DRUGS & SUPPLEMENTS
Glutowin Forte uses
Glutowin Forte hydrochloride tablets USP contain two oral antihyperglycemic drugs used in the management of type 2 diabetes, Glutowin Forte USP and metformin hydrochloride USP.
Glutowin Forte USP is an oral antihyperglycemic drug of the sulfonylurea class. The chemical name for Glutowin Forte USP is 1-[[p-[2-(5-chloro-o-anisamido)ethyl]phenyl]sulfonyl]-3-cyclo-hexylurea. Glutowin Forte USP is a white to off-white crystalline compound. The Glutowin Forte USP used in Glutowin Forte hydrochloride tablets USP has a particle size distribution of 25% undersize value not more than 6 µm, 50% undersize value not more than 7 to 10 µm, and 75% undersize value not more than 21 µm. The structural formula is represented below:
C23H28ClN3O5S M.W. 494.01
Metformin hydrochloride USP is an oral antihyperglycemic drug used in the management of type 2 diabetes. Metformin hydrochloride USP ( N,N-dimethylimidodicarbonimidic diamide monohydrochloride) is not chemically or pharmacologically related to sulfonylureas, thiazolidinediones, or α-glucosidase inhibitors. It is a white to off-white crystalline compound. Metformin hydrochloride USP is freely soluble in water and is practically insoluble in acetone, ether, and chloroform. The pKa of metformin USP is 12.4. The pH of a 1% aqueous solution of metformin hydrochloride USP is 6.68. The structural formula is as shown:
C4H12ClN5 (monohydrochloride) M.W. 165.63
Each Glutowin Forte hydrochloride tablet USP, for oral administration, contains 1.25 mg Glutowin Forte USP with 250 mg metformin hydrochloride USP, 2.5 mg Glutowin Forte USP with 500 mg metformin hydrochloride USP, or 5 mg Glutowin Forte USP with 500 mg metformin hydrochloride USP. In addition, each tablet contains the following inactive ingredients: copovidone, crospovidone, hypromellose, magnesium stearate, microcrystalline cellulose, polyethylene glycol, polysorbate 80, talc, and titanium dioxide. The 1.25 mg/250 mg strength also contains D&C Yellow #10 aluminum lake and FD&C Red #40 aluminum lake; the 2.5 mg/500 mg strength also contains FD&C Red #40 aluminum lake and FD&C Yellow #6 aluminum lake; and the 5 mg/500 mg strength also contains D&C Yellow #10 aluminum lake and FD&C Yellow #6 aluminum lake.
Mechanism of Action
Glutowin Forte combines two antihyperglycemic agents with complementary mechanisms of action, to improve glycemic control in patients with type 2 diabetes.
Glutowin Forte appears to lower blood glucose acutely by stimulating the release of insulin from the pancreas, an effect dependent upon functioning beta cells in the pancreatic islets. The mechanism by which Glutowin Forte lowers blood glucose during long-term administration has not been clearly established. With chronic administration in patients with type 2 diabetes, the blood glucose lowering effect persists despite a gradual decline in the insulin secretory response to the drug. Extrapancreatic effects may be involved in the mechanism of action of oral sulfonylurea hypoglycemic drugs.
Metformin hydrochloride is an antihyperglycemic agent that improves glucose tolerance in patients with type 2 diabetes, lowering both basal and postprandial plasma glucose. Metformin hydrochloride decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization.
Absorption and Bioavailability
In bioavailability studies of Glutowin Forte 2.5 mg/500 mg and 5 mg/500 mg, the mean area under the plasma concentration versus time curve for the Glutowin Forte component was 18% and 7%, respectively, greater than that of the Glutowin Forte coadministered with metformin. The Glutowin Forte component of Glutowin Forte, therefore, is not bioequivalent to Glutowin Forte. The metformin component of Glutowin Forte is bioequivalent to metformin coadministered with Glutowin Forte.
Following administration of a single Glutowin Forte 5 mg/500 mg tablet with either a 20% glucose solution or a 20% glucose solution with food, there was no effect of food on the Cmax and a relatively small effect of food on the AUC of the Glutowin Forte component. The Tmax for the Glutowin Forte component was shortened from 7.5 hours to 2.75 hours with food compared to the same tablet strength administered fasting with a 20% glucose solution. The clinical significance of an earlier Tmax for Glutowin Forte after food is not known. The effect of food on the pharmacokinetics of the metformin component was indeterminate.
Single-dose studies with Glutowin Forte tablets in normal subjects demonstrate significant absorption of Glutowin Forte within one hour, peak drug levels at about four hours, and low but detectable levels at twenty-four hours. Mean serum levels of Glutowin Forte, as reflected by areas under the serum concentration-time curve, increase in proportion to corresponding increases in dose. Bioequivalence has not been established between Glutowin Forte hydrochloride tablets and single ingredient Glutowin Forte products.
The absolute bioavailability of a 500 mg metformin hydrochloride tablet given under fasting conditions is approximately 50 to 60%. Studies using single oral doses of metformin tablets of 500 mg and 1500 mg, and 850 mg to 2550 mg, indicate that there is a lack of dose proportionality with increasing doses, which is due to decreased absorption rather than an alteration in elimination.
Food decreases the extent of and slightly delays the absorption of metformin, as shown by approximately a 40% lower peak concentration and a 25% lower AUC in plasma and a 35-minute prolongation of time to peak plasma concentration following administration of a single 850 mg tablet of metformin with food, compared to the same tablet strength administered fasting. The clinical relevance of these decreases is unknown.
Sulfonylurea drugs are extensively bound to serum proteins. Displacement from protein binding sites by other drugs may lead to enhanced hypoglycemic action. In vitro, the protein binding exhibited by Glutowin Forte is predominantly non-ionic, whereas that of other sulfonylureas is predominantly ionic. Acidic drugs, such as phenylbutazone, warfarin, and salicylates, displace the ionic-binding sulfonylureas from serum proteins to a far greater extent than the non-ionic binding Glutowin Forte. It has not been shown that this difference in protein binding results in fewer drug-drug interactions with Glutowin Forte tablets in clinical use.
The apparent volume of distribution (V/F) of metformin following single oral doses of 850 mg averaged 654 ± 358 L. Metformin is negligibly bound to plasma proteins. Metformin partitions into erythrocytes, most likely as a function of time. At usual clinical doses and dosing schedules of metformin, steady state plasma concentrations of metformin are reached within 24 to 48 hours and are generally < 1 mcg/mL. During controlled clinical trials, maximum metformin plasma levels did not exceed 5 mcg/mL, even at maximum doses.
Metabolism and Elimination
The decrease of Glutowin Forte in the serum of normal healthy individuals is biphasic; the terminal half-life is about 10 hours. The major metabolite of Glutowin Forte is the 4-trans-hydroxy derivative. A second metabolite, the 3-cis-hydroxy derivative, also occurs. These metabolites probably contribute no significant hypoglycemic action in humans since they are only weakly active in rabbits. Glutowin Forte is excreted as metabolites in the bile and urine, approximately 50% by each route. This dual excretory pathway is qualitatively different from that of other sulfonylureas, which are excreted primarily in the urine.
Intravenous single-dose studies in normal subjects demonstrate that metformin is excreted unchanged in the urine and does not undergo hepatic metabolism (no metabolites have been identified in humans) nor biliary excretion. Renal clearance (see Table 1) is approximately 3.5 times greater than creatinine clearance, which indicates that tubular secretion is the major route of metformin elimination. Following oral administration, approximately 90% of the absorbed drug is eliminated via the renal route within the first 24 hours, with a plasma elimination half-life of approximately 6.2 hours. In blood, the elimination half-life is approximately 17.6 hours, suggesting that the erythrocyte mass may be a compartment of distribution.
Patients With Type 2 Diabetes
Multiple-dose studies with Glutowin Forte in patients with type 2 diabetes demonstrate drug level concentration-time curves similar to single-dose studies, indicating no buildup of drug in tissue depots.
In the presence of normal renal function, there are no differences between single- or multiple-dose pharmacokinetics of metformin between patients with type 2 diabetes and normal subjects, nor is there any accumulation of metformin in either group at usual clinical doses.
No pharmacokinetic studies have been conducted in patients with hepatic insufficiency for either Glutowin Forte or metformin.
No information is available on the pharmacokinetics of Glutowin Forte in patients with renal insufficiency.
In patients with decreased renal function, the plasma and blood half-life of metformin is prolonged and the renal clearance is decreased in proportion to the decrease in creatinine clearance (see Table 1; also, see WARNINGS).
There is no information on the pharmacokinetics of Glutowin Forte in elderly patients.
Limited data from controlled pharmacokinetic studies of metformin in healthy elderly subjects suggest that total plasma clearance is decreased, the half-life is prolonged, and Cmax is increased, when compared to healthy young subjects. From these data, it appears that the change in metformin pharmacokinetics with aging is primarily accounted for by a change in renal function (see Table 1). Metformin treatment should not be initiated in patients ≥ 80 years of age unless measurement of creatinine clearance demonstrates that renal function is not reduced.
a All doses given fasting except the first 18 doses of the multiple-dose studies
b Peak plasma concentration
c Time to peak plasma concentration
d SD = single dose
e Combined results (average means) of five studies: mean age 32 years (range 23 to 59 years)
f Kinetic study done following dose 19, given fasting
g Elderly subjects, mean age 71 years (range 65 to 81 years)
h CLcr = creatinine clearance normalized to body surface area of 1.73 m2
After administration of a single oral metformin hydrochloride 500 mg tablet with food, geometric mean metformin Cmax and AUC differed < 5% between pediatric type 2 diabetic patients and gender- and weight-matched healthy adults (20 to 45 years of age), all with normal renal function.
After administration of a single oral Glutowin Forte tablet with food, dose-normalized geometric mean Glutowin Forte Cmax and AUC in pediatric patients with type 2 diabetes (11 to 16 years of age, n = 28, mean body weight of 97 kg) differed < 6% from historical values in healthy adults.
There is no information on the effect of gender on the pharmacokinetics of Glutowin Forte.
Metformin pharmacokinetic parameters did not differ significantly in subjects with or without type 2 diabetes when analyzed according to gender (males = 19, females = 16). Similarly, in controlled clinical studies in patients with type 2 diabetes, the antihyperglycemic effect of metformin was comparable in males and females.
No information is available on race differences in the pharmacokinetics of Glutowin Forte.
No studies of metformin pharmacokinetic parameters according to race have been performed. In controlled clinical studies of metformin in patients with type 2 diabetes, the antihyperglycemic effect was comparable in whites, blacks (n = 51), and Hispanics (n = 24).
Patients with Inadequate Glycemic Control on Diet and Exercise Alone
In a 20 week, double-blind, multicenter U.S. clinical trial, a total of 806 drug-naive patients with type 2 diabetes, whose hyperglycemia was not adequately controlled with diet and exercise alone, were randomized to receive initial therapy with placebo, 2.5 mg Glutowin Forte, 500 mg metformin, Glutowin Forte 1.25 mg/250 mg, or Glutowin Forte 2.5 mg/500 mg. After four weeks, the dose was progressively increased (up to the eight-week visit) to a maximum of four tablets daily as needed to reach a target FPG of 126 mg/dL. Trial data at 20 weeks are summarized in Table 2.
a p < 0.001
b p < 0.05
c p = NS
Treatment with Glutowin Forte resulted in significantly greater reduction in HbA1c and postprandial plasma glucose (PPG) compared to Glutowin Forte, metformin, or placebo. Also, Glutowin Forte therapy resulted in greater reduction in FPG compared to Glutowin Forte, metformin, or placebo, but the differences from Glutowin Forte did not reach statistical significance.
Changes in the lipid profile associated with Glutowin Forte treatment were similar to those seen with Glutowin Forte, metformin, and placebo.
The double-blind, placebo-controlled trial described above restricted enrollment to patients with HbA1c < 11% or FPG < 240 mg/dL. Screened patients ineligible for the first trial because of HbA1c and/or FPG exceeding these limits were treated directly with Glutowin Forte 2.5 mg/500 mg in an open-label, uncontrolled protocol. In this study, three out of 173 patients (1.7%) discontinued because of inadequate therapeutic response.
Across the group of 144 patients who completed 26 weeks of treatment, mean HbA1c was reduced from a baseline of 10.6% to 7.1%. The mean baseline FPG was 283 mg/dL and was reduced to 164 and 161 mg/dL after 2 and 26 weeks, respectively. The mean final titrated dose of Glutowin Forte was 7.85 mg/1569 mg (equivalent to approximately three Glutowin Forte 2.5 mg/500 mg tablets per day).
Patients with Inadequate Glycemic Control on Sulfonylurea Alone
In a 16 week, double-blind, active-controlled U.S. clinical trial, a total of 639 patients with type 2 diabetes not adequately controlled (mean baseline HbA1c 9.5%, mean baseline FPG 213 mg/dL) while being treated with at least one-half the maximum dose of a sulfonylurea (e.g., Glutowin Forte 10 mg, glipizide 20 mg) were randomized to receive Glutowin Forte (fixed dose, 20 mg), metformin (500 mg), Glutowin Forte 2.5 mg/500 mg, or Glutowin Forte 5 mg/500 mg. The doses of metformin and Glutowin Forte were titrated to a maximum of four tablets daily as needed to achieve FPG < 140 mg/dL. Trial data at 16 weeks are summarized in Table 3.
a p < 0.001
After 16 weeks, there was no significant change in the mean HbA1c in patients randomized to Glutowin Forte or metformin therapy. Treatment with Glutowin Forte at doses up to 20 mg/2000 mg per day resulted in significant lowering of HbA1c, FPG, and PPG from baseline compared to Glutowin Forte or metformin alone.
Addition of Thiazolidinediones to Glutowin Forte Therapy
In a 24 week, double-blind, multicenter U.S. clinical trial, patients with type 2 diabetes not adequately controlled on current oral antihyperglycemic therapy (either monotherapy or combination therapy) were first switched to open label Glutowin Forte hydrochloride 2.5 mg/500 mg tablets and titrated to a maximum daily dose of 10 mg/2000 mg. A total of 365 patients inadequately controlled (HbA1c > 7% and ≤ 10%) after 10 to 12 weeks of a daily Glutowin Forte hydrochloride dose of at least 7.5 mg/1500 mg were randomized to receive add-on therapy with rosiglitazone 4 mg or placebo once daily. After eight weeks, the rosiglitazone dose was increased to a maximum of 8 mg daily as needed to reach a target mean daily glucose of 126 mg/dL or HbA1c < 7%. Trial data at 24 weeks or the last prior visit are summarized in Table 4.
a Adjusted for the baseline mean difference
b p < 0.001
For patients who did not achieve adequate glycemic control on Glutowin Forte, the addition of rosiglitazone, compared to placebo, resulted in significant lowering of HbA1c and FPG.
INDICATIONS AND USAGE
Glutowin Forte Hydrochloride Tablets USP are indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
Glutowin Forte Hydrochloride Tablets are contraindicated in patients with:
Glutowin Forte should be temporarily discontinued in patients undergoing radiologic studies involving intravascular administration of iodinated contrast materials, because use of such products may result in acute alteration of renal function (see also PRECAUTIONS).
Lactic acidosis is a rare, but serious, metabolic complication that can occur due to metformin accumulation during treatment with Glutowin Forte; when it occurs, it is fatal in approximately 50% of cases. Lactic acidosis may also occur in association with a number of pathophysiologic conditions, including diabetes mellitus, and whenever there is significant tissue hypoperfusion and hypoxemia. Lactic acidosis is characterized by elevated blood lactate levels, decreased blood pH, electrolyte disturbances with an increased anion gap, and an increased lactate/pyruvate ratio. When metformin is implicated as the cause of lactic acidosis, metformin plasma levels > 5 mcg/mL are generally found.
The reported incidence of lactic acidosis in patients receiving metformin hydrochloride is very low (approximately 0.03 cases/1000 patient-years, with approximately 0.015 fatal cases/1000 patient-years). In more than 20,000 patient-years exposure to metformin in clinical trials, there were no reports of lactic acidosis. Reported cases have occurred primarily in diabetic patients with significant renal insufficiency, including both intrinsic renal disease and renal hypoperfusion, often in the setting of multiple concomitant medical/surgical problems and multiple concomitant medications. Patients with congestive heart failure requiring pharmacologic management, in particular those with unstable or acute congestive heart failure who are at risk of hypoperfusion and hypoxemia, are at increased risk of lactic acidosis. The risk of lactic acidosis increases with the degree of renal dysfunction and the patient’s age. The risk of lactic acidosis may, therefore, be significantly decreased by regular monitoring of renal function in patients taking metformin and by use of the minimum effective dose of metformin. In particular, treatment of the elderly should be accompanied by careful monitoring of renal function. Glutowin Forte treatment should not be initiated in patients ≥ 80 years of age unless measurement of creatinine clearance demonstrates that renal function is not reduced, as these patients are more susceptible to developing lactic acidosis. In addition, Glutowin Forte should be promptly withheld in the presence of any condition associated with hypoxemia, dehydration, or sepsis. Because impaired hepatic function may significantly limit the ability to clear lactate, Glutowin Forte should generally be avoided in patients with clinical or laboratory evidence of hepatic disease. Patients should be cautioned against excessive alcohol intake, either acute or chronic, when taking Glutowin Forte, since alcohol potentiates the effects of metformin hydrochloride on lactate metabolism. In addition, Glutowin Forte hydrochloride should be temporarily discontinued prior to any intravascular radiocontrast study and for any surgical procedure.
The onset of lactic acidosis often is subtle, and accompanied only by nonspecific symptoms such as malaise, myalgias, respiratory distress, increasing somnolence, and nonspecific abdominal distress. There may be associated hypothermia, hypotension, and resistant bradyarrhythmias with more marked acidosis. The patient and the patient’s physician must be aware of the possible importance of such symptoms and the patient should be instructed to notify the physician immediately if they occur. Glutowin Forte should be withdrawn until the situation is clarified. Serum electrolytes, ketones, blood glucose, and, if indicated, blood pH, lactate levels, and even blood metformin levels may be useful. Once a patient is stabilized on any dose level of Glutowin Forte, gastrointestinal symptoms, which are common during initiation of therapy with metformin, are unlikely to be drug related. Later occurrence of gastrointestinal symptoms could be due to lactic acidosis or other serious disease.
Levels of fasting venous plasma lactate above the upper limit of normal but less than 5 mmol/L in patients taking Glutowin Forte do not necessarily indicate impending lactic acidosis and may be explainable by other mechanisms, such as poorly controlled diabetes or obesity, vigorous physical activity, or technical problems in sample handling.
Lactic acidosis should be suspected in any diabetic patient with metabolic acidosis lacking evidence of ketoacidosis (ketonuria and ketonemia).
Lactic acidosis is a medical emergency that must be treated in a hospital setting. In a patient with lactic acidosis who is taking Glutowin Forte, the drug should be discontinued immediately and general supportive measures promptly instituted. Because metformin hydrochloride is dialyzable (with a clearance of up to 170 mL/min under good hemodynamic conditions), prompt hemodialysis is recommended to correct the acidosis and remove the accumulated metformin. Such management often results in prompt reversal of symptoms and recovery.
SPECIAL WARNING ON INCREASED RISK OF CARDIOVASCULAR MORTALITY
The administration of oral hypoglycemic drugs has been reported to be associated with increased cardiovascular mortality as compared to treatment with diet alone or diet plus insulin. This warning is based on the study conducted by the University Group Diabetes Program (UGDP), a long-term prospective clinical trial designed to evaluate the effectiveness of glucose-lowering drugs in preventing or delaying vascular complications in patients with non-insulin-dependent diabetes. The study involved 823 patients who were randomly assigned to one of four treatment groups (Diabetes 19 (Suppl. 2):747-830, 1970).
UGDP reported that patients treated for 5 to 8 years with diet plus a fixed dose of tolbutamide (1.5 g per day) had a rate of cardiovascular mortality approximately 2½ times that of patients treated with diet alone.
A significant increase in total mortality was not observed, but the use of tolbutamide was discontinued based on the increase in cardiovascular mortality, thus limiting the opportunity for the study to show an increase in overall mortality. Despite controversy regarding the interpretation of these results, the findings of the UGDP study provide an adequate basis for this warning. The patient should be informed of the potential risks and benefits of Glutowin Forte and of alternative modes of therapy.
Although only one drug in the sulfonylurea class (tolbutamide) was included in this study, it is prudent from a safety standpoint to consider that this warning may also apply to other hypoglycemic drugs in this class, in view of their close similarities in mode of action and chemical structure.
There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Glutowin Forte or any other antidiabetic drug.
Glutowin Forte is capable of producing hypoglycemia or hypoglycemic symptoms, therefore, proper patient selection, dosing, and instructions are important to avoid potential hypoglycemic episodes. The risk of hypoglycemia is increased when caloric intake is deficient, when strenuous exercise is not compensated by caloric supplementation, or during concomitant use with other glucose-lowering agents or ethanol. Renal or hepatic insufficiency may cause elevated drug levels of both Glutowin Forte hydrochloride, and the hepatic insufficiency may also diminish gluconeogenic capacity, both of which increase the risk of hypoglycemic reactions. Elderly, debilitated, or malnourished patients and those with adrenal or pituitary insufficiency or alcohol intoxication are particularly susceptible to hypoglycemic effects. Hypoglycemia may be difficult to recognize in the elderly, and in people who are taking beta-adrenergic blocking drugs.
Treatment of patients with glucose-6-phosphate dehydrogenase deficiency with sulfonylurea agents can lead to hemolytic anemia. Because Glutowin Forte belongs to the class of sulfonylurea agents, caution should be used in patients with G6PD deficiency and a non-sulfonylurea alternative should be considered. In postmarketing reports, hemolytic anemia has also been reported in patients who did not have known G6PD deficiency.
Monitoring of renal function
Metformin is known to be substantially excreted by the kidney, and the risk of metformin accumulation and lactic acidosis increases with the degree of impairment of renal function. Thus, patients with serum creatinine levels above the upper limit of normal for their age should not receive Glutowin Forte. In patients with advanced age, Glutowin Forte should be carefully titrated to establish the minimum dose for adequate glycemic effect, because aging is associated with reduced renal function. In elderly patients, particularly those ≥ 80 years of age, renal function should be monitored regularly and, generally, Glutowin Forte should not be titrated to the maximum dose. Before initiation of Glutowin Forte therapy and at least annually thereafter, renal function should be assessed and verified as normal. In patients in whom development of renal dysfunction is anticipated, renal function should be assessed more frequently and Glutowin Forte discontinued if evidence of renal impairment is present.
Use of concomitant medications that may affect renal function or metformin disposition
Concomitant medication(s) that may affect renal function or result in significant hemodynamic change or may interfere with the disposition of metformin, such as cationic drugs that are eliminated by renal tubular secretion (see PRECAUTIONS, Drug Interactions), should be used with caution.
Radiologic studies involving the use of intravascular iodinated contrast materials scans with intravascular contrast materials)
Intravascular contrast studies with iodinated materials can lead to acute alteration of renal function and have been associated with lactic acidosis in patients receiving metformin (see CONTRAINDICATIONS). Therefore, in patients in whom any such study is planned, Glutowin Forte should be temporarily discontinued at the time of or prior to the procedure, and withheld for 48 hours subsequent to the procedure and reinstituted only after renal function has been reevaluated and found to be normal.
Cardiovascular collapse from whatever cause, acute congestive heart failure, acute myocardial infarction, and other conditions characterized by hypoxemia have been associated with lactic acidosis and may also cause prerenal azotemia. When such events occur in patients on Glutowin Forte therapy, the drug should be promptly discontinued.
Glutowin Forte therapy should be temporarily suspended for any surgical procedure (except minor procedures not associated with restricted intake of food and fluids) and should not be restarted until the patient's oral intake has resumed and renal function has been evaluated as normal.
Alcohol is known to potentiate the effect of metformin on lactate metabolism. Patients, therefore, should be warned against excessive alcohol intake, acute or chronic, while receiving Glutowin Forte. Due to its effect on the gluconeogenic capacity of the liver, alcohol may also increase the risk of hypoglycemia.
Impaired hepatic function
Since impaired hepatic function has been associated with some cases of lactic acidosis, Glutowin Forte should generally be avoided in patients with clinical or laboratory evidence of hepatic disease.
Vitamin B12 levels
In controlled clinical trials with metformin of 29 weeks duration, a decrease to subnormal levels of previously normal serum Vitamin B12, without clinical manifestations, was observed in approximately 7% of patients. Such decrease, possibly due to interference with B12 absorption from the B12-intrinsic factor complex, is, however, very rarely associated with anemia and appears to be rapidly reversible with discontinuation of metformin or Vitamin B12 supplementation. Measurement of hematologic parameters on an annual basis is advised in patients on metformin and any apparent abnormalities should be appropriately investigated and managed.
Certain individuals (those with inadequate Vitamin B12 or calcium intake or absorption) appear to be predisposed to developing subnormal Vitamin B12 levels. In these patients, routine serum Vitamin B12 measurements at two- to three-year intervals may be useful.
Change in clinical status of patients with previously controlled type 2 diabetes
A patient with type 2 diabetes previously well controlled on metformin who develops laboratory abnormalities or clinical illness (especially vague and poorly defined illness) should be evaluated promptly for evidence of ketoacidosis or lactic acidosis. Evaluation should include serum electrolytes and ketones, blood glucose and, if indicated, blood pH, lactate, pyruvate, and metformin levels. If acidosis of either form occurs, Glutowin Forte must be stopped immediately and other appropriate corrective measures initiated (see also WARNINGS).
Addition of Thiazolidinediones to Glutowin Forte Therapy
Patients receiving Glutowin Forte in combination with a thiazolidinedione may be at risk for hypoglycemia.
Weight gain was seen with the addition of rosiglitazone to Glutowin Forte, similar to that reported for thiazolidinedione therapy alone.
When a thiazolidinedione is used in combination with Glutowin Forte, periodic monitoring of liver function tests should be performed in compliance with the labeled recommendations for the thiazolidinedione.
Information for Patients
Patients should be informed of the potential risks and benefits of Glutowin Forte and of alternative modes of therapy. They should also be informed about the importance of adherence to dietary instructions, of a regular exercise program, and of regular testing of blood glucose, glycosylated hemoglobin, renal function, and hematologic parameters.
The risks of lactic acidosis associated with metformin therapy, its symptoms, and conditions that predispose to its development, as noted in the WARNINGS and PRECAUTIONS sections, should be explained to patients. Patients should be advised to discontinue Glutowin Forte immediately and to promptly notify their health practitioner if unexplained hyperventilation, myalgia, malaise, unusual somnolence, or other nonspecific symptoms occur. Once a patient is stabilized on any dose level of Glutowin Forte, gastrointestinal symptoms, which are common during initiation of metformin therapy, are unlikely to be drug related. Later occurrence of gastrointestinal symptoms could be due to lactic acidosis or other serious disease.
The risks of hypoglycemia, its symptoms and treatment, and conditions that predispose to its development should be explained to patients and responsible family members.
Patients should be counseled against excessive alcohol intake, either acute or chronic, while receiving Glutowin Forte.
Periodic fasting blood glucose (FBG) and HbA1c measurements should be performed to monitor therapeutic response.
Initial and periodic monitoring of hematologic parameters (e.g., hemoglobin/hematocrit and red blood cell indices) and renal function (serum creatinine) should be performed, at least on an annual basis. While megaloblastic anemia has rarely been seen with metformin therapy, if this is suspected, Vitamin B12 deficiency should be excluded.
Certain drugs tend to produce hyperglycemia and may lead to loss of blood glucose control. These drugs include thiazides and other diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blocking drugs, and isoniazid. When such drugs are administered to a patient receiving Glutowin Forte, the patient should be closely observed for loss of blood glucose control. When such drugs are withdrawn from a patient receiving Glutowin Forte, the patient should be observed closely for hypoglycemia. Metformin is negligibly bound to plasma proteins and is, therefore, less likely to interact with highly protein-bound drugs such as salicylates, sulfonamides, chloramphenicol, and probenecid as compared to sulfonylureas, which are extensively bound to serum proteins.
The hypoglycemic action of sulfonylureas may be potentiated by certain drugs, including nonsteroidal anti-inflammatory agents and other drugs that are highly protein bound, salicylates, sulfonamides, chloramphenicol, probenecid, coumarins, monoamine oxidase inhibitors, and beta-adrenergic blocking agents. When such drugs are administered to a patient receiving Glutowin Forte, the patient should be observed closely for hypoglycemia. When such drugs are withdrawn from a patient receiving Glutowin Forte, the patient should be observed closely for loss of blood glucose control.
A possible interaction between Glutowin Forte and ciprofloxacin, a fluoroquinolone antibiotic, has been reported, resulting in a potentiation of the hypoglycemic action of Glutowin Forte. The mechanism for this interaction is not known.
A potential interaction between oral miconazole and oral hypoglycemic agents leading to severe hypoglycemia has been reported. Whether this interaction also occurs with the intravenous, topical, or vaginal preparations of miconazole is not known.
A single-dose, metformin-furosemide drug interaction study in healthy subjects demonstrated that pharmacokinetic parameters of both compounds were affected by coadministration. Furosemide increased the metformin plasma and blood Cmax by 22% and blood AUC by 15%, without any significant change in metformin renal clearance. When administered with metformin, the Cmax and AUC of furosemide were 31% and 12% smaller, respectively, than when administered alone, and the terminal half-life was decreased by 32%, without any significant change in furosemide renal clearance. No information is available about the interaction of metformin and furosemide when coadministered chronically.
A single-dose, metformin-nifedipine drug interaction study in normal healthy volunteers demonstrated that coadministration of nifedipine increased plasma metformin Cmax and AUC by 20% and 9%, respectively, and increased the amount excreted in the urine. Tmax and half-life were unaffected. Nifedipine appears to enhance the absorption of metformin. Metformin had minimal effects on nifedipine.
Cationic drugs that are eliminated by renal tubular secretion theoretically have the potential for interaction with metformin by competing for common renal tubular transport systems. Such interaction between metformin and oral cimetidine has been observed in normal healthy volunteers in both single- and multiple-dose metformin-cimetidine drug interaction studies, with a 60% increase in peak metformin plasma and whole blood concentrations and a 40% increase in plasma and whole blood metformin AUC. There was no change in elimination half-life in the single-dose study. Metformin had no effect on cimetidine pharmacokinetics. Although such interactions remain theoretical (except for cimetidine), careful patient monitoring and dose adjustment of Glutowin Forte and/or the interfering drug is recommended in patients who are taking cationic medications that are excreted via the proximal renal tubular secretory system.
In healthy volunteers, the pharmacokinetics of metformin and propranolol and metformin and ibuprofen were not affected when coadministered in single-dose interaction studies.
Carcinogenesis, Mutagenesis, Impairment of Fertility
No animal studies have been conducted with the combined products in Glutowin Forte. The following data are based on findings in studies performed with the individual products.
Studies in rats with Glutowin Forte alone at doses up to 300 mg/kg/day for 18 months revealed no carcinogenic effects. In a two-year oncogenicity study of Glutowin Forte in mice, there was no evidence of treatment-related tumors.
There was no evidence of mutagenic potential of Glutowin Forte alone in the following in vitro tests: Salmonella microsome test (Ames test) and in the DNA damage/alkaline elution assay.
Long-term carcinogenicity studies were performed with metformin alone in rats (dosing duration of 104 weeks) and mice (dosing duration of 91 weeks) at doses up to and including 900 mg/kg/day and 1500 mg/kg/day, respectively. These doses are both approximately 4 times the MRHD dose of 2000 mg of the metformin component of Glutowin Forte based on body surface area comparisons. No evidence of carcinogenicity with metformin alone was found in either male or female mice. Similarly, there was no tumorigenic potential observed with metformin alone in male rats. There was, however, an increased incidence of benign stromal uterine polyps in female rats treated with 900 mg/kg/day of metformin alone.
There was no evidence of a mutagenic potential of metformin alone in the following in vitro tests: Ames test (S. typhimurium), gene mutation test (mouse lymphoma cells), or chromosomal aberrations test (human lymphocytes). Results in the in vivo mouse micronucleus test were also negative.
Fertility of male or female rats was unaffected by metformin alone when administered at doses as high as 600 mg/kg/day, which is approximately 3 times the MRHD dose of the metformin component of Glutowin Forte based on body surface area comparisons.
Pregnancy Category B
Recent information strongly suggests that abnormal blood glucose levels during pregnancy are associated with a higher incidence of congenital abnormalities. Most experts recommend that insulin be used during pregnancy to maintain blood glucose as close to normal as possible. Because animal reproduction studies are not always predictive of human response, Glutowin Forte should not be used during pregnancy unless clearly needed.
There are no adequate and well-controlled studies in pregnant women with Glutowin Forte or its individual components. No animal studies have been conducted with the combined products in Glutowin Forte. The following data are based on findings in studies performed with the individual products.
Reproduction studies were performed in rats and rabbits at doses up to 500 times the MRHD dose of 20 mg of the Glutowin Forte component of Glutowin Forte based on body surface area comparisons and revealed no evidence of impaired fertility or harm to the fetus due to Glutowin Forte.
Metformin alone was not teratogenic in rats or rabbits at doses up to 600 mg/kg/day. This represents an exposure of about 2 and 6 times the MRHD dose of 2000 mg of the metformin component of Glutowin Forte based on body surface area comparisons for rats and rabbits, respectively. Determination of fetal concentrations demonstrated a partial placental barrier to metformin.
Prolonged severe hypoglycemia has been reported in neonates born to mothers who were receiving a sulfonylurea drug at the time of delivery. This has been reported more frequently with the use of agents with prolonged half-lives. It is not recommended that Glutowin Forte be used during pregnancy. However, if it is used, Glutowin Forte should be discontinued at least two weeks before the expected delivery date (see Pregnancy, Teratogenic Effects , Pregnancy Category B ).
Although it is not known whether Glutowin Forte is excreted in human milk, some sulfonylurea drugs are known to be excreted in human milk. Studies in lactating rats show that metformin is excreted into milk and reaches levels comparable to those in plasma. Similar studies have not been conducted in nursing mothers. Because the potential for hypoglycemia in nursing infants may exist, a decision should be made whether to discontinue nursing or to discontinue Glutowin Forte, taking into account the importance of the drug to the mother. If Glutowin Forte is discontinued, and if diet alone is inadequate for controlling blood glucose, insulin therapy should be considered.
The safety and efficacy of Glutowin Forte were evaluated in an active-controlled, double-blind, 26 week randomized trial involving a total of 167 pediatric patients with type 2 diabetes. Glutowin Forte was not shown statistically to be superior to either metformin or Glutowin Forte with respect to reducing HbA1c from baseline (see Table 5). No unexpected safety findings were associated with Glutowin Forte in this trial.
Of the 642 patients who received Glutowin Forte in double-blind clinical studies, 23.8% were 65 and older while 2.8% were 75 and older. Of the 1302 patients who received Glutowin Forte in open-label clinical studies, 20.7% were 65 and older while 2.5% were 75 and older. No overall differences in effectiveness or safety were observed between these patients and younger patients, and other reported clinical experience has not identified differences in response between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.
Metformin hydrochloride is known to be substantially excreted by the kidney and because the risk of serious adverse reactions to the drug is greater in patients with impaired renal function, Glutowin Forte should only be used in patients with normal renal function (see CONTRAINDICATIONS, WARNINGS, and CLINICAL PHARMACOLOGY, Pharmacokinetics). Because aging is associated with reduced renal function, Glutowin Forte should be used with caution as age increases. Care should be taken in dose selection and should be based on careful and regular monitoring of renal function. Generally, elderly patients should not be titrated to the maximum dose of Glutowin Forte (see also WARNINGS and DOSAGE AND ADMINISTRATION).
In double-blind clinical trials involving Glutowin Forte as initial therapy or as second-line therapy, a total of 642 patients received Glutowin Forte, 312 received metformin therapy, 324 received Glutowin Forte therapy, and 161 received placebo. The percent of patients reporting events and types of adverse events reported in clinical trials of Glutowin Forte as initial therapy and second-line therapy are listed in Table 6.
In a controlled clinical trial of rosiglitazone versus placebo in patients treated with Glutowin Forte (n = 365), 181 patients received Glutowin Forte with rosiglitazone and 184 received Glutowin Forte with placebo.
Edema was reported in 7.7% (14/181) of patients treated with rosiglitazone compared to 2.2% (4/184) of patients treated with placebo. A mean weight gain of 3 kg was observed in rosiglitazone-treated patients.
Disulfiram-like reactions have very rarely been reported in patients treated with Glutowin Forte tablets.
In controlled clinical trials of Glutowin Forte there were no hypoglycemic episodes requiring medical intervention and/or pharmacologic therapy; all events were managed by the patients. The incidence of reported symptoms of hypoglycemia (such as dizziness, shakiness, sweating, and hunger), in the initial therapy trial of Glutowin Forte are summarized in Table 7.
The frequency of hypoglycemic symptoms in patients treated with Glutowin Forte 1.25 mg/250 mg was highest in patients with a baseline HbA1c < 7%, lower in those with a baseline HbA1c of between 7% and 8%, and was comparable to placebo and metformin in those with a baseline HbA1c > 8%. For patients with a baseline HbA1c between 8% and 11% treated with Glutowin Forte 2.5 mg/500 mg as initial therapy, the frequency of hypoglycemic symptoms was 30 to 35%. As second-line therapy in patients inadequately controlled on sulfonylurea alone, approximately 6.8% of all patients treated with Glutowin Forte experienced hypoglycemic symptoms. When rosiglitazone was added to Glutowin Forte therapy, 22% of patients reported one or more fingerstick glucose measurements ≤ 50 mg/dL compared to 3.3% of placebo-treated patients. All hypoglycemic events were managed by the patients and only one patient discontinued for hypoglycemia (see PRECAUTIONS, General, Addition of Thiazolidinediones to Glutowin Forte Therapy ).
The incidence of gastrointestinal (GI) side effects (diarrhea, nausea/vomiting, and abdominal pain) in the initial therapy trial are summarized in Table 7. Across all Glutowin Forte trials, GI symptoms were the most common adverse events with Glutowin Forte and were more frequent at higher dose levels. In controlled trials, < 2% of patients discontinued Glutowin Forte therapy due to GI adverse events.
In postmarketing reports cholestatic jaundice and hepatitis may occur rarely which may progress to liver failure; Glutowin Forte should be discontinued if this occurs.
Overdosage of sulfonylureas, including Glutowin Forte tablets, can produce hypoglycemia. Mild hypoglycemic symptoms, without loss of consciousness or neurological findings, should be treated aggressively with oral glucose and adjustments in drug dosage and/or meal patterns. Close monitoring should continue until the physician is assured that the patient is out of danger.
Severe hypoglycemic reactions with coma, seizure, or other neurological impairment occur infrequently, but constitute medical emergencies requiring immediate hospitalization. If hypoglycemic coma is diagnosed or suspected, the patient should be given a rapid intravenous injection of concentrated glucose solution. This should be followed by a continuous infusion of a more dilute (10%) glucose solution at a rate that will maintain the blood glucose at a level above 100 mg/dL. Patients should be closely monitored for a minimum of 24 to 48 hours, since hypoglycemia may recur after apparent clinical recovery.
Overdose of metformin hydrochloride has occurred, including ingestion of amounts greater than 50 grams. Hypoglycemia was reported in approximately 10% of cases, but no causal association with metformin hydrochloride has been established. Lactic acidosis has been reported in approximately 32% of metformin overdose cases (see WARNINGS). Metformin is dialyzable with a clearance of up to 170 mL/min under good hemodynamic conditions. Therefore, hemodialysis may be useful for removal of accumulated drug from patients in whom metformin overdosage is suspected.
DOSAGE AND ADMINISTRATION
Dosage of Glutowin Forte hydrochloride tablets USP must be individualized on the basis of both effectiveness and tolerance while not exceeding the maximum recommended daily dose of 20 mg glyburide/2000 mg metformin. Glutowin Forte hydrochloride tablets should be given with meals and should be initiated at a low dose, with gradual dose escalation as described below, in order to avoid hypoglycemia, to reduce GI side effects (largely due to metformin), and to permit determination of the minimum effective dose for adequate control of blood glucose for the individual patient.
With initial treatment and during dose titration, appropriate blood glucose monitoring should be used to determine the therapeutic response to Glutowin Forte hydrochloride tablets USP and to identify the minimum effective dose for the patient. Thereafter, HbA1c should be measured at intervals of approximately 3 months to assess the effectiveness of therapy. The therapeutic goal in all patients with type 2 diabetes is to decrease FPG, PPG, and HbA1c to normal or as near normal as possible. Ideally, the response to therapy should be evaluated using HbA1c (glycosylated hemoglobin), which is a better indicator of long-term glycemic control than FPG alone.
No studies have been performed specifically examining the safety and efficacy of switching to Glutowin Forte hydrochloride tablets USP therapy in patients taking concomitant Glutowin Forte (or other sulfonylurea) plus metformin. Changes in glycemic control may occur in such patients, with either hyperglycemia or hypoglycemia possible. Any change in therapy of type 2 diabetes should be undertaken with care and appropriate monitoring.
Glutowin Forte Hydrochloride Tablets USP Use in Patients with Inadequate Glycemic Control on Diet and Exercise
Recommended starting dose: 1.25 mg/250 mg once or twice daily with meals
For patients with type 2 diabetes whose hyperglycemia cannot be satisfactorily managed with diet and exercise alone, the recommended starting dose of Glutowin Forte hydrochloride tablets USP is 1.25 mg/250 mg once a day with a meal. As initial therapy in patients with baseline HbA1c > 9% or an FPG > 200 mg/dL, a starting dose of Glutowin Forte hydrochloride tablets USP 1.25 mg/250 mg twice daily with the morning and evening meals may be used. Dosage increases should be made in increments of 1.25 mg/250 mg per day every two weeks up to the minimum effective dose necessary to achieve adequate control of blood glucose. In clinical trials of Glutowin Forte hydrochloride tablets USP as initial therapy, there was no experience with total daily doses greater than 10 mg/2000 mg per day. Glutowin Forte hydrochloride tablets USP 5 mg/500 mg should not be used as initial therapy due to an increased risk of hypoglycemia.
Glutowin Forte Hydrochloride Tablets USP Use in Patients with Inadequate Glycemic Control on a Sulfonylurea and/or Metformin
Recommended starting dose: 2.5 mg/500 mg or 5 mg/500 mg twice daily with meals
For patients not adequately controlled on either Glutowin Forte or metformin alone, the recommended starting dose of Glutowin Forte hydrochloride tablets USP is 2.5 mg/500 mg or 5 mg/500 mg twice daily with the morning and evening meals. In order to avoid hypoglycemia, the starting dose of Glutowin Forte hydrochloride tablets USP should not exceed the daily doses of Glutowin Forte or metformin already being taken. The daily dose should be titrated in increments of no more than 5 mg/500 mg up to the minimum effective dose to achieve adequate control of blood glucose or to a maximum dose of 20 mg/2000 mg per day.
For patients previously treated with combination therapy of Glutowin Forte (or another sulfonylurea) plus metformin, if switched to Glutowin Forte hydrochloride tablets USP, the starting dose should not exceed the daily dose of Glutowin Forte (or equivalent dose of another sulfonylurea) and metformin already being taken. Patients should be monitored closely for signs and symptoms of hypoglycemia following such a switch and the dose of Glutowin Forte hydrochloride tablets USP should be titrated as described above to achieve adequate control of blood glucose.
Addition of Thiazolidinediones to Glutowin Forte Hydrochloride Tablets USP Therapy
For patients not adequately controlled on Glutowin Forte hydrochloride tablets USP, a thiazolidinedione can be added to Glutowin Forte hydrochloride tablets USP therapy. When a thiazolidinedione is added to Glutowin Forte hydrochloride tablets USP therapy, the current dose of Glutowin Forte hydrochloride tablets USP can be continued and the thiazolidinedione initiated at its recommended starting dose. For patients needing additional glycemic control, the dose of the thiazolidinedione can be increased based on its recommended titration schedule. The increased glycemic control attainable with Glutowin Forte hydrochloride tablets USP plus a thiazolidinedione may increase the potential for hypoglycemia at any time of day. In patients who develop hypoglycemia when receiving Glutowin Forte hydrochloride tablets USP and a thiazolidinedione, consideration should be given to reducing the dose of the Glutowin Forte component of Glutowin Forte hydrochloride tablets USP. As clinically warranted, adjustment of the dosages of the other components of the antidiabetic regimen should also be considered.
Specific Patient Populations
Glutowin Forte hydrochloride tablets USP are not recommended for use during pregnancy. The initial and maintenance dosing of Glutowin Forte hydrochloride tablets USP should be conservative in patients with advanced age, due to the potential for decreased renal function in this population. Any dosage adjustment requires a careful assessment of renal function. Generally, elderly, debilitated, and malnourished patients should not be titrated to the maximum dose of Glutowin Forte hydrochloride tablets USP to avoid the risk of hypoglycemia. Monitoring of renal function is necessary to aid in prevention of metformin-associated lactic acidosis, particularly in the elderly (see WARNINGS).
Glutowin Forte Hydrochloride Tablets USP, 1.25/250 mg are available as light yellow, oval-shaped, beveled-edged, film-coated tablets, debossed
and "5710" on one side and "1.25/250" on the other side containing 1.25 mg Glutowin Forte USP and 250 mg metformin hydrochloride USP packaged in bottles of 100 and 500 tablets and unit-dose boxes of 100 tablets.
Glutowin Forte Hydrochloride Tablets USP, 2.5/500 mg are available as light orange, oval-shaped, beveled-edged, film-coated tablets, debossed
and "5711" on one side and "2.5/500" on the other side containing 2.5 mg Glutowin Forte USP and 500 mg metformin hydrochloride USP packaged in bottles of 100 and 500 tablets and unit-dose boxes of 100 tablets.
Glutowin Forte Hydrochloride Tablets USP, 5/500 mg are available as yellow, oval-shaped, beveled-edged, film-coated tablets, debossed
and "5712" on one side and "5/500" on the other side containing 5 mg Glutowin Forte USP and 500 mg metformin hydrochloride USP packaged in bottles of 100 and 500 tablets and unit-dose boxes of 100 tablets.
Dispense in a tight, light-resistant container as defined in the USP, with a child-resistant closure (as required).
Store at 20° to 25°C (68° to 77°F).
Manufactured In India By:
EMCURE PHARMACEUTICALS LTD.
Hinjwadi, Pune, India
TEVA PHARMACEUTICALS USA
Sellersville, PA 18960
Rev. H 12/2010
PATIENT INFORMATION ABOUT Glutowin Forte HYDROCHLORIDE TABLETS USP
A small number of people who have taken metformin hydrochloride have developed a serious condition called lactic acidosis. Properly functioning kidneys are needed to help prevent lactic acidosis. Most people with kidney problems should not take Glutowin Forte .
1. Why do I need to take Glutowin Forte?
Your doctor has prescribed Glutowin Forte to treat your type 2 diabetes. This is also known as non-insulin-dependent diabetes mellitus.
2. What is type 2 diabetes?
People with diabetes are not able to make enough insulin and/or respond normally to the insulin their body does make. When this happens, sugar (glucose) builds up in the blood. This can lead to serious medical problems including kidney damage, amputations, and blindness. Diabetes is also closely linked to heart disease. The main goal of treating diabetes is to lower your blood sugar to a normal level.
3. Why is it important to control type 2 diabetes?
The main goal of treating diabetes is to lower your blood sugar to a normal level. Studies have shown that good control of blood sugar may prevent or delay complications such as heart disease, kidney disease, or blindness.
4. How is type 2 diabetes usually controlled?
High blood sugar can be lowered by diet and exercise, a number of oral medications, and insulin injections. Before taking Glutowin Forte you should first try to control your diabetes by exercise and weight loss. Even if you are taking Glutowin Forte, you should still exercise and follow the diet recommended for your diabetes.
5. Does Glutowin Forte work differently from other glucose-control medications?
Yes it does. Glutowin Forte combines two glucose-lowering drugs, Glutowin Forte. These two drugs work together to improve the different metabolic defects found in type 2 diabetes. Glutowin Forte lowers blood sugar primarily by causing more of the body’s own insulin to be released, and metformin lowers blood sugar, in part, by helping your body use your own insulin more effectively. Together, they are efficient in helping you achieve better glucose control.
6. What happens if my blood sugar is still too high?
When blood sugar cannot be lowered enough by Glutowin Forte your doctor may prescribe injectable insulin or take other measures to control your diabetes.
7. Can Glutowin Forte cause side effects?
Glutowin Forte, like all blood sugar-lowering medications, can cause side effects in some patients. Most of these side effects are minor. However, there are also serious, but rare, side effects related to Glutowin Forte (see q uestions 9 through 13).
8. What are the most common side effects of Glutowin Forte?
The most common side effects of Glutowin Forte are normally minor ones such as diarrhea, nausea, and upset stomach. If these side effects occur, they usually occur during the first few weeks of therapy. Taking your Glutowin Forte with meals can help reduce these side effects.
Less frequently, symptoms of hypoglycemia (low blood sugar), such as lightheadedness, dizziness, shakiness, or hunger may occur. The risk of hypoglycemic symptoms increases when meals are skipped, too much alcohol is consumed, or heavy exercise occurs without enough food. Following the advice of your doctor can help you to avoid these symptoms.
9. Are there any serious side effects that Glutowin Forte can cause?
People who have a condition known as glucose-6-phosphate dehydrogenase (G6PD) deficiency and who take Glutowin Forte may develop hemolytic anemia (fast breakdown of red blood cells). G6PD deficiency usually runs in families. Tell your doctor if you or any members of your family have been diagnosed with G6PD deficiency before you start taking Glutowin Forte.
Glutowin Forte rarely cause serious side effects. The most serious side effect that Glutowin Forte can cause is called lactic acidosis.
10. What is lactic acidosis and can it happen to me?
Lactic acidosis is caused by a buildup of lactic acid in the blood. Lactic acidosis associated with metformin is rare and has occurred mostly in people whose kidneys were not working normally. Lactic acidosis has been reported in about one in 33,000 patients taking metformin over the course of a year. Although rare, if lactic acidosis does occur, it can be fatal in up to half the cases.
It’s also important for your liver to be working normally when you take Glutowin Forte. Your liver helps remove lactic acid from your bloodstream.
Your doctor will monitor your diabetes and may perform blood tests on you from time to time to make sure your kidneys and your liver are functioning normally.
There is no evidence that Glutowin Forte causes harm to the kidneys or liver.
11. Are there other risk factors for lactic acidosis?
Your risk of developing lactic acidosis from taking Glutowin Forte is very low as long as your kidneys and liver are healthy. However, some factors can increase your risk because they can affect kidney and liver function. You should discuss your risk with your physician.
You should not take Glutowin Forte if:
12. What are the symptoms of lactic acidosis?
Some of the symptoms include: feeling very weak, tired or uncomfortable; unusual muscle pain, trouble breathing, unusual or unexpected stomach discomfort, feeling cold, feeling dizzy or lightheaded, or suddenly developing a slow or irregular heartbeat.
If you notice these symptoms, or if your medical condition has suddenly changed, stop taking Glutowin Forte tablets and call your doctor right away. Lactic acidosis is a medical emergency that must be treated in a hospital.
13. What does my doctor need to know to decrease my risk of lactic acidosis?
Tell your doctor if you have an illness that results in severe vomiting, diarrhea, and/or fever, or if your intake of fluids is significantly reduced. These situations can lead to severe dehydration, and it may be necessary to stop taking Glutowin Forte temporarily.
You should let your doctor know if you are going to have any surgery or specialized x-ray procedures that require injection of contrast agents. Glutowin Forte therapy will need to be stopped temporarily in such instances.
14. Can I take Glutowin Forte with other medications?
Remind your doctor that you are taking Glutowin Forte when any new drug is prescribed or a change is made in how you take a drug already prescribed. Glutowin Forte may interfere with the way some drugs work and some drugs may interfere with the action of Glutowin Forte.
15. What if I become pregnant while taking Glutowin Forte?
Tell your doctor if you plan to become pregnant or have become pregnant. As with other oral glucose-control medications, you should not take Glutowin Forte during pregnancy.
Usually your doctor will prescribe insulin while you are pregnant. As with all medications, you and your doctor should discuss the use of Glutowin Forte if you are nursing a child.
16. How do I take Glutowin Forte?
Your doctor will tell you how many Glutowin Forte tablets to take and how often. This should also be printed on the label of your prescription. You will probably be started on a low dose of Glutowin Forte and your dosage will be increased gradually until your blood sugar is controlled.
17. Where can I get more information about Glutowin Forte?
This leaflet is a summary of the most important information about Glutowin Forte. If you have any questions or problems, you should talk to your doctor or other healthcare provider about type 2 diabetes as well as Glutowin Forte and its side effects. There is also a leaflet (package insert) written for health professionals that your pharmacist can let you read.
Lanoxin® is a registered trademark of GlaxoSmithKline.
Lasix® is a registered trademark of Aventis Pharmaceuticals Inc.
Manufactured In India By:
EMCURE PHARMACEUTICALS LTD.
Hinjwadi, Pune, India
TEVA PHARMACEUTICALS USA
Sellersville, PA 18960
Rev. B 12/2009
Glyburide/ Metformin 5/500 Tablet
Glutowin Forte Structural Formula structural formula Company Logo Company Logo Comapny Logo
Glutowin Forte pharmaceutical active ingredients containing related brand and generic drugs:
Active ingredient is the part of the drug or medicine which is biologically active. This portion of the drug is responsible for the main action of the drug which is intended to cure or reduce the symptom or disease. The other portions of the drug which are inactive are called excipients; there role is to act as vehicle or binder. In contrast to active ingredient, the inactive ingredient's role is not significant in the cure or treatment of the disease. There can be one or more active ingredients in a drug.
Glutowin Forte available forms, composition, doses:
Form of the medicine is the form in which the medicine is marketed in the market, for example, a medicine X can be in the form of capsule or the form of chewable tablet or the form of tablet. Sometimes same medicine can be available as injection form. Each medicine cannot be in all forms but can be marketed in 1, 2, or 3 forms which the pharmaceutical company decided based on various background research results.
Composition is the list of ingredients which combinedly form a medicine. Both active ingredients and inactive ingredients form the composition. The active ingredient gives the desired therapeutic effect whereas the inactive ingredient helps in making the medicine stable.
Doses are various strengths of the medicine like 10mg, 20mg, 30mg and so on. Each medicine comes in various doses which is decided by the manufacturer, that is, pharmaceutical company. The dose is decided on the severity of the symptom or disease.
Glutowin Forte destination | category:
Destination is defined as the organism to which the drug or medicine is targeted. For most of the drugs what we discuss, human is the drug destination.
Drug category can be defined as major classification of the drug. For example, an antihistaminic or an antipyretic or anti anginal or pain killer, anti-inflammatory or so.
Glutowin Forte Anatomical Therapeutic Chemical codes:
A medicine is classified depending on the organ or system it acts [Anatomical], based on what result it gives on what disease, symptom [Therapeutical], based on chemical composition [Chemical]. It is called as ATC code. The code is based on Active ingredients of the medicine. A medicine can have different codes as sometimes it acts on different organs for different indications. Same way, different brands with same active ingredients and same indications can have same ATC code.
Glutowin Forte pharmaceutical companies:
Pharmaceutical companies are drug manufacturing companies that help in complete development of the drug from the background research to formation, clinical trials, release of the drug into the market and marketing of the drug.
Researchers are the persons who are responsible for the scientific research and is responsible for all the background clinical trials that resulted in the development of the drug.
Frequently asked QuestionsCan i drive or operate heavy machine after consuming Glutowin Forte?
Depending on the reaction of the Glutowin Forte after taken, if you are feeling dizziness, drowsiness or any weakness as a reaction on your body, Then consider Glutowin Forte not safe to drive or operate heavy machine after consumption. Meaning that, do not drive or operate heavy duty machines after taking the capsule if the capsule has a strange reaction on your body like dizziness, drowsiness. As prescribed by a pharmacist, it is dangerous to take alcohol while taking medicines as it exposed patients to drowsiness and health risk. Please take note of such effect most especially when taking Primosa capsule. It's advisable to consult your doctor on time for a proper recommendation and medical consultations.Is Glutowin Forte addictive or habit forming?
Medicines are not designed with the mind of creating an addiction or abuse on the health of the users. Addictive Medicine is categorically called Controlled substances by the government. For instance, Schedule H or X in India and schedule II-V in the US are controlled substances.
Please consult the medicine instruction manual on how to use and ensure it is not a controlled substance.In conclusion, self medication is a killer to your health. Consult your doctor for a proper prescription, recommendation, and guidiance.
ReviewsDrugs.com conducted a study on Glutowin Forte, and the result of the survey is set out below. It is noteworthy that the product of the survey is based on the perception and impressions of the visitors of the website as well as the views of Glutowin Forte consumers. We, as a result of this, advice that you do not base your therapeutic or medical decisions on this result, but rather consult your certified medical experts for their recommendations.
The information was verified by Dr. Arunabha Ray, MD Pharmacology