insulin glargine/lixisenatide (Rx)

Brand and Other Names:Soliqua 100/33
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Dosing & Uses

AdultPediatricGeriatric

Dosage Forms & Strengths

insulin glargine/lixisenatide

subcutaneous injection

  • (100units/33mcg) per mL
  • Available as a 3-mL single-use pen

Type 2 Diabetes Mellitus

Indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus

Starting dose

  • Discontinue basal insulin or GLP-1 agonist before initiating insulin glargine/lixisenatide
  • Patients who are naïve to basal insulin or GLP-1 agonists, currently on a GLP-1 receptor agonist, or on basal insulin <30 units/day: insulin glargine 15 units/lixisenatide 5 mcg SC qDay
  • Patients currently on basal insulin 30-60 units/day with or without a GLP-1 agonist: insulin glargine 30 units/lixisenatide 10 mcg SC qDay

Dose titration

  • May titrate dose upwards or downwards by 2-4 units of insulin glargine every week based on the patient’s metabolic needs, blood glucose monitoring results, and glycemic control goal until the desired fasting plasma glucose is achieved
  • To minimize the risk of hypoglycemia or hyperglycemia, additional titration may be needed with the following
    • Changes in physical activity, meal patterns (ie, macronutrient content or timing of food intake), or renal or hepatic function
    • During acute illness
    • When used with other medications

Dosage Modifications

Renal impairment

  • Mild-to-moderate: No dosage adjustment required; monitor for lixisenatide related adverse effects
  • Severe (eGFR 15 to <30 mL/min/1.73 m²): Closely monitor; may increase occurrence of lixisenatide-associated GI and renal adverse effects
  • ESRD (eGFR <15 mL/min/1.73 m²): Not studied; use not recommended

Hepatic impairment

  • Not studied
  • Frequent glucose monitoring and dose adjustment may be needed

Dosing Considerations

Discontinue therapy with lixisenatide or basal insulin prior to initiation

Limitations of use

  • Has not been studied in patients with a history of pancreatitis; consider other antidiabetic therapies
  • Not recommended in combination with any other product containing another GLP-1 receptor agonist
  • Not indicated for type 1 diabetes mellitus or treatment of diabetic ketoacidosis
  • Has not been studied in patients with gastroparesis and is not recommended in patients with gastroparesis
  • Has not been studied in combination with prandial insulin

<18 years: Safety and efficacy not established

Initial dosing, dose increments, and maintenance dosage should be conservative to avoid hypoglycemic reactions

Hypoglycemia may be more difficult to recognize in elderly individuals

Next:

Interactions

Interaction Checker

and insulin glargine/lixisenatide

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            Contraindicated (1)

            • pramlintide

              insulin glargine, pramlintide. Mechanism: unspecified interaction mechanism. Contraindicated. Must be administered separately.

            Serious - Use Alternative (2)

            • ethanol

              ethanol, insulin glargine. Other (see comment). Avoid or Use Alternate Drug. Comment: Alcohol may either increase or decrease the blood glucose lowering effect of insulin; alcohol may decrease endogenous glucose production (increased hypoglycemia risk) or worsen glycemic control by adding calories.

            • macimorelin

              insulin glargine, macimorelin. unspecified interaction mechanism. Avoid or Use Alternate Drug. Drugs that may transiently elevate growth hormone (GH) concentrations may impact the accuracy of the macimorelin diagnostic test. Allow sufficient washout time of drugs affecting GH release before administering macimorelin.

            Monitor Closely (137)

            • acarbose

              acarbose, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • acetaminophen

              lixisenatide will decrease the level or effect of acetaminophen by inhibition of GI absorption. Applies only to oral form of both agents. Modify Therapy/Monitor Closely. GLP1 agonists delay gastric emptying, which may affect absorption of concomitantly administered oral medications. No effects on acetaminophen Cmax and Tmax were observed when acetaminophen was administered 1 hr before lixisenatide. When administered 1 or 4 hr after lixisenatide, acetaminophen Cmax was decreased by 29% and 31% respectively and median Tmax was delayed by 2 and 1.75 hr, respectively.

            • albiglutide

              albiglutide, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • alogliptin

              alogliptin, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • aripiprazole

              aripiprazole, insulin glargine. Other (see comment). Use Caution/Monitor. Comment: Atypical antipsychotics have been associated with hyperglycemia that may alter blood glucose control; monitor glucose levels closely.

            • asenapine

              asenapine, insulin glargine. Other (see comment). Use Caution/Monitor. Comment: Atypical antipsychotics have been associated with hyperglycemia that may alter blood glucose control; monitor glucose levels closely.

            • aspirin

              aspirin increases effects of insulin glargine by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of insulin with high doses of salicylates (3 g/day or more) may increase risk for hypoglycemia. Insulin dose adjustment and increased frequency of glucose monitoring may be required.

            • atazanavir

              atazanavir decreases effects of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Reports of hyperglycemia due to insulin resistance with protease inhibitors. .

            • azilsartan

              azilsartan increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and ARBs may require insulin dosage adjustment and increased glucose monitoring.

            • benazepril

              benazepril increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor. Enhanced hypoglycemic effects; Monitor blood glucose.

            • bitter melon

              bitter melon increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor. Risk of hypoglycemia.

            • canagliflozin

              insulin glargine, canagliflozin. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Consider a lower dose of insulin or insulin secretagogue to avoid hypoglycemia when coadministered with canagliflozin.

              canagliflozin, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • candesartan

              candesartan increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and ARBs may require insulin dosage adjustment and increased glucose monitoring.

            • captopril

              captopril increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor. Both drugs decrease blood glucose. Monitor blood glucose.

            • chlorpropamide

              chlorpropamide, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

              lixisenatide, chlorpropamide. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Risk of hypoglycemia increased when coadministered with sulfonylureas. Sulfonylurea dosage reduction may be required.

            • cinnamon

              cinnamon increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor. Potential for hypoglycemia.

            • dienogest/estradiol valerate

              lixisenatide will decrease the level or effect of dienogest/estradiol valerate by inhibition of GI absorption. Applies only to oral form of both agents. Modify Therapy/Monitor Closely. GLP1 agonists delay gastric emptying, which may affect absorption of concomitantly administered oral medications. Oral contraceptives should be taken at least 1 hr before lixisenatide administration or 11 hr after lixisenatide.

            • ciprofibrate

              ciprofibrate increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Hypoglycemia; increased risk in hypoalbuminemia.

            • clozapine

              clozapine, insulin glargine. Other (see comment). Use Caution/Monitor. Comment: Atypical antipsychotics have been associated with hyperglycemia that may alter blood glucose control; monitor glucose levels closely.

            • dapagliflozin

              insulin glargine, dapagliflozin. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Consider a lower dose of insulin or insulin secretagogue to avoid hypoglycemia when coadministered with dapagliflozin.

              dapagliflozin, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • darunavir

              darunavir decreases effects of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Reports of hyperglycemia due to insulin resistance with protease inhibitors. .

            • deflazacort

              insulin glargine and deflazacort both decrease serum potassium. Use Caution/Monitor.

            • dexfenfluramine

              dexfenfluramine increases effects of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Dexfenfluramine enhances glucose uptake in peripheral tissue, increasing risk of hypoglycemia.

            • dichlorphenamide

              dichlorphenamide and insulin glargine both decrease serum potassium. Use Caution/Monitor.

            • disopyramide

              disopyramide increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and disopyramide may require insulin dosage adjustment and increased glucose monitoring.

            • dulaglutide

              dulaglutide, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • empagliflozin

              empagliflozin, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Consider a lower dose of insulin or insulin secretagogue to avoid hypoglycemia when coadministered with SGLT2 inhibitors.

            • enalapril

              enalapril increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor.

            • eprosartan

              eprosartan increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and ARBs may require insulin dosage adjustment and increased glucose monitoring.

            • ertugliflozin

              ertugliflozin, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Consider a lower dose of insulin or insulin secretagogue to avoid hypoglycemia when coadministered with ertugliflozin.

            • ethinylestradiol

              lixisenatide will decrease the level or effect of ethinylestradiol by inhibition of GI absorption. Applies only to oral form of both agents. Modify Therapy/Monitor Closely. GLP1 agonists delay gastric emptying, which may affect absorption of concomitantly administered oral medications. Oral contraceptives should be taken at least 1 hr before lixisenatide administration or 11 hr after lixisenatide.

              ethinylestradiol decreases effects of insulin glargine by pharmacodynamic antagonism. Use Caution/Monitor. Oral contraceptives may decrease hypoglycemic effects of antidiabetics by impairing glucose tolerance. Monitor for glycemic control in diabetic patients.

            • exenatide injectable solution

              exenatide injectable solution, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • glimepiride

              lixisenatide, glimepiride. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Risk of hypoglycemia increased when coadministered with sulfonylureas. Sulfonylurea dosage reduction may be required.

            • exenatide injectable suspension

              exenatide injectable suspension, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • fenfluramine

              fenfluramine increases effects of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Fenfluramine enhances glucose uptake in peripheral tissue, increasing risk of hypoglycemia.

            • fenofibrate

              fenofibrate increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Hypoglycemia; increased risk in hypoalbuminemia.

            • fenofibrate micronized

              fenofibrate micronized increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Hypoglycemia; increased risk in hypoalbuminemia.

            • fenofibric acid

              fenofibric acid increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Hypoglycemia; increased risk in hypoalbuminemia.

            • fleroxacin

              fleroxacin increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor. Quinolone antibiotic administration may result in hyper- or hypoglycemia. Gatifloxacin is most likely to produce dysglycemia; moxifloxacin is least likely.

            • fluoxetine

              fluoxetine increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and fluoxetine may require insulin dosage adjustment and increased glucose monitoring.

            • fosamprenavir

              fosamprenavir decreases effects of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Reports of hyperglycemia due to insulin resistance with protease inhibitors. .

            • fosinopril

              fosinopril increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor.

            • gemfibrozil

              gemfibrozil increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Hypoglycemia; increased risk in hypoalbuminemia.

            • gemifloxacin

              gemifloxacin increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor. Quinolone antibiotic administration may result in hyper- or hypoglycemia. Gatifloxacin is most likely to produce dysglycemia; moxifloxacin is least likely.

            • glimepiride

              glimepiride, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • glipizide

              lixisenatide, glipizide. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Risk of hypoglycemia increased when coadministered with sulfonylureas. Sulfonylurea dosage reduction may be required.

              glipizide, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • glucagon

              glucagon decreases effects of insulin glargine by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

            • glyburide

              lixisenatide, glyburide. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Risk of hypoglycemia increased when coadministered with sulfonylureas. Sulfonylurea dosage reduction may be required.

            • glucagon intranasal

              glucagon intranasal decreases effects of insulin glargine by pharmacodynamic antagonism. Use Caution/Monitor. Endogenous glucagon is a regulatory hormone that increases blood glucose levels; exogenous glucagon is often used to treat hypoglycemia in patients with diabetes mellitus.

            • glyburide

              glyburide, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • iloperidone

              iloperidone, insulin glargine. Other (see comment). Use Caution/Monitor. Comment: Atypical antipsychotics have been associated with hyperglycemia that may alter blood glucose control; monitor glucose levels closely.

            • imidapril

              imidapril increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor.

            • indinavir

              indinavir decreases effects of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Reports of hyperglycemia due to insulin resistance with protease inhibitors. .

            • insulin degludec

              lixisenatide, insulin degludec. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Risk of hypoglycemia increased when coadministered with basal insulins. Basal insulin dose reduction may be required.

            • insulin detemir

              lixisenatide, insulin detemir. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Risk of hypoglycemia increased when coadministered with basal insulins. Basal insulin dose reduction may be required.

            • insulin glargine

              lixisenatide, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Risk of hypoglycemia increased when coadministered with basal insulins. Basal insulin dose reduction may be required.

            • irbesartan

              irbesartan increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and ARBs may require insulin dosage adjustment and increased glucose monitoring.

            • isocarboxazid

              isocarboxazid increases effects of insulin glargine by unknown mechanism. Use Caution/Monitor.

            • ketotifen, ophthalmic

              ketotifen, ophthalmic, insulin glargine. Other (see comment). Use Caution/Monitor. Comment: Combination may result in thrombocytopenia (rare). Monitor CBC.

            • lanreotide

              lanreotide increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and somatostatin analogs may require insulin dosage adjustment and increased glucose monitoring.

            • levofloxacin

              levofloxacin increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor. Quinolone antibiotic administration may result in hyper- or hypoglycemia. Gatifloxacin is most likely to produce dysglycemia; moxifloxacin is least likely.

            • levonorgestrel oral/ethinylestradiol/ferrous bisglycinate

              lixisenatide will decrease the level or effect of levonorgestrel oral/ethinylestradiol/ferrous bisglycinate by inhibition of GI absorption. Applies only to oral form of both agents. Modify Therapy/Monitor Closely. GLP1 agonists delay gastric emptying, which may affect absorption of concomitantly administered oral medications. Oral contraceptives should be taken at least 1 hr before lixisenatide administration or 11 hr after lixisenatide.

            • linagliptin

              linagliptin, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • linezolid

              linezolid increases effects of insulin glargine by unknown mechanism. Use Caution/Monitor.

            • liraglutide

              liraglutide, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • lisinopril

              lisinopril increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor.

            • lithium

              lithium, insulin glargine. unspecified interaction mechanism. Use Caution/Monitor. Lithium salts may cause either hypoglycemia or hyperglycemia. Insulin dosage adjustment and increased glucose monitoring may be required.

            • lixisenatide

              lixisenatide, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Risk of hypoglycemia increased when coadministered with basal insulins. Basal insulin dose reduction may be required.

            • lopinavir

              lopinavir decreases effects of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Reports of hyperglycemia due to insulin resistance with protease inhibitors. .

            • losartan

              losartan increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and ARBs may require insulin dosage adjustment and increased glucose monitoring.

            • lurasidone

              lurasidone, insulin glargine. Other (see comment). Use Caution/Monitor. Comment: Atypical antipsychotics have been associated with hyperglycemia that may alter blood glucose control; monitor glucose levels closely.

            • magnesium salicylate

              magnesium salicylate increases effects of insulin glargine by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of insulin with high doses of salicylates (3 g/day or more) may increase risk for hypoglycemia. Insulin dose adjustment and increased frequency of glucose monitoring may be required.

            • marijuana

              marijuana decreases effects of insulin glargine by pharmacodynamic antagonism. Use Caution/Monitor.

            • mecasermin

              mecasermin increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor. Additive hypoglycemic effects.

            • mestranol

              lixisenatide will decrease the level or effect of mestranol by inhibition of GI absorption. Applies only to oral form of both agents. Modify Therapy/Monitor Closely. GLP1 agonists delay gastric emptying, which may affect absorption of concomitantly administered oral medications. Oral contraceptives should be taken at least 1 hr before lixisenatide administration or 11 hr after lixisenatide.

            • metformin

              metformin, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • methyltestosterone

              methyltestosterone increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor. It is important to monitor all patients with type 2 diabetes on antidiabetic agents receiving androgens for changes in glycemic control. Potential for hypoglycemia.

            • metoclopramide intranasal

              metoclopramide intranasal increases effects of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Increased GI motility by metoclopramide may increase delivery of food to the intestines and increase blood glucose. Monitor blood glucose and adjust insulin dosage regimen as needed.

            • metreleptin

              insulin glargine, metreleptin. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Coadministration of metreleptin with insulin and/or insulin secretagogues (eg, sulfonylureas, meglitinide derivatives) may increase risk for hypoglycemia; may require lower dose of insulin or insulin secretagogue.

            • miglitol

              miglitol, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • moexipril

              moexipril increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor.

            • moxifloxacin

              moxifloxacin increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor. Quinolone antibiotic administration may result in hyper- or hypoglycemia. Gatifloxacin is most likely to produce dysglycemia; moxifloxacin is least likely.

            • nadolol

              nadolol, insulin glargine. Mechanism: pharmacodynamic antagonism. Use Caution/Monitor. Non selective beta blockers delay recovery of normoglycemia after insulin induced hypoglycemia; however, they also inhibit insulin secretion, so long term beta blocker Tx may result in reduced glucose tolerance. Insulin induced hypoglycemia may induce hypertension during non selective beta blocker Tx.

            • nateglinide

              nateglinide, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • nelfinavir

              nelfinavir decreases effects of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Reports of hyperglycemia due to insulin resistance with protease inhibitors. .

            • niacin

              niacin decreases effects of insulin glargine by pharmacodynamic antagonism. Use Caution/Monitor. Concomitant use of insulin and niacin may require insulin dosage adjustment and increased glucose monitoring.

            • octreotide

              octreotide increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and somatostatin analogs may require insulin dosage adjustment and increased glucose monitoring.

            • ofloxacin

              ofloxacin increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor. Quinolone antibiotic administration may result in hyper- or hypoglycemia. Gatifloxacin is most likely to produce dysglycemia; moxifloxacin is least likely.

            • olanzapine

              olanzapine, insulin glargine. Other (see comment). Use Caution/Monitor. Comment: Atypical antipsychotics have been associated with hyperglycemia that may alter blood glucose control; monitor glucose levels closely.

            • olmesartan

              olmesartan increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and ARBs may require insulin dosage adjustment and increased glucose monitoring.

            • opuntia ficus indica

              opuntia ficus indica increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor.

            • paliperidone

              paliperidone, insulin glargine. Other (see comment). Use Caution/Monitor. Comment: Atypical antipsychotics have been associated with hyperglycemia that may alter blood glucose control; monitor glucose levels closely.

            • pasireotide

              pasireotide increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and somatostatin analogs may require insulin dosage adjustment and increased glucose monitoring.

            • pentamidine

              pentamidine, insulin glargine. unspecified interaction mechanism. Use Caution/Monitor. Pentamidine may cause either hypoglycemia or hyperglycemia followed by the opposing effect. Insulin dosage adjustment and increased glucose monitoring may be required.

            • perindopril

              perindopril increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor.

            • phenelzine

              phenelzine increases effects of insulin glargine by unknown mechanism. Use Caution/Monitor.

            • pindolol

              pindolol, insulin glargine. Mechanism: pharmacodynamic antagonism. Use Caution/Monitor. Non selective beta blockers delay recovery of normoglycemia after insulin induced hypoglycemia; however, they also inhibit insulin secretion, so long term beta blocker Tx may result in reduced glucose tolerance. Insulin induced hypoglycemia may induce hypertension during non selective beta blocker Tx.

            • pioglitazone

              insulin glargine increases toxicity of pioglitazone by unknown mechanism. Use Caution/Monitor. Insulin may increase the fluid retention associated with thiazolidinediones (peroxisome proliferator-activated receptor [PPAR]-gamma agonists).

              pioglitazone, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • procarbazine

              procarbazine increases effects of insulin glargine by unknown mechanism. Use Caution/Monitor.

            • propranolol

              propranolol, insulin glargine. Mechanism: pharmacodynamic antagonism. Use Caution/Monitor. Non selective beta blockers delay recovery of normoglycemia after insulin induced hypoglycemia; however, they also inhibit insulin secretion, so long term beta blocker Tx may result in reduced glucose tolerance. Insulin induced hypoglycemia may induce hypertension during non selective beta blocker Tx.

            • pseudoephedrine

              pseudoephedrine decreases effects of insulin glargine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Sympathomimetics increase blood glucose by stimulating alpha and beta receptors; this action results in increased hepatic glucose production, glycogenolysis, and decreased insulin secretion.

            • quetiapine

              quetiapine, insulin glargine. Other (see comment). Use Caution/Monitor. Comment: Atypical antipsychotics have been associated with hyperglycemia that may alter blood glucose control; monitor glucose levels closely.

            • quinapril

              quinapril increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor.

            • ramipril

              ramipril increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor.

            • rasagiline

              rasagiline increases effects of insulin glargine by unknown mechanism. Use Caution/Monitor.

            • risperidone

              risperidone, insulin glargine. Other (see comment). Use Caution/Monitor. Comment: Atypical antipsychotics have been associated with hyperglycemia that may alter blood glucose control; monitor glucose levels closely.

            • ritonavir

              ritonavir decreases effects of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Reports of hyperglycemia due to insulin resistance with protease inhibitors. .

            • rosiglitazone

              insulin glargine increases toxicity of rosiglitazone by unknown mechanism. Use Caution/Monitor. Insulin may increase the fluid retention associated with thiazolidinediones (peroxisome proliferator-activated receptor [PPAR]-gamma agonists).

              rosiglitazone, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • sacubitril/valsartan

              sacubitril/valsartan increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and ARBs may require insulin dosage adjustment and increased glucose monitoring.

            • salsalate

              salsalate increases effects of insulin glargine by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of insulin with high doses of salicylates (3 g/day or more) may increase risk for hypoglycemia. Insulin dose adjustment and increased frequency of glucose monitoring may be required.

            • saquinavir

              saquinavir decreases effects of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Reports of hyperglycemia due to insulin resistance with protease inhibitors. .

            • saxagliptin

              saxagliptin, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • selegiline

              selegiline increases effects of insulin glargine by unknown mechanism. Use Caution/Monitor.

            • semaglutide

              semaglutide, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Coadministration of insulin with GLP-1 agonists may increase hypoglycemia risk. Lowering the insulin dose may reduce hypoglycemia risk.

            • shark cartilage

              shark cartilage increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor. Theoretical interaction.

            • sitagliptin

              sitagliptin, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • sodium sulfate/?magnesium sulfate/potassium chloride

              sodium sulfate/?magnesium sulfate/potassium chloride increases toxicity of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Coadministration with medications that cause fluid and electrolyte abnormalities may increase the risk of adverse events of seizure, arrhythmias, and renal impairment.

            • sodium sulfate/potassium sulfate/magnesium sulfate

              sodium sulfate/potassium sulfate/magnesium sulfate increases toxicity of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Coadministration with medications that cause fluid and electrolyte abnormalities may increase the risk of adverse events of seizure, arrhythmias, and renal impairment.

            • sodium sulfate/potassium sulfate/magnesium sulfate/polyethylene glycol

              insulin glargine and sodium sulfate/potassium sulfate/magnesium sulfate/polyethylene glycol both decrease serum potassium. Modify Therapy/Monitor Closely.

            • somapacitan

              somapacitan decreases effects of lixisenatide by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Growth hormone products may decrease insulin sensitivity, particularly at higher doses. Antidiabetic agents may require dose adjustment after initiating somapacitan. .

              somapacitan decreases effects of insulin glargine by pharmacodynamic antagonism. Modify Therapy/Monitor Closely. Growth hormone products may decrease insulin sensitivity, particularly at higher doses. Antidiabetic agents may require dose adjustment after initiating somapacitan. .

            • somatropin

              somatropin decreases effects of insulin glargine by pharmacodynamic antagonism. Use Caution/Monitor.

            • tolazamide

              lixisenatide, tolazamide. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Risk of hypoglycemia increased when coadministered with sulfonylureas. Sulfonylurea dosage reduction may be required.

            • sulfadiazine

              sulfadiazine increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and sulfonamide antibiotics may require insulin dosage adjustment and increased glucose monitoring.

            • sulfamethoxypyridazine

              sulfamethoxypyridazine increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Risk of hypoglycemia.

            • sulfisoxazole

              sulfisoxazole increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and sulfonamide antibiotics may require insulin dosage adjustment and increased glucose monitoring.

            • telmisartan

              telmisartan increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and ARBs may require insulin dosage adjustment and increased glucose monitoring.

            • testosterone intranasal

              testosterone intranasal increases effects of insulin glargine by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Androgens may decrease blood glucose and, therefore, may necessitate a decrease in the dose of antidiabetic medication.

            • timolol

              timolol, insulin glargine. Mechanism: pharmacodynamic antagonism. Use Caution/Monitor. Non selective beta blockers delay recovery of normoglycemia after insulin induced hypoglycemia; however, they also inhibit insulin secretion, so long term beta blocker Tx may result in reduced glucose tolerance. Insulin induced hypoglycemia may induce hypertension during non selective beta blocker Tx.

            • tipranavir

              tipranavir decreases effects of insulin glargine by Other (see comment). Use Caution/Monitor. Comment: Reports of hyperglycemia due to insulin resistance with protease inhibitors. .

            • tolazamide

              tolazamide, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • tolbutamide

              lixisenatide, tolbutamide. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Risk of hypoglycemia increased when coadministered with sulfonylureas. Sulfonylurea dosage reduction may be required.

              tolbutamide, insulin glargine. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Antidiabetic agents are often used in combination; dosage adjustments may be required when initiating or discontinuing antidiabetic agents.

            • trandolapril

              trandolapril increases effects of insulin glargine by pharmacodynamic synergism. Use Caution/Monitor.

            • tranylcypromine

              tranylcypromine increases effects of insulin glargine by unknown mechanism. Use Caution/Monitor.

            • triamcinolone acetonide injectable suspension

              triamcinolone acetonide injectable suspension decreases effects of insulin glargine by pharmacodynamic antagonism. Use Caution/Monitor. Corticosteroids may diminish hypoglycemic effect of antidiabetic agents. Monitor blood glucose levels carefully.

            • valsartan

              valsartan increases effects of insulin glargine by unspecified interaction mechanism. Use Caution/Monitor. Concomitant use of insulin and ARBs may require insulin dosage adjustment and increased glucose monitoring.

            • xipamide

              xipamide decreases levels of insulin glargine by increasing renal clearance. Use Caution/Monitor.

            • ziprasidone

              ziprasidone, insulin glargine. Other (see comment). Use Caution/Monitor. Comment: Atypical antipsychotics have been associated with hyperglycemia that may alter blood glucose control; monitor glucose levels closely.

            Minor (76)

            • agrimony

              agrimony increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • American ginseng

              American ginseng increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • amitriptyline

              amitriptyline increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • amoxapine

              amoxapine increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • anamu

              anamu increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Theoretical interaction.

            • aspirin/citric acid/sodium bicarbonate

              aspirin/citric acid/sodium bicarbonate increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Large dose of salicylate.

            • balsalazide

              balsalazide increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Large dose of salicylate.

            • bendroflumethiazide

              bendroflumethiazide decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown. Thiazide dosage >50 mg/day may increase blood glucose.

            • bexarotene

              bexarotene increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • budesonide

              budesonide decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown.

            • chlorothiazide

              chlorothiazide decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown. Thiazide dosage >50 mg/day may increase blood glucose.

            • chlorthalidone

              chlorthalidone decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown. Thiazide dosage >50 mg/day may increase blood glucose.

            • chromium

              chromium increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • clomipramine

              clomipramine increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • clonidine

              clonidine, insulin glargine. Other (see comment). Minor/Significance Unknown. Comment: Decreased symptoms of hypoglycemia. Mechanism: decreased hypoglycemia induced catecholamine production.

              clonidine decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown. Diminished symptoms of hypoglycemia.

            • coenzyme Q10

              coenzyme Q10 increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Monitor insulin requirements.

            • cornsilk

              cornsilk increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Increased risk of hypoglycemia (theoretical interaction).

            • cortisone

              cortisone decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown.

            • cyclopenthiazide

              cyclopenthiazide decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown. Thiazide dosage >50 mg/day may increase blood glucose.

            • damiana

              damiana decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown. Theoretical interaction.

            • danazol

              danazol increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • deflazacort

              deflazacort decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown.

            • desipramine

              desipramine increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • devil's claw

              devil's claw increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • dexamethasone

              dexamethasone decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown.

            • diflunisal

              diflunisal increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Large dose of salicylate.

            • doxepin

              doxepin increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • elderberry

              elderberry increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Increased risk of hypoglycemia (in vitro research).

            • eucalyptus

              eucalyptus increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Theoretical interaction.

            • fludrocortisone

              fludrocortisone decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown.

            • fluoxymesterone

              fluoxymesterone increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • fo-ti

              fo-ti increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • forskolin

              forskolin increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Colenol, a compound found in Coleus root, may stimulate insulin release.

            • gotu kola

              gotu kola increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. (Theoretical interaction).

            • guanfacine

              guanfacine, insulin glargine. Other (see comment). Minor/Significance Unknown. Comment: Decreased symptoms of hypoglycemia. Mechanism: decreased hypoglycemia induced catecholamine production.

              guanfacine decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown. Diminished symptoms of hypoglycemia.

            • gymnema

              gymnema increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • horse chestnut seed

              horse chestnut seed increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • hydrochlorothiazide

              hydrochlorothiazide decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown. Thiazide dosage >50 mg/day may increase blood glucose.

            • hydrocortisone

              hydrocortisone decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown.

            • imipramine

              imipramine increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • indapamide

              indapamide decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown. Thiazide dosage >50 mg/day may increase blood glucose.

            • isoniazid

              isoniazid decreases effects of insulin glargine by unspecified interaction mechanism. Minor/Significance Unknown.

            • juniper

              juniper increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Increased risk of hypoglycemia (theoretical interaction).

            • lofepramine

              lofepramine increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • lycopus

              lycopus increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Increased risk of hypoglycemia (theoretical interaction).

            • maitake

              maitake increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Increased risk of hypoglycemia (animal research).

            • maprotiline

              maprotiline increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • mesalamine

              mesalamine increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Large dose of salicylate.

            • mesterolone

              mesterolone increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • methylprednisolone

              methylprednisolone decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown.

            • metolazone

              metolazone decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown. Thiazide dosage >50 mg/day may increase blood glucose.

            • nettle

              nettle increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. (Theoretical interaction).

            • nortriptyline

              nortriptyline increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • ofloxacin

              ofloxacin, insulin glargine. Mechanism: unspecified interaction mechanism. Minor/Significance Unknown. Potential dysglycemia.

            • oxandrolone

              oxandrolone increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • oxymetholone

              oxymetholone increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • panax ginseng

              panax ginseng increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • pegvisomant

              pegvisomant increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • potassium acid phosphate

              potassium acid phosphate increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Interaction especially seen in the treatment of hypokalemia.

            • potassium chloride

              potassium chloride increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Interaction especially seen in the treatment of hypokalemia.

            • potassium citrate

              potassium citrate increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Interaction especially seen in the treatment of hypokalemia.

            • prednisolone

              prednisolone decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown.

            • prednisone

              prednisone decreases effects of insulin glargine by pharmacodynamic antagonism. Minor/Significance Unknown.

            • protriptyline

              protriptyline increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • sage

              sage increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • salicylates (non-asa)

              salicylates (non-asa) increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Large dose of salicylate.

            • Siberian ginseng

              Siberian ginseng increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • sulfasalazine

              sulfasalazine increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Large dose of salicylate.

            • testosterone

              testosterone increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • testosterone buccal system

              testosterone buccal system increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • testosterone topical

              testosterone topical increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • tongkat ali

              tongkat ali increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Risk of hypoglycemia.

            • trazodone

              trazodone increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • trimipramine

              trimipramine increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • vanadium

              vanadium increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown.

            • willow bark

              willow bark increases effects of insulin glargine by pharmacodynamic synergism. Minor/Significance Unknown. Large dose of salicylate.

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            Adverse Effects

            >10%

            Documented symptomatic hypoglycemia (25.6-40%)

            1-10%

            Nausea (10%)

            Nasopharyngitis (7%)

            Diarrhea (7%)

            Upper respiratory tract infection (5.5%)

            Headache (5.4%)

            Severe symptomatic hypoglycemia (1.1%)

            Injection site reactions (1.7%)

            <1%

            Anaphylaxis

            Frequency Not Defined

            Lipodystrophy

            Peripheral edema

            Weight gain

            Immunogenicity

            Localized cutaneous amyloidosis at the injection site

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            Warnings

            Contraindications

            During episodes of hypoglycemia

            Hypersensitivity to either of the active drugs or any excipients

            Cautions

            Anaphylaxis reported; severe, life-threatening, generalized allergic reactions, including anaphylaxis, generalized skin reactions, angioedema, bronchospasm, hypotension, and shock reported; inform and closely monitor patients with a history of anaphylaxis or angioedema with another GLP-1 receptor agonist for allergic reactions; unknown whether such patients will be predisposed to anaphylaxis

            Do not share insulin pens between patients

            Caution when changing dosage regimens; increase frequency of blood glucose monitoring to detect hypoglycemia or hyperglycemia

            Do not exceed maximum dose or use with other GLP-1 agonists or basal insulins

            No clinical studies have established conclusive evidence of macrovascular risk reduction with any antidiabetic drugs

            Kidney injury

            • Acute kidney injury and worsening of chronic renal failure, which may sometimes require hemodialysis, has been reported post marketing in patients treated with the 100/33 formulation
            • Some of these events were reported in patients without known underlying renal disease; majority of reported events occurred in patients who had experienced nausea, vomiting, diarrhea, or dehydration
            • Monitor renal function when initiating or escalating doses of the 100/33 formulation in patients with renal impairment and in patients reporting severe gastrointestinal reactions
            • Advise patients of potential risk of dehydration due to gastrointestinal adverse reactions and take precautions to avoid fluid depletion; the 100/33 formulation is not recommended in patients with end-stage renal disease

            Medication errors

            • The 100/33 formulation contains two drugs: insulin glargine and lixisenatide; daily administration of more than 60 units of the 100/33 formulation can result in overdose of the lixisenatide component
            • Do not exceed the 20-mcg maximum recommended dose of lixisenatide or use with other glucagon­like peptide-1 receptor agonists
            • Accidental mix-ups between insulin products reported; to avoid medication errors between the 100/33 formulation and other insulins, instruct patients to always check the insulin label before each injection

            Immunogenicity

            • Patients may develop antibodies to insulin and lixisenatide following treatment
            • Attenuated glycemic response reported in patients with the highest antibody concentrations (>100 nmol/L); a higher incidence of allergic reactions and injection-site reactions reported in antibody positive patients
            • Consider alternative antidiabetic therapy if there is worsening glycemic control or failure to achieve targeted glycemic control, significant injection-site reactions or allergic reactions

            Pancreatitis

            • Acute pancreatitis, including fatal and nonfatal hemorrhagic or necrotizing pancreatitis, reported postmarketing
            • After initiation therapy, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back and which may or may not be accompanied by vomiting)
            • If pancreatitis suspected, promptly discontinue therapy and initiate appropriate management; if confirmed, restarting drug not recommended; consider antidiabetic therapies other than this drug in patients with a history of pancreatitis

            Hypokalemia

            • All insulin-containing products, including the 100/33 formulation, cause a shift in potassium from extracellular to intracellular space, possibly leading to hypokalemia
            • Untreated hypokalemia may cause respiratory paralysis, ventricular arrhythmia, and death; monitor potassium levels in patients at risk for hypokalemia if indicated (eg, patients using potassium-lowering medications, patients taking medications sensitive to serum potassium concentrations)

            Fluid retention

            • Increased risk of fluid retention and CHF with coadministration of peroxisome proliferator-activated receptor (PPAR)-gamma agonists (eg, thiazolidinediones)
            • Thiazolidinediones (TZDs), which are peroxisome proliferator-activated receptor (PPAR)­gamma agonists, can cause dose-related fluid retention, particularly when used in combination with insulin-containing products
            • Fluid retention may lead to or exacerbate heart failure; patients treated with the 100/33 formulation and a PPAR-gamma agonist should be observed for signs and symptoms of heart failure
            • If heart failure develops, it should be managed according to current standards of care, and discontinuation or dose reduction of the PPAR-gamma agonist must be considered

            Hyperglycemia or hypoglycemia with changes in insulin regimen

            • Changes in insulin, insulin strength, manufacturer, type, or method of administration may affect glycemic control and predispose to hypoglycemia or hyperglycemia
            • Hypoglycemia is the most common adverse effect of insulin; self-monitoring of blood glucose is essential to prevent and manage hypoglycemia
            • Severe hypoglycemia can cause seizures, may be life-threatening or cause death
            • Hypoglycemia can impair concentration ability and reaction time; this may place an individual and others at risk in situations where these abilities are important (eg, driving or operating other machinery
            • Changes should be made cautiously and only under close medical supervision and frequency of blood glucose monitoring should be increased
            • Repeated insulin injections into areas of lipodystrophy or localized cutaneous amyloidosis reported to result in hyperglycemia; a sudden change in the injection site (to unaffected area) has been reported to result in hypoglycemia
            • Insulin, should not be used during episodes of hypoglycemia; hypoglycemia can happen suddenly, and symptoms may differ in each individual and change over time in the same individual
            • Make any changes to a patient’s insulin regimen under close medical supervision with increased frequency of blood glucose monitoring
            • Symptomatic awareness of hypoglycemia may be less pronounced in patients with longstanding diabetes, in patients with diabetic nerve disease, or in patients who experience recurrent hypoglycemia
            • Advise patients who have repeatedly injected into areas of lipodystrophy or localized cutaneous amyloidosis to change injection site to unaffected areas and closely monitor for hypoglycemia
            • Risk of hypoglycemia generally increases with intensity of glycemic control; risk of hypoglycemia after an injection is related to duration of action of insulin and, in general, is highest when glucose lowering effect of insulin is maximal
            • As with all insulin-containing preparations, the glucose lowering effect time course of the 100/33 formulation may vary in different individuals or at different times in the same individual and depends on many conditions, including the area of injection as well as the injection-site blood supply and temperature
            • Other factors which may increase the risk of hypoglycemia include changes in meal pattern (eg, macronutrient content or timing of meals), changes in level of physical activity, or changes to coadministered medication; patients with renal or hepatic impairment may be at higher risk of hypoglycemia
            • Patients and caregivers must be educated to recognize and manage hypoglycemia; self-monitoring of blood glucose plays an essential role in prevention and management of hypoglycemia; in patients at higher risk for hypoglycemia and patients who have reduced symptomatic awareness of hypoglycemia, increased frequency of blood glucose monitoring recommended
            • The long-acting effect of insulin glargine may delay recovery from hypoglycemia
            • For patients with type 2 diabetes, dosage adjustments in concomitant oral antidiabetic treatment may be needed

            Drug interaction overview

            • Drugs that may increase hypoglycemia risk
              • May require dose reduction and increased glucose monitoring frequency if coadministered with drugs that cause hypoglycemia
              • Examples include antidiabetic agents, ACE inhibitors, angiotensin II receptor blocking agents, disopyramide, fibrates, fluoxetine, monoamine oxidase inhibitors, pentoxifylline, pramlintide, propoxyphene, salicylates, somatostatin analogs (eg, octreotide), and sulfonamide antibiotics
            • Drug that may decrease blood glucose-lowering effect of lixisenatide/insulin glargine
              • May require dose increase and increased glucose monitoring frequency if coadministered with drugs that increase blood glucose
              • Examples include atypical antipsychotics (eg, olanzapine and clozapine), corticosteroids, danazol, diuretics, estrogens, glucagon, isoniazid, niacin, oral contraceptives, phenothiazines, progestogens (eg, in oral contraceptives), protease inhibitors, somatropin, sympathomimetic agents (eg, albuterol, epinephrine, terbutaline), and thyroid hormones
            • Drugs that may increase or decrease the blood glucose-lowering effects of lixisenatide/insulin glargine
              • Dose adjustment in increased blood glucose monitoring may be required
              • Examples include alcohol, beta-blockers, clonidine, and lithium salts; pentamidine may cause hypoglycemia, which may sometimes be followed by hyperglycemia
            • Drugs that may blunt signs and symptoms of hypoglycemia
              • Increase frequency of blood glucose monitoring
              • Examples include beta-blockers, clonidine, guanethidine, and reserpine
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            Pregnancy

            Pregnancy

            Based on animal reproduction studies, there may be risks to the fetus from exposure to lixisenatide during pregnancy

            Use during pregnancy only if the potential benefit justifies the potential risk to the fetus

            There are no available data with use in pregnant women to inform a drug-associated risk for major birth defects or miscarriage

            There are clinical considerations regarding the risks of poorly controlled diabetes in pregnancy

            Lactation

            Unknown if distributed in human breast milk

            Consider the developmental and health benefits of breastfeeding along with the mother’s clinical need for the drug, and any potential adverse effects on the breastfed infant from the drug or from the underlying maternal condition

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of Action

            Lixisenatide: Incretin mimetic; analogue of human glucagonlike peptide-1 (GLP-1); acts as GLP-1 receptor agonist to augment glucose-dependent insulin secretion, decreases glucagon secretion, and slows gastric emptying

            Insulin glargine: Basal insulin analog; insulin lowers blood glucose by stimulating peripheral glucose uptake, especially by skeletal muscle and fat, and by inhibiting hepatic glucose production; insulin inhibits lipolysis and proteolysis and enhances protein synthesis; targets include skeletal muscle, liver, and adipose tissue

            Absorption

            Peak plasma time (lixisenatide): 2.5-3 hr

            Distribution

            Protein bound (lixisenatide): 55%

            Metabolism

            Insulin glargine: Partly metabolized at the carboxyl terminus of the B chain in the subcutaneous depot to form 2 active metabolites with in vitro activity similar to that of human insulin

            Lixisenatide: Presumed to be eliminated through glomerular filtration and proteolytic degradation

            Elimination

            Half-life (lixisenatide): 3 hr

            Clearance (lixisenatide): 35 L/hr

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            Administration

            SC Administration

            The pen delivers 15-60 units of insulin glargine with each injection

            Administer SC once daily within 1 hr prior to the first meal of the day

            Inject SC in thigh, upper arm, or abdomen

            Rotate injection site within the same region from 1 injection to the next to reduce lipodystrophy risk

            Do not administer IV, IM, or by infusion pump

            Do not dilute or mix with any other insulin products or solutions

            Do not split the dose

            Missed doses

            • Resume the once-daily regimen as prescribed with the next scheduled dose
            • Do not administer an extra dose or increase the dose to make up for the missed dos

            Storage

            Prior to first use

            • Refrigerate between 36-46°F (2-8°C)
            • Do not freeze; discard if it has been frozen
            • Protect from light

            After first use

            • Store at room temperature below 86°F (30°C)
            • Replace the pen cap after each use to protect from light
            • Discard pen 14 days after first use
            • Always remove the needle after each injection and store the pen without a needle attached; this prevents contamination and/or infection, or leakage of the pen, and ensures accurate dosing
            • Always use a new needle for each injection to prevent contamination
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            Images

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            Patient Handout

            A Patient Handout is not currently available for this monograph.
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            Formulary

            FormularyPatient Discounts

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            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.