Adverse reactions : תופעות לוואי

4.8    Undesirable effects

Summary of safety profile
In the completed phase 2 and phase 3 studies to support the initial registration of dulaglutide 0.75 mg and 1.5 mg, 4,006 patients were exposed to dulaglutide alone or in combination with other glucose lowering medicinal products. The most frequently reported adverse reactions in clinical trials were gastrointestinal, including nausea, vomiting and diarrhoea. In general, these reactions were mild or moderate in severity and transient in nature. Results from the long-term cardiovascular outcome study with 4,949 patients randomised to dulaglutide and followed for a median of 5.4 years were consistent with these findings.

Tabulated list of adverse reactions

The following adverse reactions have been identified based on evaluation of the full duration of the phase 2 and phase 3 clinical studies, the long-term cardiovascular outcome study and post-marketing reports. The adverse reactions are listed in Table 1 as MedDRA preferred term by system organ class and in order of decreasing incidence (very common: ≥ 1/10; common: ≥ 1/100 to < 1/10; uncommon: ≥ 1/1,000 to < 1/100; rare: ≥ 1/10,000 to < 1/1,000; very rare: < 1/10,000 and not known: cannot be estimated from available data). Within each incidence grouping, adverse reactions are presented in order of decreasing frequency. Frequencies for events have been calculated based on their incidence in the phase 2 and phase 3 registration studies.

Table 1: The frequency of adverse reactions of dulaglutide

System organ        Very common            Common              Uncommon            Rare         Not known class

Immune system                                                  Hypersensitivity Anaphylactic disorders                                                                       reaction# Metabolism          Hypoglycaemia*      Hypoglycaemia*         Dehydration and nutrition       (when used in       (when used as disorders           combination         monotherapy or with insulin,       in combination glimepiride,        with metformin metformin† or       plus pioglitazone)
 metformin plus glimepiride)
Gastrointestinal Nausea,            Decreased                                  Acute           Non- disorders        diarrhoea,         appetite,                                  pancreatitis,   mechanical vomiting†,         dyspepsia,                                 delayed         intestinal abdominal pain†    constipation,                              gastric         obstruction flatulence,                                emptying abdominal distention,
gastroesophageal reflux disease,
eructation
Hepatobiliary                                                Cholelithiasis, disorders                                                    cholecystitis Skin and                                                                       Angioedema# subcutaneous tissue disorders
General                             Fatigue                  Injection site disorders and                                                reactions administration site conditions
Investigations                      Sinus tachycardia, first degree atrioventricular block (AVB)
#
From post-marketing reports.
* Documented, symptomatic hypoglycaemia with blood glucose ≤ 3.9 mmol/L † For dulaglutide 0.75 mg, adverse reaction met frequency for next lower incidence grouping.


Description of selected adverse reactions
Hypoglycaemia
When dulaglutide 0.75 mg and 1.5 mg were used as monotherapy or in combination with metformin alone or metformin and pioglitazone, the incidences of documented symptomatic hypoglycaemia were 5.9% to 10.9% and the rates were 0.14 to 0.62 events/patient/year, and no episodes of severe hypoglycaemia were reported.

The incidences of documented symptomatic hypoglycaemia when dulaglutide 0.75 mg and 1.5 mg, respectively, were used in combination with a sulphonylurea and metformin were 39.0% and 40.3% and the rates were 1.67 and 1.67 events/patient/year. The severe hypoglycaemia event incidences were 0% and 0.7%, and rates were 0.00 and 0.01 events/patient/year for each dose, respectively. The incidence of documented symptomatic hypoglycaemia when dulaglutide 1.5 mg was used with sulphonylurea alone was 11.3% and the rate was 0.90 events/patient/year, and there were no episodes of severe hypoglycaemia.

The incidence of documented symptomatic hypoglycaemia when dulaglutide 1.5 mg was used in combination with insulin glargine was 35.3% and the rate was 3.38 events/patient/year. The severe hypoglycaemia event incidence was 0.7% and the rate was 0.01 events/patient/year.


The incidences when dulaglutide 0.75 mg and 1.5 mg, respectively, were used in combination with prandial insulin were 85.3% and 80.0% and rates were 35.66 and 31.06 events/patient/year. The severe hypoglycaemia event incidences were 2.4% and 3.4%, and rates were 0.05 and 0.06 events/patient/year.


Gastrointestinal adverse reactions
Cumulative reporting of gastrointestinal events up to 104 weeks with dulaglutide 0.75 mg and 1.5 mg, respectively, included nausea (12.9% and 21.2%), diarrhoea (10.7% and 13.7%) and vomiting (6.9% and 11.5%). These were typically mild or moderate in severity and were reported to peak during the first 2 weeks of treatment and rapidly declined over the next 4 weeks, after which the rate remained relatively constant.

In clinical pharmacology studies conducted in patients with type 2 diabetes mellitus up to 6 weeks, the majority of gastrointestinal events were reported during the first 2-3 days after the initial dose and declined with subsequent doses.

Acute pancreatitis
The incidence of acute pancreatitis in phase 2 and 3 registration studies was 0.07% for dulaglutide compared to 0.14% for placebo and 0.19% for comparators with or without additional background antidiabetic therapy. Acute pancreatitis and pancreatitis have also been reported in the post-marketing setting.

Pancreatic enzymes
Dulaglutide is associated with mean increases from baseline in pancreatic enzymes (lipase and/or pancreatic amylase) of 11% to 21% (see section 4.4). In the absence of other signs and symptoms of acute pancreatitis, elevations in pancreatic enzymes alone are not predictive of acute pancreatitis.

Heart rate increase
Small mean increases in heart rate of 2 to 4 beats per minute (bpm) and a 1.3% and 1.4% incidence of sinus tachycardia, with a concomitant increase from baseline ≥ 15 bpm, were observed with dulaglutide 0.75 mg and 1.5 mg, respectively.

First degree AV block/PR interval prolongation
Small mean increases from baseline in PR interval of 2 to 3 msec and a 1.5% and 2.4% incidence of first- degree AV block were observed with dulaglutide 0.75 mg and 1.5 mg, respectively.

Immunogenicity
In registration studies, treatment with dulaglutide was associated with a 1.6% incidence of treatment emergent dulaglutide anti-drug antibodies, indicating that the structural modifications in the GLP-1 and modified IgG4 parts of the dulaglutide molecule, together with high homology with native GLP-1 and native IgG4, minimise the risk of immune response against dulaglutide. Patients with dulaglutide anti-drug antibodies generally had low titres, and although the number of patients developing dulaglutide anti-drug antibodies was low, examination of the phase 3 data revealed no clear impact of dulaglutide anti-drug antibodies on changes in HbA1c. None of the patients with systemic hypersensitivity developed dulaglutide anti-drug antibodies.

Hypersensitivity
In the phase 2 and phase 3 registration studies, systemic hypersensitivity events (e.g., urticaria, edema) were reported in 0.5% of patients receiving dulaglutide. Cases of anaphylactic reaction have been rarely reported with marketed use of dulaglutide.


Injection site reactions
Injection site adverse events were reported in 1.9% of patients receiving dulaglutide. Potentially immune-mediated injection site adverse events (e.g., rash, erythema) were reported in 0.7% of patients and were usually mild.

Discontinuation due to an adverse event
In studies of 26 weeks duration, the incidence of discontinuation due to adverse events was 2.6% (0.75 mg) and 6.1% (1.5 mg) for dulaglutide versus 3.7% for placebo. Through the full study duration (up to 104 weeks), the incidence of discontinuation due to adverse events was 5.1% (0.75 mg) and 8.4% (1.5 mg) for dulaglutide. The most frequent adverse reactions leading to discontinuation for 0.75 mg and 1.5 mg dulaglutide, respectively, were nausea (1.0%, 1.9%), diarrhoea (0.5%, 0.6%), and vomiting (0.4%, 0.6%), and were generally reported within the first 4-6 weeks.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product.
Any suspected adverse events should be reported to the Ministry of Health according to the National Regulation by using an online form https://sideeffects.health.gov.il