequently.
• Radiological Studies with Contrast: Stop SYNJARDY or SYNJARDY XR at the time of, or prior to, an iodinated contrast imaging procedure in patients with an eGFR of 45-60 mL/min/1.73m²; patients with a history of hepatic impairment, alcoholism or heart failure; or patients who will be administered intra-arterial iodinated contrast. Re-evaluate eGFR 48 hours after the procedure and restart SYNJARDY or SYNJARDY XR if renal function is stable.
• Surgery and Other Procedures: Discontinue while patients have restricted food and fluid intake.
• Hypoxic States: Discontinue in conditions associated with hypoxemia.
• Excessive Alcohol Intake: Warn patients against excessive alcohol intake.
• Hepatic Impairment: Avoid use in patients with hepatic disease.

Hypotension: JARDIANCE, SYNJARDY, SYNJARDY XR, GLYXAMBI
Empagliflozin causes intravascular volume contraction and symptomatic hypotension may occur. Before initiating, assess and correct volume status in the elderly, and in patients with renal impairment, low systolic blood pressure, or on diuretics. Monitor for hypotension.

Pancreatitis: GLYXAMBI
Acute pancreatitis, including fatal pancreatitis, has been reported in patients taking linagliptin, a component of GLYXAMBI. Take careful notice of potential signs and symptoms of pancreatitis and, if suspected, promptly discontinue and initiate appropriate management. It is unknown whether patients with a history of pancreatitis are at increased risk for the development of pancreatitis while using GLYXAMBI.

Ketoacidosis: JARDIANCE, SYNJARDY, SYNJARDY XR, GLYXAMBI
Ketoacidosis, a serious life-threatening condition requiring urgent hospitalization, has been identified in patients with type 1 and type 2 diabetes mellitus receiving sodium glucose cotransporter 2 (SGLT2) inhibitors, including empagliflozin. Fatal cases of ketoacidosis have been reported in patients taking empagliflozin. Patients who present with signs and symptoms of metabolic acidosis should be assessed for ketoacidosis, even if blood glucose levels are less than 250 mg/dL. If suspected, discontinue, evaluate, and treat promptly. Before initiating, consider risk factors for ketoacidosis. Patients may require monitoring and temporary discontinuation in situations known to predispose to ketoacidosis.

Heart Failure: GLYXAMBI
Heart failure has been observed with two other members of the dipeptidyl peptidase-4 (DPP-4) inhibitor class. Consider risks and benefits of GLYXAMBI in patients at risk for heart failure, such as those with a prior history of heart failure and a history of renal impairment. Monitor patients for signs and symptoms. Advise patients of the symptoms of heart failure and to immediately report such symptoms. If heart failure develops, consider discontinuation of GLYXAMBI.

Acute Kidney Injury and Impairment in Renal Function: JARDIANCE, SYNJARDY, SYNJARDY XR, GLYXAMBI
Empagliflozin causes intravascular volume contraction and can cause renal impairment. Acute kidney injury requiring hospitalization and dialysis have been identified in patients taking SGLT2 inhibitors, including empagliflozin; some reports involved patients younger than 65 years of age. Before initiating, consider factors that may predispose patients to acute kidney injury. Consider temporary discontinuation in settings of reduced oral intake or fluid losses. Monitor patients for signs and symptoms of acute kidney injury. If it occurs, discontinue and treat promptly.

Empagliflozin increases serum creatinine and decreases eGFR. Patients with hypovolemia may be more susceptible to these changes. Before initiating, evaluate renal function and monitor thereafter. More frequent monitoring is recommended in patients with eGFR <60 mL/min/1.73 m². Discontinue in patients with a persistent eGFR <45 mL/min/1.73 m².

Urosepsis and Pyelonephritis: JARDIANCE, SYNJARDY, SYNJARDY XR, GLYXAMBI
Serious urinary tract infections including urosepsis and pyelonephritis requiring hospitalization have been identified in patients receiving SGLT2 inhibitors, including empagliflozin. Treatment with SGLT2 inhibitors increases the risk for urinary tract infections. Evaluate for signs and symptoms of urinary tract infections and treat promptly.

Hypoglycemia: JARDIANCE, SYNJARDY, SYNJARDY XR, GLYXAMBI
The use in combination with insulin or insulin secretagogues can increase the risk of hypoglycemia. A lower dose of insulin or the insulin secretagogue may be required.

Hypoglycemia could occur when caloric intake is deficient, when strenuous exercise is not compensated by caloric supplementation or during concomitant use of SYNJARDY or SYNJARDY XR with other glucose-lowering agents or with the use of ethanol.

Genital Mycotic Infections: JARDIANCE, SYNJARDY, SYNJARDY XR, GLYXAMBI
Empagliflozin increases the risk for genital mycotic infections, especially in patients with prior infections. Monitor and treat as appropriate.

Vitamin B₁₂ Deficiency: SYNJARDY, SYNJARDY XR
Metformin may lower vitamin B₁₂ levels. Monitor hematologic parameters annually for patients on SYNJARDY or SYNJARDY XR.

Hypersensitivity Reactions: JARDIANCE, SYNJARDY, SYNJARDY XR, GLYXAMBI
Discontinue JARDIANCE, SYNJARDY, SYNJARDY XR, or GLYXAMBI, treat promptly, and monitor until signs and symptoms resolve.

Use caution in a patient with a history of angioedema to another DPP-4 inhibitor because it is unknown whether such patients will be predisposed to angioedema with linagliptin.

Increased Low-Density Lipoprotein Cholesterol (LDL-C): JARDIANCE, SYNJARDY, SYNJARDY XR, GLYXAMBI

Monitor and treat as appropriate

Severe and Disabling Arthralgia: GLYXAMBI
Severe and disabling arthralgia has been reported in patients taking DPP-4 inhibitors. Consider linagliptin as a possible cause for severe joint pain and discontinue, if appropriate.

Bullous Pemphigoid: GLYXAMBI
There have been reports of bullous pemphigoid requiring hospitalization. Tell patients to report development of blisters or erosions. If bullous pemphigoid is suspected, discontinue.

Macrovascular Outcomes: SYNJARDY, SYNJARDY XR, GLYXAMBI
There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with SYNJARDY, SYNJARDY XR, or GLYXAMBI.

MOST COMMON ADVERSE REACTIONS (≥5%)

JARDIANCE: urinary tract infections and female genital mycotic infections

SYNJARDY and SYNJARDY XR: urinary tract infections and female genital mycotic infections, diarrhea, nausea/vomiting, flatulence, abdominal discomfort, indigestion, asthenia, and headache

GLYXAMBI: urinary tract infections, nasopharyngitis, upper respiratory tract infections

DRUG INTERACTIONS

Empagliflozin: Coadministration with diuretics may enhance the potential for volume depletion.

Metformin Hydrochloride: More frequent monitoring is recommended when SYNJARDY or SYNJARDY XR is administered with drugs that impair renal function, result in hemodynamic change, interfere with acid-base balance, or increase metformin accumulation.

Drugs that reduce metformin clearance such as ranolazine, vandetanib, dolutegravir, or cimetidine may increase the accumulation of metformin and increase the risk of lactic acidosis. Consider the benefits and risks of concomitant use.

Carbonic Anhydrase Inhibitors: The concomitant use of carbonic anhydrase inhibitors (e.g., topiramate) and metformin may increase the risk of lactic acidosis. Consider more frequent monitoring.

Alcohol: Alcohol is known to potentiate the effect of metformin on lactate metabolism. Warn patients against excessive alcohol intake while taking SYNJARDY or SYNJARDY XR.

Linagliptin: The efficacy of linagliptin may be reduced when administered in combination with a strong P-gp or CYP3A4 inducer. Alternative treatments should be used.

USE IN SPECIAL POPULATIONS

Pregnancy: JARDIANCE, SYNJARDY, SYNJARDY XR, and GLYXAMBI are not recommended, especially during the second and third trimesters. With SYNJARDY or SYNJARDY XR, discuss the potential for unintended pregnancy with premenopausal women as therapy with metformin may result in ovulation in some anovulatory women.

Lactation: JARDIANCE, SYNJARDY, SYNJARDY XR, and GLYXAMBI are not recommended while breastfeeding.

Geriatric Use: JARDIANCE, SYNJARDY, SYNJARDY XR, and GLYXAMBI are expected to have diminished efficacy in elderly patients with renal impairment. Renal function should be assessed more frequently in elderly patients. Dose selection should be cautious, starting at the lowest dose. The incidence of volume depletion-related adverse reactions and urinary tract infections increased in patients ≥75 years treated with empagliflozin.