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CLINICAL PHARMACOLOGY Mechanism Of Action Nateglinide lowers blood glucose levels by stimulating insulin secretion from the pancreas. This action is dependent upon functioning beta-cells in the pancreatic islets. Nateglinide interacts with the ATP-sensitive potassium (K+ATP) channel on pancreatic beta-cells. The subsequent depolarization of the beta cell opens the calcium channel, producing calcium influx and insulin secretion. The extent of insulin release is glucose dependent and diminishes at low glucose levels. Nateglinide is highly tissue selective with low affinity for heart and skeletal muscle. Pharmacodynamics STARLIX stimulates pancreatic insulin secretion within 20 minutes of oral administration. When STARLIX is dosed before meals, the peak rise in plasma insulin occurs approximately 1 hour after dosing and falls to baseline by 4 hours after dosing. Pharmacokinetics In patients with Type 2 diabetes, multiple dose administration of nateglinide over the dosage range of 60 mg to 240 mg shows linear pharmacokinetics for both AUC and Cmax. In patients with Type 2 diabetes, there is no apparent accumulation of nateglinide upon multiple dosing of up to 240 mg three times daily for 7 days. Absorption Absolute bioavailability of nateglinide is approximately 73%. Plasma profiles are characterized by multiple plasma concentration peaks when nateglinide is administered under fasting conditions. This effect is diminished when nateglinide is taken prior to a meal. Following oral administration immediately prior to a meal, the mean peak plasma nateglinide concentrations (Cmax) generally occur within 1 hour (Tmax) after dosing. Tmax is independent of dose. The pharmacokinetics of nateglinide are not affected by the composition of a meal (high protein, fat, or carbohydrate). However, peak plasma levels are significantly reduced when STARLIX is administered 10 minutes prior to a liquid meal as compared to solid meal. When given with or after meals, the extent of nateglinide absorption (AUC) remains unaffected. However, there is a delay in the rate of absorption characterized by a decrease in Cmax and a delay in time to peak plasma concentration (Tmax). STARLIX did not have any effect on gastric emptying in healthy subjects as assessed by acetaminophen testing. Distribution Following intravenous (IV) administration of nateglinide, the steady-state volume of distribution of nateglinide is estimated to be approximately 10 L in healthy subjects. Nateglinide is extensively bound (98%) to serum proteins, primarily serum albumin, and to a lesser extent α1 acid glycoprotein. The extent of serum protein binding is independent of drug concentration over the test range of 0.1 to 10 mcg/mL. Elimination In healthy volunteers and patients with type 2 diabetes mellitus, nateglinide plasma concentrations declined with an average elimination half-life of approximately 1.5 hours. Metabolism In vitro drug metabolism studies indicate that STARLIX is predominantly metabolized by the cytochrome P450 isozyme CYP2C9 (70%) and to a lesser extent CYP3A4 (30%). The major routes of metabolism are hydroxylation followed by glucuronide conjugation. The major metabolites are less potent antidiabetic agents than nateglinide. The isoprene minor metabolite possesses potency similar to that of the parent compound nateglinide. Excretion Nateglinide and its metabolites are rapidly and completely eliminated following oral administration. Eighty-three percent of the 14C-nateglinide was excreted in the urine with an additional 10% eliminated in the feces. Approximately 16% of the 14C-nateglinide was excreted in the urine as parent compound. Specific Populations Renal Impairment No pharmacokinetic data are available in subjects with mild renal impairment (CrCl 60 to 89 mL/min). Compared to healthy matched subjects, patients with type 2 diabetes mellitus and moderate and severe renal impairment (CrCl 15-50 mL/min) not on dialysis displayed similar apparent clearance, AUC, and Cmax. Patients with type 2 diabetes and renal failure on dialysis exhibited reduced overall drug exposure (Cmax decreased by 49%; not statistically significant). However, hemodialysis patients also experienced reductions in plasma protein binding compared to the matched healthy volunteers. Hepatic Impairment In patients with mild hepatic impairment, the mean increase in Cmax and AUC of nateglinide were 37% and 30 % respectively, as compared to healthy matched control subjects. There is no data on pharmacokinetics of STARLIX in patients with moderate-to-severe hepatic impairment. Gender No clinically significant differences in nateglinide pharmacokinetics were observed between men and women. Race Results of a population pharmacokinetic analysis including subjects of Caucasian, Black, and other ethnic origins suggest that race has little influence on the pharmacokinetics of nateglinide. Age Age does not influence the pharmacokinetic properties of nateglinide. Drug Interactions In Vitro Assessment Of Drug Interactions STARLIX is a potential inhibitor of the CYP2C9 isoenzyme in vivo as indicated by its ability to inhibit the in vitro metabolism of tolbutamide. Inhibition of CYP3A4 metabolic reactions was not detected in in vitro experiments. In vitro displacement studies with highly protein-bound drugs such as furosemide, propranolol, captopril, nicardipine, pravastatin, glyburide, warfarin, phenytoin, acetylsalicylic acid, tolbutamide, and metformin showed no influence on the extent of nateglinide protein binding. Similarly, nateglinide had no influence on the serum protein binding of propranolol, glyburide, nicardipine, warfarin, phenytoin, acetylsalicylic acid, and tolbutamide in vitro. However, prudent evaluation of individual cases is warranted in the clinical setting. In Vivo Assessment Of Drug Interactions The effect of coadministered drugs on the pharmacokinetics of nateglinide and the effect of nateglinide on pharmacokinetics of coadministered drugs are shown in Tables 3 and 4. No clinically relevant change in pharmacokinetic parameters of either agent was reported when nateglinide was coadministered with glyburide, metformin, digoxin, warfarin, and diclofenac. Table 3: Effect of Coadministered Drugs on Pharmacokinetics of Nateglinide Coadministered drug Dosing regimen of coadministered drug Dosing regimen of nateglinide Change in Cmax Change in AUC Glyburide 10 mg once daily for 3 weeks 120 mg three times a day, single dose 8.78%↓ 3.53%↓ Metformin 500 mg three times a day for 3 weeks 120 mg three times a day, single dose AM: 7.14% ↑ PM: 11.4% ↓ AM: 1.51% ↑ PM: 5.97% ↑ Digoxin 1 mg, single dose 120 mg three times a day, single dose AM: 2.17% ↓ PM: 3.19% ↑ AM: 7.62% ↑ PM: 2.22% ↑ Warfarin 30 mg, single dose 120 mg three times a day for 4 days 2.65% ↑ 3.72%↓ Diclofenac 75 mg, single dose 120 mg twice daily, single dose AM: 13.23% ↓ *PM: 3.76% ↑ AM: 2.2% ↓ *PM: 7.5% ↑ AM: after morning dose; PM: after evening dose; * after second dose; ↑ increase in the parameter; ↓:decrease in the parameter Table 4: Effect of Nateglinide on Pharmacokinetics of Coadministered Drugs Coadministered drug Dosing regimen of coadministered drug Dosing regimen of nateglinide Change in Cmax Change in AUC Glyburide 10 mg once daily for 3 weeks 120 mg three times a day, single dose 3.18% ↓ 7.34% ↓ Metformin 500 mg three times a day for 3 weeks 120 mg three times a day, single dose AM: 10.7% ↑ PM: 0.40% ↑ AM: 13.3% ↑ PM: 2.27% ↑ Digoxin 1 mg, single dose 120 mg three times a day, single dose 5.41% ↓ 6.58 % ↑ Warfarin 30 mg, single dose 120 mg three times a day for 4 days R-warfarin: 1.03% ↓ S-warfarin: 0.85% ↓ R-warfarin: 0.74% ↑ S-warfarin: 7.23% ↑ Diclofenac 75 mg, single dose 120 mg twice daily, single dose 2.19% ↑ 7.97% ↑ AM: after morning dose; PM: after evening dose; SD: single dose; ↑: increase in the parameter; ↓: decrease in the parameter Clinical Studies Monotherapy In a 24-week, double-blind, placebo-controlled study, patients with type 2 diabetes were randomized to receive either STARLIX (60 mg or 120 mg three times daily before meals) or placebo. Patients previously treated with antidiabetic medications were required to discontinue that medication for at least 2 months before randomization. At Week 24, treatment with STARLIX before meals resulted in statistically significant reductions in mean HbA1C and mean fasting plasma glucose (FPG) compared to placebo (see Table 5). The reductions in HbA1C and FPG were similar for patient’s naïve to, and those previously exposed to, antidiabetic medications. Table 5: Endpoint Results for a 24-week, Fixed Dose Study of STARLIX Monotherapy Placebo STARLIX 60 mg three times daily before meals STARLIX 120 mg three times daily before meals HbA1C (%) N=168 N=167 N=168 Baseline (mean) 8.0 7.9 8.1 Change from baseline (mean) +0.2 -0.3 -0.5 Difference from placebo (mean) -0.5 a -0.7 a FPG (mg/dL) N=172 N=171 N=169 Baseline (mean) 167.9 161.0 166.5 Change from baseline (mean) +9.1 +0.4 -4.5 Difference from placebo (mean) -8.7 a -13.6a a p-value ≤ 0.004 Monotherapy Compared To Glyburide In a 24-week, double-blind, active-controlled trial, patients with type 2 diabetes who had been on a sulfonylurea for 3 or more months and who had a baseline HbA1C greater than or equal to 6.5% were randomized to receive STARLIX (60 mg or 120 mg three times daily before meals) or glyburide 10 mg once daily. Patients randomized to STARLIX had significant increases in mean HbA1C and mean FPG at endpoint compared to patients randomized to glyburide. Table 6: Endpoint Results for a 24-week Study of STARLIX Monotherapy Compared to Glyburide Glyburide 10 mg Once daily STARLIX 60 mg three times daily before meals STARLIX 120 mg three times daily before meals HbA1C (%) N=183 N=178 N=179 Baseline (mean) 7.8 8.0 7.9 Change from baseline (mean) 0.3 1.3 1.1 Difference from placebo (mean) 1.0 a 0.9a FPG (mg/dL) N=184 N=182 N=180 Baseline (mean) 9.44 9.67 9.61 Change from baseline (mean) 0.19 3.06 2.84 Difference from placebo (mean) 2.87 a 2.66a a p-value <0.001 Monotherapy And In Combination With Metformin In a 24-week, double-blind, active- and placebo-controlled study, patients with type 2 diabetes were randomized to receive either STARLIX alone (120 mg three times daily before meals), metformin alone (500 mg three times daily), a combination of STARLIX 120 mg (three times daily before meals) and metformin (500 mg three times daily), or placebo. Fifty-seven percent of patients were previously untreated with oral antidiabetic therapy. Patients previously treated with antidiabetic medications were required to discontinue medication for at least 2 months before randomization. At Week 24, statistically significant reductions in mean HbA1c and FPG were observed with metformin monotherapy compared to STARLIX monotherapy, and the combination of STARLIX and metformin compared to either STARLIX or metformin monotherapy (see Table 7). Compared to placebo, STARLIX monotherapy was associated with a statistically significant increase in mean body weight, while no significant change in body weight was observed with metformin monotherapy or combination of STARLIX and metformin therapy (see Table 7). Among the subset of patients previously treated with other antidiabetic agents, primarily glyburide, HbA1C in the STARLIX monotherapy group increased slightly from baseline, whereas HbA1C was reduced in the metformin monotherapy group (see Table 7). Table 7: Endpoint results for a 24-week study of STARLIX Monotherapy and Combination with Metformin Placebo STARLIX 120 mg three times daily before meals Metformin 500 mg three times daily STARLIX 120 mg before meals plus Metformin* HbA1C (%) All N=160 N=171 N=172 N=162 Baseline (mean) 8.3 8.3 8.4 8.4 Change from baseline (mean) +0.4 -0.4bc -0.8c -1.5 Difference from placebo -0.8a -1.2a -1.9a Naїve N=98 N=99 N=98 N=81 Baseline (mean) 8.2 8.1 8.3 8.2 Change from baseline (mean) +0.3 -0.7c -0.8c -1.6 Difference from placebo -1.0 a -1.1a -1.9 a Non-Naїve N=62 N=72 N=74 N=81 Baseline (mean) 8.3 8.5 8.7 8.7 Change from baseline (mean) +0.6 +0.004bc -0.8c -1.4 Difference from placebo -0.6 a -1.4 a -2.0 a FPG (mg/dL) All N=166 N=173 N=174 N=167 Baseline (mean) 194.0 196.5 196.0 197.7 Change from baseline (mean) +8.0 -13.1bc -30.0c -44.9 Difference from placebo -21.1 a -38.0 a -52.9 a a p-value ≤ 0.05 vs. placebo b p-value ≤ 0.03 vs. metformin c p-value ≤ 0.05 vs. combination * Metformin was administered three times daily In another 24-week, double-blind, placebo-controlled trial, patients with type 2 diabetes with HbA1C greater than or equal to 6.8% after treatment with metformin (greater than or equal to 1500 mg daily for at least 1 month) were first entered into a four week run-in period of metformin monotherapy (2000 mg daily) and then randomized to receive either STARLIX (60 mg or 120 mg three times daily before meals) or placebo as add-on to metformin. At the end of treatment, STARLIX 60 mg and 120 mg three times daily resulted in a statistically significantly greater reductions in HbA1C compared to placebo when added to metformin (-0.4% and -0.6% for STARLIX 60 mg and STARLIX 120 mg plus metformin, respectively). Table 8: Endpoint Results for a 24-week Study of STARLIX Monotherapy as Add-on to Metformin Placebo + metformin STARLIX 60 mg +metformin STARLIX 120 mg +metformin HbA1C (%) N=150 N=152 N=154 Baseline (mean) 8.2 8.0 8.2 Change from baseline (mean) 0.01 -0.4 -0.6 Difference from placebo (mean) -0.4 a -0.6 b a p-value 0.003 vs. metformin bp-value < 0.001 vs. metformin All STARLIX/placebo taken three times daily before meals; all metformin 1000 mg twice daily. Add-On Combination Therapy With Rosiglitazone A 24-week, double blind, multicenter, placebo-controlled trial was performed in patients with type 2 diabetes not adequately controlled on rosiglitazone 8 mg daily. The addition of STARLIX (120 mg three times per day with meals) was associated with statistically significantly greater reductions in HbA1C compared to placebo as add-on to rosiglitazone. The mean change in weight from baseline was +3 kg for patients treated with STARLIX compared to +1 kg for patients treated with placebo when added to rosiglitazone. Table 9: Endpoint Results for a 24-week Study of the Effect of Adding STARLIX or Placebo to Rosiglitazone Placebo + rosiglitazone 8 mg once daily STARLIX 120 mg before meals + rosiglitazone 8 mg once daily HbA1C (%) N=191 N=194 Baseline (mean) 8.4 8.3 Change from baseline (mean) 0.03 -0.7 Difference from rosiglitazone (mean) -0.7a a p-value . 0.0001 Add-On Combination Therapy With Glyburide In a 12-week study of patients with type 2 diabetes inadequately controlled on glyburide 10 mg once daily, the addition of STARLIX (60 mg or 120 mg three times daily before meals) did not produce any additional benefit. Table 10: Endpoint Results for a 12-week Study of the Effect of Adding STARLIX or Placebo to Glyburide Placebo + glyburide 10 mg once daily STARLIX 60 mg before meals + glyburide 10 mg once daily STARLIX 120 mg before meals + glyburide 10 mg once daily HbA1C (%) N=58 N=55 N=54 Baseline (mean) 8.7 8.7 8.7 Change from baseline (mean) 0.3 0.2 -0.02 Difference from glyburide (mean) -0.1a -0.3b Placebo or STARLIX given 10 minutes prior to breakfast, lunch, and dinner; glyburide given with the breakfast dose of STARLIX or placebo. a p-value 0.6959 b p-value 0.1246

Find Lowest Prices on STARLIX® (nateglinide) Tablets DESCRIPTION STARLIX® (nateglinide) is an oral blood glucose-lowering drug of the glinide class. STARLIX, (-)-N-[(trans-4-isopropylcyclohexane)carbonyl]-D-phenylalanine, is structurally unrelated to the oral sulfonylurea insulin secretagogues. The structural formula is as shown: Nateglinide is a white powder with a molecular weight of 317.43. It is freely soluble in methanol, ethanol, and chloroform, soluble in ether, sparingly soluble in acetonitrile and octanol, and practically insoluble in water. STARLIX biconvex tablets contain 60 mg, or 120 mg, of nateglinide for oral administration. Inactive Ingredients colloidal silicon dioxide, croscarmellose sodium, hydroxypropyl methylcellulose, iron oxides (red or yellow), lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, povidone, talc, and titanium dioxide.

STARLIX® (nateglinide) Tablets DESCRIPTION STARLIX® (nateglinide) is an oral blood glucose-lowering drug of the glinide class. STARLIX, (-)-N-[(trans-4-isopropylcyclohexane)carbonyl]-D-phenylalanine, is structurally unrelated to the oral sulfonylurea insulin secretagogues. The structural formula is as shown: Nateglinide is a white powder with a molecular weight of 317.43. It is freely soluble in methanol, ethanol, and chloroform, soluble in ether, sparingly soluble in acetonitrile and octanol, and practically insoluble in water. STARLIX biconvex tablets contain 60 mg, or 120 mg, of nateglinide for oral administration. Inactive Ingredients colloidal silicon dioxide, croscarmellose sodium, hydroxypropyl methylcellulose, iron oxides (red or yellow), lactose monohydrate, magnesium stearate, microcrystalline cellulose, polyethylene glycol, povidone, talc, and titanium dioxide.

INDICATIONS STARLIX is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. Limitations Of Use STARLIX should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. DOSAGE AND ADMINISTRATION The recommended dose of STARLIX is 120 mg orally three times daily before meals. The recommended dose of STARLIX is 60 mg orally three times daily before meals in patients who are near glycemic goal when treatment is initiated. Instruct patients to take STARLIX 1 to 30 minutes before meals. In patients who skip meals, instruct patients to skip the scheduled dose of STARLIX to reduce the risk of hypoglycemia [see WARNINGS AND PRECAUTIONS]. HOW SUPPLIED Dosage Forms And Strengths 60 mg tablets: pink, round, beveled edge film-coated tablet with “STARLIX” debossed on one side and “60” on the other 120 mg tablets: yellow, ovaloid film-coated tablet with “STARLIX” debossed on one side and “120” on the other Storage And Handling 60 mg Pink, round, beveled edge film-coated tablet with “STARLIX” debossed on one side and “60” on the other. Bottles of 100 NDC 0078-0351-05 120 mg Yellow, ovaloid film-coated tablet with “STARLIX” debossed on one side and “120” on the other. Bottles of 100 NDC 0078-0352-05 Storage And Handling Store at 25°C (77°F); excursions permitted to 15°C-30°C (59°F-86°F). Dispense in a tight container, USP. Distributed by: Novartis Pharmaceuticals Corporation East Hanover, New Jersey 07936. Revised: March 2017.

PATIENT INFORMATION Patients should be informed of the potential risks and benefits of nateglinide and of alternative modes of therapy. The risks and management of hypoglycemia should be explained. Patients should be instructed to take nateglinide 1 to 30 minutes before ingesting a meal, but to skip their scheduled dose if they skip the meal so that the risk of hypoglycemia will be reduced. Drug interactions should be discussed with patients. Patients should be informed of potential drug-drug interactions with nateglinide.

OVERDOSE There have been no instances of overdose with STARLIX in clinical trials. However, an overdose may result in an exaggerated glucose-lowering effect with the development of hypoglycemic symptoms. Hypoglycemic symptoms without loss of consciousness or neurological findings should be treated with oral glucose and adjustments in dosage and/or meal patterns. Severe hypoglycemic reactions with coma, seizure, or other neurological symptoms should be treated with intravenous glucose. As STARLIX is highly protein bound, dialysis is not an efficient means of removing it from the blood. CONTRAINDICATIONS STARLIX is contraindicated in patients with a history of hypersensitivity to STARLIX or its active ingredients.

SIDE EFFECTS The following serious adverse reaction is also described elsewhere in the labeling: Hypoglycemia [see WARNINGS AND PRECAUTIONS] Clinical Trials 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. In clinical trials, approximately 2,600 patients with type 2 diabetes mellitus were treated with STARLIX. Of these, approximately 1,335 patients were treated for 6 months or longer and approximately 190 patients for one year or longer. Table 1 shows the most common adverse reactions associated with STARLIX. Table 1: Adverse Reactions other than Hypoglycemia (%) occurring Greater than or Equal to 2% in STARLIX-Treated Patients from Pool of 12 to 64 week Placebo Controlled Trials PlaceboN=458 STARLIXN=1441 Preferred Term Upper Respiratory Infection 8.1 10.5 Back Pain 3.7 4.0 Flu Symptoms 2.6 3.6 Dizziness 2.2 3.6 Arthropathy 2.2 3.3 Diarrhea 3.1 3.2 Accidental Trauma 1.7 2.9 Bronchitis 2.6 2.7 Coughing 2.2 2.4 Hypoglycemia Episodes of severe hypoglycemia (plasma glucose less than 36 mg/dL) were reported in two patients treated with STARLIX. Non-severe hypoglycemia occurred in 2.4 % of STARLIX treated patients and 0.4 % of placebo treated patients [see WARNINGS AND PRECAUTIONS]. Weight Gain Patients treated with STARLIX had statistically significant mean increases in weight compared to placebo. In clinical trials, the mean weight increases with STARLIX 60 mg (3 times daily) and STARLIX 120 mg (3 times daily) compared to placebo were 1.0 kg and 1.6 kg respectively. Laboratory Test Increases in Uric Acid: There were increases in mean uric acid levels for patients treated with STARLIX alone, STARLIX in combination with metformin, metformin alone, and glyburide alone. The respective differences from placebo were 0.29 mg/dL, 0.45 mg/dL, 0.28 mg/dL, and 0.19 mg/dL. Postmarketing Experience The following adverse reactions have been identified during post-approval use of STARLIX. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Hypersensitivity reactions: Rash, itching, and urticaria Hepatobiliary Disorders: Jaundice, cholestatic hepatitis, and elevated liver enzymes DRUG INTERACTIONS Table 2 includes a list of drugs with clinically important drug interactions when concomitantly administered or withdrawn with STARLIX and instructions for managing or preventing them. Table 2: Clinically Significant Drug Interactions with STARLIX Drugs That May Increase the Blood-Glucose-Lowering Effect of STARLIX and Susceptibility to Hypoglycemia Drugs: Nonsteroidal anti-inflammatory drugs (NSAIDs), salicylates, monoamine oxidase inhibitors, non-selective beta-adrenergic-blocking agents, anabolic hormones (e.g. methandrostenolone), guanethidine, gymnema sylvestre, glucomannan, thioctic acid, and inhibitors of CYP2C9 (e.g. amiodarone, fluconazole, voriconazole, sulfinpyrazone), alcohol. Intervention: Dose reductions and increased frequency of glucose monitoring may be required when STARLIX is coadministered with these drugs. Drugs and Herbals That May Reduce the Blood-Glucose-Lowering Effect of STARLIX and Increase Susceptibility to Hyperglycemia Drugs: Thiazides, corticosteroids, thyroid products, sympathomimetics, somatropin, somatostatin analogues (e.g. lanreotide, octreotide), and CYP inducers (e.g. rifampin, phenytoin and St John’s Wort). Intervention: Dose increases and increased frequency of glucose monitoring may be required when STARLIX is coadministered with these drugs. Drugs That May Blunt Signs and Symptoms of Hypoglycemia Drugs: beta-blockers, clonidine, guanethidine, and reserpine Intervention: Increased frequency of glucose monitoring may be required when STARLIX is coadministered with these drugs.

WARNINGS No information provided. PRECAUTIONS Macrovascular Outcomes There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with nateglinide or any other antidiabetic drug. Hypoglycemia All oral blood glucose lowering drugs that are absorbed systemically are capable of producing hypoglycemia. The frequency of hypoglycemia is related to the severity of the diabetes, the level of glycemic control, and other patient characteristics. Geriatric patients, malnourished patients, and those with adrenal or pituitary insufficiency or severe renal impairment are more susceptible to the glucose lowering effect of these treatments. The risk of hypoglycemia may be increased by strenuous physical exercise, ingestion of alcohol, insufficient caloric intake on an acute or chronic basis, or combinations with other oral antidiabetic agents. Hypoglycemia may be difficult to recognize in patients with autonomic neuropathy and/or those who use beta-blockers. Nateglinide should be administered prior to meals to reduce the risk of hypoglycemia. Patients who skip meals should also skip their scheduled dose of nateglinide to reduce the risk of hypoglycemia. Hepatic Impairment Nateglinide should be used with caution in patients with moderate-to-severe liver disease because such patients have not been studied. Loss Of Glycemic Control Transient loss of glycemic control may occur with fever, infection, trauma, or surgery. Insulin therapy may be needed instead of nateglinide therapy at such times. Secondary failure, or reduced effectiveness of nateglinide over a period of time, may occur. Laboratory Tests Response to therapies should be periodically assessed with glucose values and HbA1Clevels Carcinogenesis, Mutagenesis, Impairment Of Fertility Carcinogenicity A two-year carcinogenicity study in Sprague-Dawley rats was performed with oral doses of nateglinide up to 900 mg/kg/day, which produced AUC exposures in male and female rats approximately 30 and 40 times the human therapeutic exposure respectively with a recommended nateglinide dose of 120 mg, three times daily before meals. A two-year carcinogenicity study in B6C3F1 mice was performed with oral doses of nateglinide up to 400 mg/kg/day, which produced AUC exposures in male and female mice approximately 10 and 30 times the human therapeutic exposure with a recommended nateglinide dose of 120 mg, three times daily before meals. No evidence of a tumorigenic response was found in either rats or mice. Mutagenesis Nateglinide was not genotoxic in the in vitro Ames test, mouse lymphoma assay, chromosome aberration assay in Chinese hamster lung cells, or in the in vivo mouse micronucleus test. Impairment Of Fertility Fertility was unaffected by administration of nateglinide to rats at doses up to 600 mg/kg (approximately16 times the human therapeutic exposure with a recommended nateglinide dose of 120 mg three times daily before meals). Pregnancy Pregnancy Category C Nateglinide was not teratogenic in rats at doses up to 1000 mg/kg (approximately 60 times the human therapeutic exposure with a recommended nateglinide dose of 120 mg, three times daily before meals). In the rabbit, embryonic development was adversely affected and the incidence of gallbladder agenesis or small gallbladder was increased at a dose of 500 mg/kg (approximately 40 times the human therapeutic exposure with a recommended nateglinide dose of 120 mg, three times daily before meals). There are no adequate and well-controlled studies in pregnant women. Nateglinide should not be used during pregnancy. Labor And Delivery The effect of nateglinide on labor and delivery in humans is not known. Nursing Mothers Studies in lactating rats showed that nateglinide is excreted in the milk; the AUC0-48h ratio in milk to plasma was approximately 1:4. During the peri- and postnatal period body weights were lower in offspring of rats administered nateglinide at 1000 mg/kg (approximately 60 times the human therapeutic exposure with a recommended nateglinide dose of 120 mg, three times daily before meals). It is not known whether nateglinide is excreted in human milk. Because many drugs are excreted in human milk, nateglinide should not be administered to a nursing woman. Pediatric Use Clinical trials to demonstrate the safety and effectiveness in pediatric patients have not been conducted. Geriatric Use No differences were observed in safety or efficacy of nateglinide between patients age 65 and over, and those under age 65. However, greater sensitivity of some older individuals to nateglinide therapy cannot be ruled out.