8.4 Pediatric Use
The safety and effectiveness of metformin hydrochloride tablets for the treatment of type 2 diabetes mellitus have been established in pediatric patients 10 to 16 years old. Safety and effectiveness of metformin hydrochloride tablets have not been established in pediatric patients less than 10 years old.
Use of metformin hydrochloride tablets in pediatric patients 10 to 16 years old for the treatment of type 2 diabetes mellitus is supported by evidence from adequate and well-controlled studies of metformin hydrochloride tablets in adults with additional data from a controlled clinical study in pediatric patients 10 to 16 years old with type 2 diabetes mellitus, which demonstrated a similar response in glycemic control to that seen in adults [see Clinical Studies (14.1)]. In this study, adverse reactions were similar to those described in adults. A maximum daily dose of 2000 mg of metformin hydrochloride tablets is recommended. [See Dosage and Administration (2.2).]
8.5 Geriatric Use
Controlled clinical studies of metformin hydrochloride tablets did not include sufficient numbers of elderly patients to determine whether they respond differently from younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy and the higher risk of lactic acidosis.
Assess renal function more frequently in elderly patients [see Warnings and Precautions (5.1)].
8.6 Renal Impairment
Metformin is substantially excreted by the kidney, and the risk of metformin accumulation and lactic acidosis increases with the degree of renal impairment. Metformin hydrochloride tablet is contraindicated in severe renal impairment, patients with an estimated glomerular filtration rate (eGFR) below 30 mL/min/1.73 m2 [see Dosage and Administration (2.3), Contraindications (4) , Warnings and Precautions (5.1) , and Clinical Pharmacology (12.3)].
8.7 Hepatic Impairment
Use of metformin in patients with hepatic impairment has been associated with some cases of lactic acidosis. Metformin hydrochloride tablet is not recommended in patients with hepatic impairment. [see Warnings and Precautions (5.1) ].
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 has been established. Lactic acidosis has been reported in approximately 32% of metformin overdose cases [see Warnings and Precautions (5.1) ]. 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.
Metformin Hydrochloride Tablets, USP contain the antihyperglycemic agent metformin, which is a biguanide, in the form of monohydrochloride. The chemical name of metformin hydrochloride is N, N -dimethylimidodicarbonimidic diamide hydrochloride. The structural formula is as shown below:
Metformin hydrochloride is a white to off-white crystalline compound with a molecular formula of C4 H11 N5 • HCl and a molecular weight of 165.63. It is freely soluble in water and is practically insoluble in acetone, ether, and chloroform. The pKa of metformin is 12.4. The pH of a 1% aqueous solution of metformin hydrochloride is 6.68.
Metformin Hydrochloride Tablets, USP contain 500 mg, 850 mg or 1000 mg of metformin hydrochloride, which is equivalent to 389.93 mg, 662.88 mg 779.86 mg metformin base, respectively.
Each tablet contains the inactive ingredients magnesium stearate, microcrystalline cellulose, polyethylene glycol, polyvinyl alcohol, povidone, talc and titanium dioxide.
12.1 Mechanism of Action
Metformin is an antihyperglycemic agent which improves glucose tolerance in patients with type 2 diabetes mellitus, lowering both basal and postprandial plasma glucose. Metformin decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization. With metformin therapy, insulin secretion remains unchanged while fasting insulin levels and day-long plasma insulin response may decrease.
The absolute bioavailability of a metformin hydrochloride 500 mg tablet given under fasting conditions is approximately 50% to 60%. Studies using single oral doses of metformin hydrochloride tablets 500 to 1500 mg, and 850 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. At usual clinical doses and dosing schedules of metformin hydrochloride tablets, steady state plasma concentrations of metformin are reached within 24 to 48 hours and are generally <1 μg/mL.
Following a single oral dose of metformin hydrochloride extended-release tablet, Cmax is achieved with a median value of 7 hours and a range of 4 to 8 hours. Peak plasma levels are approximately 20% lower compared to the same dose of metformin hydrochloride tablets, however, the extent of absorption (as measured by AUC) is comparable to metformin hydrochloride tablets.
At steady state, the AUC and Cmax are less than dose proportional for metformin hydrochloride extended-release tablets within the range of 500 mg to 2000 mg administered once daily. Peak plasma levels are approximately 0.6, 1.1, 1.4, and 1.8 mcg/mL for 500, 1000, 1500, and 2000 mg once-daily doses, respectively. The extent of metformin absorption (as measured by AUC) from metformin hydrochloride extended-release tablets at a 2000 mg once-daily dose is similar to the same total daily dose administered as metformin hydrochloride tablets 1000 mg twice daily. After repeated administration of metformin hydrochloride extended-release tablets, metformin did not accumulate in plasma.
Effect of food: Food decreases the extent of absorption and slightly delays the absorption of metformin, as shown by approximately a 40% lower mean peak plasma concentration (Cmax ), a 25% lower area under the plasma concentration versus time curve (AUC), and a 35-minute prolongation of time to peak plasma concentration (Tmax ) following administration of a single 850 mg tablet of metformin hydrochloride with food, compared to the same tablet strength administered fasting.
The apparent volume of distribution (V/F) of metformin following single oral doses of metformin hydrochloride tablets 850 mg averaged 654 ± 358 L. Metformin is negligibly bound to plasma proteins, Metformin partitions into erythrocytes, most likely as a function of time.
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 3) 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.
In patients with decreased renal function, the plasma and blood half-life of metformin is prolonged, and the renal clearance is decreased (see Table 3) [See Dosage and Administration (2.3), Contraindications (4) , Warnings and Precautions (5.1) and Use in Specific Populations (8.6)].
Limited data from controlled pharmacokinetic studies of metformin hydrochloride tablets in healthy elderly subjects suggest that total plasma clearance of metformin is decreased, the half-life is prolonged, and Cmax is increased, compared to healthy young subjects. it appears that the change in metformin pharmacokinetics with aging is primarily accounted for by a change in renal function (see Table 3). [ See Warnings and Precautions (5.1) and Use in Specific Populations (8.5)].
Table 3: Select Mean (±S.D.) Metformin Pharmacokinetic Parameters Following Single or Multiple Oral Doses of Metformin Hydrochloride Tablets
|Subject Groups: Metformin Hydrochloride Tablets dosea (number of subjects)||Cmax b (mcg/mL)||Tmax c (hrs)||Renal Clearance (mL/min)|
|Healthy, nondiabetic adults: 500 mg single dose (24)850 mg single dose (74)d 850 mg three times daily for 19 dosese (9)||1.03 (±0.33)1.60 (±0.38)2.01 (±0.42)||2.75 (±0.81)2.64 (±0.82)1.79 (±0.94)||600 (±132)552 (±139)642 (±173)|
|Adults with type 2 diabetes mellitus: 850 mg single dose (23)850 mg three times daily for 19 dosese (9)||1.48 (±0.5)1.90 (±0.62)||3.32 (±1.08)2.01 (±1.22)||491 (±138)550 (±160)|
|Elderlyf , healthy nondiabetic adults:850 mg single dose (12)||2.45 (±0.70)||2.71 (±1.05)||412 (±98)|
|Renal-impaired adults: 850 mg single dose Mild (CLcr g 61-90 mL/min) (5)Moderate (CLcr 31-60 mL/min) (4)Severe (CLcr 10-30 mL/min) (6)||1.86 (±0.52)4.12 (±1.83)3.93 (±0.92)||3.20 (±0.45)3.75 (±0.50)4.01 (±1.10)||384 (±122)108(±57)130 (±90)|
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 Combined results (average means) of five studies: mean age 32 years (range 23-59 years)
e Kinetic study done following dose 19, given fasting
f Elderly subjects, mean age 71 years (range 65-81 years)
g 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 less than 5% between pediatric type 2 diabetic patients (12 to 16 years of age) and gender- and weight-matched healthy adults (20 to 45 years of age), all with normal renal function.
Metformin pharmacokinetic parameters did not differ significantly between normal subjects and patients with type 2 diabetes mellitus when analyzed according to gender (males = 19, females = 16).
No studies of metformin pharmacokinetic parameters according to race have been performed.
In Vivo Assessment of Drug Interactions
Table 4: Effect of Coadministered Drug on Plasma Metformin Systemic Exposure
|Coadministered Drug||Dose of Coadministered Drug *||Dose of Metformin *||Geometric Mean Ratio (ratio with/without coadministered drug) No Effect = 1.00|
|No dosing adjustments required for the following:|
|Glyburide||5 mg||850 mg||metformin||0.91‡||0.93‡|
|Furosemide||40 mg||850 mg||metformin||1.09‡||1.22‡|
|Nifedipine||10 mg||850 mg||metformin||1.16||1.21|
|Propranolol||40 mg||850 mg||metformin||0.90||0.94|
|Ibuprofen||400 mg||850 mg||metformin||1.05‡||1.07‡|
|Cationic drugs eliminated by renal tubular secretion may reduce metformin elimination [See Warnings and Precautions (5) and Drug Interactions (7). ]|
|Cimetidine||400 mg||850 mg||metformin||1.40||1.61|
|Carbonic anhydrase inhibitors may cause metabolic acidosis [See Warnings and Precautions (5.1) and Drug Interactions (7). ]|
|Topiramate||100 mg§||500 mg§||metformin||1.25§||1.17|
* All metformin and coadministered drugs were given as single doses
† AUC = AUC(INF)
‡ Ratio of arithmetic means
§ At steady state with topiramate 100 mg every 12 hours and metformin 500 mg every 12 hours; AUC = AUC0-12h
Table 5: Effect of Metformin on Coadministered Drug Systemic Exposure
|Coadministered Drug||Dose of Coadministered Drug *||Dose of Metformin *||Geometric Mean Ratio (ratio with/without metformin) No Effect = 1.00|
|No dosing adjustments required for the following:|
|Glyburide||5 mg||850 mg||glyburide||0.78‡||0.63‡|
|Furosemide||40 mg||850 mg||furosemide||0.87‡||0.69‡|
|Nifedipine||10 mg||850 mg||nifedipine||1.10§||1.08|
|Propranolol||40 mg||850 mg||propranolol||1.01§||1.02|
|Ibuprofen||400 mg||850 mg||ibuprofen||0.97¶||1.01¶|
|Cimetidine||400 mg||850 mg||cimetidine||0.95§||1.01|
* All metformin and coadministered drugs were given as single doses
† AUC = AUC(INF) unless otherwise noted
‡ Ratio of arithmetic means, p-value of difference <0.05
§ AUC (0-24 hr) reported
¶ Ratio of arithmetic means
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