Trajenta Duo Special Precautions

General: Linagliptin + Metformin HCl (Trajenta Duo) should not be used in patients with type 1 diabetes.
Pancreatitis: Acute pancreatitis has been observed in patients taking linagliptin.
If pancreatitis is suspected, Linagliptin + Metformin HCl (Trajenta Duo) should be discontinued.
Hypoglycaemia: Linagliptin alone showed a comparable incidence of hypoglycaemia to placebo. In clinical trials of linagliptin as part of combination therapy with agents not considered to cause hypoglycaemia (metformin, thiazolidinediones) rates of hypoglycaemia reported with linagliptin were similar to rates in patients taking placebo.
Sulphonylureas are known to cause hypoglycaemia. Therefore, caution is advised when Linagliptin + Metformin HCl (Trajenta Duo) is used in combination with a sulphonylurea. A dose reduction of the sulphonylurea may be considered.
Insulin is known to cause hypoglycaemia. Therefore, caution is advised when Linagliptin + Metformin HCl (Trajenta Duo) is used in combination with insulin. A dose reduction of insulin may be considered.
Metformin alone does not cause hypoglycaemia under usual circumstances of use, but hypoglycaemia could occur when caloric intake is deficient, when strenuous exercise is not compensated by caloric supplementation, or during concomitant use with other glucose-lowering agents (such as sulphonylureas and insulin) or ethanol.
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 Contraindications and Interactions).
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 agent: Intravascular administration of iodinated contrast agents may lead to contrast induced nephropathy, resulting in metformin accumulation and an 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 Renal impairment under Dosage & Administration and Interactions.
Renal function: GFR should be assessed before treatment initiation and regularly thereafter, see Dosage & Administration. Linagliptin + Metformin HCl (Trajenta Duo) is contraindicated in patients with GFR<30 ml/min and should be temporarily discontinued in the presence of conditions that alter renal function, see Contraindications.
Cardiac function: Patients with heart failure are more at risk of hypoxia and renal insufficiency. In patients with stable chronic heart failure, Linagliptin + Metformin HCl (Trajenta Duo) may be used with a regular monitoring of cardiac and renal function.
For patients with acute and unstable heart failure, Linagliptin + Metformin HCl (Trajenta Duo) is contraindicated due to the metformin component (see Contraindications).
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.
Bullous pemphigoid: Bullous pemphigoid has been observed in patients taking linagliptin.
If bullous pemphigoid is suspected, Linagliptin + Metformin HCl (Trajenta Duo) should be discontinued.
Vitamin B12: The risk of low vitamin B12 levels increases with increasing metformin dose, treatment duration, and/or in patients with risk factors known to cause vitamin B12 deficiency. In case of suspicion of vitamin B12 deficiency (such as anaemia or neuropathy), vitamin B12 serum levels should be monitored. Periodic vitamin B12 monitoring could be necessary in patients with risk factors for vitamin B12 deficiency. Metformin therapy should be continued for as long as it is tolerated and not contra-indicated and appropriate corrective treatment for vitamin B12 deficiency provided in line with current clinical guidelines.
Driving and Using Machines: No studies on the effects on the ability to drive and use machines have been performed.