canagliflozin (invokana), a novel oral agent for type-2 diabetes

7/23/2019 Canagliflozin (Invokana), A Novel Oral Agent for Type-2 Diabetes

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INTRODUCTIONThe prevalence of diabetes in the U.S.

has more than tripled, from 5.6 million to20.9 million over the last three decades,with type-2 diabetes accounting for 90%

to 95% of the diagnosed cases.1,2It is pro-jected that one in three American adultswill have diabetes in 2050 if this trend

continues.3

Type-2 diabetes mellitus is a pro-gressive disease resulting from an insulinsecretory defect characterized by insulinresistance and some degree of insulindeficiency.4The prevalence of the diseaseis increased in obese patients, minority

populations, and the elderly.2,5Chroniclong-term hyperglycemia associated

with diabetes is the cause of serious

complications, including blindness,

kidney failure, amputations, and death.2

The economic burden associated with

complications of diabetes in the U.S. was

$245 billion in 2012.6Oral hypoglycemia agents and insulin

are standard therapeutic approaches,

along with lifestyle modifications, to

manage type-2 diabetes and to prevent

complications.7,8Despite current availabletherapies, about 50% of patients in the U.S.are not achieving their goals for glycosyl-ated hemoglobin (HbA1c), blood pressure,and low-density lipoprotein-cholesterol(HDL-C) levels, as recommended by the

American Diabetes Association (ADA),and 81.2% are reported to be deficient inmeeting all three goals.8

Metformin (Glucophage, Bristol-MyersSquibb) is considered the initial standardof care unless it is contraindicated.7In-

sulin with or without additional agents canbe added to treat newly diagnosed type-2diabetes in patients with elevated glucoseor elevated HbA1clevels.

7A second oralagentsuch as a glucagon-like peptide

(GLP) receptor agonist, a dipeptidyl pep-tidase IV (DPP-4) inhibitor, a peroxisomeproliferator-activated receptor (PPAR)agonist, or insulinmay be required if

non-insulin monotherapy has been in-

effective in achieving HbA1c goals within3 to 6 months.7

Recent recommendations from the

ADA and the European Association for

the Study of Diabetes (EASD), along

with the American Association of Clini-

cal Endocrinologists (AACE), advise a

patient-centered approach to manage-

ment.9,10Preferred medications are thosethat carry a low risk of hypoglycemia,minimize the risk of weight gain, are easyto administer, are cost-effective, and aresafe to use.10

In March 2013, the FDA approvedcanagliflozin (Invokana, Janssen) as an

adjunct to diet and exercise for adults

with type-2 diabetes mellitus. This is thefirst oral agent in a novel class of diabetesdrugs known as sodiumglucose co-trans-porter-2 (SGLT-2) inhibitors.11Current

research has focused on the role of thekidney in glucose homeostasis and has

identified the role of SGLT-2 in mediatingthe reabsorption of filtered glucose in

the proximal tubule.11,12The inhibition

of SGLT-2 provides a novel mechanismto lower elevated plasma glucose levelsin diabetic patients.12,13

PHARMACOLOGY ANDMECHANISM OF ACTION1418

SGLT-2 is a high-capacity, low-affinitytransporter located in the brush borderof the membrane of the early segment ofthe proximal tubule. Canagliflozin is an

SGLT-2 inhibitor that increases glucoseexcretion in the urine by reducing re-

absorption of filtered glucose and low-

ering the renal glucose threshold. Thestructural formula of canagliflozin is

shown in Figure 1.

PHARMACOKINETICS ANDPHARMACODYNAMICS11,14,17

Canagliflozin is rapidly absorbed in thegastrointestinal (GI) tract. It has a relativeoral bioavailability of 65% and reaches

peak concentrations within 1 to 2 hours.It can be taken without regard to food,

but it is recommended that it be taken

before the first meal of the day to allow

for the potential to reduce postprandialplasma glucose excursions resulting fromdelayed intestinal glucose absorption.

Canagliflozin is highly protein-bound,mostly to albumin at 99%. The half-livesof 100 mg and 300 mg are 10.6 hours

and 13.1 hours, respectively. The drug

is metabolized primarily into two inactivemetabolites by uridine diphosphate glu-curonosyl transferase (UGT) enzymes:

UGT 1A9 and UGT 2B4 via glucuronida-tion. Approximately 7% of the drug alsoundergoes oxidation via cytochrome

Canagliozin (Invokana), a Novel Oral AgentFor Type-2 DiabetesSheila Sarnoski-Brocavich, BS, MS, PharmD, BCACP, CGP;

and Olga Hilas, PharmD, MPH, BCPS, CGP

DRUG FORECAST

Dr. Sarnoski-Brocavich is Assistant Clinical

Professor in Clinical Pharmacy Practice at

St. Johns University College of Pharmacy and

Health Sciences, in Queens, New York, and

Ambulatory Care Affi liate Pharmacy Faculty

at Queens Hospital Center in Jamaica, New

York. Dr. Hilas is Associate Clinical Professorin Clinical Pharmacy Practice at St. Johns

University College of Pharmacy and Health

Sciences in Queens. She is also a Clinical

Pharmacy Manager of Internal Medicine/

Geriatrics at New YorkPresbyterian Hospital,

Weill Cornell Medical Center, in New York,

New York. Drug Forecast is a regular column

coordinated by Alan Caspi, PhD, PharmD,

MBA, President of Caspi & Associates in New

York, New York.

Disclosure:The authors report that they have

no commercial or financial relationships in

regard to this article.

Figure 1 Structure of canagliflozin.


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P450 (CYP) isoenzymes. Canagliflozin iseliminated largely unchanged in the feces(41.5%) and as metabolites in the urine

(30.5%). Removal by dialysis is negligible,and hepatic involvement is minimal.

CLINICAL EFFICACY1921

Several phase 2 and phase 3 clinical

trials have been conducted to evaluate

the efficacy and safety of canagliflozin.

Three important studies have been pub-lished and may aid in determining therole of canagliflozin in the treatment of

type-2 diabetes. Table 1 summarizes thesignificant findings of each trial.

Stenlofet al.19

A randomized, double-blind, placebo-

controlled phase 3 study was conductedto compare the efficacy and safety of cana-gliflozin and placebo in patients with type-2 diabetes mellitus that was not controlledwith diet and exercise. This multicenter,multinational study enrolled 584 patientsbetween 18 and 80 years of age. Patientshad to have one of the following criteria:(1) they were not receiving an antihy-

perglycemic agent at screening with

HbA1c between 7% and 10%, or (2) they

were taking an antihyperglycemic agentas monotherapy (except for a PPAR-

agonist) or metformin and sulfonylureacombination therapy.

Patients who were not taking an anti-hyperglycemic drug underwent a 2-week,single-blind, placebo run-in period. Thosewho were receiving antihyperglycemic

treatment had an 8-week washout and

a diet/exercise period, followed by a

2-week placebo run-in phase. All patientsthen received canagliflozin 100 mg daily,canagliflozin 300 mg daily, or placebo

once daily for 26 weeks.The primary endpoint was the change

in HbA1c from baseline. Secondary end-points included the proportion of patientswho achieved HbA1cbelow 7%; changesin fasting plasma glucose (FPG) levels,

2-hour postprandial glucose (PPG) levels,and systolic blood pressure (BP); and thepercentage of change in body weight,

high-density lipoprotein-cholesterol

(HDL-C) levels, and triglyceride levels.At 26 weeks, HbA1c values were

significantly reduced with canagliflo-

zin 100 mg daily and 300 mg daily com-

pared with placebo (0.77%; 1.03%,and 0.14%, respectively;P< 0.001 for

both canagliflozin groups). Similar re-

ductions in HbA1cwere noted amongpatients who had not used an anti-

hyperglycemic agent before the study

and those who underwent a washout pe-riod of anti-hyperglycemic therapy. Morepatients receiving canagliflozin 100 mg and

300 mg also achieved HbA1cgoals of be-low 7% (44.5% and 62.4%, respectively)

and below6.5% (17.8% and 28.4%, respec-tively), compared with patients receiv-ing placebo (20.6% and 5.3%, respectively;

P< 0.001 for both canagliflozin groups).Fewer patients receiving canagliflozin

100 mg and 300 mg (2.6% and 2%, re-

spectively), compared with placebo

patients (22.7%), required glycemic res-cue therapy. These doses also brought

about greater reductions in FPG levels

over the 26-week study period; the differ-ences in least-squares mean changes were2 mmol/L and 2.4 mmol/L, respectively;

P< 0.001 for both canagliflozin groups).Reported differences in least-squares

mean changes for 2-hour PPG levels were2.7 mmol/L with canagliflozin 100 mg

and 3.6 mmol/L with 300 mg (P< 0.001for both canagliflozin groups).

Differences in least-squares mean

changes in systolic BP from baseline

were also significant at 26 weeks for

canagliflozin 100 mg or 300 mg, com-

pared with placebo (3.7 mm Hg and5.4 mm Hg, respectively;P< 0.001 for

both canagliflozin groups).Rapid reductions in body weight were

observed during the first 6 weeks of cana-gliflozin treatment, with progressive de-creases seen in patients receiving 300 mgand smaller weight reductions in patientsreceiving 100 mg over the final 20 weeksof the study. Least-squares mean changesin body weight with both 100 mg and 300mg were significant compared with pla-cebo (1.9 kg and 2.9 kg, respectively;

P< 0.001 for both canagliflozin groups).Statistically significant HDL-C eleva-

tions were reported at week 26 (differ-

ences in least-squares mean changes of6.8% for 100 mg and 6.1% for 300 mg vs.placebo;P< 0.001 for both canagliflozingroups). Nonsignificant reductions in tri-glyceride levels were also noted for bothcanagliflozin doses compared with pla-

cebo at the end of the treatment period.Adverse events (ADEs) were reported

in 61% of patients receiving canagliflozin

100 mg, in 59.9% of patients receiving300 mg, and in 52.6% of those receivingplacebo. Most ADEs were described as

mild to moderate in severity. Comparedwith placebo patients, the canagliflozin

treatment groups experienced more

genital mycotic infections, urinary tractinfections (UTIs), and ADEs associatedwith osmotic diuresis and reduced intra-

vascular volume. Hypoglycemia was ob-served in 3.6% of the canagliflozin 100-mggroup, in 3% of the 300-mg group, and in2.6% of the placebo group; no severe caseswere reported. One percent of patients

in the placebo group and 2.6% of those

receiving canagliflozin discontinued treat-ment because of ADEs. Two deaths (oneplacebo patient and one patient receivingcanagliflozin 100 mg) were reported butwere not found to be associated with thetreatments.

The authors concluded that treatmentwith canagliflozin in patients with type-2diabetes that had been inadequately con-trolled with diet and exercise improvedglycemic control, reduced body weight,and was well tolerated.

Rosenstock et al.20

Another randomized, double-blind,

placebo-controlled, parallel-group, multi-center, multinational phase 3study wasconducted to evaluate the efficacy and

safety of various canagliflozin doses in

patients with type-2 diabetes that had notbeen adequately controlled with metfor-min. Eligibility criteria included patients18 to 65 years of age with type-2 diabetesfor a period of at least 3 months; HbA1c

level of 7% or higher; 10.5% or fewer re-ceiving metformin alone for 3 months

or more at a dose of 1,500 mg/day or

higher; a body mass index (BMI) of 25

to 45 kg/m2(24 to 45 kg/m2for Asian

descendants); and serum creatinine lev-els below 1.5 mg/dL for men and below1.4 mg/dL for women.

Patients (n = 451) received canagli-flozin 50, 100, 200, or 300 mg once daily;canagliflozin 300 mg twice daily; or pla-

cebo. An arm receiving sitagliptin (Janu-via, Merck) 100 mg once daily was alsoincluded as an active-reference treatmentgroup but was not compared with the

canagliflozin groups. All patients under-went a 3- to 4-week pretreatment screen-ing phase, followed by a 12-week treat-

ment phase and a 2-week post-treatmentphase.

The primary endpoint was the changein HbA1c from baseline to the completionof treatment. The secondary endpoints


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Table 1 Evaluating the Use of Canagliozin in Type-2 Diabetes: Signicant Findings From Three Clinical Trials

Study Endpoints Results

Stenlof

et al.19Primary:a

1. Change in HbA1c

Secondary:a

1. Proportion of patients who achieved HbA1c< 7%

2. Change in FPG

3. Change in 2-hour PPG

4. Change in systolic BP

5. Change in body weight

6. Change in HDL-C

Canagliozin 100 mg daily: 0.77%b


Placebo 0.14%



Placebo: 20.6%

Canagliozin 100 mg daily: 1.5 mmol/Lb,c


Placebo: 0.5 mmol/L



Placebo: 0.3 mmol/L

Canagliozin 100 mg daily: 3.3 mm Hgb,c

Canagliozin 300 mg daily: 5 mm Hgb,c

Placebo: 0.4 mmHg

Canagliozin 100 mg daily: 2.5 kgb,c

Canagliozin 300 mg daily: 3.4 kgb,c

Placebo: 0.5 kg

Canagliozin 100 mg daily: 11.2%b,c

Canagliozin 300 mg daily: 10.6%c,d

Placebo: 4.5%

Rosenstock

et al.20Primary:eChange in HbA1c

Secondary:e

1. Percentage of patients who achieved HbA1c< 7%

2. Percentage of patients who achieved HbA1c< 6.5%

3. Change in FPG

Canagliozin 50, 100, 200, and 300 mg daily:

0.79%,b0.76%,b0.70%,band 0.92%b(respectively)

Canagliozin 300 mg twice daily: 0.95%b

Sitagliptin 100 mg daily: 0.74%b

Placebo: 0.22%

Canagliozin >100 mg daily: 53%72%f

Sitagliptin 100 mg daily: 65%f

Placebo: 34%

Canagliozin >100 mg daily: 27%42%f

Sitagliptin 100 mg daily: 45%f

Placebo: 13%


16.2 mg/dL,b25.2 mg/dL,b27 mg/dL,band 25.2 mg/dLb

(respectively)

Canagliozin 300 mg twice daily: 23.4 mg/dLb

Sitagliptin 100 mg daily: 12.6 mg/dL

Placebo: 3.6 mg/dL


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Table 1 Evaluating the Use of Canagliozin in Type-2 Diabetes: Signicant Findings From Three Clinical Trials(continued)

Study Endpoints Results

included the change in the percentage

of patients who achieved HbA1c below

7% and below 6.5% and changes in FPG,body weight, and an overnight urinary

glucose-to-creatinine (UGC) ratio after 12weeks. Forty-nine patients discontinued

treatment before the end of the 12-weekperiod. A similar number of patients inall treatment arms discontinued therapy.

At 12 weeks, efficacy analyses revealedsignificant changes in HbA1c from base-

line for canagliflozin 50, 100, 200, or

300 mg once daily and canagliflozin 300mg twice daily compared with placebo

(0.79%, 0.76%, 0.70%, 0.92%, 0.95%

and 0.22%, respectively;P< 0.001 for allcanagliflozin doses), with a 0.74% reduc-tion for the sitagliptin arm (P< 0.001 vs.

placebo). Fifty-three to 72% of patients

who received 100 mg or more of cana-gliflozin and 65% of those who received

sitagliptin achieved HbA1cvalues below

7%, compared with 34% of those in the

placebo group. HbA1cvalues below 6.5%

were also achieved by 27%, 42%, and 32%of patients receiving canagliflozin 100 and300 mg once daily and 300 mg twice daily,

Rosenstock

et al.20

continued

4. Mean weight reduction

5. Change in UGC ratio


2.3 kg,b2.6 kg,b2.7 kg,band 3.4 kgb(respectively)

Canagliozin 300 mg twice daily: 3.4 kgb

Sitagliptin 100 mg daily: 0.6 kg

Placebo: 1.1 kg


35.4 mg/mg,b51.5 mg/mg,b50.5 mg/mg,band 49.4 mg/mgb

(respectively)

Canagliozin 300 mg twice daily: 61.6 mg/mgb

Sitagliptin 100 mg daily: 1.9 mg/mg

Placebo: 1.9 mg/mg

Schernthaner

et al.21Primary:g Change in HbA1c

1. Percentage of patients who achieved HbA1c< 7%

2. Percentage of patients who achieved HbA1c< 6.5%

Secondary:g

1. Changes in FPG

2. Change in systolic BP

3. Change in body weight

4. Change in HDL-C

Canagliozin 300 mg daily: 1.03%c,h

Sitagliptin 100 mg daily: 0.66%



Canagliozin 300 mg daily: 22.5 %c,h


Canagliozin 300 mg daily: 28.7 mg/dLc,h

Sitagliptin 100 mg daily: 2.2 mg/dL

Canagliozin 300 mg daily: 5.1 mm Hgc,h

Sitagliptin 100 mg daily: 0.9 mm Hg

Canagliozin 300 mg daily: 2.3 kgc,h

Sitagliptin 100 mg daily: 0.1 kg



BP = blood pressure; FGP = fasting plasma glucose; HBA1c= glycosylated hemoglobin; HDL-C = high-density lipoprotein-cholesterol; PPG = postprandial glucose;

UGC = urinary glucose-to-creatinine.aResults at 26 weeks (from baseline).bP< 0.001, compared with placebo.cLeast-squares mean change.d

P< 0.01, compared with placebo.eResults at 12 weeks (from baseline).fP< 0.05, compared with placebo.gResults at 52 weeks (from baseline).hP< 0.001, compared with sitagliptin.


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respectively, as well as 45% of those whoreceived sitagliptin, compared with the

placebo group (13%).Significant and greater mean reduc-

tions in FPG levels were noted for all cana-gliflozin groups at 3 weeks and were main-

tained throughout the 12-week treatmentperiod (16.2, 25.2, 27, 25.2, and 23.4 mg/dL, respectively, vs. 3.6 mg/dL in the pla-cebo group;P< 0.001 for all canagliflozindoses). Sitagliptin reduced FPG levels by12.6 mg/dL, but the change was not statis-tically significant compared with placebo.

At week 12, changes in body weightand UGC ratios were also statistically

significant, compared with placebo.

Mean weight reductions from baseline

for canagliflozin subjects were 2.3, 2.6,

2.7, 3.4, and 3.4 kg, respectively, com-pared with 1.1 kg for placebo. A weightreduction of 0.6 kg was also seen in thesitagliptin patients, but this change wasnot statistically significant when com-

pared with placebo. Increases in UGCratios were reported for all canagliflozinpatients (35.4, 51.5, 50.5, 49.4, and 61.6

mg/mg) and were significantly greater

than for placebo patients (1.9 mg/mg;

P< 0.001). The sitagliptin patients ex-

perienced reductions in the UGC ratio

(1.9 mg/mg).

HDL-C levels were significantly in-creased with canagliflozin 300 mg twice

daily, and triglyceride levels were signifi-cantly reduced with 300 mg once dailyand twice daily, compared with placebo

(P< 0.001,P= 0.025, andP= 0.001, re-spectively).

ADEs were reported in 26% to 56% ofcanagliflozin patients, 35% of sitagliptin

patients, and 40% of placebo patients.

Most ADEs were described as mild to

moderate in severity. Nine canagliflozinpatients and two placebo patients discon-

tinued therapy because of ADEs, mainlygastrointestinal disorders. Compared

with the placebo group, patients receiv-ing the study drug experienced more

genital infections (2% vs. 38%, respec-

tively), particularly in female patients

(3% vs. 13%25%, respectively). Low andsimilar incidences of hypoglycemia, UTIs,polyuria (excess diuresis), pollakiuria

(abnormal frequency of urination) andhypovolemia-associated ADEs were

observed among all study participants.

Small reductions in systolic BP werealso noted with canagliflozin treatment.

(Polyuria can be associated with diabetes;

pollakiuria is thought to be associated

with psychological stress.)The authors concluded that the ad-

dition of canagliflozin treatment to in-

adequate metformin monotherapy in

patients with type-2 diabetes was relatively

well tolerated and resulted in significantimprovement of glycemic control while

yielding favorable effects on body weight,HDL-C levels, and triglyceride levels.

Schernthaner et al.21

In a 52-week, randomized, double-

blind, active-controlled, phase 3 study,the efficacy and safety of canagliflozin

were evaluated and compared with sita-gliptin in patients with type-2 diabetes

who were not responding adequately to

metformin and sulfonylurea therapy. Thismulticenter, multinational trial enrolledpatients 18 years of age or older with type-2 diabetes who were following a stable

regimen of metformin (1,500 mg/day orhigher) and a sulfonylurea (half-maximaldaily doses or more) and HbA1cvaluesbetween 7% and 10.5%.

Eligible patients underwent a single-

blind 2-week placebo run-in period, fol-

lowed by double-blind randomization toreceive either canagliflozin 300 mg oncedaily or sitagliptin 100 mg once daily. A

4-week post-treatment period followedthe 52-week treatment period.

The primary endpoint was the changein HbA1cfrom baseline to week 52. Second-ary endpoints included changes in systolicBP; body weight; and FPG, HDL-C, andtriglyceride levels. The authors analyzednon-inferiority between the treatment

groups, but they also evaluated superior-ity if non-inferiority was determined.

Of the 756 patients initially assigned

to active-treatment, 464 completed the

52-week treatment period and were in-

cluded in the efficacy and safety analyses.Approximately 33% of the canagliflozingroup and 44% of the sitagliptin group

stopped therapy because of the need forglycemic rescue therapy, elevated cre-

atinine levels (>1.4 for men or 1.3 for

women), estimated glomerular filtrationrate (eGFR) (


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ADVERSE DRUG REACTIONS17,1921

In clinical trials, canagliflozin was

generally associated with a higher inci-

dence of genital mycotic infections, UTIs,increased urination, and ADEs associ-

ated with osmotic diuresis and reducedintravascular volume. Uncircumcisedmen and both men and women with

a history of genital mycotic infectionswere predisposed to recurrent mycotic

genital infections requiring oral or topi-

cal antifungal treatment and antimicro-

bial therapy. Decreases in eGFR, serumurate, alanine aminotransferase (ALT),

gamma-glutamyl transferase (GGT), andalkaline phosphatase levels have also

been observed in patients treated with

canagliflozin, in addition to increases in

serum creatinine, blood urea nitrogen,hemoglobin, hematocrit, and bilirubin

compared with placebo and other activetreatments.

INDICATIONS AND USAGE17

Canagliflozin is approved for adults

with type-2 diabetes mellitus who requireimproved glycemic control in addition

to diet and exercise. This drug has not

been studied and is not recommend forpatients with type-1 diabetes mellitus ordiabetic ketoacidosis.

DRUG INTERACTIONS17

UGT enzyme inducers (e.g., rifampin,phenytoin, ritonavir)may decrease theplasma levels ans efficacy of canagliflozin.

The canagliflozin dose can be increased to300 mg once daily (1) in patients with aneGFR exceeding 60 mL/minute/1.73 m2,(2) in those requiring a UGT enzyme in-ducer and additional glycemic control, and(3) in those currently tolerating a dose

of 100 mg once daily. Alternative anti-hyperglycemic agents are suggested in

patients with an eGFR of 45 to 60 mL/minute/1.72 m2who require additional

glycemic management.There appear to be no significant in-

teractions between canagliflozin and

CYP450 enzymes 1A2, 2A6, 3A4, 2B6,2C9, 2C19, 2D6, and 2E1. Digoxin plasmaconcentrations may be increased with

the concomitant administration of cana-gliflozin; therefore, monitoring is advised.

CONTRAINDICATIONS17

Canagliflozin is contraindicated inpatients with a severe hypersensitivity

reaction to the drug, in individuals with

severe renal impairment (an eGFR below30 mL/minute/1.732), in those with end-stage renal disease, and in patients ondialysis.

PRECAUTIONS AND WARNINGS17

Volume status should be assessed andcorrected before canagliflozin is initiatedin patients with low BP, in those using

diuretics or drugs that interfere with thereninangiotensinaldosterone system

(RAS), or in those with impaired renal

function. Symptomatic hypotension wasobserved more frequently in patients

receiving the 300-mg dose, in those withimpaired renal function, in those receiv-ing loop diuretics, and in people 75 yearsof age or older.

Caution is warranted if the eGFR isbelow 60 mL/minute/1.73 m2. Frequentmonitoring of renal function is recom-mended during the initiation of therapy.

Monitoring of serum potassium levels isalso recommended upon the initiation ofcanagliflozin therapy in patients with renalimpairment and in those taking medica-tions that can interfere with potassium se-cretion to avoid the risk of hyperkalemia.

Prescribers should also exercise cau-tion for patients who are using insulin orinsulin secretagogues. Dose adjustments

of the insulin or insulin secretagoguesmay be needed to avoid hypoglycemia.

Patients taking canagliflozin should

be informed about and monitored for

signs and symptoms of genital mycotic

infections. Uncircumcised males and

patients with a history of genital mycoticinfections may be at increased risk and

may require treatment.It is also recom-mended that LDL-C levels be monitored,as dose-related increases in LDL-C levelshave been observed with this medication.

Canagliflozin has been designated as

a Pregnancy Category C drug. Well-con-trolled studies have not been conductedin pregnant women, and it is unknown

whether this medication is excreted inhuman milk. There is no evidence to sup-port its use in lactation.

DOSAGE AND ADMINISTRATION17

The recommended starting dose of

canagliflozin is 100 mg once daily beforethe first meal. Patients who need addi-

tional glycemic control can increase the

dose to 300 mg once daily if the 100-mgdose was well tolerated and the eGFR was60 mL/minute/1.73 m2or greater. The

dose should not exceed 100 mg once dailyin patients with moderate renal impair-

ment (eGFR, 4560 mL/minute/1.73 m2),and therapy should not be initiated if theeGFR is below 45 mL/minute/1.73 m2.

COST22Canagliflozin (Invokana) is sold as

100-mg film-coated, yellow capsule-shaped tablets and as 300-mg film-coated,white capsule-shaped tablets. Accordingto the 2013 edition of Red Book, the

average wholesale price of a bottle of

30 tablets (100 mg or 300 mg) is $236.10,and a bottle of 90 tablets (100 mg or 300mg) is $789.30.

CONCLUSION

Treatment options for type-2 dia-betes are often limited by the degree of

glycemic control provided and by safetyprofiles. Canagliflozin is a novel agent

that may aid in achieving glycemic goalsin many patients with type-2 diabetes

who are also following diet and exerciseregimens and who have not responded

adequately to other antihyperglycemic

agents. This drug is generally well toler-ated and may yield additional favorable ef-fects, for example, on BP and body weight.

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