Pharmacotherapeutic group: SGLT2 Inhibitor.
ATC code: A10BK03.
Pharmacology: Mode of action: Empagliflozin is a reversible, highly potent and selective competitive inhibitor of SGLT2 with an IC50 of 1.3 nM. It has a 5000-fold selectivity over human SGLT1 (IC50 of 6278 nM), responsible for glucose absorption in the gut. Furthermore high selectivity could be shown toward other glucose transporters (GLUTs) responsible for glucose homeostasis in the different tissues.
SGLT-2 is highly expressed in the kidney, whereas expression in other tissues is absent or very low. It is responsible as the predominant transporter for reabsorption of glucose from the glomerular filtrate back into the circulation. In patients with type 2 diabetes mellitus (T2DM) and hyperglycaemia a higher amount of glucose is filtered and reabsorbed.
Empagliflozin improves glycaemic control in patients with T2DM by reducing renal glucose reabsorption. The amount of glucose removed by the kidney through this glucuretic mechanism is dependent upon the blood glucose concentration and GFR. Through inhibition of SGLT-2 in patients with T2DM and hyperglycaemia, excess glucose is excreted in the urine.
In patients with T2DM, urinary glucose excretion increased immediately following the first dose of empagliflozin and is continuous over the 24 hour dosing interval. Increased urinary glucose excretion was maintained at the end of 4-week treatment period, averaging approximately 78 g/day with empagliflozin 25 mg once daily. Increased urinary glucose excretion resulted in an immediate reduction in plasma glucose levels in patients with T2DM.
Empagliflozin (10 mg and 25 mg) improves both fasting and post-prandial plasma glucose levels. The mechanism of action of empagliflozin is independent of beta cell function and insulin pathway, and this contributes to a low risk of hypoglycaemia. Improvement of surrogate markers of beta cell function including Homeostasis Model Assessment-B (HOMA-β) and proinsulin to insulin ratio were noted. In addition urinary glucose excretion triggers calorie loss, associated with body fat loss and body weight reduction.
The glucosuria observed with empagliflozin is accompanied by mild diuresis which may contribute to sustained and moderate reduction of blood pressure.
Empagliflozin also reduces sodium reabsorption and increases the delivery of sodium to the distal tubule. This may influence several physiological functions including, but not restricted to, increasing tubuloglomerular feedback and reducing intraglomerular pressure, lowering both pre- and afterload of the heart, downregulating sympathetic activity and reducing left ventricular wall stress as evidenced by lower NT-proBNP values which may have beneficial effects on cardiac remodeling, filling pressures and diastolic function
as well as preserving kidney structure and function. Other effects such as an increase in haematocrit, a reduction in body weight and blood pressure may further contribute to the beneficial
cardiac and renal effects.
Clinical Trials: Type 2 diabetes mellitus: A total of 17331 patients with type 2 diabetes were evaluated in 15 double-blind, placebo- and active-controlled clinical studies, of which 4603 patients received empagliflozin 10 mg and 5567 received empagliflozin 25 mg. Six studies had a treatment duration of 24 weeks; in extensions of applicable studies, and other trials, patients were exposed to JARDIANCE for up to 102 weeks.
Treatment with empagliflozin (10 mg and 25 mg) as monotherapy and in combination with metformin, pioglitazone, sulfonylurea, DPP-4 inhibitors, and insulin lead to clinically relevant improvements in HbA
1c, fasting plasma glucose (FPG), body weight, systolic and diastolic blood pressure (SBP and DBP, respectively). Administration of empagliflozin 25 mg resulted in a higher proportion of patients achieving an HbA
1c goal of less than 7% and fewer patients needing glycaemic rescue compared to empagliflozin 10 mg and placebo. There was a clinically meaningful improvement in HbA
1c in all subgroups of gender, race, geographic region, time since diagnosis of T2DM, body mass index, insulin resistance based on HOMA-IR, and beta cell function based on HOMA-β. Higher baseline HbA
1c was associated with a greater reduction in HbA
1c. Clinically meaningful HbA
1c reduction was seen for patients with eGFR
>30 mL/min/1.73m2 (see Dosage & Administration and
Precautions). In patients aged 75 years and older, reduced efficacy of JARDIANCE was observed.
Empagliflozin as monotherapy: The efficacy and safety of empagliflozin (10 mg and 25 mg) as monotherapy was evaluated in a double-blind, placebo- and active-controlled study of 24 weeks duration in treatment-naïve patients. Treatment with JARDIANCE resulted in statistically significant reductions in HbA
1c, body weight and SBP compared to placebo (Table 1) and a clinically meaningful decrease in FPG. A numerical decrease in DPB was seen but did not reach statistical significance versus placebo (-1.0 mmHg for empagliflozin 10 mg, -1.9 mmHg for empagliflozin 25 mg, -0.5 for placebo, and +0.7 mmHg for sitagliptin).
In a prespecified analysis of patients (N=201) with a baseline HbA
1c ≥8.5%, treatment resulted in a reduction in HbA
1c from baseline of -1.44% for empagliflozin 10 mg, -1.43% for empagliflozin 25 mg, -1.04% for sitagliptin and an increase of 0.01% for placebo.
In the double-blind placebo-controlled extension of this study, reductions of HbA
1c (change from baseline of -0.65% for empagliflozin 10 mg, -0.76% for empagliflozin 25 mg, +0.13% for placebo, and -0.53% for sitagliptin), body weight (change from baseline of -2.24 kg for empagliflozin 10 mg, -2.45 kg for empagliflozin 25 mg, -0.43 kg for placebo, and +0.10 kg for sitagliptin) and blood pressure (SBP: change from baseline of, -4.1 mmHg for empagliflozin 10 mg, -4.2 mmHg for empagliflozin 25 mg, -0.7 mmHg for placebo, and -0.3 mmHg for sitagliptin, DBP: change from baseline of -1.6 mmHg for empagliflozin 10 mg, -1.6 mmHg for empagliflozin 25 mg, -0.6 mmHg for placebo, and -0.1 mmHg for sitagliptin) were sustained up to Week 76.
Treatment with Jardiance daily significantly improved markers of beta cell function, including HOMA-β and proinsulin to insulin ratio. (See Table 1.)
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Empagliflozin as add on to metformin therapy: A double-blind, placebo-controlled study of 24 weeks duration was conducted to evaluate the efficacy and safety of empagliflozin in patients not sufficiently treated with metformin. Treatment with JARDIANCE resulted in statistically significant improvements in HbA
1c and body weight, and clinically meaningful reductions in FPG and blood pressure compared to placebo (Table 2).
In the double-blind placebo-controlled extension of this study, reductions of HbA
1c (change from baseline of -0.62% for empagliflozin 10 mg, -0.74% for empagliflozin 25 mg and -0.01% for placebo), body weight (change from baseline of -2.39 kg for empagliflozin 10 mg, -2.65 kg for empagliflozin 25 mg and -0.46 kg for placebo) and blood pressure (SBP: change from baseline of -5.2 mmHg for empagliflozin 10 mg, -4.5 mmHg for empagliflozin 25 mg and -0.8 mmHg for placebo, DBP: change from baseline of -2.5 mmHg for empagliflozin 10 mg, -1.9 mmHg for empagliflozin 25 mg and -0.5 mmHg for placebo) were sustained up to Week 76. (See Table 2.)
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Empagliflozin and metformin combination therapy in drug-naïve patients: A factorial design study of 24 weeks duration was conducted to evaluate the efficacy and safety of empagliflozin in drug-naïve patients. Treatment with empagliflozin in combination with metformin (5 mg and 500 mg; 5 mg and 1000 mg; 12.5 mg and 500 mg, and 12.5 mg and 1000 mg given twice daily) provided statistically significant improvements in HbA
1c and led to significantly greater reductions in FPG and body weight compared to the individual components. A greater proportion of patients with a baseline HbA
1c ≥7.0% and treated with empagliflozin in combination with metformin achieved a target HbA
1c <7% compared to the individual components (Tables 3 and 4). (See Tables 3 and 4.)
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Empagliflozin as add on to a combination of metformin and sulphonylurea therapy: A double-blind, placebo-controlled study of 24 weeks duration was conducted to evaluate the efficacy and safety of empagliflozin in patients not sufficiently treated with a combination of metformin and a sulphonylurea. Treatment with JARDIANCE resulted in statistically significant improvements in HbA
1c and body weight and clinically meaningful reductions in FPG and blood pressure compared to placebo (Table 5).
In the double-blind placebo-controlled extension of this study, reductions of HbA
1c (change from baseline of -0.74% for empagliflozin 10 mg, -0.72% for empagliflozin 25 mg and -0.03% for placebo), body weight (change from baseline of -2.44 kg for empagliflozin 10 mg, -2.28 kg for empagliflozin 25 mg and -0.63 kg for placebo) and blood pressure (SBP: change from baseline of -3.8 mmHg for empagliflozin 10 mg, -3.7 mmHg for empagliflozin 25 mg and -1.6 mmHg for placebo, DBP: change from baseline of -2.6 mmHg for empagliflozin 10 mg, -2.3 mmHg for empagliflozin 25 mg and -1.4 mmHg for placebo) were sustained up to Week 76. (See Table 5.)
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Empagliflozin as add on to a combination of pioglitazone therapy (+/- metformin): The efficacy and safety of empagliflozin was evaluated in a double-blind, placebo-controlled study of 24 weeks duration in patients not sufficiently treated with a combination of metformin and pioglitazone or pioglitazone alone. Empagliflozin in combination with pioglitazone (mean dose ≥30 mg) with or without metformin resulted in statistically significant reductions in HbA
1c, FPG, and body weight and clinically meaningful reductions in blood pressure compared to placebo (Table 6).
In the double-blind placebo-controlled extension of this study, reductions of HbA
1c (change from baseline of -0.61% for empagliflozin 10 mg, -0.70% for empagliflozin 25 mg and -0.01% for placebo), body weight (change from baseline of -1.47 kg for empagliflozin 10 mg, -1.21 kg for empagliflozin 25 mg and +0.50 kg for placebo) and blood pressure (SBP: change from baseline of -1.7 mmHg for empagliflozin 10 mg, -3.4 mmHg for empagliflozin 25 mg and +0.3 mmHg for placebo, DBP: change from baseline of -1.3 mmHg for empagliflozin 10 mg, -2.0 mmHg for empagliflozin 25 mg and +0.2 mmHg for placebo) were sustained up to Week 76. (See Table 6.)
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Empagliflozin and linagliptin in treatment naïve patients: After 24-weeks treatment, empagliflozin 25 mg/linagliptin 5 mg in treatment-naïve patients provided statistically significant improvement in A1C compared to linagliptin 5 mg but there was no statistically significant difference between the FDC empagliflozin 25 mg/linagliptin 5 mg and empagliflozin 25 mg (Table 7). Compared to linagliptin 5 mg, both doses of the empagliflozin/linagliptin FDC provided statistically relevant improvements in body weight. After 24 weeks' treatment with empagliflozin/linagliptin, both SBPs and DBPs were reduced, -2.9/-1.1 mmHg (n.s. versus linagliptin 5 mg for SBP and DBP) for empagliflozin 25 mg/linagliptin 5 mg and -3.6/-0.7 mmHg (p<0.05 versus linagliptin 5 mg for SBP, n.s. for DBP) for empagliflozin 10 mg/linagliptin 5 mg. Rescue therapy was used in 2 (1.5%) patients treated with empagliflozin 25 mg/linagliptin 5 mg and in 1 (0.7%) patient treated with empagliflozin 10 mg/linagliptin 5 mg compared to 11 (8.3%) patients treated with linagliptin 5 mg, 1 (0.8%) patients treated with empagliflozin 25 mg and 4 (3.0%) patients treated with empagliflozin 10 mg. Clinically meaningful reductions in HbA
1c (Table 7) and SBPs were observed at week 52, -2.0 mmHg (n.s. versus linagliptin 5 mg) for empagliflozin 25 mg/linagliptin 5 mg and -1.7 mmHg (n.s. versus linagliptin 5 mg) for empagliflozin 10 mg/linagliptin 5 mg. (See Table 7.)
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In a prespecified subgroup of patients with baseline HbA
1c greater or equal than 8.5% the reduction from baseline in HbA
1c with empagliflozin 25 mg/linagliptin 5 mg was -1.9% at 24 weeks (p<0.0001 versus linagliptin 5 mg, n.s. versus empagliflozin 25 mg) and -2.0% at 52 weeks (p<0.0001 versus linagliptin 5 mg, p<0.05 versus empagliflozin 25 mg) and with empagliflozin 10 mg/linagliptin 5 mg -1.9% at 24 weeks (p<0.0001 versus linagliptin 5 mg, p<0.05 versus empagliflozin 10 mg) and -2.0% at 52 weeks (p<0.0001 versus linagliptin 5 mg, p<0.05 versus empagliflozin 10 mg).
Empagliflozin and linagliptin as add-on therapy to metformin: In patients inadequately controlled on metformin 24-weeks treatment with both doses of the empagliflozin/linagliptin FDC provided statistically significant improvements in HbA
1c and FPG compared to linagliptin 5 mg and also compared to empagliflozin 10 or 25 mg. Compared to linagliptin 5 mg, both doses of the empagliflozin/linagliptin FDC provided statistically significant improvements in body weight.
A greater proportion of patients with a baseline HbA
1c ≥7.0% and treated with the empagliflozin/linagliptin FDC achieved a target HbA
1c of <7% compared to the individual components (Table 8).
After 24 weeks' treatment with empagliflozin/linagliptin, both SBPs and DBPs were reduced, -5.6/-3.6 mmHg (p<0.001 versus linagliptin 5 mg for SBP and DBP) for empagliflozin 25 mg/linagliptin 5 mg and -4.1/-2.6 mmHg (p<0.05 versus linagliptin 5 mg for SBP, n.s. for DBP) for empagliflozin 10 mg/linagliptin 5 mg. Clinically meaningful reductions in HbA
1c (Table 8) and both SBPs and DBPs were observed at week 52, -3.8/-1.6 mmHg (p<0.05 versus linagliptin 5 mg for SBP and DBP) for empagliflozin 25 mg/linagliptin 5 mg and -3.1/-1.6 mmHg (p<0.05 versus linagliptin 5 mg for SBP, n.s. for DBP) for empagliflozin 10 mg/linagliptin 5 mg.
After 24 weeks, rescue therapy was used in 1 (0.7%) patient treated with empagliflozin 25 mg/linagliptin 5 mg and in 3 (2.2%) patients treated with empagliflozin 10 mg/linagliptin 5 mg, compared to 4 (3.1%) patients treated with linagliptin 5 mg and 6 (4.3%) patients treated with empagliflozin 25 mg and 1 (0.7%) patient treated with empagliflozin 10 mg. (See Table 8.)
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In a prespecified subgroup of patients with baseline HbA
1c greater or equal than 8.5% the reduction from baseline in HbA
1c with empagliflozin 25 mg/linagliptin 5 mg was -1.8% at 24 weeks (p<0.0001 versus linagliptin 5 mg, p<0.001 versus empagliflozin 25 mg) and -1.8% at 52 weeks (p<0.0001 versus linagliptin 5 mg, p<0.05 versus empagliflozin 25 mg) and with empagliflozin 10 mg/5 mg linagliptin -1.6% at 24 weeks (p<0.01 versus linagliptin 5 mg, n.s. versus empagliflozin 10 mg) and -1.5% at 52 weeks (p<0.01 versus linagliptin 5 mg, n.s. versus empagliflozin 10 mg).
Empagliflozin vs. placebo in patients inadequately controlled on metformin and linagliptin: In patients inadequately controlled on metformin and linagliptin, 24-weeks treatment with both doses (10 mg and 25 mg) of empagliflozin provided statistically significant improvements in HbA
1c, FPG and body weight compared to placebo (background linagliptin 5 mg). A statistically significant greater number of patients with a baseline HbA
1c ≥7.0% and treated with empagliflozin achieved a target HbA
1c of <7% compared to placebo (background linagliptin 5 mg) (Table 9). After 24 weeks' treatment with empagliflozin, both SBPs and DBPs were reduced, -2.6/-1.1 mmHg (n.s. versus placebo for SBP and DBP) for empagliflozin 25 mg/linagliptin 5 mg and -1.3/-0.1 mmHg (n.s. versus placebo for SBP and DBP) for empagliflozin 10 mg/linagliptin 5 mg.
After 24 weeks, rescue therapy was used in 4 (3.6%) patients treated with empagliflozin 25 mg/linagliptin 5 mg and in 2 (1.8%) patients treated with empagliflozin 10 mg/linagliptin 5 mg, compared to 13 (12.0%) patients treated with placebo (background linagliptin 5 mg). (See Table 9.)
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In a prespecified subgroup of patients with baseline HbA
1c greater or equal than 8.5% the reduction from baseline in HbA
1c with empagliflozin 25 mg/linagliptin 5 mg was -1.3% at 24 weeks (p<0.0001 versus placebo [background linagliptin 5 mg]) and with empagliflozin 10 mg/linagliptin 5 mg -1.3% at 24 weeks (p<0.0001 versus placebo [background linagliptin 5 mg]).
Empagliflozin 2 years data, as add on to metformin in comparison to glimepiride: In a study comparing the efficacy and safety of empagliflozin 25 mg versus glimepiride (4 mg) in patients with inadequate glycaemic control on metformin alone, treatment with empagliflozin 25 mg daily resulted in superior reduction in HbA
1c, and a clinically meaningful reduction in FPG, compared to glimepiride (Table 10). Empagliflozin 25 mg daily resulted in a statistically significant reduction in body weight, systolic and diastolic blood pressure (change from baseline in DBP of -1.8 mmHg for empagliflozin and +0.9 mmHg for glimepiride, p<0.0001).
Treatment with empagliflozin 25 mg daily resulted in statistically significantly lower proportion of patients with hypoglycemic events compared to glimepiride (2.5% for empagliflozin 25 mg, 24, 2% for glimepiride, p<0.0001). (See Table 10.)
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Empagliflozin as add on to MDI insulin therapy and metformin: The efficacy and safety of empagliflozin as add-on to multiple daily insulin with or without concomitant metformin therapy (71.0% of all patients were on metformin background) was evaluated in a double-blind, placebo-controlled trial of 52 weeks duration. During the initial 18 weeks and the last 12 weeks, the insulin dose was to be kept stable, but was adjusted to achieve pre-prandial glucose levels <100 mg/dl [5.5 mmol/L], and post-prandial glucose levels <140 mg/dl [7.8 mmol/L] between Weeks 19 and 40.
At Week 18, empagliflozin provided statistically significant improvement in HbA
1c compared with placebo (Table 11). A greater proportion of patients with a baseline HbA
1c ≥7.0% (19.5% empagliflozin 10 mg, 31.0% empagliflozin 25 mg) achieved a target HbA
1c of <7% compared with placebo (15.1%).
At Week 52, treatment with empagliflozin resulted in a statistically significant decrease in HbA
1c and insulin sparing compared with placebo and a reduction in FPG (change from baseline of -0.3 mg/dl [-0.02 mmol/L] for placebo, -19.7 mg/dl [-1.09 mmol/L] for empagliflozin 10 mg, and -23.7 mg/dl [-1.31 mmol/L] for empagliflozin 25 mg), body weight, and blood pressure (SBP: change from baseline of -2.6 mmHg for placebo, -3.9 mmHg for empagliflozin 10 mg and -4.0 mmHg for empagliflozin 25 mg, DBP: change from baseline of -1.0 mmHg for placebo, -1.4 mmHg for empagliflozin 10 mg and -2.6 mmHg for empagliflozin 25 mg). (See Table 11.)
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Empagliflozin as add on to basal insulin therapy: The efficacy and safety of empagliflozin (10 mg or 25 mg) as add on to basal insulin with or without concomitant metformin and/or sulfonylurea therapy was evaluated in a double-blind, placebo-controlled trial of 78 weeks duration. During the initial 18 weeks the insulin dose was kept stable, but was adjusted to achieve a FPG <110 mg/dL in the following 60 weeks.
At week 18, empagliflozin (10 mg or 25 mg) provided statistically significant improvement in HbA
1c compared to placebo. A greater proportion of patients with a baseline HbA
1c ≥7.0% achieved a target HbA
1c of <7% compared to placebo. At 78 weeks, empagliflozin resulted in a statistically significant decrease in HbA
1c and insulin sparing compared to placebo (Table 12).
At week 78, empagliflozin resulted in a reduction in FPG -10.51 mg/dl [-0.58 mmol/l] for empagliflozin 10 mg, -17.43 mg/dL [0.3 mmol/L] for empagliflozin 25 mg and -5.48 mg/dL [-0.97 mmol/L] for placebo), body weight (-2.47 kg for empagliflozin 10 mg, -1.96 kg for empagliflozin 25 mg and +1.16 kg for placebo, p<0.0001), blood pressure (SBP: -4.1 mmHg for empagliflozin 10 mg, -2.4 mmHg for empagliflozin 25 mg and +0.1 mmHg for placebo, DPB: -2.9 mmHg for empagliflozin 10 mg, -1.5 mmHg for empagliflozin 25 mg and -0.3 mmHg for placebo). (See Table 12.)
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Empagliflozin as add on to dipeptidyl peptidase 4 (DPP-4) inhibitor therapy: The efficacy and safety of empagliflozin as add on to DPP-4 inhibitors plus metformin, with or without one additional oral antidiabetes drug was evaluated in 160 patients with high cardiovascular risk. Treatment with empagliflozin for 28 weeks reduced HbA
1c compared to placebo (change from baseline -0.52% for empagliflozin and -0.02% for placebo).
Patients with renal impairment, 52 week placebo controlled data: The efficacy and safety of empagliflozin as add on to antidiabetic therapy was evaluated in patients with mild and moderate renal impairment in a double-blind, placebo-controlled study for 52 weeks.
Treatment with JARDIANCE led to statistically significant reduction of HbA
1c and clinically meaningful improvement in FPG (fasting plasma glucose), body weight and blood pressure compared to placebo at Week 24 (Table 13). The improvement in HbA
1c, FPG, body weight, and blood pressure was sustained up to 52 weeks. (See Table 13.)
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2 hour post-prandial glucose: Treatment with empagliflozin (10 mg or 25 mg) as add-on to metformin or metformin plus sulfonylurea resulted in clinically meaningful improvement of 2-hour post-prandial glucose (meal tolerance test) at 24 weeks (add-on to metformin, placebo +5.9 mg/dL, empagliflozin 10 mg -46.0 mg/dL, empagliflozin 25 mg -44.6 mg/dL; add-on to metformin plus sulphonylurea, placebo -2.3 mg/dL, empagliflozin 10 mg -35.7 mg/dL, empagliflozin 25 mg (n=46): -36.6 mg/dL).
Patients with high baseline HbA
1c >10%: In a pre-specified pooled analysis of three phase 3 studies, treatment with open-label empagliflozin 25 mg in patients with severe hyperglycaemia (N=184, mean baseline HbA
1c 11.15%) resulted in a clinically meaningful reduction in HbA
1c from baseline (-3.27%) at week 24.
Body weight: In a pre-specified pooled analysis of 4 placebo controlled studies, treatment with empagliflozin resulted in body weight reduction compared to placebo at week 24 (-2.04 kg for empagliflozin 10 mg, -2.26 kg for empagliflozin 25 mg and -0.24 kg for placebo) that was maintained up to week 52 (-1.96 kg for empagliflozin 10 mg, -2.25 kg for empagliflozin 25 mg and -0.16 kg for placebo).
Waist circumference: Treatment with empagliflozin as monotherapy or as add-on to metformin, pioglitazone, or metformin plus sulphonylurea resulted in sustained reduction of waist circumference over the duration of studies in a range of -1.7 cm to -0.9 cm for empagliflozin and -0.5 cm to +0.2 cm for placebo.
Blood pressure: The efficacy and safety of empagliflozin (10 mg or 25 mg) was evaluated in a double-blind, placebo controlled study of 12 weeks duration in patients with type 2 diabetes and high blood pressure on different antidiabetic and up to 2 antihypertensive therapies (Table 14). Treatment with empagliflozin once daily resulted in statistically significant improvement in HbA
1c, 24 hour mean systolic and diastolic blood pressure as determined by ambulatory blood pressure monitoring. Treatment with empagliflozin provided reductions in seated SBP (change from baseline of -0.67 mmHg for placebo, -4.60 mmHg for empagliflozin 10 mg and -5.47 mmHg for empagliflozin 25 mg) and seated DBP (change from baseline of -1.13 mmHg for placebo, -3.06 mmHg for empagliflozin 10 mg and -3.02 mmHg for empagliflozin 25 mg). (See Table 14.)
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In a pre-specified pooled analysis of 4 placebo-controlled studies, treatment with empagliflozin resulted in a reduction in systolic blood pressure (empagliflozin 10 mg -3.9 mmHg, empagliflozin 25 mg -4.3 mmHg) compared with placebo (-0.5 mmHg), and in diastolic blood pressure (empagliflozin 10 mg -1.8 mmHg, empagliflozin 25 mg -2.0 mmHg) compared with placebo (-0.5 mmHg), at week 24, that were maintained up to week 52.
Laboratory parameters: Hematocrit increased: In a pooled safety analysis (pooling of all patients with diabetes, n=13,402), mean changes from baseline in haematocrit were 3.4% and 3.6% for empagliflozin 10 mg and 25 mg, respectively, compared to -0.1% for placebo. In the EMPA-REG Outcome study, haematocrit values returned towards baseline values after a follow-up period of 30 days after treatment stop.
Serum lipids increased: In a pooled safety analysis (pooling of all patients with diabetes, n=13,402), mean percent increases from baseline for empagliflozin 10 mg and 25 mg versus placebo, respectively, were total cholesterol 4.9% and 5.7% versus 3.5%; HDL-cholesterol 3.3% and 3.6% versus 0.4%; LDL-cholesterol 9.5% and 10.0% versus 7.5%; triglycerides 9.2% and 9.9% versus 10.5%.
Cardiovascular outcome: The EMPA-REG OUTCOME study is a multi-centre, multi-national, randomized, double-blind, placebo-controlled trial investigating the effect of JARDIANCE as adjunct to standard care therapy in reducing cardiovascular events in patients with type 2 diabetes and one or more cardiovascular risk factors, including coronary artery disease, peripheral artery disease, history of myocardial infarction (MI), or history of stroke. The primary endpoint was the time to first event in the composite of CV death, nonfatal MI, or non-fatal stroke (Major Adverse Cardiovascular Events (MACE-3)). Additional pre-specified endpoints addressing clinically relevant outcomes tested in an exploratory manner included CV death, the composite of heart failure requiring hospitalisation or CV death, all-cause mortality and the composite of new or worsening nephropathy.
A total of 7020 patients were treated with JARDIANCE (empagliflozin 10 mg: 2345, empagliflozin 25 mg: 2342, placebo: 2333) and followed for a median of 3.1 years.
The population was 72.4% Caucasian, 21.6% Asian, and 5.1% Black. The mean age was 63 years and 71.5% were male. At baseline, approximately 81% of patients were being treated with renin angiotensin system inhibitors, 65% with beta-blockers, 43% with diuretics, 89% with anticoagulants, and 81% with lipid lowering medication. Approximately 74% of patients were being treated with metformin at baseline, 48% with insulin and 43% with sulphonylurea.
About half of the patients (52.2%) had an eGFR of 60-90 ml/min/1.73 m
2, 17.8% of 45-60 ml/min/1.73 m
2 and 7.7% of 30-45 ml/min/1.73 m
2. Mean systolic BP was 136 mmHg, diastolic BP 76 mmHg, LDL 86 mg/dL, HDL 44 mg/dL, and urinary albumin to creatinine ratio (UACR) 175 mg/g at baseline.
Reductions in risk of CV death and all-cause mortality: JARDIANCE was superior in reducing the primary composite endpoint of cardiovascular death, non-fatal MI, or non-fatal stroke compared to placebo. The treatment effect reflected a significant reduction in cardiovascular death with no significant change in non-fatal MI, or non-fatal stroke (Table 15 and Figure 1).
JARDIANCE also improved overall survival (Table 15 and Figure 2), which was driven by a reduction in cardiovascular death with JARDIANCE. There was no statistically significant difference between empagliflozin and placebo in non-cardiovascular mortality. (See Table 15, Figures 1 and 2.)
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Reductions in risk of heart failure requiring hospitalization or CV death: JARDIANCE significantly reduced the risk of hospitalization for heart failure and cardiovascular death or hospitalization for heart failure compared with placebo (Table 16 and Figure 3). (See Table 16 and Figure 3.)
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The cardiovascular benefits of JARDIANCE observed were consistent across the subgroups depicted in Figure 4. (See Figure 4.)
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Diabetic kidney disease: In the EMPA-REG OUTCOME study population, the risk of new or worsening nephropathy (defined as onset of macroalbuminuria, doubling of serum creatinine, and initiation of renal replacement therapy (i.e. hemodialysis)) was significantly reduced in empagliflozin group compared to placebo (Table 17 and Figure 5).
JARDIANCE compared with placebo showed a significantly higher occurrence of sustained normo- or microalbuminuria in patients with baseline macroalbuminuria (HR 1.82, 95% CI 1.40, 2.37). (See Table 17 and Figure 5.)
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Treatment with empagliflozin preserved eGFR and eGFR increased during the post treatment 4-week follow up. However, the placebo group showed a gradual decline in GFR during the course of the study with no further change during 4-week follow up (see Figure 6).
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Thorough QTc study: In a randomized, placebo-controlled, active-comparator, crossover study of 30 healthy subjects, no increase in QTc was observed with either 25 mg or 200 mg empagliflozin.
Heart failure: Empagliflozin in patients with heart failure and reduced ejection fraction: A randomized, double-blind, placebo-controlled study (EMPEROR-reduced) was conducted in 3730 patients with chronic heart failure (New York Heart Association [NYHA] II-IV) and reduced ejection fraction (LVEF ≤40%) to evaluate the efficacy and safety of empagliflozin 10 mg once daily as adjunct to standard of care heart failure therapy. The primary endpoint was the time to adjudicated first event of either cardiovascular (CV) death or hospitalisation for heart failure (HHF). Occurrence of adjudicated HHF (first and recurrent), and eGFR(CKD-EPI)cr slope of change from baseline were included in the confirmatory testing. Heart Failure therapy at baseline included ACE inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitor (88.3%), beta blockers (94.7%), mineralocorticoid receptor antagonists (71.3%) and diuretics (95.0%).
A total of 1863 patients were randomized to empagliflozin 10 mg (placebo: 1867) and followed for a median of 15.7 months. The study population consisted of 76.1% men and 23.9% women with a mean age of 66.8 years (range: 25-94 years), 26.8% were 75 years of age or older. 70.5% of the study population were White, 18.0% Asian and 6.9% Black/African American. At randomization, 75.1% of patients were NYHA class II, 24.4% were class III and 0.5% were class IV. The mean LVEF was 27.5%. At baseline, the mean eGFR was 62.0 ml/min/1.73 m
2 and the median urinary albumin to creatinine ratio (UACR) was 22 mg/g. About half of the patients (51.7%) had an eGFR of ≥60 ml/min/1.73 m
2, 24.1% of 45 to <60 ml/min/1.73 m
2, 18.6% of 30 to <45 ml/min/1.73 m
2 and 5.3% 20 to <30 ml/min/1.73 m
2.
Empagliflozin was superior in reducing the risk of the primary composite endpoint of cardiovascular death or hospitalization for heart failure compared with placebo.
Additionally, empagliflozin significantly reduced the risk of occurrence of HHF (first and recurrent), and significantly reduced the rate of eGFR decline (see Table 18, Figures 7 and 8).
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The results of the primary composite endpoint were generally consistent with a hazard ratio (HR) below 1 across the pre-specified subgroups, including heart failure patients with and without type 2 diabetes mellitus (see Figure 9).
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Renal Outcome: During treatment, eGFR decline over time was slower in the empagliflozin group compared to the placebo group (see Figure 10). Treatment with empagliflozin 10 mg significantly reduced the rate of eGFR decline and the effect was consistent across all pre-specified subgroups (see Table 18). Patients treated with empagliflozin experienced an initial drop in eGFR which returned towards baseline after treatment discontinuation supporting that haemodynamic changes play a role in the acute effects of empagliflozin on eGFR. (See Figure 10.)
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Empagliflozin in patients with heart failure and preserved ejection fraction: A randomised, double-blind, placebo-controlled study (EMPEROR-Preserved) was conducted in 5988 patients with chronic heart failure (NYHA II-IV) and preserved ejection fraction (LVEF >40%) to evaluate the efficacy and safety of empagliflozin 10 mg once daily as adjunct to standard of care therapy. The primary endpoint was the time to adjudicated first event of either cardiovascular (CV) death or hospitalisation for heart failure (HHF). Occurrence of adjudicated HHF (first and recurrent), and eGFR(CKD-EPI)cr slope of change from baseline were included in the confirmatory testing. Baseline therapy included ACE inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitor (80.7%), beta blockers (86.3%), mineralocorticoid receptor antagonists (37.5%) and diuretics (86.2%).
A total of 2997 patients were randomised to empagliflozin 10 mg (placebo: 2991) and followed for a median of 26.2 months. The study population consisted of 55.3% men and 44.7% women with a mean age of 71.9 years (range: 22-100 years), 43.0% were 75 years of age or older. 75.9% of the study population were White, 13.8% Asian and 4.3% Black/African American. At randomisation, 81.5% of patients were NYHA class II, 18.1% were class III and 0.3% were class IV. The EMPEROR-Preserved study population included patients with a LVEF <50% (33.1%), with a LVEF 50 to <60% (34.4%) and a LVEF ≥60% (32.5%). At baseline, the mean eGFR was 60.6 ml/min/1.73 m
2 and the median urinary albumin to creatinine ratio (UACR) was 21 mg/g. About half of the patients (50.1%) had an eGFR of ≥60 ml/min/1.73 m
2, 26.1% of 45 to <60 ml/min/1.73 m
2, 18.6% of 30 to <45 ml/min/1.73 m
2 and 4.9% 20 to <30 ml/min/1.73 m
2.
Empagliflozin was superior in reducing the risk of the primary composite endpoint of cardiovascular death or hospitalization for heart failure compared with placebo. Additionally, empagliflozin significantly reduced the risk of occurrence of HHF (first and recurrent), and significantly reduced the rate of eGFR decline (see Table 19). (See Table 19, Figures 11 and 12.)
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The results of the primary composite endpoint were consistent across each of the pre-specified subgroups categorized by e.g., LVEF, diabetes status or renal function down to an eGFR of 20 ml/min/1.73 m
2 (see Figure 13).
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Renal Outcome: During treatment, eGFR decline over time was slower in the empagliflozin group compared to the placebo group (see Figure 14). Treatment with empagliflozin 10 mg significantly reduced the rate of eGFR decline and the effect was consistent across all pre-specified subgroups (see Table 19). Patients treated with empagliflozin experienced an initial drop in eGFR which returned towards baseline after treatment discontinuation supporting that haemodynamic changes play a role in the acute effects of empagliflozin on eGFR. (See Figure 14.)
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Chronic Kidney Disease Trial in Adults: EMPA-KIDNEY (NCT03594110) was a randomized, double-blind, placebo-controlled trial conducted in adults with chronic kidney disease (eGFR ≥20 to <45 mL/min/1.73 m2; or eGFR ≥45 to <90 mL/min/1.73 m2 with urine albumin to creatinine ratio [UACR] ≥200 mg/g). The trial excluded patients with polycystic kidney disease or patients requiring intravenous immunosuppressive therapy in the preceding three months or >45 mg of prednisone (or equivalent) at the time of screening. The primary objective of the trial was to assess the effects of empagliflozin as an adjunct to standard of care therapy, including RAS-inhibitor therapy when appropriate, on time to kidney disease progression or cardiovascular death.
A total of 6,609 patients, were equally randomized to JARDIANCE 10 mg or placebo and were followed for a median of 24 months.
The mean age of the study population was 63 years (range: 18 to 94 years) and 67% were male. Approximately 58% of the study population were White, 36% Asian, and 4% Black or African American. Approximately 44% of the patients had type 2 diabetes mellitus.
At baseline, the mean eGFR was 37 mL/min/1.73 m2, 21% of patients had an eGFR equal to or above 45 mL/min/1.73 m2, 44% had an eGFR 30 to less than 45 mL/min/1.73 m2, and 35% had an eGFR less than 30 mL/min/1.73 m2. The median UACR was 329 mg/g, 20% of patients had a UACR <30 mg/g, 28% had a UACR 30 to ≤300 mg/g, and 52% had a UACR >300 mg/g. Approximately 1% of patients had type 1 diabetes at baseline. The most common etiologies of CKD were diabetic nephropathy/diabetic kidney disease (31%), glomerular disease (25%), hypertensive/renovascular disease (22%) and other/unknown (22%).
At baseline, 85% of patients were treated with ACE inhibitor or ARB, 64% with statins, and 34% with antiplatelet agents.
JARDIANCE was superior to placebo in reducing the risk of the primary composite endpoint of sustained ≥40% eGFR decline, sustained eGFR <10 mL/min/1.73 m2, progression to end-stage kidney disease, or CV or renal death. The treatment effect reflected a reduction in a sustained ≥40% eGFR decline, sustained eGFR <10 mL/min/1.73 m2, progression to end-stage kidney disease, and CV death. There were few renal deaths during the trial. JARDIANCE also reduced the risk of first and recurrent hospitalization (see Table 20 and Figure 15); information collected on the reason for hospitalization was insufficient to further characterize the benefit. (See Table 20 and Figure 15.)
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The results of the primary composite endpoint were generally consistent across the pre-specified subgroups examined, including eGFR categories, underlying cause of kidney disease, diabetes status, or background use of RAS inhibitors (see Figure 16). The treatment benefit with JARDIANCE on the primary composite endpoint was not evident in patients with very low levels of albuminuria, however there were few events in these patients. (See Figure 16.)
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Pharmacokinetics: Absorption: The pharmacokinetics of empagliflozin have been extensively characterized in healthy volunteers and patients with T2DM. After oral administration, empagliflozin was rapidly absorbed with peak plasma concentrations occurring at a median t
max 1.5 h post-dose. Thereafter, plasma concentrations declined in a biphasic manner with a rapid distribution phase and a relatively slow terminal phase. The steady state mean plasma AUC was 4740 nmol·h/L and C
max was 687 nmol/L with 25 mg empagliflozin once daily (qd). Systemic exposure of empagliflozin increased in a dose-proportional manner. The single-dose and steady-state pharmacokinetics parameters of empagliflozin were similar suggesting linear pharmacokinetics with respect to time. There were no clinically relevant differences in empagliflozin pharmacokinetics between healthy volunteers and patients with T2DM.
Administration of 25 mg empagliflozin after intake of a high-fat and high calorie meal resulted in slightly lower exposure; AUC decreased by approximately 16% and C
max decreased by approximately 37%, compared to fasted condition. The observed effect of food on empagliflozin pharmacokinetics was not considered clinically relevant and empagliflozin may be administered with or without food.
Distribution: The apparent steady-state volume of distribution was estimated to be 73.8 L, based on a population pharmacokinetic analysis. Following administration of an oral [
14C]-empagliflozin solution to healthy subjects, the red blood cell partitioning was approximately 36.8% and plasma protein binding was 86.2%.
Metabolism: No major metabolites of empagliflozin were detected in human plasma and the most abundant metabolites were three glucuronide conjugates (2-O-, 3-O-, and 6-O-glucuronide). Systemic exposure of each metabolite was less than 10% of total drug-related material.
In vitro studies suggested that the primary route of metabolism of empagliflozin in humans is glucuronidation by the uridine 5'-diphospho-glucuronosyltransferases UGT2B7, UGT1A3, UGT1A8, and UGT1A9.
Elimination: The apparent terminal elimination half-life of empagliflozin was estimated to be 12.4 h and apparent oral clearance was 10.6 L/h based on the population pharmacokinetic analysis. The inter-subject and residual variabilities for empagliflozin oral clearance were 39.1% and 35.8%, respectively. With once-daily dosing, steady-state plasma concentrations of empagliflozin were reached by the fifth dose. Consistent with half-life, up to 22% accumulation, with respect to plasma AUC, was observed at steady-state. Following administration of an oral [
14C]-empagliflozin solution to healthy subjects, approximately 95.6% of the drug related radioactivity was eliminated in faeces (41.2%) or urine (54.4%). The majority of drug related radioactivity recovered in faeces was unchanged parent drug and approximately half of drug related radioactivity excreted in urine was unchanged parent drug.
Specific Populations: Renal Impairment: In patients with mild (eGFR: 60-<90 mL/min/1.73 m
2) moderate (eGFR: 30-<60 mL/min/1.73 m
2), severe (eGFR: <30 mL/min/1.73 m
2) renal impairment and patients with kidney failure/ESRD patients, AUC of empagliflozin increased by approximately 18%, 20%, 66%, and 48%, respectively, compared to subjects with normal renal function. Peak plasma levels of empagliflozin were similar in subjects with moderate renal impairment and kidney failure/ESRD compared to patients with normal renal function. Peak plasma levels of empagliflozin were roughly 20% higher in subjects with mild and severe renal impairment as compared to subjects with normal renal function. In line with the Phase I study, the population pharmacokinetic analysis showed that the apparent oral clearance of empagliflozin decreased with a decrease in eGFR leading to an increase in drug exposure. Based on pharmacokinetics, no dosage adjustment is recommended in patients with renal insufficiency.
Hepatic Impairment: In subjects with mild, moderate, and severe hepatic impairment according to the Child-Pugh classification, AUC of empagliflozin increased approximately by 23%, 47%, and 75% and C
max by approximately 4%, 23%, and 48%, respectively, compared to subjects with normal hepatic function. Based on pharmacokinetics, no dosage adjustment is recommended in patients with hepatic impairment.
Body Mass Index (BMI): No dosage adjustment is necessary based on BMI. Body mass index had no clinically relevant effect on the pharmacokinetics of empagliflozin based on the population pharmacokinetic analysis.
Gender: No dosage adjustment is necessary based on gender. Gender had no clinically relevant effect on the pharmacokinetics of empagliflozin based on the population pharmacokinetic analysis.
Race: No dosage adjustment is necessary based on race. Based on the population pharmacokinetic analysis, AUC was estimated to be 13.5% higher in Asian patients with a BMI of 25 kg/m
2 compared to non-Asian patients with a BMI of 25 kg/m
2.
Geriatric: Age did not have a clinically meaningful impact on the pharmacokinetics of empagliflozin based on the population pharmacokinetic analysis.
Paediatric: Studies characterizing the pharmacokinetics of empagliflozin in paediatric patients have not been performed.
Toxicology: In general toxicity studies in rodents and dogs, signs of toxicity were observed at exposures greater than or equal to 10-times the clinical dose of 25 mg. Most toxicity was consistent with secondary pharmacology related to urinary glucose loss and included decreased body weight and body fat, increased food consumption, diarrhea, dehydration, decreased serum glucose and increases in other serum parameters reflective of increased protein metabolism, gluconeogenesis and electrolyte imbalances, urinary changes such as polyuria and glucosuria, and microscopic changes in kidney.
Carcinogenicity: Empagliflozin did not increase the incidence of tumours in female rats at doses up to the highest dose of 700 mg/kg/day, which corresponds to approximately 72- and 182-times the clinical AUC exposure associated with the 25 and 10 mg doses, respectively. In male rats, treatment-related benign vascular proliferative lesions (hemangiomas) of the mesenteric lymph node, were observed at 700 mg/kg/day, which corresponds to approximately 42- and 105-times the clinical exposure associated with the 25 mg and 10 mg doses, respectively. These tumours are common in rats and are unlikely to be relevant to humans. Empagliflozin did not increase the incidence of tumours in female mice at doses up to 1000 mg/kg/day, which corresponds to approximately 62- and 158-times the clinical exposure associated with the 25 mg and 10 mg doses, respectively. Empagliflozin induced renal tumours in male mice at 1000 mg/kg/day, which corresponds to approximately 45- and 113-times the clinical exposure associated with the 25 mg and 10 mg doses, respectively. The mode of action for these tumours is dependent on the natural predisposition of the male mouse to renal pathology and a metabolic pathway not reflective of humans. The male mouse renal tumours are considered not relevant to humans.
Genotoxicity: Empagliflozin is not genotoxic.
Reproduction Toxicity: Nonclinical studies show that empagliflozin crosses the placenta during late gestation to a very limited extent, but do not indicate direct or indirect harmful effects with respect to early embryonic development. Empagliflozin administered during the period of organogenesis was not teratogenic at doses up to 300 mg/kg in the rat or rabbit, which corresponds to approximately 48- and 122-times or 128- and 325-times the clinical dose of empagliflozin based on AUC exposure associated with the 25 mg and 10 mg doses, respectively. Doses of empagliflozin causing maternal toxicity in the rat also caused the malformation of bent limb bones at exposures approximately 155- and 393-times the clinical dose associated with the 25 mg and 10 mg doses, respectively. Maternally toxic doses in the rabbit also caused increased embryofetal loss at doses approximately 139- and 353-times the clinical dose associated with the 25 mg and 10 mg doses, respectively.
In pre- and postnatal toxicity studies in rats, reduced weight gain in offspring was observed at maternal exposures approximately 4- and 11-times the clinical dose associated with the 25 mg and 10 mg doses, respectively.
In a juvenile toxicity study in the rat, when empagliflozin was administered from postnatal day 21 until postnatal day 90, non-adverse, minimal to mild renal tubular and pelvic dilation in juvenile rats was seen only at 100 mg/kg/day, which approximates 11-times the maximum clinical dose of 25 mg. These findings were absent after a 13 weeks drug-free recovery period.
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