Prescription Drugs

CLINICAL PHARMACOLOGY Mechanism Of Action Incretins, such as glucagon-like peptide-1 (GLP-1), enhance glucose-dependent insulin secretion and exhibit other antihyperglycemic actions following their release into the circulation from the gut. BYDUREON is a GLP-1 receptor agonist that enhances glucose-dependent insulin secretion by the pancreatic beta-cell, suppresses inappropriately elevated glucagon secretion, and slows gastric emptying. The amino acid sequence of exenatide partially overlaps that of human GLP-1. Exenatide is a GLP-1 receptor agonist that has been shown to bind and activate the human GLP-1 receptor in vitro. This leads to an increase in both glucose-dependent synthesis of insulin and in vivo secretion of insulin from pancreatic beta cells, by mechanisms involving cyclic AMP and/or other intracellular signaling pathways. Exenatide promotes insulin release from pancreatic beta-cells in the presence of elevated glucose concentrations. Pharmacodynamics Exenatide improves glycemic control through the actions described below. Glucose-Dependent Insulin Secretion The effect of exenatide infusion on glucose-dependent insulin secretion rates (ISR) was investigated in 11 healthy subjects. In these healthy subjects, on average, the ISR response was glucose-dependent (Figure 1). Exenatide did not impair the normal glucagon response to hypoglycemia. Figure 1: Mean (SE) Insulin Secretion Rates During Infusion of Exenatide or Placebo by Treatment, Time, and Glycemic Condition in Healthy Subjects SE = standard error. Notes: 5 mmol = 90 mg/dL, 4 mmol/L = 72 mg/dL, 3.2 mmol/L = 58 mg/dL; Study medication infusion was started at time = 0 minutes. Statistical assessments were for the last 30 minutes of each glycemic step, during which the target glucose concentrations were maintained. *p <0.05, exenatide treatment relative to placebo. Glucagon Secretion In patients with type 2 diabetes, exenatide moderates glucagon secretion and lowers serum glucagon concentrations during periods of hyperglycemia. Gastric Emptying Exenatide slows gastric emptying, thereby reducing the rate at which postprandial glucose appears in the circulation. Fasting and Postprandial Glucose In a clinical study in adults with type 2 diabetes mellitus, treatment with once weekly BYDUREON resulted in mean reductions in fasting plasma glucose of -45 mg/dL and 2-hour PPG concentrations of -95 mg/dL. Cardiac Electrophysiology The effect of exenatide at therapeutic (253 pg/mL) and supratherapeutic (627 pg/mL) concentrations, following an intravenous infusion on QTc interval was evaluated in a randomized, placebo-and active-controlled (moxifloxacin 400 mg) three-period crossover thorough QT study in 74 healthy subjects. The upper bound of the one-sided 95% confidence interval for the largest placebo adjusted, baseline-corrected QTc based on population correction method (QTcP) was below 10 ms. Therefore, exenatide was not associated with prolongation of the QTc interval at therapeutic and supratherapeutic concentrations. Pharmacokinetics Absorption Following a single dose of BYDUREON, exenatide is released from the microspheres over approximately 10 weeks. There is an initial period of release of surface-bound exenatide followed by a gradual release of exenatide from the microspheres, which results in two subsequent peaks of exenatide in plasma at around week 2 and week 6 to 7, respectively, representing the hydration and erosion of the microspheres. Following initiation of once every 7 days (weekly) administration of 2 mg BYDUREON, a gradual increase in the plasma exenatide concentration is observed over 6 to 7 weeks. After 6 to 7 weeks, mean exenatide concentrations of approximately 300 pg/mL were maintained over once every 7 days (weekly) dosing intervals indicating that steady state was achieved. Distribution The mean apparent volume of distribution of exenatide following subcutaneous administration of a single dose of BYETTA is 28.3 L and is expected to remain unchanged for BYDUREON. Metabolism Elimination Nonclinical studies have shown that exenatide is predominantly eliminated by glomerular filtration with subsequent proteolytic degradation. The mean apparent clearance of exenatide in humans is 9.1 L/hour and is independent of the dose. Approximately 10 weeks after discontinuation of BYDUREON therapy, plasma exenatide concentrations generally fall below the minimal detectable concentration of 10 pg/mL. Drug Interaction Studies Acetaminophen When 1000 mg acetaminophen tablets were administered, either with or without a meal, following 14 weeks of BYDUREON therapy (2 mg weekly), no significant changes in acetaminophen AUC were observed compared to the control period. Acetaminophen Cmax decreased by 16% (fasting) and 5% (fed) and Tmax was increased from approximately 1 hour in the control period to 1.4 hours (fasting) and 1.3 hours (fed). The following drug interactions have been studied using BYETTA. The potential for drug-drug interaction with BYDUREON is expected to be similar to that of BYETTA. Digoxin Administration of repeated doses of BYETTA 30 minutes before oral digoxin (0.25 mg once daily) decreased the Cmax of digoxin by 17% and delayed the Tmax of digoxin by approximately 2.5 hours; however, the overall steady-state pharmacokinetic exposure (e.g., AUC) of digoxin was not changed. Lovastatin Administration of BYETTA (10 mcg twice daily) 30 minutes before a single oral dose of lovastatin (40 mg) decreased the AUC and Cmax of lovastatin by approximately 40% and 28%, respectively, and delayed the Tmax by about 4 hours compared with lovastatin administered alone. In the 30-week controlled clinical trials of BYETTA, the use of BYETTA in patients already receiving HMG CoA reductase inhibitors was not associated with consistent changes in lipid profiles compared to baseline. Lisinopril In patients with mild to moderate hypertension stabilized on lisinopril (5-20 mg/day), BYETTA (10 mcg twice daily) did not alter steady-state Cmax or AUC of lisinopril. Lisinopril steady-state Tmax was delayed by 2 hours. There were no changes in 24-hour mean systolic and diastolic blood pressure. Oral Contraceptives The effect of BYETTA (10 mcg twice daily) on single and on multiple doses of a combination oral contraceptive (30 mcg ethinyl estradiol plus 150 mcg levonorgestrel) was studied in healthy female subjects. Repeated daily doses of the oral contraceptive (OC) given 30 minutes after BYETTA administration decreased the Cmax of ethinyl estradiol and levonorgestrel by 45% and 27%, respectively, and delayed the Tmax of ethinyl estradiol and levonorgestrel by 3.0 hours and 3.5 hours, respectively, as compared to the oral contraceptive administered alone. Administration of repeated daily doses of the OC one hour prior to BYETTA administration decreased the mean Cmax of ethinyl estradiol by 15%, but the mean Cmax of levonorgestrel was not significantly changed as compared to when the OC was given alone. BYETTA did not alter the mean trough concentrations of levonorgestrel after repeated daily dosing of the oral contraceptive for both regimens. However, the mean trough concentration of ethinyl estradiol was increased by 20% when the OC was administered 30 minutes after BYETTA administration injection as compared to when the OC was given alone. The effect of BYETTA on OC pharmacokinetics is confounded by the possible food effect on OC in this study [see DRUG INTERACTIONS]. Warfarin Administration of warfarin (25 mg) 35 minutes after repeated doses of BYETTA (5 mcg twice daily on days 1-2 and 10 mcg twice daily on days 3-9) in healthy volunteers delayed warfarin Tmax by approximately 2 hours. No clinically relevant effects on Cmax or AUC of S-and R-enantiomers of warfarin were observed. BYETTA did not significantly alter the pharmacodynamic properties (e.g., international normalized ratio) of warfarin [see DRUG INTERACTIONS]. Specific Populations Patients With Renal Impairment BYDUREON has not been studied in patients with severe renal impairment (creatinine clearance <30 mL/min) or end-stage renal disease receiving dialysis. Population pharmacokinetic analysis of renally impaired patients receiving 2 mg BYDUREON indicate that there is a 62% and 33% increase in exposure in moderate (N=10) and mild (N=56) renally impaired patients, respectively, as compared to patients with normal renal function (N=84). In a study of BYETTA in subjects with end-stage renal disease receiving dialysis, mean exenatide exposure increased by 3.4-fold compared to that of subjects with normal renal function [see Use In Specific Populations]. Patients With Hepatic Impairment BYDUREON has not been studied in patients with acute or chronic hepatic impairment. Age, Male And Female Patients, Race, And Body Weight Age, gender, race and body weight did not alter the pharmacokinetics of BYDUREON in population pharmacokinetic analyses. Pediatric Patients BYDUREON has not been studied in pediatric patients [see Use In Specific Populations]. Clinical Studies BYDUREON has been studied as monotherapy and in combination with metformin, a sulfonylurea, a thiazolidinedione, a combination of metformin and a sulfonylurea, a combination of metformin and a thiazolidinedione, or in combination with a SGLT2 inhibitor on a background of metformin. Monotherapy BYDUREON Monotherapy Versus Metformin, Sitagliptin, And Pioglitazone A 26-week, randomized, comparator-controlled trial was conducted to compare the safety and efficacy of BYDUREON to metformin, sitagliptin, and pioglitazone in patients with type 2 diabetes whose glycemic control was inadequate with diet and exercise (NCT00676338). A total of 820 patients were studied: 552 (67%) were Caucasian, 102 (12%) were East Asian, 71 (9%) were West Asian, 65 (8%) were Hispanic, 25 (3.0%) were Black, 4 (0.5%) were Native American, and 1 was classified otherwise. The mean baseline HbA1c was 8.5%. Patients were randomly assigned to receive BYDUREON 2 mg once every seven days (weekly), titrated metformin from 1000 to 2500 mg/day, sitagliptin 100 mg/day or titrated pioglitazone from 30 to 45 mg/day, all dosed according to approved labeling. The primary endpoint was change in HbA1c from baseline to week 26 (or the last value at time of early discontinuation). Treatment with BYDUREON 2 mg once weekly (QW) resulted in mean HbA1c reduction that was statistically significantly greater compared to sitagliptin 100 mg/day. The mean reduction in HbA1c was non-inferior compared with metformin 1000-2500 mg/day (mean dose 2077 mg/day at study endpoint). Non-inferiority of BYDUREON 2 mg QW to pioglitazone 30-45 mg/day (mean dose 40 mg/day at study endpoint) in reducing HbA1c after 26 weeks of treatment was not demonstrated (the mean change from baseline in HbA1c after 26 weeks was -1.6% with BYDUREON and -1.7% with pioglitazone). The non-inferiority margin was set at +0.3% in this study. The results for the primary endpoint at 26 weeks are summarized in Table 5. Table 5: Results of 26-Week Trial of BYDUREON Monotherapy versus Metformin, Sitagliptin, and Pioglitazone in Patients with Type 2 Diabetes Mellitus BYDUREON 2 mg QW Metformin 1000-2500 (mean dose 2077) mg/day Sitagliptin 100 mg/day Pioglitazone 30-45 (mean dose 40) mg/day Intent-to-Treat Population (N) 248 246 163 163 HbA1c (%) Mean Baseline 8.4 8.6 8.4 8.5 Mean Change at Week 26* −1.6 −1.5 −1.2 −1.7 Difference from metformin* [Bonferroni-adjusted 98.3% CI] −0.05 [−0.26, 0.17] Difference from sitagliptin* [Bonferroni-adjusted 98.3% CI] −0.39† [−0.63, −0.16] Difference from pioglitazone* [Bonferroni-adjusted 98.3% CI] 0.16 [−0.08, 0.41] N = number of patients in each treatment group. Note: mean change is least squares mean change. Note: The primary efficacy analysis was adjusted for multiple comparisons and a two-sided 98.3% confidence interval was utilized to assess difference between treatments. Note: HbA1c change data at 26 weeks were available from 86%, 87%, 85%, and 82% of the randomized subjects in the BYDUREON, metformin, sitagliptin, and pioglitazone groups, respectively. QW = once weekly. * Least squares means were obtained using a mixed model repeated measure analysis with treatment, pooled country, visit, baseline HbA1c value, and treatment by visit interaction as fixed effects, and subject as a random effect. † p<0.001, treatment vs comparator. The proportion of patients with a week 26 value achieving HbA1c of less than 7% at week 26 were 56%, 52%, 40%, and 55% for BYDUREON, metformin, sitagliptin, and pioglitazone, respectively. Patients who did achieve and HbA1c goal <7% and discontinued before week 26 were not included as responders. The mean changes from baseline to week 26 for fasting serum glucose were -41 mg/dL, -36 mg/dL, -20 mg/dL and -46 mg/dL, and for body weight were -2.0 kg, -2.0 kg, -0.8 kg and +1.5 kg for BYDUREON, metformin, sitagliptin, and pioglitazone, respectively. Combination Therapy BYDUREON Versus Sitagliptin And Pioglitazone, All As Add-On To Metformin Therapy A 26-week double-blind comparator-controlled trial was conducted to compare the safety and efficacy of BYDUREON to sitagliptin and pioglitazone in patients with type 2 diabetes whose glycemic control was inadequate with metformin therapy (NCT00637273). A total of 491 patients were studied 168 (34.2%) were Caucasian, 143 (29.1%) were Hispanic, 119 (24.2%) were Asian, 52 (10.6%) were Black, 3 (0.6%) were Native American, and 6 (1.2%) were classified otherwise. The mean baseline HbA1c was 8.5%. Patients were randomly assigned to receive BYDUREON 2 mg once every 7 days (weekly), sitagliptin 100 mg/day or pioglitazone 45 mg/day, in addition to their existing metformin therapy. The primary endpoint was change in HbA1c from baseline to week 26 (or the last value at time of early discontinuation). In this study, treatment with BYDUREON 2 mg QW resulted in a statistically significant mean HbA1c reduction compared to sitagliptin 100 mg/day. There was a numerically greater reduction in HbA1c with BYDUREON compared to pioglitazone, but there was not sufficient evidence to conclude superiority of BYDUREON 2 mg QW to pioglitazone 45 mg/day in reducing HbA1c after 26 weeks of treatment. Results for the primary endpoint at 26 weeks are summarized in Table 6. Table 6: Results of 26-Week Trial of BYDUREON versus Sitagliptin and Pioglitazone, All as Add-On to Metformin Therapy in Patients with Type 2 Diabetes Mellitus BYDUREON 2 mg QW Sitagliptin 100 mg/day Pioglitazone 45 mg/day Intent-to-Treat Population (N) 160 166 165 HbA1c (%) Mean Baseline 8.6 8.5 8.5 Mean Change at Week 26* −1.5 −0.9 −1.2 Difference from sitagliptin* [95% CI] −0.63 [−0.89, −0.37] Difference from pioglitazone* [95% CI] −0.32 [−0.57, −0.06] N = number of patients in each treatment group. Note: mean change is least squares mean change. QW = once weekly. * Least squares means were obtained using an ANCOVA model with treatment, baseline HbA1c stratum, and country as fixed effects. Missing week 26 data (28%, 18%, and 24% for the BYDUREON, sitagliptin, and pioglitazone groups, respectively) were imputed by the LOCF technique. The proportion of patients with a week 26 value achieving HbA1c of less than 7% at week 26 were 46%, 30%, and 39% for BYDUREON, sitagliptin, and pioglitazone, respectively. Patients who did achieve an HbA1c goal <7% and discontinued before week 26 were not included as responders. The mean changes from baseline to week 26 for fasting serum glucose were -32 mg/dL, -16 mg/dL and -27 mg/dL, and for body weight were -2.3 kg, -0.8 kg and +2.8 kg for BYDUREON, sitagliptin, and pioglitazone, respectively. BYDUREON Versus Insulin Glargine, Both As Add-On To Metformin Or Metformin + Sulfonylurea Therapy A 26-week open-label comparator-controlled trial was conducted to compare the safety and efficacy of BYDUREON to titrated insulin glargine in patients with type 2 diabetes whose glycemic control was inadequate with metformin or metformin plus sulfonylurea therapy (NCT00641056). A total of 456 patients were studied: 379 (83.1%) were Caucasian, 47 (10.3%) were Hispanic, 25 (5.5%) were East Asian, 3 (0.7%) were Black, and 2 (0.4%) were West Asian. Background therapy was either metformin (70%) or metformin plus sulfonylurea (30%). The mean baseline HbA1c was 8.3%. Patients were randomly assigned to receive BYDUREON 2 mg once every 7 days (weekly) or insulin glargine once daily in addition to their existing oral antidiabetic therapy. Insulin glargine was dosed to a target fasting glucose concentration of 72 to 100 mg/dL. The mean dose of insulin glargine was 10 units/day at baseline and 31 units/day at endpoint. At week 26, 21% of insulin glargine treated patients were at fasting glucose goal. The primary endpoint was change in HbA1c from baseline to week 26 (or the last value at time of early discontinuation). Treatment with BYDUREON once weekly resulted in a mean reduction in HbA1c from baseline at 26 weeks of -1.5%. The mean reduction in HbA1c seen in insulin glargine arm at 26 weeks was -1.3%. The difference in observed effect size between BYDUREON and glargine in this trial excluded the pre-specified non-inferiority margin of +0.3%. The proportion of patients with a week 26 value achieving HbA1c of less than 7% at week 26 were 57% and 48% for BYDUREON and insulin glargine, respectively. Patients who did achieve an HbA1c goal <7% and discontinued before week 26 were not included as responders. The mean changes from baseline to week 26 for fasting serum glucose in this study were -38 mg/dL and -50 mg/dL, and for body weight were -2.6 kg and +1.4 kg for BYDUREON and insulin glargine, respectively. BYDUREON Versus BYETTA, Both As Monotherapy Or As Add-On To Metformin, A Sulfonylurea, A Thiazolidinedione, Or Combination Of Oral Agents A 24-week, randomized, open-label trial was conducted to compare the safety and efficacy of BYDUREON to BYETTA in patients with type 2 diabetes and inadequate glycemic control with diet and exercise alone or with oral antidiabetic therapy, including metformin, a sulfonylurea, a thiazolidinedione, or combination of two of those therapies (NCT00877890). A total of 252 patients were studied: 149 (59%) were Caucasian, 78 (31%) Hispanic, 15 (6%) Black, and 10 (4%) Asian. Patients were treated with diet and exercise alone (19%), a single oral antidiabetic agent (47%), or combination therapy of oral antidiabetic agents (35%). The mean baseline HbA1c was 8.4%. Patients were randomly assigned to receive BYDUREON 2 mg once every 7 days (weekly) or BYETTA (10 mcg twice daily), in addition to existing oral antidiabetic agents. Patients assigned to BYETTA initiated treatment with 5 mcg twice daily then increased the dose to 10 mcg twice daily after 4 weeks. The primary endpoint was change in HbA1c from baseline to week 24 (or the last value at time of early discontinuation). Treatment with BYDUREON 2 mg QW resulted in a statistically significantly greater mean HbA1c reduction compared to BYETTA 10 mcg twice daily. Change in body weight was a secondary endpoint. Twenty-four week study results are summarized in Table 7. Table 7: Results of 24-Week Trial of BYDUREON versus BYETTA, Both as Monotherapy or as Add-On to Metformin, a Sulfonylurea, a Thiazolidinedione, or Combination of Oral Agents in Patients with Type 2 Diabetes Mellitus BYDUREON 2 mg QW BYETTA 10 mcg twice daily* Intent-to-Treat Population (N) 129 123 HbA1c (%) Mean Baseline 8.5 8.4 Mean Change at Week 24† −1.6 −0.9 Difference from BYETTA† [95% CI] −0.7 [−0.9, −0.4]¶ Percentage Achieving HbA1c <7% at Week 24 (%) 58¶ 30 Fasting Plasma Glucose (mg/dL) Mean Baseline 173 168 Mean Change at Week 24 −25 −5 Difference from BYETTA† [95% CI] −20 [−31, −10]¶ N = number of patients in each treatment group. Note: mean change is least squares mean change. QW = once weekly. * BYETTA 5 mcg twice daily before the morning and evening meals for 4 weeks followed by 10 mcg twice daily for 20 weeks. † Least squares (LS) means are adjusted for baseline HbA1c strata, background antihyperglycemic therapy, and baseline value of the dependent variable (if applicable). ¶ p<0.001, treatment vs comparator. Reductions from mean baseline (97/94 kg) in body weight were observed in both BYDUREON (-2.3 kg) and BYETTA (-1.4 kg) treatment groups. BYDUREON Versus Liraglutide, Both As Add-On To Metformin, A Sulfonylurea, Metformin + Sulfonylurea, Or Metformin + Pioglitazone Therapy A 26-week open-label comparator-controlled trial was conducted to compare the safety and efficacy of BYDUREON to liraglutide in patients with type 2 diabetes whose glycemic control was inadequate with metformin, a sulfonylurea, metformin plus sulfonylurea, or metformin plus pioglitazone therapy (NCT01029886). A total of 911 patients were studied: 753 (82.7%) were Caucasian, 111 (12.2%) were Asian, 32 (3.5%) were American Indian or Alaska Native, 8 (0.9%) were Black, 6 (0.7%) were multiple races, and 1 (0.1%) was Pacific Islander. Background therapy was either a single oral antidiabetic agent (35%) or a combination of oral antidiabetic agents (65%). The mean baseline HbA1c was 8.4%. Patients were randomly assigned to receive BYDUREON 2 mg once every 7 days (weekly) or liraglutide uptitrated from 0.6 mg/day to 1.2 mg/day, then 1.8 mg/day in addition to their existing oral antidiabetic therapy. Each titration was to be completed after at least one week, but could be delayed if the patient had severe nausea or vomiting as established by the investigator. Patients not tolerating the 1.8 mg/day dose of liraglutide by week 4 were discontinued from the study. The primary endpoint was change in HbA1c from baseline to week 26 (or the last value at time of early discontinuation). Treatment with BYDUREON once weekly resulted in a mean reduction in HbA1c from baseline at 26 weeks of -1.3%. The mean reduction in HbA1c seen in the liraglutide arm at 26 weeks was -1.5%. The HbA1c reduction with BYDUREON did not meet predefined non-inferiority criteria compared to liraglutide 1.8 mg/day. The non-inferiority margin was set at +0.25% in this study. Results for the primary endpoint at 26 weeks are summarized in Table 8. Table 8: Results of 26-Week Trial of BYDUREON versus Liraglutide, Both as Add-On to Metformin, a Sulfonylurea, Metformin + Sulfonylurea, or Metformin + Pioglitazone Therapy in Patients with Type 2 Diabetes Mellitus BYDUREON 2 mg QW Liraglutide 1.8 mg/day Intent-to-Treat Population (N) 461 450 HbA1c (%) Mean Baseline 8.5 8.4 Mean Change at Week 26* −1.3 −1.5 Difference from liraglutide* [95% CI] 0.2 [0.08, 0.33] N = number of patients in each treatment group. Note: mean change is least squares mean change. Note: HbA1c change data at 26 weeks were available from 85% and 86% of the randomized subjects in the BYDUREON and liraglutide groups, respectively. QW = once weekly. * Least squares means were obtained using a mixed model repeated measure analysis with treatment, country, OAD stratum, baseline HbA1c stratum, visit, baseline HbA1c, and treatment by visit interaction as fixed effects, and subject as a random effect. The proportion of patients with a week 26 value achieving HbA1c of less than 7% at week 26 were 48% and 56% for BYDUREON and liraglutide, respectively. Patients who did achieve an HbA1c goal <7% and discontinued before week 26 were not included as responders. The mean changes from baseline to week 26 for fasting serum glucose were -32 mg/dL and -38 mg/dL, and for body weight were -27 kg and -3.6 kg for BYDUREON and liraglutide, respectively. BYDUREON In Combination With Dapagliflozin Versus BYDUREON Alone And Dapagliflozin Alone, All As Add-On To Metformin A 28-week double-blind comparator controlled trial was conducted to compare the efficacy of BYDUREON and dapagliflozin (an SGLT2 inhibitor) to BYDUREON alone and dapagliflozin alone in patients with type 2 diabetes with inadequate glycemic control with metformin therapy (NCT02229396). A total of 694 patients were studied; 580 (83.6%) were Caucasian, 96 (13.8%) were Black, 5 (0.7%) were Asian, 2 (0.3%) were American Indian or Alaska Native and 11 (1.6%) were classified otherwise. The mean baseline HbA1c was 9.3%. All patients entered a 1-week placebo lead-in period. Patients with HbA1c ≥8.0% and ≤12% and on metformin at a dose of at least 1,500 mg per day were randomly assigned to receive either BYDUREON 2 mg once every 7 days (weekly) plus dapagliflozin 10 mg once daily, BYDUREON 2 mg once weekly, or dapagliflozin 10 mg once daily. The primary endpoint was change in HbA1c from baseline to Week 28. At week 28, BYDUREON in combination with dapagliflozin provided statistically significantly greater reductions in HbA1c (-1.77%) compared to BYDUREON alone (-1.42%, p=0.012) and dapagliflozin alone (-1.32%, p=0.001). BYDUREON in combination with dapagliflozin provided statistically significantly greater reductions in FPG (-57.35 mg/dL) compared to BYDUREON alone (-40.53, p <0.001) and dapagliflozin alone (-44.72 mg/dL, p=0.006).

Find Lowest Prices on BYDUREON® (exenatide) Extended-Release for Injectable Suspension WARNING RISK OF THYROID C-CELL TUMORS Exenatide extended-release causes an increased incidence in thyroid C-cell tumors at clinically relevant exposures in rats compared to controls. It is unknown whether BYDUREON causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans, as the human relevance of exenatide extended-release-induced rodent thyroid C-cell tumors has not been determined [see WARNINGS AND PRECAUTIONS and Nonclinical Toxicology]. BYDUREON is contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Counsel patients regarding the potential risk for MTC with the use of BYDUREON and inform them of symptoms of thyroid tumors (e.g., mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for detection of MTC in patients treated with BYDUREON [see CONTRAINDICATIONS and WARNINGS AND PRECAUTIONS]. DESCRIPTION BYDUREON (exenatide extended-release) for injectable suspension is a GLP-1 receptor agonist supplied as a sterile powder to be suspended in diluent and administered by subcutaneous injection. Exenatide is a 39-amino acid synthetic peptide amide with an empirical formula of C184H282N50O60S and a molecular weight of 4186.6 Daltons. The amino acid sequence for exenatide is shown below. H-His-Gly-Glu-Gly-Thr-Phe-Thr-Ser-Asp-Leu-Ser-Lys-Gln-Met-Glu-Glu-Glu-Ala-Val-Arg-Leu-Phe-IleGlu- Trp-Leu-Lys-Asn-Gly-Gly-Pro-Ser-Ser-Gly-Ala-Pro-Pro-Pro-Ser-NH2 BYDUREON is a white to off-white powder that is available in a dosage strength of 2 mg exenatide per vial or per pen. Exenatide is incorporated in an extended-release microsphere formulation containing the 50:50 poly(D,L-lactide-co-glycolide) polymer (37.2 mg per dose) along with sucrose (0.8 mg per dose). The powder must be suspended in the diluent prior to injection. The diluent for the BYDUREON vial is supplied in a prefilled syringe within each single-dose tray. The diluent for the BYDUREON Pen is contained within each single-dose pen. Each configuration contains sufficient diluent to deliver 0.65 mL. The diluent is a clear, colorless to pale-yellow solution composed of carboxymethylcellulose sodium (19 mg), polysorbate 20 (0.63 mg), sodium phosphate monobasic monohydrate (0.61 mg), sodium phosphate dibasic heptahydrate (0.51 mg), sodium chloride (4.1 mg), and water for injection. Sodium hydroxide may be added during manufacture of BYDUREON Pen for pH adjustment.

INDICATIONS BYDUREON is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus [see Clinical Studies]. Limitations Of Use BYDUREON is not recommended as first-line therapy for patients who have inadequate glycemic control on diet and exercise because of the uncertain relevance of the rat thyroid C-cell tumor findings to humans [see WARNINGS AND PRECAUTIONS]. BYDUREON is not a substitute for insulin. BYDUREON is not indicated for use in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis, as it would not be effective in these settings. The concurrent use of BYDUREON with insulin has not been studied and is not recommended. BYDUREON is an extended-release formulation of exenatide. BYDUREON should not be used with other products containing the active ingredient exenatide. BYDUREON has not been studied in patients with a history of pancreatitis. Consider other antidiabetic therapies in patients with a history of pancreatitis [see WARNINGS AND PRECAUTIONS and ADVERSE REACTIONS]. DOSAGE AND ADMINISTRATION Recommended Dosing The recommended dose of BYDUREON is 2 mg subcutaneously once every 7 days (weekly). The dose can be administered at any time of day, with or without meals. The day of weekly administration can be changed if necessary as long as the last dose was administered 3 or more days before the new day of administration. Missed Dose If a dose is missed, administer the dose as soon as noticed, provided the next regularly scheduled dose is due at least 3 days later. Thereafter, patients can resume their usual dosing schedule of once every 7 days (weekly). If a dose is missed and the next regularly scheduled dose is due 1 or 2 days later, do not administer the missed dose and instead resume BYDUREON with the next regularly scheduled dose. Administration Instructions There are two presentations of BYDUREON (i.e., a single dose tray and a single dose pen) [see HOW SUPPLIED]. The BYDUREON “Instructions for Use” for each presentation contains detailed instructions on the preparation and administration of BYDUREON [see Instructions for Use]. Each presentation of BYDUREON requires constitution prior to use to obtain a final concentration of 2 mg of exenatide per 0.65 mL of suspension. BYDUREON is intended for patient self-administration. Prior to initiation, train patients on proper mixing and injection technique to ensure the product is adequately mixed and a full dose is delivered. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration. The suspension should appear white to off-white and cloudy. (BYDUREON contains microspheres which appear as white to off-white particles). Do not use if foreign particulate matter is present or if discoloration is observed. Refer patients to the accompanying Instructions for Use for disposal information [see Instructions for Use]. Administer BYDUREON immediately after the dose is prepared as a subcutaneous injection in the abdomen, thigh, or upper arm region. Advise patients to use a different injection site each week when injecting in the same region. Do not administer BYDUREON intravenously or intramuscularly. Refer patients to the accompanying Instructions for Use for complete administration instructions with illustrations [see Instructions for Use]. Initiating BYDUREON Therapy Prior treatment with an immediate-or extended-release exenatide product is not required when initiating BYDUREON therapy. Discontinue an immediate-or extended-release exenatide product prior to initiation of BYDUREON. HOW SUPPLIED Dosage Forms And Strengths Extended-release for injectable suspension available as: Single-dose tray which contains one single dose vial of 2 mg exenatide white to off-white powder, one vial connector, one prefilled diluent syringe, and two needles (one provided as a spare). Single-dose pen which contains 2 mg of exenatide white to off-white powder, diluent, and includes one needle. Each carton contains one spare needle. Do not substitute needles or any other components provided with BYDUREON. See HOW SUPPLIED for additional information. Storage And Handling BYDUREON (exenatide extended-release for injectable suspension) for once every 7 days (weekly) subcutaneous administration is supplied as: BYDUREON single-dose tray, supplied in cartons that contain four single-dose trays (NDC 0310-652004). Each single-dose tray contains: One single-dose vial containing 2 mg exenatide (as a white to off-white powder) One prefilled syringe delivering 0.65 mL diluent One vial connector Two custom needles (23G, 5/16") specific to this delivery system (one is a spare needle) BYDUREON Pen, supplied in cartons that contain four single-dose pens and one spare needle (NDC 0310-6530-04). Each single-dose pen contains: One single-dose pen containing 2 mg of exenatide (as a white to off-white powder) and delivering 0.65 mL diluent. One custom needle (23G, 9/32") specific to this delivery system. Do not substitute needles or any other components provided with BYDUREON. Storage And Handling BYDUREON should be stored in the refrigerator at 36°F to 46°F (2°C to 8°C), up to the expiration date or until preparing for use. BYDUREON should not be used past the expiration date. The expiration date can be found on the carton, on the cover of the single-dose tray, or on the pen label. Do not freeze BYDUREON. Do not use BYDUREON if it has been frozen. Protect from light. BYDUREON can be kept at room temperature not to exceed 77°F (25°C) [see USP Controlled Room Temperature] for no more than a total of 4 weeks, if needed. Use the diluent only if it is clear and free of particulate matter. After suspension, the mixture should be white to off-white and cloudy. BYDUREON must be administered immediately after the exenatide powder is suspended in the diluent. Use a puncture-resistant container to discard BYDUREON with the needle still attached. Do not reuse or share needles or syringes. Keep out of the reach of children. Manufactured By: Amylin Ohio LLC West Chester, OH 45071. Revised: Oct 2017

PATIENT INFORMATION BYDUREON® (by-DUR-ee-on) (exenatide) Extended-Release for Injectable Suspension What is the most important information I should know about BYDUREON? BYDUREON may cause serious side effects, including: Possible thyroid tumors, including cancer. Tell your healthcare provider if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. In studies with rats or mice, BYDUREON and medicines that work like BYDUREON caused thyroid tumors, including thyroid cancer. It is not known if BYDUREON will cause thyroid tumors or a type of thyroid cancer called medullary thyroid carcinoma (MTC) in people. Do not use BYDUREON if you or any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC), or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). What is BYDUREON? BYDUREON is an injectable prescription medicine that may improve blood sugar (glucose) in adults with type 2 diabetes mellitus, and should be used along with diet and exercise. BYDUREON is not recommended as the first choice of medicine for treating diabetes. BYDUREON is not a substitute for insulin and is not for use in people with type 1 diabetes or people with diabetic ketoacidosis. BYDUREON is a long-acting form of the medicine in BYETTA (exenatide). BYDUREON and BYETTA should not be used at the same time. It is not known if BYDUREON can be used in people who have had pancreatitis. It is not known if BYDUREON is safe and effective for use in children. Who should not use BYDUREON? Do not use BYDUREON if: you or any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC) or if you have an endocrine system condition called Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). you are allergic to exenatide or any of the ingredients in BYDUREON. See the end of this Medication Guide for a complete list of ingredients in BYDUREON. What should I tell my healthcare provider before using BYDUREON? Before using BYDUREON, tell your healthcare provider about all of your medical conditions, including if you: have or have had problems with your pancreas, kidneys, or liver. have severe problems with your stomach, such as slowed emptying of your stomach (gastroparesis) or problems with digesting food. are pregnant or plan to become pregnant. BYDUREON may harm your unborn baby. Tell your healthcare provider if you become pregnant while using BYDUREON. Talk to your healthcare provider about the best way to control your blood sugar if you plan to become pregnant or while you are pregnant. are breastfeeding or plan to breastfeed. It is not known if BYDUREON passes into your breast milk. You should talk with your healthcare provider about the best way to feed your baby while using BYDUREON. Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. BYDUREON may affect the way some medicines work and some medicines may affect the way BYDUREON works. Before using BYDUREON, talk to your healthcare provider about low blood sugar and how to manage it. Tell your healthcare provider if you are taking other medicines to treat diabetes including insulin or sulfonylureas. Know the medicines you take. Keep a list of them to show your healthcare provider and pharmacist when you get a new medicine. How should I use BYDUREON? Read the Instructions for Use that comes with BYDUREON. Use BYDUREON exactly as your healthcare provider tells you to. BYDUREON should be injected right away after you prepare your dose. Your healthcare provider should show you how to use BYDUREON before you use it for the first time. BYDUREON is injected under the skin (subcutaneously) of your stomach (abdomen), thigh, or upper arm. Do not inject BYDUREON into a muscle (intramuscularly) or vein (intravenously). Use BYDUREON 1 time each week on the same day each week at any time of the day. BYDUREON may be taken with or without food. If you miss a dose of BYDUREON, take the missed dose as soon as possible if there are at least 3 days (72 hours) until your next scheduled dose. If there are less than 3 days remaining, skip the missed dose and take your next dose on the regularly scheduled day. Do not take 2 doses of BYDUREON within 3 days of each other. You may change the day of the week as long as your last dose was given 3 or more days before. Do not mix insulin and BYDUREON together in the same injection. You may give an injection of BYDUREON and insulin in the same body area (such as, your stomach area), but not right next to each other. Change (rotate) your injection site with each weekly injection. Do not use the same site for each injection. Do not share your BYDUREON pen, prefilled syringe, or needles with another person. You may give another person an infection or get an infection from them. Your dose of BYDUREON and other diabetes medicines may need to change because of: change in level of physical activity or exercise, weight gain or loss, increased stress, illness, change in diet, or because of other medicines you take. What are the possible side effects of BYDUREON? BYDUREON may cause serious side effects, including: See "What is the most important information I should know about BYDUREON?" inflammation of your pancreas (pancreatitis). Stop using BYDUREON and call your healthcare provider right away if you have severe pain in your stomach area (abdomen) that will not go away, with or without vomiting. You may feel the pain from your abdomen to your back. low blood sugar (hypoglycemia). Your risk for getting low blood sugar may be higher if you use BYDUREON with another medicine that can cause low blood sugar, such as a sulfonylurea or insulin. Signs and symptoms of low blood sugar may include: dizziness or lightheadedness blurred vision anxiety, irritability, or mood changes sweating slurred speech hunger confusion or drowsiness shakiness weakness headache fast heartbeat feeling jittery kidney problems (kidney failure). In people who have kidney problems, diarrhea, nausea, and vomiting may cause a loss of fluids (dehydration) which may cause kidney problems to get worse. stomach problems. Other medicines like BYDUREON may cause severe stomach problems. It is not known if BYDUREON causes or worsens stomach problems. serious allergic reactions. Stop using BYDUREON, and get medical help right away if you have any symptoms of a serious allergic reaction, including itching, rash, or difficulty breathing. injection-site reactions. Serious injection-site reactions, with or without bumps (nodules), have happened in some people who use BYDUREON. Some of these injection-site reactions have required surgery. Call your healthcare provider if you have any symptoms of an injection-site reaction, including severe pain, swelling, blisters, an open wound, a dark scab. The most common side effects of BYDUREON may include nausea, diarrhea, headache, vomiting, constipation, itching at the injection site, a small bump (nodule) at the injection site, indigestion. Nausea is most common when you first start using BYDUREON, but decreases over time in most people as their body gets used to the medicine. Talk to your healthcare provider about any side effect that bothers you or does not go away. These are not all the possible side effects of BYDUREON. For more information, ask your healthcare provider or pharmacist. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. Keep BYDUREON and all medicines out of the reach of children. General information about the safe and effective use of BYDUREON. Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use BYDUREON for a condition for which it was not prescribed. Do not give your BYDUREON to other people, even if they have the same symptoms you have. It may harm them. You can ask your pharmacist or healthcare provider for information about BYDUREON that is written for health professionals. What are the ingredients in BYDUREON? Contents of the powder: Active Ingredient: exenatide Inactive Ingredients: polylactide-co-glycolide and sucrose Contents of liquid (diluent): Inactive Ingredients: carboxymethylcellulose sodium, polysorbate 20, sodium phosphate monobasic monohydrate, sodium phosphate dibasic heptahydrate, sodium chloride, water for injection. Sodium hydroxide may be added during manufacture of BYDUREON Pen for pH adjustment. Instructions for Use BYDUREON® (by-DUR-ee-on) Single-Dose Tray (exenatide extended-release) for injectable suspension Before using Bydureon, your healthcare provider should show you how to use it the right way. Read these Instructions for Use before you start using BYDUREON Single-Dose Tray and each time you get a refill. There may be new information. This information does not take the place of talking to your healthcare provider about your medical condition or your treatment. Getting ready Never share your BYDUREON vials or needles with anyone else. You may give an infection to them or get an infection from them. BYDUREON Single-Dose Tray is not for self-injection by people who are blind or cannot see well. Supplies needed to give your BYDUREON Single-Dose Tray injection (not all supplies are included): 1 BYDUREON Single-Dose Tray that contains: 1 BYDUREON vial 1 Syringe 2 Needles 1 Vial connector alcohol swab a clean flat surface sharps container for throwing away used needles, vials, and syringes. See Step 4h "Disposing of used Needles and Syringes." Your guide to your BYDUREON Single-Dose Tray Single-dose tray Keep this flap open so you can refer to it as you go through the steps. Your guide to the parts Single-dose tray What is Inside To take the correct dose, read each page so that you do every step in order. This step-by-step guide is divided into 4 sections: Getting Started Connecting the Parts Mixing the Medicine and Filling the Syringe Injecting the Medicine For Common Questions and Answers, see page X. How to store your Single-Dose Trays of BYDUREON Store your BYDUREON trays in the refrigerator at 36°F to 46°F (2°C to 8°C). If needed, you can keep your BYDUREON tray out of the refrigerator at 68°F to 77°F (20°C to 25°C) for up to 4 weeks. Protect BYDUREON from light until you are ready to prepare and use your dose. Do not freeze BYDUREON trays. Do not use BYDUREON past the expiration date. The expiration date is labeled EXP and can be found on the paper cover of each tray. Keep BYDUREON, and all medicines, out of the reach of children. Getting Started 1a) Take a Single-Dose Tray from the refrigerator. 1b) Wash your hands. Prepare to clean your injection site with soap and water or an alcohol swab prior to injecting your medicine. Peel back the paper cover to open. Remove the syringe. The liquid in the syringe should be clear with no particles in it. It is okay if there are bubbles. Place the needle, vial connector package, vial, and syringe on a clean, flat surface. Pick up the needle, and twist off the blue cap. Set the covered needle aside. You will use it later. There is a spare needle in the tray if you need it. Pick up the vial. Tap the vial several times against a hard surface to loosen the powder. Use your thumb to remove the green cap. Put the vial aside. Connecting the Parts Pick up the vial connector package and peel off the paper cover. Do not touch the orange connector inside. Hold the vial connector package. In your other hand, hold the vial. Press the top of the vial firmly into the orange connector. Then lift the vial with the orange connector now attached out of the clear package. This is what the vial should now look like. Put it aside for later. Pick up the syringe. With your other hand, firmly grasp the 2 gray squares on the white cap. Break off the cap. Be careful not to push in the plunger. Just like you might break a stick, you are breaking off the cap. This is what the broken-off cap looks like. You will not be using the cap and can throw it away. This is what the syringe should now look like. Now, pick up the vial with the orange connector attached. Twist the orange connector onto the syringe until snug. While twisting, be sure to grasp the orange connector. Do not over tighten. This is how the parts should now look when they are connected. Mixing the Medicine and Filling the Syringe Important: During these next steps, you will be mixing the medicine and filling the syringe. After you mix the medicine, you must inject it. You cannot save the mixed medicine to inject at a later time. With your thumb, push down the plunger until it stops. The plunger may feel like it is springing back a little. For steps 3a to 3f, keep pushing down on the plunger with your thumb. Hold the plunger down and shake hard. Keep shaking until the liquid and powder are mixed well. The vial will not come off. The orange connector will keep it attached to the syringe. Shake hard like you would shake a bottle of oil-and-vinegar salad dressing. When the medicine is mixed well, it should look cloudy. If you see clumps of dry powder on the sides or bottom of the vial, the medicine is not mixed well. Shake hard again until well mixed. Keep pushing down on the plunger while shaking. If you have any questions or are not sure if your BYDUREON is mixed well, call 1-877-700-7365 for help. Now, hold the vial upside down so the syringe is pointing up. Continue to hold the plunger in place with your thumb. Gently tap the vial with the other hand. Continue to hold the plunger in place. The tapping helps the medicine drip down. It is okay if there are bubbles. Pull the plunger down beyond the black dashed Dose Line. This draws the medicine from the vial into the syringe. You may see air bubbles. This is normal. A little bit of liquid may cling to the sides of the vial. With 1 hand, hold the plunger in place so it does not move. With the other hand, twist the orange connector to remove it from the syringe. Be careful not to push in the plunger. This is what the syringe should now look like. Injecting the Medicine Pick up the needle. Twist the needle onto the syringe until snug. Do not remove the needle cover yet. Important: Read the next steps carefully and look closely at the pictures. This helps you get the correct dose of medicine. Slowly push in the plunger so the top of the plunger lines up with the black dashed Dose Line. Then, take your thumb off the plunger. The top of the plunger must stay lined up with the black dashed Dose Line as you go through the next steps. This will help you get the correct dose of medicine. Put aside the syringe with the needle attached. Important: It is normal to see a few bubbles in the mixture. The bubbles will not harm you or affect your dose. You can inject the medicine in your stomach area (abdomen), your thigh, or the back of your upper arm. Each week you can use the same area of your body but choose a different injection site in that area. Gently clean the site you choose with soap and water or an alcohol swab. Now, pick up the syringe and hold it near the black dashed Dose Line. Pull the needle cover straight off. Do not twist. Be careful not to push in the plunger. When you remove the cover, you may see 1 or 2 drops of liquid. This is normal. Insert the needle into your skin (subcutaneously). To inject your full dose, push down on the plunger with your thumb until it stops. Withdraw the needle. Be sure to use the injection technique recommended by your healthcare provider. Disposing of used Needles and Syringes: Put your used needles and syringes in a FDA-cleared sharps disposal container right away after use. Do not throw away (dispose of) loose needles and syringes in your household trash. If you do not have a FDA-cleared sharps disposal container, you may use a household container that is: made of a heavy-duty plastic, can be closed with a tight-fitting, puncture-resistant lid, without sharps being able to come out, upright and stable during use, leak-resistant, and properly labeled to warn of hazardous waste inside the container. When your sharps disposal container is almost full, you will need to follow your community guidelines for the right way to dispose of your sharps disposal container. There may be state or local laws about how you should throw away used needles and pens. For more information about safe sharps disposal, and for specific information about sharps disposal in the state that you live in, go to the FDA’s website at: http://www.fda.gov/safesharpsdisposal. Please keep these Instructions for Use for your next dose. Common Questions and Answers If your question is about: See question number: How soon to inject after mixing 1 Mixing the medicine 2 Air bubbles in syringe 3 Attaching the needle 4 Removing the needle cover 5 Plunger not lining up with black dashed Dose Line 6 Being unable to push the plunger down when injecting 7 After I mix the medicine, how long can I wait before taking the injection? You must take your injection of BYDUREON right after mixing it. If you do not inject BYDUREON right away, the medicine will start to form small clumps in the syringe. These clumps can clog the needle when you take the injection (see question 7). How do I know that the medicine is mixed well? When the medicine is mixed well, it should look cloudy. There should not be any dry powder on the sides or bottom of the vial. If you do see any dry powder, shake hard while continuing to push down on the plunger with your thumb. (This question relates to the steps shown on pages X through X.) I'm ready to take the injection. What should I do if I see air bubbles in the syringe? It is normal for air bubbles to be in the syringe. The air bubbles will not harm you or affect your dose. BYDUREON is injected into your skin (subcutaneously). Air bubbles are not a problem with this type of injection. (This question relates to step 3f shown on page X and step 4c shown on page X.) What should I do if I have trouble attaching the needle? First, be sure you have removed the blue cap. Then, twist the needle onto the syringe until snug. To prevent losing medicine, do not push in the plunger while attaching the needle. (This question relates to step 4a on page X.) What should I do if I have trouble removing the needle cover? With one hand, hold the syringe near the black dashed Dose Line. With your other hand, hold the needle cover. Pull the needle cover straight off. Do not twist it. (This question relates to step 4f on page X.) I am at step 4c. What should I do if the top of the plunger has been pushed past the black dashed Dose Line? The black dashed Dose Line shows the correct dose. If the top of the plunger has been pushed past the line, you should continue from step 4d and take the injection. Before your next injection in 1 week, carefully review the instructions on pages X through X. When I inject, what should I do if I cannot push the plunger all the way down? This means the needle has become clogged. Remove the needle from your skin and replace it with the spare needle from your tray. Then choose a different injection site and finish taking the injection. To review how to: Remove the blue cap of the needle, see page X Attach the needle, see page X Remove the needle cover and give the injection, see pages X and X If you still cannot push the plunger all the way down, remove the needle from your skin. Use a puncture-resistant container to throw away the syringe with the needle still attached. It is important that you then call 1-877-7007365. To help prevent a clogged needle, always mix the medicine very well and inject right after mixing. Where to learn more about BYDUREON Talk with your healthcare provider Read the Medication Guide that came with your BYDUREON. The Medication Guide can help answer your questions about BYDUREON, such as what it is used for, possible side effects, and when to take BYDUREON. Enroll in BYDUREON Support for FREE ongoing help managing your diabetes. Visit www.bydureon.com or call 1-877-700-7365. Instructions for Use BYDUREON® (by-DUR-ee-on) Pen (exenatide extended-release) for injectable suspension Figure A Before using Bydureon Pen, your healthcare provider should show you how to use it the right way. Read the Instructions for Use before you start using Bydureon Pen and each time you get a refill. There may be new information. This information does not take the place of talking to your healthcare provider about your medical condition or your treatment. Getting ready Never share your Bydureon Pen or needles with anyone else. You may give an infection to them or get an infection from them. Bydureon Pen is not for self-injection by people who are blind or cannot see well. Supplies needed to give your Bydureon Pen injection (not all supplies are included): 1 Bydureon single-use "Pen" tray that contains: 1 Bydureon Pen 1 custom needle a clean flat surface alcohol swab sharps container for throwing away used needles and Pens. See "Properly dispose of your Pen" at the end of these instructions. How should I store Bydureon? Store your Bydureon Pens in the refrigerator at 36°F to 46°F (2°C to 8°C). Protect pens from light until you are ready to prepare and use your dose. Do not use pens past the expiration date. Do not freeze Bydureon. Do not use Bydureon if it has been frozen. Keep Bydureon in its sealed tray until ready for use. If needed, you can keep your Bydureon Pen out of the refrigerator at 68°F to 77°F (20°C to 25°C) for up to 4 weeks. Keep Bydureon Pen, and all medicines, out of the reach of children. Step 1: Prepare your Bydureon Pen Let your Pen come to room temperature. Remove 1 Pen from the refrigerator and let it stand at room temperature for at least 15 minutes. Do not use a pen past its expiration date. Wash your hands. Open the tray. Pull up on the corner tab. Remove the Pen and needle. Do not use your Pen or needle if any parts are broken or missing. Check the liquid in your Pen. Check the liquid inside the inspection window. It should be clear and free of particles. Do not use the Pen if the liquid is colored, has particles, or is not clear. Throw it away and get a new one. You may see bubbles in the liquid, this is normal. Peel off the paper tab from the needle cover. Attach the needle to the Pen. Screw the needle onto the Pen by pushing and twisting clockwise until it is tight. Do not remove the needle cover yet. Step 2: Mix your dose Combine the medicine. While holding the pen straight up, slowly turn the knob. Stop when you hear the click and the green label disappears. Firmly tap your Pen to mix. Hold your Pen by the end with the orange label and tap the Pen firmly against the palm of your hand. DO NOT twist the white knob. ROTATE your Pen every 10 taps. You may need to tap your Pen 80 times or more. Check the Bydureon mix. Hold your Pen up to the light and look through both sides of the mixing window. The solution should have no clumps and be uniformly cloudy (see Figure B). Figure B To get your full dose, Bydureon must be mixed well. If Bydureon is not mixed well, keep tapping your Pen longer and more firmly until it is mixed well. Do not give your Bydureon injection unless your Bydureon is mixed well. Stop. Do Not proceed unless your medicine is mixed well. To get your full dose the medicine must be mixed well. If it’s not mixed well, tap longer and more firmly. Check the Bydureon mix again. Compare both sides of the mixing window to the photos below by holding your Pen against the page. Pay attention to the bottom surface. If you do not see clumps you are ready to inject (see Figure C). Figure C If you have any questions or are not sure if your Bydureon is mixed well, call 1-877-700-7365 for help. Step 3: Inject your dose Important: After the medicine is mixed well, you must inject your dose right away. You cannot save it for later use. Choose your injection site. The recommended injection sites for Bydureon are your stomach (abdomen), thigh, or back of the arm. Each week you can use the same area of your body but choose a different injection site in that area. Gently wipe the site you choose with an alcohol swab (not included). Twist knob to release injection button. Hold your Pen with the needle pointing straight up and turn the white knob until the orange label disappears and the injection button is released. Do not push the injection button yet. Remove the needle cover. Pull the needle cover straight off. Do not twist the needle cover. You may see a few drops of liquid on the needle or in the cover. Inject your Bydureon. Insert the needle into your skin. Press the injection button with your thumb until you hear a “click.” Keep holding the button down and slowly count to 10 to get your full dose. Properly dispose of your used Pen. Put your used needles and Pens in an FDA-cleared sharps disposal container right away after use. Do not throw away (dispose of) loose needles and Pens in your household trash. See Common Questions and Answers for additional disposal information. Common Questions and Answers: How do I know that the Bydureon is mixed well? The Bydureon is mixed well when the liquid looks cloudy from both sides of the window. You should not see any clumps in the liquid. It may help to hold your Pen up to the light to see in the window. If you see clumps of any size keep tapping your Pen firmly against the palm of your hand until mixed. I am having trouble mixing my dose. What should I do? Remember, before preparing your dose, leave your Pen out of the refrigerator for at least 15 minutes. This will let your Pen warm up to room temperature. It will be easier to mix Bydureon if your Pen is at room temperature. Be sure you are holding your Pen at the end with the knob and the orange label. This will help you grip your Pen better and tap it more firmly against your palm. It may also help to tap the mixing window on both sides against your palm. If you see any clumps, keep tapping. After I mix Bydureon, how long can I wait before taking the injection? You must inject your dose of Bydureon right after mixing it. If you do not inject your Bydureon right away, small clumps of medicine may form in your Pen and you may not get your full dose. I am ready to inject my dose. What should I do if I see air bubbles in the Pen? It is normal for air bubbles to be in your Pen. Bydureon is injected into your skin (subcutaneously). Air bubbles will not harm you or affect your dose with this type of injection. What should I do if I cannot push the injection button all the way in when trying to inject my dose? Check that you have fully screwed on the pen needle. Also be sure you twisted the knob until it stopped, the orange label disappeared, and the injection button appears. If you still cannot push the button in, this may mean that the needle is clogged. Remove the needle from your skin and replace it with the spare needle from the carton. Review how to attach the needle. Then choose a different injection site and finish taking the injection. If you still cannot push the button all the way in, remove the needle from your skin. Use a puncture-resistant container to throw away the pen with the needle still attached. If you have problems giving your Bydureon Pen injection or have any questions call 1-877-700-7365 for more instructions. How do I know if I injected my full dose? To be sure you get your full dose, press the injection button with your thumb until you hear a "click." After the "click," continue to hold the needle in your skin for 10 seconds. This will allow enough time for you to get your full dose. What if I do not have an FDA-cleared sharps disposal container? Do not throw away (dispose of) loose needles and Pens in your household trash. If you do not have an FDA-cleared sharps disposal container, you may use a household container that is: made of a heavy-duty plastic, can be closed with a tight-fitting, puncture-resistant lid, without sharps being able to come out, upright and stable during use, leak-resistant, and properly labeled to warn of hazardous waste inside the container. When your sharps disposal container is almost full, you will need to follow your community guidelines for the right way to dispose of your sharps disposal container. There may be state or local laws about how you should throw away used needles and Pens. For more information about safe sharps disposal, and for specific information about sharps disposal in the state that you live in, go to the FDA’s website at: http://www.fda.gov/safesharpsdisposal This Instructions for Use has been approved by the U.S. Food and Drug Administration.

SIDE EFFECTS The following serious adverse reactions are described below or elsewhere in the prescribing information: Risk of Thyroid C-cell Tumors [see WARNINGS AND PRECAUTIONS] Acute Pancreatitis [see WARNINGS AND PRECAUTIONS] Hypoglycemia [see WARNINGS AND PRECAUTIONS] Acute Kidney Injury and Impairment of Renal Function [see WARNINGS AND PRECAUTIONS] Gastrointestinal Disease [see WARNINGS AND PRECAUTIONS] Immunogenicity [see WARNINGS AND PRECAUTIONS] Hypersensitivity [see WARNINGS AND PRECAUTIONS] Injection-Site Reactions [see WARNINGS AND PRECAUTIONS] Clinical Trial Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice. The safety of BYDUREON was assessed in six comparator-controlled trials in patients who entered the studies not achieving adequate glycemic control on their current therapy. In a double-blind 26-week trial, patients on diet and exercise were treated with BYDUREON 2 mg once every 7 days (weekly), sitagliptin 100 mg daily, pioglitazone 45 mg daily, or metformin 2000 mg daily. In a double-blind 26-week trial, patients on metformin were treated with BYDUREON 2 mg once every 7 days (weekly), sitagliptin 100 mg daily, or pioglitazone 45 mg daily. In an open-label 26-week trial, patients on metformin or metformin plus sulfonylurea were treated with BYDUREON 2 mg once every 7 days (weekly) or optimized insulin glargine. In two open-label 24-to 30-week studies, patients on diet and exercise or metformin, a sulfonylurea, a thiazolidinedione, or combination of oral agents were treated with BYDUREON 2 mg once every 7 days (weekly) or BYETTA 10 mcg twice daily. In an open-label 26-week trial, patients on metformin, a sulfonylurea, metformin plus a sulfonylurea, or metformin plus pioglitazone were treated with BYDUREON 2 mg every 7 days (weekly) or liraglutide 1.8 mg once daily. Common Adverse Reactions Tables 1 and 2 summarize adverse reactions with an incidence ≥5% reported in the six comparator-controlled 24-to 30-week trials of BYDUREON used as monotherapy or as add-on to metformin, a sulfonylurea, a thiazolidinedione, or combination of these oral antidiabetic agents. Table 1: Adverse Reactions Reported in ≥5% of BYDUREON-Treated Patients with Type 2 Diabetes Mellitus in Monotherapy Trial 26-Week Monotherapy Trial BYDUREON 2 mg N = 248 % Sitagliptin 100 mg N = 163 % Pioglitazone 30-45 (mean dose 40) mg N = 163 % Metformin 1000-2500 (mean dose 2077) mg N = 246 % Nausea 11.3 3.7 4.3 6.9 Diarrhea 10.9 5.5 3.7 12.6 Injection-site nodule† 10.5 6.7 3.7 10.2 Constipation 8.5 2.5 1.8 3.3 Headache 8.1 9.2 8.0 12.2 Dyspepsia 7.3 1.8 4.9 3.3 N = number of intent-to-treat patients. Table 2: Adverse Reactions Reported in ≥5% of BYDUREON-Treated Patients with Type 2 Diabetes Mellitus in 24-to 30-Week Add-On Combination Therapy Trials 26-Week Add-On to Metformin Trial BYDUREON 2 mg N = 160 % Sitagliptin 100 mg N = 166 % Pioglitazone 45 mg N = 165 % Nausea 24.4 9.6 4.8 Diarrhea 20.0 9.6 7.3 Vomiting 11.3 2.4 3.0 Headache 9.4 9.0 5.5 Constipation 6.3 3.6 1.2 Fatigue 5.6 0.6 3.0 Dyspepsia 5.0 3.6 2.4 Decreased appetite 5.0 1.2 0.0 Injection-site pruritus† 5.0 4.8 1.2 26-Week Add-On to Metformin or Metformin + Sulfonylurea Trial BYDUREON 2 mg N = 233 % Insulin Glargine Titrated N = 223 % Nausea 12.9 1.3 Headache 9.9 7.6 Diarrhea 9.4 4.0 Injection-site nodule 6.0 0.0 30-Week Monotherapy or as Add-On to Metformin, a Sulfonylurea, a Thiazolidinedione, or Combination of Oral Agents Trial BYDUREON 2 mg N = 148 % BYETTA 10 mcg N = 145 % Nausea 27.0 33.8 Diarrhea 16.2 12.4 Vomiting 10.8 18.6 Injection-site pruritus 18.2 1.4 Constipation 10.1 6.2 Gastroenteritis viral 8.8 5.5 Gastroesophageal reflux disease 7.4 4.1 Dyspepsia 7.4 2.1 Injection-site erythema 7.4 0.0 Fatigue 6.1 3.4 Headache 6.1 4.8 Injection-site hematoma 5.4 11.0 24-Week Monotherapy or as Add-On to Metformin, a Sulfonylurea, a Thiazolidinedione, or Combination of Oral Agents Trial BYDUREON 2 mg N = 129 % BYETTA 10 mcg N = 123 % Nausea 14.0 35.0 Diarrhea 9.3 4.1 Injection-site erythema 5.4 2.4 26-Week Add-On to Metformin, a Sulfonylurea, Metformin + Sulfonylurea, or Metformin + Pioglitazone Trial BYDUREON 2 mg N = 461 % Injection-site nodule 10.4 Nausea 9.3 Diarrhea 6.1 N = number of intent-to-treat patients. Note: Percentages are based on the number of intent-to-treat patients in each treatment group. † Patients in the sitagliptin, pioglitazone, and metformin treatment groups received weekly placebo injections. Nausea was a common adverse reaction associated with initiation of treatment with BYDUREON and usually decreased over time. Adverse Reactions Leading To Study Withdrawal The incidence of withdrawal due to adverse reactions was 4.1% (N=57) for BYDUREON-treated patients, 4.9% (N=13) for BYETTA-treated patients, and 2.9% (N=46) for other comparator-treated patients in the six comparator-controlled 24-to 30-week trials. The most common classes of adverse reactions (0.5%) leading to withdrawal for BYDUREON-treated patients were, Gastrointestinal Disorders 1.6% (N=22) versus 4.1% (N=11) for BYETTA and 1.9% (N=30) for other comparators, and Administration Site Conditions 0.8% (N=11) versus 0.0% for BYETTA and 0.2% (N=3) for other comparators. The most frequent adverse reactions within each of these respective classes were, nausea 0.4% (N=6) for BYDUREON versus 1.5% (N=4) for BYETTA and 0.8% (N=12) for other comparators, and injection-site nodule, 0.4% (N=6) for BYDUREON versus 0.0% for BYETTA and 0.0% for other comparators. Hypoglycemia Table 3 summarizes the incidence of minor hypoglycemia in the six comparator-controlled 24-to 30week trials of BYDUREON used as monotherapy or as add-on to metformin, a sulfonylurea, a thiazolidinedione, or combination of these oral antidiabetic agents. In these trials, an event was classified as minor hypoglycemia if there were symptoms of hypoglycemia with a concomitant glucose <54 mg/dL and the patient was able to self-treat. Table 3: Incidence (% of Subjects) of Minor† Hypoglycemia in Clinical Trials in Patients with Type 2 Diabetes Mellitus 26-Week Monotherapy Trial BYDUREON 2 mg (N = 248) 2.0% Sitagliptin 100 mg (N = 163) 0.0% Pioglitazone 30-45 (mean dose 40) mg (N = 163) 0.0% Metformin 1000-2500 (mean dose 2077) mg (N = 246) 0.0% 26-Week Add-On to Metformin Trial BYDUREON 2 mg (N = 160) 1.3% Sitagliptin 100 mg (N = 166) 3.0% Pioglitazone 45 mg (N = 165) 1.2% 26-Week Add-On to Metformin or Metformin + Sulfonylurea Trial With Concomitant Sulfonylurea Use (N = 136) BYDUREON 2 mg (N = 70) 20.0% Titrated Insulin Glargine (N = 66) 43.9% Without Concomitant Sulfonylurea Use (N = 320) BYDUREON 2 mg (N = 163) 3.7% Titrated Insulin Glargine‡ (N = 157) 19.1% 24-Week Monotherapy or Add-On to Metformin, a Sulfonylurea, a Thiazolidinedione, or Combination of Oral Agents Trial With Concomitant Sulfonylurea Use (N = 74) BYDUREON 2 mg (N = 40) 12.5% BYETTA 10 mcg (N = 34) 11.8% Without Concomitant Sulfonylurea Use (N = 178) BYDUREON 2 mg (N = 89) 0.0% BYETTA 10 mcg (N = 89) 0.0% 30-Week Monotherapy or Add-On to Metformin, a Sulfonylurea, a Thiazolidinedione, or Combination of Oral Agents Trial With Concomitant Sulfonylurea Use (N = 107) BYDUREON 2 mg (N = 55) 14.5% BYETTA 10 mcg (N = 52) 15.4% Without Concomitant Sulfonylurea Use (N = 186) BYDUREON 2 mg (N = 93) 0.0% BYETTA 10 mcg (N = 93) 1.1% 26-Week as Add-On to Metformin, a Sulfonylurea, Metformin + Sulfonylurea, or Metformin + Pioglitazone Trial With Concomitant Sulfonylurea Use (N = 590) BYDUREON 2 mg (N = 294) 15.3% Without Concomitant Sulfonylurea Use (N = 321) BYDUREON 2 mg (N = 167) 3.6% N = number of intent-to-treat patients. Note: Percentages are based on the number of intent-to-treat patients in each treatment group. † Reported event that has symptoms consistent with hypoglycemia with a concomitant glucose <54 mg/dL and the patient was able to self-treat. ‡ Insulin glargine was dosed to a target fasting glucose concentration of 72 to 100 mg/dL. The mean dose of insulin glargine was 10 units/day at baseline and 31 units/day at endpoint. Injection-Site Adverse Reactions In the five comparator-controlled 24-to 30-week trials, injection-site reactions were observed more frequently in patients treated with BYDUREON (17.1%) than in patients treated with BYETTA (12.7%), titrated insulin glargine (1.8%), or those patients who received placebo injections (sitagliptin (10.6%), pioglitazone (6.4%), and metformin (13.0%) treatment groups). These reactions for patients treated with BYDUREON were more commonly observed in antibody-positive patients (14.2%) compared with antibody-negative patients (3.1%), with a greater incidence in those with higher titer antibodies [see WARNINGS AND PRECAUTIONS]. Incidence of injection-site reactions for patients treated with BYETTA was similar for antibody-positive patients (5.8%) and antibody-negative patients (7.0%). One percent of patients treated with BYDUREON withdrew due to injection-site adverse reactions (injection-site mass, injection-site nodule, injection-site pruritus, and injection-site reaction). Subcutaneous injection-site nodules may occur with the use of BYDUREON. In a separate 15-week study in which information on nodules were collected and analyzed, 24 out of 31 subjects (77%) experienced at least 1 injection-site nodule during treatment; 2 subjects (6.5%) reported accompanying localized symptoms. The mean duration of events was 27 days. The formation of subcutaneous nodules is consistent with the known properties of the microspheres used in BYDUREON. Increase In Heart Rate Increases in heart rate from baseline ranging from 1.5 to 4.5 beats per minute have been observed in comparator-controlled clinical trials. The long-term effects of the increase in heart rate have not been established. Other Adverse Reactions The following adverse reactions were also reported in three 30-week controlled trials of BYETTA (N=963) add-on to metformin and/or sulfonylurea, with an incidence of ≥1% and reported more frequently than with placebo: feeling jittery (9% BYETTA, 4% placebo), dizziness (9% BYETTA, 6% placebo), asthenia (4% BYETTA, 2% placebo), and hyperhidrosis (3% BYETTA, 1% placebo). Immunogenicity As with all therapeutic proteins, there is potential for immunogenicity. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay. Additionally, the observed incidence of antibody (including neutralizing antibody) positivity in an assay may be influenced by several factors including assay methodology, sample handling, timing of sample collection, concomitant medications, and underlying disease. For these reasons, the incidence of antibodies to exenatide cannot be directly compared with the incidence of antibodies with other products. Anti-exenatide antibodies were measured at prespecified intervals (4-14 weeks) in all BYDUREON-treated patients (N=918) in the five comparator-controlled studies of BYDUREON. In these five trials, 452 BYDUREON-treated patients (49%) had low titer antibodies (≤125) to exenatide at any time during the trials and 405 BYDUREON-treated patients (45%) had low titer antibodies to exenatide at study endpoint (24-30 weeks). The level of glycemic control in these patients was generally comparable to that observed in the 379 BYDUREON-treated patients (43%) without antibody titers. An additional 107 BYDUREON-treated patients (12%) had higher titer antibodies at endpoint. Of these patients, 50 (6% overall) had an attenuated glycemic response to BYDUREON (<0.7% reduction in HbA1c); the remaining 57 (6% overall) had a glycemic response comparable to that of patients without antibodies [see WARNINGS AND PRECAUTIONS]. In the 30-week trial in which anti-exenatide antibody assessments were performed at baseline and at 4-week intervals from week 6 to week 30, the mean anti-exenatide antibody titer in the BYDUREON-treated patients peaked at week 6 then declined by 56% from this peak by week 30. A total of 246 patients with antibodies to exenatide in the BYETTA and BYDUREON clinical trials were tested for the presence of cross-reactive antibodies to GLP-1 and/or glucagon. No treatment-emergent cross-reactive antibodies were observed across the range of titers. Postmarketing Experience The following additional adverse reactions have been reported during post-approval use of another formulation of exenatide. Because these events are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Allergy/Hypersensitivity: injection-site reactions, generalized pruritus and/or urticaria, macular or papular rash, angioedema; anaphylactic reaction. Drug Interactions: increased international normalized ratio (INR), sometimes associated with bleeding, with concomitant warfarin use [see DRUG INTERACTIONS]. Gastrointestinal: nausea, vomiting, and/or diarrhea resulting in dehydration; abdominal distension, abdominal pain, eructation, constipation, flatulence, acute pancreatitis, hemorrhagic and necrotizing pancreatitis sometimes resulting in death [see INDICATIONS.] Neurologic: dysgeusia; somnolence Renal and Urinary Disorders: altered renal function, including increased serum creatinine, renal impairment, worsened chronic renal failure or acute renal failure (sometimes requiring hemodialysis), kidney transplant and kidney transplant dysfunction. Skin and Subcutaneous Tissue Disorders: alopecia DRUG INTERACTIONS Table 4: Clinically Relevant Interactions Affecting Drugs Co-Administered with BYDUREON and Other Exenatide-Containing Products Orally Administered Drugs (e.g., acetaminophen) Clinical Impact Exenatide slows gastric emptying. Therefore, BYDUREON has the potential to reduce the rate of absorption of orally administered drugs [see CLINICAL PHARMACOLOGY]. Intervention Use caution when administering oral medications with BYDUREON where a slower rate of oral absorption may be clinically meaningful. Warfarin Clinical Impact BYDUREON has not been studied with warfarin. However, in a drug interaction study, BYETTA did not have a significant effect on INR [see CLINICAL PHARMACOLOGY]. There have been postmarketing reports for exenatide of increased INR with concomitant use of warfarin, sometimes associated with bleeding [see ADVERSE REACTIONS]. Intervention In patients taking warfarin, the INR should be monitored more frequently after initiating BYDUREON. Once a stable INR has been documented, the INR can be monitored at the intervals usually recommended for patients on warfarin. Concomitant Use of Insulin Secretagogues or Insulin Clinical Impact Exenatide promotes insulin release from pancreatic beta-cells in the presence of elevated glucose concentrations. The risk of hypoglycemia is increased when exenatide is used in combination with insulin secretagogues (e.g., sulfonylureas) or insulin [see ADVERSE REACTIONS]. Intervention Patients may require a lower dose of the secretagogue or insulin to reduce the risk of hypoglycemia in this setting.

WARNINGS Included as part of the "PRECAUTIONS" Section PRECAUTIONS Risk Of Thyroid C-Cell Tumors In both genders of rats, exenatide extended-release caused a dose-related and treatment-duration- dependent increase in the incidence of thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures compared to controls [see Nonclinical Toxicology]. A statistically significant increase in malignant thyroid C-cell carcinomas was observed in female rats receiving exenatide extended-release at 25-times clinical exposure compared to controls and higher incidences were noted in males above controls in all treated groups at ≥2-times clinical exposure. The potential of exenatide extended-release to induce C-cell tumors in mice has not been evaluated. Other GLP-1 receptor agonists have also induced thyroid C-cell adenomas and carcinomas in male and female mice and rats at clinically relevant exposures. It is unknown whether BYDUREON will cause thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans as the human relevance of exenatide extended-release-induced rodent thyroid C-cell tumors has not been determined. Cases of MTC in patients treated with liraglutide, another GLP-1 receptor agonist, have been reported in the postmarketing period; the data in these reports are insufficient to establish or exclude a causal relationship between MTC and GLP-1 receptor agonist use in humans. BYDUREON is contraindicated in patients with a personal or family history of MTC or in patients with MEN 2. Counsel patients regarding the potential risk of MTC with the use of BYDUREON and inform them of symptoms of thyroid tumors (e.g., a mass in the neck, dysphagia, dyspnea, persistent hoarseness). Routine monitoring of serum calcitonin or using thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with BYDUREON. Such monitoring may increase the risk of unnecessary procedures, due to the low specificity of serum calcitonin testing for MTC and a high background incidence of thyroid disease. Significantly elevated serum calcitonin may indicate MTC and patients with MTC usually have values >50 ng/L. If serum calcitonin is measured and found to be elevated, the patient should be further evaluated. Patients with thyroid nodules noted on physical examination or neck imaging should also be further evaluated. Acute Pancreatitis Based on postmarketing data, exenatide has been associated with acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis. After initiation of BYDUREON, observe patients carefully for signs and symptoms of pancreatitis (including persistent severe abdominal pain, sometimes radiating to the back, which may or may not be accompanied by vomiting). If pancreatitis is suspected, BYDUREON should promptly be discontinued and appropriate management should be initiated. If pancreatitis is confirmed, BYDUREON should not be restarted. Consider antidiabetic therapies other than BYDUREON in patients with a history of pancreatitis. Hypoglycemia With Concomitant Use Of Insulin Secretagogues Or Insulin The risk of hypoglycemia is increased when exenatide is used in combination with insulin secretagogues (e.g., sulfonylureas) or insulin. Patients may require a lower dose of the secretagogue or insulin to reduce the risk of hypoglycemia in this setting [see ADVERSE REACTIONS]. Acute Kidney Injury And Impairment Of Renal Function There have been postmarketing reports of altered renal function with exenatide, including increased serum creatinine, renal impairment, worsened chronic renal failure and acute renal failure, sometimes requiring hemodialysis or kidney transplantation. Some of these events occurred in patients receiving one or more pharmacologic agents known to affect renal function or hydration status such as angiotensin converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs, or diuretics. Some events occurred in patients who had been experiencing nausea, vomiting, or diarrhea, with or without dehydration. Reversibility of altered renal function has been observed in many cases with supportive treatment and discontinuation of potentially causative agents, including exenatide. Exenatide has not been found to be directly nephrotoxic in preclinical or clinical studies. BYDUREON is not recommended for use in patients with severe renal impairment (creatinine clearance <30 mL/min) or end-stage renal disease and should be used with caution in patients with renal transplantation [see Use In Specific Populations]. In patients with end-stage renal disease receiving dialysis, single doses of BYETTA 5 mcg were not well tolerated due to gastrointestinal side effects. Because BYDUREON may induce nausea and vomiting with transient hypovolemia, treatment may worsen renal function. Use BYDUREON with caution in patients with moderate renal impairment (creatinine clearance 30-50 mL/min) [see Use In Specific Populations and CLINICAL PHARMACOLOGY]. BYDUREON has not been studied in patients with end-stage renal disease or severe renal impairment. Gastrointestinal Disease Exenatide has not been studied in patients with severe gastrointestinal disease, including gastroparesis. Because exenatide is commonly associated with gastrointestinal adverse reactions, including nausea, vomiting, and diarrhea, the use of BYDUREON is not recommended in patients with severe gastrointestinal disease. Immunogenicity Patients may develop antibodies to exenatide following treatment with BYDUREON. Anti-exenatide antibodies were measured in BYDUREON-treated patients in five of the six comparator-controlled 24-to 30-week studies of BYDUREON. In 6% of BYDUREON-treated patients, antibody formation was associated with an attenuated glycemic response. If there is worsening glycemic control or failure to achieve targeted glycemic control, consider alternative antidiabetic therapy [see ADVERSE REACTIONS]. Hypersensitivity There have been postmarketing reports of serious hypersensitivity reactions (e.g., anaphylaxis and angioedema) in patients treated with exenatide. If a hypersensitivity reaction occurs, the patient should discontinue BYDUREON and promptly seek medical advice [see CONTRAINDICATIONS, ADVERSE REACTIONS]. Inform and closely monitor patients with a history of anaphylaxis or angioedema with another GLP-1 receptor agonist for allergic reactions, because it is unknown whether such patients will be predisposed to anaphylaxis with BYDUREON. Injection-Site Reactions There have been postmarketing reports of serious injection-site reactions (e.g., abscess, cellulitis, and necrosis), with or without subcutaneous nodules, with the use of BYDUREON. Isolated cases required surgical intervention [see ADVERSE REACTIONS]. Macrovascular Outcomes There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with BYDUREON. Patient Counseling Information Advise the patient to read the FDA-approved patient labeling (Medication Guide and Instructions for Use). Risk Of Thyroid C-Cell Tumors Inform patients that exenatide extended-release causes benign and malignant thyroid C-cell tumors in rats and that the human relevance of this finding has not been determined. Counsel patients to report symptoms of thyroid tumors (e.g., a lump in the neck, hoarseness, dysphagia, or dyspnea) to their physician [see BOX WARNING and WARNINGS AND PRECAUTIONS]. Risk Of Pancreatitis Inform patients treated with BYDUREON of the potential risk for pancreatitis. Explain that persistent severe abdominal pain that may radiate to the back, and which may or may not be accompanied by vomiting, is the hallmark symptom of acute pancreatitis. Instruct patients to discontinue BYDUREON promptly and contact their healthcare provider if persistent severe abdominal pain occurs [see WARNINGS AND PRECAUTIONS]. Risk Of Hypoglycemia Inform patients that the risk of hypoglycemia is increased when BYDUREON is used in combination with an agent that induces hypoglycemia, such as a sulfonylurea or insulin [see WARNINGS AND PRECAUTIONS]. Explain the symptoms, treatment, and conditions that predispose to the development of hypoglycemia. Review and reinforce instructions for hypoglycemia management when initiating BYDUREON therapy, particularly when concomitantly administered with a sulfonylurea or insulin [see WARNINGS AND PRECAUTIONS]. Risk Of Acute Kidney Injury Inform patients treated with BYDUREON of the potential risk for worsening kidney function and explain the associated signs and symptoms of renal impairment, as well as the possibility of dialysis as a medical intervention if renal failure occurs [see WARNINGS AND PRECAUTIONS]. Risk Of Hypersensitivity Reactions Inform patients that serious hypersensitivity reactions have been reported during postmarketing use of exenatide. Inform patients that if symptoms of hypersensitivity reactions occur, stop taking BYDUREON and seek medical advice promptly [see WARNINGS AND PRECAUTIONS]. Risk Of Injection-Site Reactions Inform patients that there have been postmarketing reports of serious injection-site reactions with or without subcutaneous nodules, with the use of BYDUREON. Isolated cases of injection-site reactions required surgical intervention. Advise patients to seek medical advice if symptomatic nodules occur, or for any signs or symptoms of abscess, cellulitis, or necrosis [see WARNINGS AND PRECAUTIONS]. Instructions Patients should be trained on how to use BYDUREON properly prior to self-administration. Instruct patients on proper mixing and injection technique to ensure the product is adequately mixed and a full dose is delivered. Refer patients to the accompanying Instructions for Use for complete administration instructions with illustrations [see DOSAGE AND ADMINISTRATION]. Counsel patients that they should never share BYDUREON with another person, even if the needle is changed. Sharing of BYDUREON or needles between patients may pose a risk of transmission of infection. If a patient is currently taking BYETTA, it should be discontinued upon starting BYDUREON. Inform patients formerly on BYETTA who start BYDUREON that they may experience transient elevations in blood glucose concentrations, which generally improve within the first 2 weeks after initiation of therapy [see DOSAGE AND ADMINISTRATION and Clinical Studies]. Treatment with BYDUREON may also result in nausea, particularly upon initiation of therapy [see ADVERSE REACTIONS]. Inform patients about the importance of proper storage of BYDUREON [see HOW SUPPLIED]. Instruct the patient to review the BYDUREON Medication Guide and the Instructions for Use each time the prescription is refilled. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment Of Fertility Thyroid C-cell tumors have been observed in rats and mice with GLP-1 receptor agonists. A 2-year carcinogenicity study was conducted with exenatide extended-release, the active component of BYDUREON, in male and female rats at doses of 0.3, 1.0, and 3.0 mg/kg (2-, 9-, and 26-times human systemic exposure at the maximum recommended human dose (MRHD) of 2 mg/week BYDUREON based on plasma exenatide AUC, respectively) administered by subcutaneous injection every other week. In this study there was an increased incidence of C-cell adenomas and C-cell carcinomas at all doses. An increase in benign fibromas was seen in the skin subcutis at injection sites of males given 3 mg/kg. No treatment-related injection-site fibrosarcomas were observed at any dose. The human relevance of these findings is currently unknown. Carcinogenicity of exenatide extended-release has not been evaluated in mice. Exenatide, the active ingredient in BYDUREON, was not mutagenic or clastogenic, with or without metabolic activation, in the Ames bacterial mutagenicity assay or chromosomal aberration assay in Chinese hamster ovary cells. Exenatide was negative in the in vivo mouse micronucleus assay. In mouse fertility studies with exenatide, the active ingredient in BYDUREON, at twice-daily subcutaneous doses of 6, 68, or 760 mcg/kg/day, males were treated for 4 weeks prior to and throughout mating, and females were treated 2 weeks prior to mating and throughout mating until gestation day 7. No adverse effect on fertility was observed at 760 mcg/kg/day, a systemic exposure 148 times the human exposure resulting from the recommended dose of 2 mg/week, based on AUC. Use In Specific Populations Pregnancy Risk Summary Limited data with exenatide, the active ingredient in BYDUREON, in pregnant women are not sufficient to determine a drug-associated risk for major birth defects or miscarriage. There are risks to the mother and fetus associated with poorly controlled diabetes in pregnancy (see Clinical Considerations). Based on animal reproduction studies, there may be risks to the fetus from exposure to BYDUREON during pregnancy. BYDUREON should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Animal reproduction studies identified increased adverse fetal and neonatal outcomes from exposure to exenatide extended-release during pregnancy, or from exposure to exenatide, during pregnancy and lactation, in association with maternal effects. In rats, exenatide extended-release administered during the period of organogenesis reduced fetal growth and produced skeletal ossification deficits at doses that approximate clinical exposures at the maximum recommended human dose (MRHD) of 2 mg/week. In mice, exenatide administered during gestation and lactation caused increased neonatal deaths at doses that approximate clinical exposures at the MRHD (see Data). Based on animal data, advise pregnant women of the potential risk to a fetus. The estimated background risk of major birth defects is 6-10% in women with pre-gestational diabetes with an HbA1c >7 and has been reported to be as high as 20-25% in women with HbA1c >10. The estimated background risk of miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively. Clinical Considerations Disease-associated maternal and/or embryo/fetal risk Poorly controlled diabetes in pregnancy increases the maternal risk for diabetic ketoacidosis, preeclampsia, spontaneous abortions, preterm delivery, still birth and delivery complications. Poorly controlled diabetes increases the fetal risk for major birth defects, stillbirth, and macrosomia related morbidity. Data Animal Data Pregnant rats given subcutaneous doses of 0.3, 1, or 3 mg/kg exenatide extended-release every 3 days during organogenesis had systemic exposures 3-, 7-, and 17-times human exposure, respectively, at the maximum recommended human dose (MRHD) of 2 mg/week BYDUREON based on plasma exenatide exposure (AUC) comparison. Reduced fetal growth at all doses and skeletal ossification deficits at 1 and 3 mg/kg occurred at doses that decreased maternal food intake and body weight gain. In studies evaluating reproduction and development in pregnant mice and rabbits, maternal animals were administered exenatide, the active ingredient in BYDUREON, by subcutaneous injection twice a day. Differences in embryo-fetal developmental toxicity from subcutaneously injected exenatide extended-release and exenatide were not evaluated in mice, rats, or rabbits. In pregnant mice given 6, 68, 460, or 760 mcg/kg/day exenatide during fetal organogenesis, skeletal variations associated with slowed fetal growth, including changes in number of rib pairs or vertebral ossifications sites, and wavy ribs were observed at 760 mcg/kg/day, a dose that produced maternal toxicity and yielded systemic exposure 200 times the human exposure resulting from the MRHD of BYDUREON based on AUC comparison. In pregnant rabbits given 0.2, 2, 22, 156, or 260 mcg/kg/day exenatide during fetal organogenesis, irregular fetal skeletal ossifications were observed at 2 mcg/kg/day, a dose yielding systemic exposure up to 4 times the human exposure from the MRHD of BYDUREON based on AUC comparison. In maternal mice given 6, 68, or 760 mcg/kg/day exenatide from gestation day 6 through lactation day 20 (weaning), an increased number of neonatal deaths were observed on postpartum days 2 to 4 in dams given 6 mcg/kg/day, a dose yielding a systemic exposure equivalent to the human exposure from the MRHD of BYDUREON based on AUC comparison. Lactation Risk Summary There is no information regarding the presence of exenatide in human milk, the effects of exenatide on the breastfed infant, or the effects of exenatide on milk production. Exenatide, the active ingredient in BYDUREON, was present in the milk of lactating mice. However, due to species-specific differences in lactation physiology, the clinical relevance of these data is not clear (see Data). The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for exenatide and any potential adverse effects on the breastfed child from exenatide or from the underlying maternal condition. Data In lactating mice subcutaneously injected twice a day with exenatide, the active ingredient in BYDUREON, the concentration of exenatide in milk was up to 2.5% of the concentration in maternal plasma. Pediatric Use Safety and effectiveness of BYDUREON have not been established in pediatric patients. BYDUREON is not recommended for use in pediatric patients. Geriatric Use In the five comparator-controlled 24-to 30-week trials, BYDUREON was studied in 132 patients (16.6%) who were at least 65 years old and 20 patients who were at least 75 years old. No differences in safety (N=152) and efficacy (N=52) were observed between these patients and younger patients, but the small sample size for patients ≥75 years old limits conclusions. Because elderly patients are more likely to have decreased renal function, use caution when initiating BYDUREON in the elderly. Renal Impairment BYDUREON is not recommended for use in patients with end-stage renal disease or severe renal impairment (creatinine clearance <30 mL/min) and should be used with caution in patients with renal transplantation. Use BYDUREON with caution in patients with moderate renal impairment (creatinine clearance 30-50 mL/min) [see WARNINGS AND PRECAUTIONS and CLINICAL PHARMACOLOGY].