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Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

Copyright  © 2024 The   Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited

Open Access  Full Text Article                                                                                                                                                               Research Article

Triple Fixed-dose combination of Dapagliflozin, Sitagliptin, and Metformin for People with Type 2 Diabetes in Indian Settings

Rajashree Dhar*, Ashish Prasad , Vivekanandan Annadurai 

USV Pvt. Ltd., Mumbai India

 

 

INTRODUCTION

Glycemic management in individuals with type 2 diabetes prevents complications and maintains quality of life.¹ According to current diabetic guidelines, lifestyle modification is recommended as well as the use of metformin as the first-line treatment for type 2 diabetes.² Metformin works primarily by improving insulin sensitivity in peripheral tissues and inhibiting hepatic gluconeogenesis.³ Most patients with type 2 diabetes require additional treatment with add-on therapy to achieve additional glycemic control as their condition progresses over time.⁴ Sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, thiazolidinedione, sulfonylureas, and basal insulin are the second-line drug alternatives added to metformin monotherapy.^2,5

Dapagliflozin, an SGLT2 inhibitor, lowers blood glucose by inhibiting SGLT2 from reabsorbing glucose in the renal proximal tubule, leading to glycosuria and decreasing plasma glucose levels.^6,7 This drug improves glycemic control independent of insulin, with a low risk of hypoglycemia.^7,8 Dapagliflozin has other beneficial effects, which include body weight loss, natriuresis, and blood pressure reduction.

Metformin and Dapagliflozin have complementary mechanisms of action and may benefit patients with type 2 diabetes, with a low risk of hypoglycemia.⁹ Because there is no pharmacokinetic (PK) interaction between Dapagliflozin and Metformin and the combination is well tolerated, Dapagliflozin can be safely co-administered with Metformin without a dose adjustment of either medication¹⁰. In two randomized, double-blind, three-arm 24-week trials comparing Dapagliflozin plus Metformin, Dapagliflozin alone, and Metformin alone in treatment-naive individuals, a combination therapy significantly decreased the levels of HbA1c compared to either monotherapy.¹¹ Adding Dapagliflozin to the treatment regimen of patients with type 2 diabetes whose condition was poorly controlled by Metformin alone significantly improved glycemic control, according to the findings of a randomized, double-blind, placebo-controlled study.¹² Compared to Dapagliflozin or Metformin monotherapy, Dapagliflozin and Metformin combination therapy showed more significant improvements in any of the components of the metabolic syndrome.¹³

The current study provides evidence for considering triple FDC of Dapagliflozin plus Sitagliptin plus Metformin ER as an alternative option with minimal risk of hypoglycemia and weight gain while considering oral triple-combination therapy for patients to achieve their glycemic target.

METHODS

Study Subjects

Participants included in the study were healthy male volunteers over the age of 18 to 45 years with a body mass index of 18.50–30.0 kg/m² at the time of screening. The following were key exclusion criteria: a history of hypersensitivity to Dapagliflozin, Metformin, and Sitagliptin, or any excipient of the study drugs; clinically significant medical disorders; abnormal laboratory findings; difficulty in blood transfusion or blood donation within 90 days of first dosing of the study drug, Habit of consuming high caffeine (more than 5 cups of coffee or tea/day), smokers who smoke >9 cigarettes per day, alcoholics who consume  >21 units of alcohol in a week, asthma, urticaria or other allergic reactions, dehydration from diarrhoea, vomiting, or any other reason within a period of 24.00 hours prior to study check-in, abnormal vitals, difficulty swallowing the investigational product. 2 subjects were withdrawn from the study due to adverse events, and the adverse event was resolved without any sequale.

Study Design and Blood Sampling Timepoints

An open label, randomized, balanced, two sequence, two period, cross-over, single-dose oral relative bioavailability study in healthy adult human male subjects under fed conditions. During each session, subjects were housed in the clinical facility from at least 11:00 hours before dosing until 24.00 hours after the dose. After each dosage, subjects were brought back to the clinical facility for ambulatory samples at 48.00 and 72.00 hours. In each period, subjects were provided with a standard meal; appropriate drinking water and posture restrictions were ensured after dosing in the study, as well as all the subjects were continuously monitored for their well-being and safety throughout the study. All the restrictions and prohibitions for diet and drinking water, posture, and housing areas as specified in the protocol were followed and complied with by all the subjects in the study.

A clinical study was conducted over 12 days. A washout of 07 days was maintained between each consecutive dosing period.

The descriptive statistics for the pharmacokinetic parameters are the area under the plasma concentration-time curve from time 0 to the last quantifiable data point (AUC_0-t) for Dapagliflozin and Metformin; the area under the plasma concentration-time curve from time 0 to 72 hours (AUC_0-72) for Sitagliptin; and the peak plasma concentration (C_max) for Dapagliflozin, Sitagliptin, and Metformin. Each endpoint was log-transformed before fitting the model. Log treatment differences estimated from that model were afterward back-transformed to the original scale to obtain the geometric mean ratio of FDC to reference products. Bioequivalence would be met if the adjusted geometric mean ratios (FDC to free combination) and two-sided 90% confidence intervals (CIs) of AUC and C_max for each component were within 80.00‒125.00%. Secondary endpoints were to monitor the adverse events and to ensure the safety of the subjects following administration of a single dose of Dapagliflozin 10mg, Sitagliptin 100mg, and Metformin 1000mg extended-release tablets.

The Independent Ethics Committee gave their approval to the study protocol. The Declaration of Helsinki’s ethical principles and Good Clinical Practice guidelines were followed in conducting this study at Notrox Research Pvt Ltd, Bangalore, Karnataka.¹⁴ Each subject received written and oral information about the study before participation, and they provided their written informed consent.

This study consisted of the crossover designs, and there was a 7-day washout period between the two treatment periods. During each study period, the subjects received a single oral dose of the test formulation Dapagliflozin 10 mg plus Sitagliptin 100 mg plus Metformin 1000 mg Extended Release Tablets (T) Manufactured by Exemed Pharmaceuticals, Gujarat, India, or Januvia^® Sitagliptin 100mg Tablets (R1) Manufactured by MSD Pharmaceuticals Pvt. Ltd., at M/s. Recipharm Pharmaservices Pvt. Ltd., Bangalore, and Xigduo^® XR Dapagliflozin 10 mg plus Metformin 1000 mg Extended Release Tablets (R2) Manufactured by AstraZeneca Pharmaceuticals LP, 4601 Highway, 62 East Mount Vernon, Indiana 47620, USA.

Before receiving the study drug, subjects were admitted to the Clinical Trial Centre of Notrox Research Pvt. Ltd., Bangalore, Karnataka. The subjects were administered the study medication in the fed state. The study drug was given to participants who had previously consumed a high-calorie and fat breakfast with 240±2 mL of 20% aqueous glucose solution followed by 60 mL of the glucose solution administered every 15 minutes (window period of ± 5 minutes) for up to 4 hours after dosing at ambient temperature under fed conditions. 

The subjects who completed the PK sampling for 24 hours were discharged on day 2, and an additional visit for the last PK sampling was made on days 3 and days 4. 

Blood samples were collected up to 72 hours after dosing (at 0, 0.33, 0.67, 1.00, 1.33, 1.67, 2.00, 2.33, 2.67, 3.00, 3.50, 4.00, 4.50, 5.00, 5.50, 6.00, 7.00, 8.00, 10.00, 12.00, 16.00, 24.00, 48.00, and 72 hours). Following centrifugation (3,500 rpm) for 10 minutes at 2-5°C, the plasma was transferred to two polypropylene tubes and frozen at -70 ± 10°C before analysis. 

Measurement of plasma Dapagliflozin, Metformin and Sitagliptin

Dapagliflozin, Metformin and Sitagliptin plasma concentrations were measured by Notrox Research Pvt Ltd., Bangalore, Karnataka, using validated ultra-performance liquid chromatography (UPLC) methods in conjunction with mass spectrometry (MS/MS).¹⁵

PK and statistical analysis

Statistical analysis was carried out using the SAS^® statistical software, version 9.4 of SAS Institute Inc., USA. The pharmacokinetic analysis was performed on subjects who completed both periods of the study. The descriptive statistics (mean, median, minimum, maximum, standard deviation, and coefficient of variation) for the pharmacokinetic parameters (primary parameters: C_max, AUC_0-t, and AUC_0-∞ and secondary parameters: t_max, t_1/2, K_el, and AUC_{_%Extrap_obs}) were estimated for both test and reference products. The Ln-transformed pharmacokinetic parameters (AUC_0-t and AUC_0-∞) were analyzed using an ANOVA model. The analysis of the variance model included sequence, treatment, period, and subject as a fixed effect. To test the two one-sided tests for bioequivalence, ratio analysis and 90% confidence intervals for the difference between the treatment’s least-square mean were calculated for Ln Transformed AUC_0-t, and AUC_0-∞. The confidence interval is expressed as a percentage difference relative to the LSM of the reference treatment.

The 90% confidence intervals for Ln-transformed pharmacokinetic parameters C_max, AUC_0-t, and AUC_0-inf are within the bioequivalence limits of 80.00 to 125.00%.

Safety assessments

Safety measurements of blood pressure, pulse rate, and body temperature were performed as specified in the study protocol, and subjects’ well-being questionnaires were also performed at all the scheduled times of vitals recording. Monitoring for adverse events was conducted at the time of recording of subject well-being as well as throughout the entire study duration. There were no serious adverse events reported in the study. Based on the review of the clinical and laboratory safety data, the safety profile of both the investigational products (test and reference) was found to be safe after exposing the healthy volunteers.

 

No. of subjects enrolled in the study N=24

Reference product Period I = 12 Period II = 11

Subjects completed the study (N=22) Subjects not reported (N=00) Subject withdrawn (N=02*) Others (N=00)

Test product Period I = 12 Period II = 12

No of subjects participated in the study N = 24

  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 1: Flow diagram of the study

 

RESULTS

Demographic data

Out of the 24 participants that were recruited in the study, 22 of them completed it. Table 1 provides a summary of the research population's demographic data.

Pharmacokinetic parameters

Based on data obtained from subjects who completed the test and reference products, the following pharmacokinetic parameters were calculated.

Table 1: Summarized Demographic Profile of Subjects

Parameter	Mean	SD	Minimum	Maximum	CV%
Age (Years)	31.86	6.21	19.00	43.00	19.47
Height (H)	1.69	0.06	1.55	1.77	3.29
Weight (KG)	72.16	11.59	55.10	90.00	16.06
BMI (Kg/m2)	25.18	3.29	19.52	29.48	13.08

 

 Table 2: Statistical Results of Log Transformed Test product (T) versus Reference product (R) Dapagliflozin

Pharmacokinetic Parameter	Geometric Least Square Mean		ISCV (%)	T/R Ratio (%)	Power (%)	90% Confidence Test Interval
	Test Product (T)	Reference Product (R)
Cmax (ng/mL)	132.7381	123.9223	30.23	102.96	69.18	88.23 TO 120.15
AUC0-t (ng.hr/mL)	883.5399	840.2715	13.84	105.15	99.70	97.85 TO 112.99
AUC0-∞ (ng.hr/mL)	988.9141	930.1807	17.56	106.31	97.39	97.06 TO 116.45

 

Figure 2: Mean plasma concentration-time curve of Dapagliflozin following a single oral administration of Dapagliflozin 10 mg + Sitagliptin 100 mg + Metformin 1000 mg Extended Release Tablets (T) vs. Dapagliflozin 10 mg + Metformin 1000 mg Extended Release Tablets (R) in 24 healthy subjects.

Table 3: Statistical Results of Log Transformed Test product (T) versus Reference product (R) Sitagliptin

Pharmacokinetic Parameter	Geometric Least Square Mean		ISCV (%)	T/R Ratio (%)	Power (%)	90% Confidence Test Interval
	Test Product (T)	Reference Product (R)
Cmax (ng/mL)	361.7459	347.6147	19.29	104.07	95.06	94.18 TO 114.99
AUC0-t (ng.hr/mL)	4564.1249	4549.5024	21.04	100.32	91.86	89.99 TO 111.84
AUC0-∞ (ng.hr/mL)	4932.8070	4925.4935	20.89	100.15	92.17	89.9 TO 111.56

Figure 3: Mean plasma concentration-time curve of Sitagliptin following a single oral administration of Dapagliflozin 10 mg + Sitagliptin 100 mg + Metformin 1000 mg Extended Release Tablets (T) vs. Sitagliptin 100 mg Tablets (R) in 24 healthy subjects.

Table 4: Statistical Results of Log Transformed Test product (T) versus Reference product (R) Metformin

Pharmacokinetic Parameter	Geometric Least Square Mean		ISCV (%)	T/R Ratio (%)	Power (%)	90% Confidence Test Interval
	Test Product (T)	Reference Product (R)
Cmax (ng/mL)	1324.7251	1418.9534	19.44	93.36	94.81	84.43 TO 103.24
AUC0-t (ng.hr/mL)	18803.894	18734.876	25.36	100.37	81.60	88.1 TO 114.35
AUC0-∞ (ng.hr/mL)	20060.614	19736.035	24.71	101.64	83.27	89.51 TO 115.42

 

Figure 4: Mean plasma concentration-time curve of Metformin following a single oral administration of Dapagliflozin 10 mg + Sitagliptin 100 mg + Metformin 1000 mg Extended Release Tablets (T) vs. Dapagliflozin 10 mg + Metformin 1000 mg Extended Release Tablets (R) in 24 healthy subjects.

 

 

Safety and tolerability assessments

The adverse event was found to be mild in severity and possibly related to the medicine being studied. The adverse event was settled with no aftereffects and the participant in the study was withdrawn. In the fed study, The AE rates of the two formulations did not differ significantly.  The study's recorded adverse events (AEs) cleared on their own without the need for special care. Neither the reference formulation nor the test formulation provoked any major or severe adverse events (AEs) throughout study.

DISCUSSION

FDC formulation of extended-release tablets comprising dapagliflozin (10 mg), sitagliptin (100 mg), and metformin (10 mg), formulated by Exemed Pharmaceuticals, Gujarat, India. Reference product 2 is utilized as Januvia^®, which includes Sitagliptin 100 mg Tablets, and Reference product 1 is used as Xigduo^® XR, which comprises Dapagliflozin and Metformin HCl XR (10 mg/1,000 mg). The PK parameters as well as safety assessments of the test formulations and the formulation used as a reference were contrasted in healthy individuals in this open-label, randomized, two-period crossover trial. Bioequivalence of the two formulations was determined in this study while the subjects were fed settings.

In fed states, the single-dose administration of Januvia^® Sitagliptin 100 mg Tablets, Xigduo^® XR Dapagliflozin 10 mg plus Metformin 1000 mg Extended-Release Tablets, and Dapagliflozin 10 mg in addition to Sitagliptin 100 mg plus Metformin 1000 mg Extended-Release Tablets proved to be safe and well-tolerated. No serious or major side effects were observed throughout the study. This result validates the development and application of the novel FDC tablet as a substitute formulation for the brands' Sitagliptin 100 mg Tablets and Dapagliflozin 10 mg plus Metformin 1000 mg Extended-Release Tablets. The study included the enrollment of 24 adult male individuals of good health. Out of the 24 participants that were enrolled, 24 of them took part in the study, while 22 of them completed both phases. The study carried out on subjects 006 and 007 was discontinued. At the stage of check-in during Period II, Subject 007 was discontinued. Over the course of 12 days, the clinical study was carried out. Between every subsequent dose interval, a washout of seven days was established. The subject safety assessment results obtained from the conduct of this study lead us to conclude that the overall condition of health of participating subjects was confirmed to be clinically suitable. And also, both the investigational products have been found to be both safe and well-tolerated in the individuals at the chosen dosage range. The 90% confidence intervals for Ln-transformed pharmacokinetic parameters C_max, AUC_0-t, and AUC_0-inf are within the bioequivalence limits of 80.00 to 125.00%.

Following the completion of the study's clinical phase and evaluation of the vital sign measures, 
 The findings of the post-study laboratory tests and the general health status of all subjects were determined to be clinically fit. Both used products in this study were well tolerated in subjects who took part in study.

CONCLUSION

Ultimately, our findings revealed that the two assessed dosages of the Dapagliflozin/Sitagliptin/Metformin XR FDC tablets exhibited bioequivalency with their corresponding reference products. The FDC's safety profiles were equivalent to the established safety profiles of the individual drugs, and it was tolerated well. Based on the data obtained so far, it appears that the triple FDC medication may offer an alternate course of therapy to the conventional stepwise treatment strategy for managing type 2 diabetes. In addition, for patients with type 2 diabetes who need numerous glucose-lowering medications, this triple FDC may assist to enhance adherence and achieve glycemic objectives as well as outcomes.

Acknowledgements

We acknowledge and are thankful to Abhijit Pednekar, and Shashikala K Borhade for their contributions to the study. We also acknowledge and thank Dr. Shivani Prajapati for her assistance in drafting this manuscript

Author Statement

Funding source: This study was conducted by Exemed Pharmaceuticals and Sponsored by USV PVT. Ltd.

Competing interests/Conflicts of interest: Dr. Rajashree Dhar, Dr. Ashish Prasad, and Dr. Vivekanandan Annadurai are the employees of USV Pvt. Ltd.

Informed Consent: Informed Consent is applicable

Ethical approval: The study was approved by the Independent Ethics Committee

Author Contributions: Dr. Rajashree Dhar, Dr. Ashish Prasad, Dr. Vivekanandan Annadurai. All authors have worked together on project development, literature research, manuscript writing, and editing.

 

 

REFERENCES:

1. Davies MJ, Aroda VR, Collins BS, Gabbay RA, Green J, Maruthur NM, et al. Management of hyperglycemia in type 2 diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) Diabetes Care. 2022; 45:2753-2786. https://doi.org/10.2337/dci22-0034 PMid:36148880 PMCid:PMC10008140

2. Doyle-Delgado K, Chamberlain JJ, Shubrook JH, Skolnik N, Trujillo J. Pharmacologic approaches to glycemic treatment of type 2 diabetes: synopsis of the 2020 American Diabetes Association's Standards of Medical Care in Diabetes Clinical Guideline. Ann Intern Med. 2020; 173:813-821. https://doi.org/10.7326/M20-2470 PMid:32866414

3. Chang M, Liu X, Cui D, Liang D, LaCreta F, Griffen SC, et al. Bioequivalence, food effect, and steady-state assessment of Dapagliflozin/Metformin extended-release fixed-dose combination tablets relative to single-component Dapagliflozin and Metformin extended-release tablets in healthy subjects. Clin Ther. 2015; 37:1517-1528. https://doi.org/10.1016/j.clinthera.2015.05.004 PMid:26048185

4. Turner RC, Cull CA, Frighi V, Holman RR UK Prospective Diabetes Study (UKPDS) Group. Glycemic control with diet, sulfonylurea, Metformin, or insulin in patients with type 2 diabetes mellitus: progressive requirement for multiple therapies (UKPDS 49) JAMA. 1999; 281:2005-2012. https://doi.org/10.1001/jama.281.21.2005 PMid:10359389

5. Kalra S, Das AK, Priya G, Ghosh S, Mehrotra RN, Das S, et al. Fixed-dose combination in management of type 2 diabetes mellitus: Expert opinion from an international panel. J Family Med Prim Care. 2020; 9:5450-5457. https://doi.org/10.4103/jfmpc.jfmpc_843_20 PMid:33532378 PMCid:PMC7842427

6. List JF, Woo V, Morales E, Tang W, Fiedorek FT. Sodium-glucose cotransport inhibition with Dapagliflozin in type 2 diabetes. Diabetes Care. 2009; 32:650-657. https://doi.org/10.2337/dc08-1863 PMid:19114612 PMCid:PMC2660449

7. Pancholia AK. Sodium-glucose cotransporter-2 inhibition for the reduction of cardiovascular events in high-risk patients with diabetes mellitus. Indian Heart J. 2018; 70:915-921. https://doi.org/10.1016/j.ihj.2018.08.022 PMid:30580866 PMCid:PMC6306386

8. Khomitskaya Y, Tikhonova N, Gudkov K, Erofeeva S, Holmes V, Dayton B, et al. Bioequivalence of Dapagliflozin/Metformin extended-release fixed-combination drug product and single-component Dapagliflozin and Metformin extended-release tablets in healthy russian subjects. Clin Ther. 2018; 40:550-561.e3. https://doi.org/10.1016/j.clinthera.2018.02.006 PMid:29548719

9. Tang W, Engman H, Zhu Y, Dayton B, Boulton DW. Bioequivalence and food effect of Dapagliflozin/saxagliptin/Metformin extended-release fixed-combination drug products compared with coadministration of the individual components in healthy subjects. Clin Ther. 2019; 41:1545-1563. https://doi.org/10.1016/j.clinthera.2019.05.015 PMid:31266654

10. Kasichayanula S, Liu X, Shyu WC, Zhang W, Pfister M, Griffen SC, et al. Lack of pharmacokinetic interaction between Dapagliflozin, a novel sodium-glucose transporter 2 inhibitor, and Metformin, pioglitazone, glimepiride or Sitagliptin in healthy subjects. Diabetes Obes Metab. 2011; 13:47-54. https://doi.org/10.1111/j.1463-1326.2010.01314.x PMid:21114603

11. Henry RR, Murray AV, Marmolejo MH, Hennicken D, Ptaszynska A, List JF. Dapagliflozin, Metformin XR, or both: initial pharmacotherapy for type 2 diabetes, a randomised controlled trial. Int J Clin Pract. 2012; 66:446-456. https://doi.org/10.1111/j.1742-1241.2012.02911.x PMid:22413962

12. Bailey CJ, Gross JL, Pieters A, Bastien A, List JF. Effect of Dapagliflozin in patients with type 2 diabetes who have inadequate glycaemic control with Metformin: a randomised, double-blind, placebo-controlled trial. Lancet. 2010; 375:2223-2233. https://doi.org/10.1016/S0140-6736(10)60407-2 PMid:20609968

13. Cheng L, Fu Q, Zhou L, Fan Y, Liu F, Fan Y, et al. Dapagliflozin, Metformin, monotherapy or both in patients with metabolic syndrome. Sci Rep. 2021; 11:24263. https://doi.org/10.1038/s41598-021-03773-z PMid:34930986 PMCid:PMC8688417

14. General Assembly of the World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J Am Coll Dent. 2014;81(3):14-18.

15. Que L, Qin W, Shi Y, et al. Pharmacokinetic comparison of sitagliptin and metformin HCl extended-release tablets versus JANUMET® XR in healthy volunteers under fasting and fed conditions. Front Pharmacol. 2023;14:1105767. Published 2023 Mar 22. https://doi.org/10.3389/fphar.2023.1105767 PMid:37033652 PMCid:PMC10073488