canagliflozin


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canagliflozin

(kan-a-gli-floe-zin ) ,

Invokana

(trade name)

Classification

Therapeutic: antidiabetics
Pharmacologic: sodium glucose co transporter 2 sglt2 inhibitors
Pregnancy Category: C

Indications

Adjunct to diet and exercise in the management of type 2 diabetes mellitusMay be used with other antidiabetic agents.

Action

Inhibits proximal renal tubular sodium-glucose co-transporter 2 (SGLT2), which determines reabsorption of glucose from the tubular lumen. Inhibits reabsorption of glucose, lowers renal threshold for glucose, and increases excretion of glucose in urine.

Therapeutic effects

Improved glycemic control

Pharmacokinetics

Absorption: Well absorbed (65%) following oral administration
Distribution: Extensive tissue distribution
Protein Binding: 99%
Metabolism and Excretion: Mostly metabolized by UDP-glucuronyl transferases (UGT) to inactive metabolites, minimal metabolism by CYP3A4 (7%). 50% excreted in feces as parent drug and metabolites, 33% as metabolites in urine, <1% excreted in urine as unchanged drug.
Half-life: 10.6 hr

Time/action profile (effects on HbA1C)

ROUTEONSETPEAKDURATION
POunknownunknown24 hr

Contraindications/Precautions

Contraindicated in: HypersensitivitySevere renal impairment (eGFR <45 mL/min/1.73 m2), end-stage renal disease or on dialysis;Severe hepatic impairment; Lactation: Avoid use, discontinue breast feeding or discontinue canagliflozin.
Use Cautiously in: eGFR <60 mL/min/1.73 m2 (monitor frequently), ↑ risk of adverse reactions related to ↓ intravascular volume; Geriatric: ↑ risk of adverse reactions related to ↓ intravascular volume;Hypotension (correct prior to treatment, especially if eGFR 30–60 mL/min, age >75 yr, or concurrent use of loop diuretics, ACE inhibitors, or ARBs; Obstetric: Use during pregnancy only if potential maternal benefit justifies potential fetal risk; Pediatric: Safe and effective use in children <18 yr has not been established.

Adverse Reactions/Side Effects

Cardiovascular

  • hypotension

Gastrointestinal

  • abdominal pain
  • constipation
  • nausea

Genitourinary

  • female mycotic infections (most frequent)
  • glucosuria
  • male mycotic infections
  • ↓ renal function
  • urinary tract infection
  • ↑ urination
  • vulvovaginal pruritus

Endocrinologic

  • hypoglycemia (with other medications) (life-threatening)

Fluid and Electrolyte

  • hyperkalemia (most frequent)
  • hypermagnesemia
  • hyperphosphatemia
  • thirst

Metabolic

  • hyperlipidemia

Miscellaneous

  • hypersensitivity reactions, including generalized urticaria

Interactions

Drug-Drug interaction

Blood levels are ↓ by UGT inducers including phenobarbital, phenytoin, rifampin, and ritonavir ; ↑dose may be required.↑ risk of hypoglycemia with insulin or insulin secretagogues, dose adjustments may be required.May↑ blood levels and effects of digoxin ; levels should be monitored.↑ risk of hyperkalemia with potassium-sparing diuretics or medications that interfere with the renin-angiotnesin-aldosterone system.

Route/Dosage

Oral (Adults) eGFR ≥ 60 mL/min/1.73 m2—100 mg once daily initially, may be increased to 300 mg once daily; Concurrent use of UGT inducers (phenobarbital, phenytoin, rifampin, ritonavir)—if maintenance dose is 100 mg daily, may require increase to 300 mg daily.

Renal Impairment

Oral (Adults) eGFR 45–60 mL/min/1.73 m2100 mg once daily

Availability

Tablets: 100 mg, 300 mg

Nursing implications

Nursing assessment

  • Observe patient for signs and symptoms of hypoglycemic reactions (abdominal pain, sweating, hunger, weakness, dizziness, headache, tremor, tachycardia, anxiety)
  • Monitor for signs and symptoms of volume depletion (dizziness, feeling faint, weakness, orthostatic hypotension) after initiating therapy.
  • Lab Test Considerations: Monitor hemoglobin A1C prior to and periodically during therapy
    • May cause ↑ uric acid levels
    • May ↑serum creatinine and ↓eGFR. Monitor renal function, especially in patients with eGFR <60 mL/min/1.73 m2
    • May cause ↑ serum potassium, magnesium, and phosphate levels. Monitor electrolytes periodically during therapy.
    • May cause ↑ LDL-C. Monitor serum lipid levels periodically during therapy.

Potential Nursing Diagnoses

Imbalanced nutrition: more than body requirements (Indications)
Noncompliance (Patient/Family Teaching)

Implementation

  • Patients stabilized on a diabetic regimen who are exposed to stress, fever, trauma, infection, or surgery may require administration of insulin
  • Correct volume depletion prior to beginning therapy with canagliflozin.
  • Oral: Administer before the first meal of the day.

Patient/Family Teaching

  • Instruct patient to take canagliflozin as directed. Take missed doses as soon as remembered, unless it is almost time for next dose; do not double doses. Advise patient to read the Medication Guide before starting and with each Rx refill; new information may be available
  • Explain to patient that canagliflozin helps control hyperglycemia but does not cure diabetes. Therapy is usually long term
  • Instruct patient not to share this medication with others, even if they have the same symptoms; it may harm them
  • Encourage patient to follow prescribed diet, medication, and exercise regimen to prevent hyperglycemic or hypoglycemic episodes
  • Review signs of hypoglycemia and hyperglycemia with patient. If hypoglycemia occurs, advise patient to take a glass of orange juice or 2–3 tsp of sugar, honey, or corn syrup dissolved in water, and notify health care professional
  • Instruct patient in proper testing of blood glucose and urine ketones. Inform patient that canagliflozin will cause a positive test result when testing for urine glucose. These tests should be monitored closely during periods of stress or illness and health care professional notified if significant changes occur
  • Inform patient that canagliflozin may cause yeast infections. Women may have signs and symptoms of a vaginal yeast infection (vaginal odor, white or yellow vaginal discharge [may be lumpy or look like cottage cheese], vaginal itching). Men may have signs and symptoms of a yeast infection of the penis (redness, itching, or swelling of penis; rash on penis; foul smelling discharge from penis; pain in skin around penis). Advise patient to notify health care professional if yeast infection occurs.
  • Advise patient to notify health care professional promptly if rash; hives; or swelling of face, lips, or throat occur
  • Advise patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care professional before taking other medications, especially other oral hypoglycemic medications
  • Advise patient to notify health care professional if pregnancy is planned or suspected or if breast feeding

Evaluation/Desired Outcomes

  • Improved hemoglobin A1C and glycemic control in adults with Type II diabetes.
References in periodicals archive ?
Statistically significant reductions in levels of A1C, a commonly used blood sugar measure, were seen at all tested doses of J&J's canagliflozin compared with a placebo in the 12-week, 451-patient study, researchers said.
Taking canagliflozin can significantly increase an individual's chances of incurring bone fractures, due to the decreased bone mineral density caused by the drug.
Head Office: Raritan, NJ, US) has received approval of canagliflozin hydrate under the brand name INVOKANAA for the treatment of adult patients with type 2 diabetes mellitus in the US and, as of August 2014, has obtained approvals in 48 countries worldwide, including the US, Europe, Canada, and Australia.
Does the more recent canagliflozin experience add further relevant insight?
The major apparent downside of canagliflozin, an inhibitor of the sodium glucose cotransporter 2 (SGL, T2), was its association with a 15% rate of genital mycotic infections in women and a 9% rate in men, compared With rates of 4% in women and less than 1% in men in the comparator arm.
Initial uptake of the SGLT-2 inhibitors has been stronger than previously anticipated, with uptake of first-to-market canagliflozin in the United States closely mirroring sales of sitagliptin (Merck's Januvia), the market-leading DPP-IV inhibitor with over $4 billion in annual sales in 2013.
and we look forward to sharing with them the latest clinical and healthcare economics data about this therapy at the American Diabetes Association Scientific Sessions," said Norman Rosenthal, MD, FACE, FACP, canagliflozin compound development team leader, Janssen.
Johnson & Johnson Analyst Notes On April 25, 2014, Janssen-Cilag International NV (Janssen), a subsidiary of Johnson & Johnson (Johnson & Johnson), announced that its VOKANAMET (a fixed-dose therapy combining canagliflozin and immediate release metformin hydrochloride in a single tablet) has been approved by European Commission (EC) in the European Union (EU), for the treatment of adults with type II diabetes mellitus to improve glycaemic control.
The Company notified that the EC decision follows a positive opinion from the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA), recommending the approval of canagliflozin and immediate release metformin hydrochloride fixed dose combination therapy, in February 2014.
Also during the quarter, the Committee for Medicinal Products for Human Use adopted several positive opinions recommending Marketing Authorization in the European Union for the use of simeprevir in combination with other medicinal products for the treatment of chronic hepatitis C in adult patients; siltuximab for the treatment of adult patients with multicentric Castleman's disease who are HIV-negative and human herpes virus-8 negative; and VOKANAMET(TM), a fixed-dose therapy combining canagliflozin and immediate release metformin in a single tablet, intended for the treatment of adults with type 2 diabetes.
The SGLT2 inhibitors approved in the United States are canagliflozin (Invokana), dapagliflozin (Farxiga), and enpagliflozin (Jardiance).
26, 2015 /PRNewswire/ -- Seeger Weiss LLP reports that in May 2015 the FDA issued a warning about the type 2 diabetes medicines canagliflozin, dapagliflozin, and empagliflozin (sold under the brand names Invokana, Farxiga, and Jardiance, respectively), alerting doctors and patients about the risk of Diabetic Ketoacidosis linked to the medications.