POM: Prescription only medicine
This information is intended for use by health professionals
Initial doseThe recommended starting dose is 30 mg daily.If blood glucose is effectively controlled, this dose may be used for maintenance treatment.If blood glucose is not adequately controlled, the dose may be increased to 60, 90 or 120 mg daily, in successive steps. The interval between each dose increment should be at least 1 month except in patients whose blood glucose has not reduced after two weeks of treatment. In such cases, the dose may be increased at the end of the second week of treatment.The maximum recommended daily dose is 120 mg.
Switching from gliclazide 80 mg tablets (immediate release formulation) to Nazdol MR 30 mg modified-release tablets1 tablet of gliclazide 80 mg is comparable to 1 modified-release tablet of Nazdol MR 30 mg. Consequently, the switch can be performed provided a careful blood glucose monitoring.
Switching from another oral antidiabetic agent to Nazdol MR modified-release tabletsNazdol MR modified-release tablets can be used to replace other oral antidiabetic agents.The dosage and the half-life of the previous antidiabetic agent should be taken into account when switching to Nazdol MR modified-release tablets.A transitional period is not generally necessary. A starting dose of 30 mg should be used and this should be adjusted to suit the patient's blood glucose response, as described above.When switching from a hypoglycaemic sulphonylurea with a prolonged half-life, a treatment free period of a few days may be necessary to avoid an additive effect of the two products, which might cause hypoglycaemia. The procedure described for initiating treatment should also be used when switching to treatment with Nazdol MR modified-release tablets, i.e. a starting dose of 30 mg/day, followed by a stepwise increase in dose, depending on the metabolic response.
Combination treatment with other antidiabetic agentsNazdol MR modified-release tablets can be given in combination with biguanides, alpha glucosidase inhibitors or insulin.In patients not adequately controlled with Nazdol MR modified-release tablets, concomitant insulin therapy can be initiated under close medical supervision.
Elderly patients (over 65)Nazdol MR modified-release tablets should be prescribed using the same dosing regimen recommended for patients under 65 years of age.
Patients with renal impairmentIn these patients, the same dosing regimen can be used as in patients with normal renal function with careful patient monitoring. These data have been confirmed in clinical trials.
Patients at risk of hypoglycaemiaHigher risk of hypoglycemia exists in following patients:• undernourished or malnourished,• severe or poorly compensated endocrine disorders (hypopituitarism, hypothyroidism, adrenocorticotrophic insufficiency),• withdrawal of prolonged and/or high dose corticosteroid therapy,• severe vascular disease (severe coronary heart disease, severe carotid impairment, diffuse vascular disease).It is recommended that the minimum daily starting dose of 30 mg is used. Paediatric populationThe safety and efficacy of Nazdol MR in children and adolescents have not been established. No data are available.
HypoglycaemiaThis treatment should be prescribed only if the patient is likely to have a regular food intake (including breakfast). It is important to have a regular carbohydrate intake due to the increased risk of hypoglycaemia if a meal is taken late, if an inadequate amount of food is consumed or if the food is low in carbohydrate. Hypoglycaemia is more likely to occur during low-calorie diets, following prolonged or strenuous exercise, alcohol intake or if a combination of hypoglycaemic agents is being used.Hypoglycaemia may occur following administration of sulphonylureas (see section 4.8). Some cases may be severe and prolonged. Hospitalisation may be necessary and glucose administration may need to be continued for several days.Careful selection of patients, of the dose used, and clear patient directions are necessary to reduce the risk of hypoglycaemic episodes.Factors which increase the risk of hypoglycaemia:• patient refuses or (particularly in elderly subjects) is unable to co-operate,• malnutrition, irregular mealtimes, skipping meals, periods of fasting or dietary changes,• imbalance between physical exercise and carbohydrate intake,• renal insufficiency,• severe hepatic insufficiency,• overdose of Nazdol MR modified-release tablets,• certain endocrine disorders: thyroid disorders, hypopituitarism and adrenal insufficiency,• concomitant administration of certain other medicinal products (see section 4.5). Renal and hepatic impairmentThe pharmacokinetics and/or pharmacodynamics of gliclazide may be altered in patients with hepatic insufficiency or severe renal failure. A hypoglycaemic episode occurring in these patients may be prolonged, so appropriate management should be initiated.
Patient informationThe risks of hypoglycaemia, together with its symptoms (see section 4.8), treatment, and conditions that predispose to its development, should be explained to the patient and to family members.The patient should be informed of the importance of following dietary advice, of taking regular exercise, and of regular monitoring of blood glucose levels.
Poor blood glucose controlBlood glucose control in a patient receiving antidiabetic treatment may be affected by any of the following: fever, trauma, infection or surgical intervention. In some cases, it may be necessary to administer insulin.The hypoglycaemic efficacy of any oral antidiabetic agent, including gliclazide, is attenuated over time in many patients: this may be due to progression in the severity of the diabetes, or to a reduced response to treatment. This phenomenon is known as secondary failure which is distinct from primary failure, when an active substance is ineffective as first-line treatment. Adequate dose adjustment and dietary compliance should be considered before classifying the patient as secondary failure.
Laboratory testsMeasurement of glycated haemoglobin levels (or fasting venous plasma glucose) is recommended in assessing blood glucose control. Blood glucose self-monitoring may also be useful.
ExcipientsNazdol MR modified-release tablets contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.Treatment of patients with G6PD-deficiency with sulfonylurea agents can lead to haemolytic anaemia. Since gliclazide belongs to the class of sulfonylurea drugs, caution should be used in patients with G6PD-deficiency and a non-sulfonylurea alternative should be considered.
The following products are likely to increase the risk of hypoglycaemia
Contra-indicated combination• Miconazole (systemic route, oromucosal gel): increases the hypoglycaemic effect with possible onset of hypoglycaemic symptoms, or even coma.
Combinations which are not recommended• Phenylbutazone (systemic route): increases the hypoglycaemic effect of sulphonylureas (displaces their binding to plasma proteins and/or reduces their elimination).It is preferable to use a different anti-inflammatory agent, or else to warn the patient and emphasise the importance of self-monitoring. Where necessary, adjust the dose during and after treatment with the anti-inflammatory agent.• Alcohol: increases the hypoglycaemic reaction (by inhibiting compensatory reactions) that can lead to the onset of hypoglycaemic coma.Alcohol or medicinal products containing alcohol should be avoided.
Combinations requiring precautions for usePotentiation of the blood glucose lowering effect and thus, in some instances, hypoglycaemia may occur when one of the following medicinal products is taken, for example: other antidiabetic agents (insulins, acarbose, matformin, thiazolidinediones, dipeptidyl peptidase-4 inhibitor, GLP-1 receptor agonists), beta-blockers, fluconazole, angiotensin converting enzyme inhibitors (captopril, enalapril), H2-receptor antagonists, MAOIs, sulfonamides, clarithromycin and nonsteroidal anti-inflammatory agents.
The following products may cause an increase in blood glucose levels
Combination which is not recommended• Danazol: diabetogenic effect of danazol.If the use of this active substance cannot be avoided, warn the patient and emphasise the importance of urine and blood glucose monitoring. It may be necessary to adjust the dose of the antidiabetic agent during and after treatment with danazol.
Combinations requiring precautions during use• Chlorpromazine (neuroleptic agent): high doses (>100 mg per day of chlorpromazine) increase blood glucose levels (reduced insulin release).Warn the patient and emphasise the importance of blood glucose monitoring. It may be necessary to adjust the dose of the antidiabetic active substance during and after treatment with the neuroleptic agent.• Glucocorticoids (systemic and local route: intra-articular, cutaneous and rectal preparations) and tetracosactrin: increase in blood glucose levels with possible ketosis (reduced tolerance to carbohydrates due to glucocorticoids).Warn the patient and emphasise the importance of blood glucose monitoring, particularly at the start of treatment. It may be necessary to adjust the dose of the antidiabetic active substance during and after treatment with glucocorticoids.• Ritodrine, salbutamol, terbutaline: intravenously.Increased blood glucose levels due to beta-2 agonist effects.Emphasise the importance of monitoring blood glucose levels. If necessary, switch to insulin.
Combination which must be taken into account• Anticoagulant therapy (e.g. warfarin):Sulphonylureas may lead to potentiation of anticoagulation during concurrent treatment. Adjustment of the anticoagulant may be necessary.
PregnancyThere is no experience with the use of gliclazide during pregnancy in humans, even though there are few data with other sulphonylureas.In animal studies, gliclazide is not teratogenic.Control of diabetes should be obtained before the time of conception to reduce the risk of congenital abnormalities linked to uncontrolled diabetes.Oral hypoglycaemic agents are not suitable; insulin is the agent of first choice for treatment of diabetes during pregnancy. It is recommended that oral hypoglycaemic therapy is changed to insulin before a pregnancy is attempted, or as soon as pregnancy is discovered.
Breast-feedingIt is not known whether gliclazide or its metabolites are excreted in breast milk. Given the risk of neonatal hypoglycaemia, the medicinal product is contra-indicated in breast-feeding mothers.
Other undesirable effectsGastrointestinal disturbances, including abdominal pain, nausea, vomiting, dyspepsia, diarrhoea, and constipation are uncommon: if these should occur, they can be avoided or minimised if gliclazide is taken with breakfast.The following undesirable effects have been more rarely reported:• Skin and subcutaneous tissue disorders: Rash, pruritus, urticaria, angioedema, erythema, maculopapular rashes, bullous reactions (such as Steven-Johnson syndrome and toxic epidermal necrolysis).• Blood and lymphatic system disorders: Changes in haematology are rare. They may include anaemia, leucopenia, thrombocytopenia, granulocytopenia. These are in general reversible upon discontinuation of gliclazide.• Hepato-biliary disorders: Raised hepatic enzyme levels (AST, ALT, alkaline phosphatase), hepatitis (isolated reports). Discontinue treatment if cholestatic jaundice appears.• Eye disorders: Transient visual disturbances may occur especially on initiation of treatment, due to changes in blood glucose levels.
Class attribution effectsAs for other sulphonylureas, the following adverse events have been observed: Cases of erythrocytopenia, agranulocytosis, haemolytic anaemia, pancytopenia and allergic vasculitis, hyponatraemia, elevated liver enzyme levels and even impairment of liver function (e.g. with cholestasis and jaundice) and hepatitis which regressed after withdrawal of the sulphonylurea or led to life-threatening liver failure in isolated cases.
Haemovascular properties:Gliclazide decreases microthrombosis by two mechanisms, which may be involved in complications of diabetes:• a partial inhibition of platelet aggregation and adhesion, with a decrease in the markers of platelet activation (beta thromboglobulin, thromboxane B2);• an action on the vascular endothelium fibrinolytic activity with an increase in tPA activity.
DistributionPlasma protein binding is approximately 95%. The volume of distribution is around 30 litres. A single daily dose of Nazdol MR modified-release tablets maintains effective gliclazide plasma concentrations over 24 hours.
BiotransformationGliclazide is mainly metabolised in the liver and excreted in the urine: less than 1% of the unchanged form is found in the urine. No active metabolites have been detected in plasma.
EliminationThe elimination half-life of gliclazide varies between 12 and 20 hours.
Linearity/non linearityThe relationship between the dose administered ranging up to 120 mg and the area under the concentration time curve is linear.
ElderlyNo clinically significant changes in pharmacokinetic parameters have been observed in elderly patients.