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Exenatide

Class: Incretin Mimetics
Molecular Formula: C184H282N50O60S
CAS Number: 141732-76-5
Brands: Bydureon, Byetta

Medically reviewed by Drugs.com on Nov 18, 2019. Written by ASHP.

Warning

    Thyroid C-cell Tumors
  • Extended-release exenatide causes thyroid C-cell tumors at clinically relevant exposures in rats. Unknown whether the drug causes thyroid C-cell tumors, including medullary thyroid carcinoma (MTC), in humans. Extended-release exenatide is contraindicated in patients with a personal or family history of MTC and in patients with multiple endocrine neoplasia syndrome type 2 (MEN 2). (See Risk of Thyroid C-cell Tumors with Extended-release Exenatide under Cautions.)

Introduction

Antidiabetic agent; synthetic, human glucagon-like peptide-1 (GLP-1) receptor agonist (incretin mimetic).

Uses for Exenatide

Type 2 Diabetes Mellitus

Used as an adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes mellitus.

Available as an injection for twice-daily administration (Byetta) and as an extended-release for injectable suspension formulation for once-weekly administration (Bydureon).

Exenatide has been used as monotherapy or in combination with metformin, a sulfonylurea, or a thiazolidinedione; in combination with metformin and a sulfonylurea or thiazolidinedione; or in combination with insulin glargine with or without metformin and/or a thiazolidinedione.

Twice-daily exenatide improves glycemic control (e.g., as determined by changes in HbA1c) more than placebo and similar to that of titrated insulin lispro or insulin aspart 70/30.

Extended-release exenatide has been used as monotherapy or in combination with metformin, a sulfonylurea, or a thiazolidinedione; in combination with metformin and a sulfonylurea; in combination with metformin and a thiazolidinedione; in combination with an SGLT2 inhibitor and metformin; or in combination with basal insulin.

Once-weekly extended-release exenatide generally as effective for glycemic control as metformin or pioglitazone and more effective than sitagliptin, titrated insulin glargine, insulin detemir, or twice-daily exenatide; such improvements maintained during long-term therapy.

Current guidelines for the treatment of type 2 diabetes mellitus generally recommend metformin as first-line therapy in addition to lifestyle modifications due to its well-established safety and efficacy (e.g., beneficial effects on glycosylated hemoglobin [hemoglobin A1c; HbA1c], weight, and cardiovascular mortality). Consider patient's comorbidities when selecting additional antidiabetic agents.

Patients with type 2 diabetes mellitus who have established atherosclerotic cardiovascular disease (ASCVD) should receive a drug with demonstrated cardiovascular disease benefit (e.g., GLP-1 receptor agonist [e.g., liraglutide], sodium-glucose cotransporter 2 [SGLT2] inhibitor [e.g., canagliflozin, empagliflozin]). An SGLT2 inhibitor with demonstrated cardiovascular benefit may be preferred in patients with ASCVD and heart failure or with an increased risk of heart failure.

An SGLT2 inhibitor or GLP-1 receptor agonist with demonstrated ability to reduce the risk of CKD progression, cardiovascular events, or both (e.g., canagliflozin, empagliflozin, liraglutide) should be considered in patients with type 2 diabetes mellitus and CKD. In patients without ASCVD, heart failure, or CKD, the decision regarding the addition of other antidiabetic agents (e.g., sulfonylurea, thiazolidinedione, dipeptidyl peptidase-4 [DPP-4] inhibitor, SGLT2 inhibitor, GLP-1 receptor agonist, basal insulin) should be based on drug-specific effects and individual patient factors.

Extended-release exenatide not recommended as first-line therapy in patients with inadequate glycemic control on diet and exercise because of uncertain relevance to humans of thyroid C-cell tumors found in rodents given the drug. (See Boxed Warning.)

Exenatide or extended-release exenatide not a substitute for insulin.

Do not use exenatide or extended-release exenatide in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis; not effective for these conditions.

Safety and efficacy of exenatide or extended-release exenatide not established in patients with a history of pancreatitis; consider other antidiabetic agents in such patients. (See Pancreatitis and Pancreatic Precancerous Changes under Cautions.)

Safety and efficacy of exenatide or extended-release exenatide in combination with prandial insulin not established; manufacturer of exenatide states that such concomitant use is not recommended.

Exenatide and extended-release exenatide contain the same active ingredient; do not use both agents concomitantly.

Exenatide Dosage and Administration

Administration

Exenatide and extended-release exenatide intended for self-administration by patient. Healthcare professionals should instruct patients in preparation and use of drug before first use.

Sub-Q Administration: Exenatide

Administer sub-Q into abdomen, thigh, or upper arm using prefilled injection pen. Safety and efficacy of IV or IM administration not established.

Administer twice daily, prior to (i.e., within 60 minutes of) morning and evening meals.

Alternatively, administer before 2 main meals of the day, approximately ≥6 hours apart.

Do not administer after a meal.

If a dose is missed, omit that dose and administer next dose at regularly scheduled time.

Do not transfer drug from injection pen to syringe or vial.

Do not mix with insulin in same syringe or vial even if taken at same time.

Consult manufacturer's instructions for use for additional details about preparation and administration of drug.

Sub-Q Administration: Extended-release Exenatide

Administer sub-Q into abdomen, thigh, or back of upper arm region using prefilled injection pen; must not administer IV or IM. Rotate injection sites with each weekly dose when injecting in the same region.

When extended-release exenatide is administered in conjunction with basal insulin, administer extended-release exenatide and insulin as separate injections; do not mix together into a single injection. Extended-release exenatide and insulin may be injected into the same body region, but the injections should not be adjacent to each other.

May administer at any time during dosing day, with or without a meal.

May change day of weekly administration if necessary, provided the last dose was administered at least 3 days previously.

If a dose is missed, administer missed dose as soon as noticed provided there are at least 3 days until the next scheduled dose; the usual regimen (once weekly) may then be resumed.

If a dose is missed and the next regularly scheduled dose is due in 1 or 2 days, do not administer the missed dose; instead, resume dosing on the next regularly scheduled day.

Consult manufacturer's instructions for use for additional details about preparation and administration of drug.

Reconstitution

Supplied as sterile, white to off-white powder in prefilled single-use injection pens and in single-dose vials; must reconstitute before administration.

If injection pen has been stored in refrigerator, allow pen to stand at room temperature for 15 minutes before reconstitution.

Diluent is contained in one compartment of injection pen with drug powder in another compartment; diluent for vial is supplied in a prefilled syringe within each single-dose tray.

Use diluent only if it is clear and free of visible particulate matter when viewed through prefilled syringe or injection window of pen.

Do not inject drug suspension until well mixed or full dose will not be delivered.

Reconstituted suspension in injection pen or vial contains 2 mg of extended-release exenatide in 0.65 mL of diluent.

Reconstituted drug suspension in vial must be transferred to manufacturer-provided syringe before administration.

Administer drug immediately after reconstitution; cannot store for later use.

Refer to manufacturer's instructions for use for detailed information regarding reconstitution.

Dosage

If exenatide or extended-release exenatide used in combination with a sulfonylurea, reduction of sulfonylurea dosage may be required. (See Use with Drugs Known to Cause Hypoglycemia under Cautions.)

If exenatide is used in combination with insulin, evaluate insulin dosage; consider reduction of insulin dosage in patients at increased risk of hypoglycemia. In a clinical trial, dosage of concomitant insulin glargine reduced by 20% in exenatide-treated patients with HbA1c concentrations ≤8%; relative safety and efficacy of this approach may not apply to patients with baseline HbA1c concentrations <7%, those with a recent history of major hypoglycemia, or those receiving long-acting GLP-1 receptor agonists. (See Use with Drugs Known to Cause Hypoglycemia under Cautions.)

Safety and efficacy of exenatide or extended-release exenatide and concomitant prandial insulin therapy not established; manufacturer of exenatide states that such concomitant use is not recommended.

Prior treatment with exenatide not required when initiating extended-release exenatide therapy.

If decision is made to initiate extended-release exenatide in a patient already receiving exenatide, discontinue exenatide.

Patients changing therapy from exenatide to extended-release exenatide may experience transient (approximately 2–4 weeks) elevations in blood glucose concentrations.

Adults

Type 2 Diabetes Mellitus
Sub-Q

Exenatide: Initially, 5 mcg twice daily. If needed, may increase to 10 mcg twice daily after 1 month.

Extended-release exenatide: 2 mg once every 7 days (weekly).

Special Populations

Hepatic Impairment

Exenatide dosage adjustments do not appear to be required.

Renal Impairment

Exenatide

Mild renal impairment (Clcr 50–80 mL/minute): No adjustment of exenatide dosage required.

Moderate renal impairment (Clcr 30–50 mL/minute): Use caution when initiating exenatide or increasing dosage from 5 mcg twice daily to 10 mcg twice daily.

End-stage renal disease (ESRD) or severe renal impairment (Clcr <30 mL/minute): Do not use. Use exenatide with caution in patients who have undergone renal transplantation. (See Renal Effects and see also Renal Impairment under Cautions.)

Extended-release Exenatide

Mild renal impairment: Manufacturer makes no recommendation about modification of extended-release exenatide dosage in patients with mild renal impairment. Monitor patients for adverse effects (e.g., nausea and vomiting) that may lead to hypovolemia.

eGFR <45 mL/minute per 1.73 m2 or ESRD: Use not recommended. Closely monitor for adverse effects that may lead to hypovolemia in patients who have undergone renal transplantation. (See Renal Effects and see also Renal Impairment under Cautions.)

Geriatric Patients

Careful selection of exenatide dosage recommended due to possible age-related decrease in renal function and concomitant disease and drug therapy; however, dosage requirements generally similar in geriatric patients and younger adults. Use caution when initiating extended-release exenatide in geriatric patients.

Obese Patients

Adjustment of exenatide dosage not required.

Cautions for Exenatide

Contraindications

Exenatide or extended-release exenatide: Known hypersensitivity to exenatide or any ingredient in the formulation.

Extended-release exenatide: Personal or family history of medullary thyroid carcinoma (MTC) or diagnosis of multiple endocrine neoplasia syndrome type 2 (MEN 2).

Warnings/Precautions

Warnings

Risk of Thyroid C-cell Tumors with Extended-release Exenatide

Dose-related and treatment-duration-dependent increase in the incidence of thyroid C-cell tumors (adenomas and/or carcinomas) at clinically relevant exposures in rats.

Not known whether extended-release exenatide causes thyroid C-cell tumors, including MTC, in humans.

Serum calcitonin, a biologic marker of MTC, not assessed in clinical trials of extended-release exenatide. Patients with MTC generally have serum calcitonin concentrations >50 ng/L.

Refer patients to endocrinologist for further evaluation if thyroid nodules noted on physical examination or neck imaging.

Although routine monitoring of serum calcitonin or use of thyroid ultrasound for early detection of MTC in patients receiving extended-release exenatide is of uncertain value, refer patient to endocrinologist for further evaluation if serum calcitonin is measured and found to be elevated.

Sensitivity Reactions

Hypersensitivity Reactions

Generalized pruritus and/or urticaria, macular or papular rash, and angioedema reported during postmarketing experience. Anaphylactic reaction also reported.

If a hypersensitivity reaction occurs, discontinue exenatide or extended-release exenatide and other suspect agents; patients should promptly seek medical advice.

Closely monitor for allergic reactions in patients who have a history of anaphylaxis or angioedema with another GLP-1 receptor agonist; unknown whether such patients will be predisposed to anaphylaxis with extended-release exenatide.

Other Warnings and Precautions

Pancreatitis and Pancreatic Precancerous Changes

Acute pancreatitis, including fatal and nonfatal hemorrhagic or necrotizing pancreatitis requiring hospitalization, reported during postmarketing experience.

Hallmark symptom of acute pancreatitis is persistent, severe abdominal pain, which sometimes radiates to the back and may be accompanied by vomiting. Most patients who developed pancreatitis during exenatide therapy had at least one other risk factor for acute pancreatitis (e.g., gallstones, severe hypertriglyceridemia, alcohol use) and required hospitalization. Serious complications include dehydration and renal failure, suspected ileus, phlegmon, and ascites; most patients have improved upon discontinuance of exenatide.

After initiation of exenatide or extended-release exenatide, and after increases in dosage, carefully observe patients for signs and symptoms of acute pancreatitis (e.g., unexplained, persistent, severe abdominal pain that may radiate to the back; nausea; vomiting; elevated serum amylase or lipase concentrations).

FDA has been evaluating unpublished findings suggesting an increased risk of pancreatitis and precancerous pancreatic cellular changes in patients with type 2 diabetes mellitus receiving incretin mimetics. FDA will notify healthcare professionals of its conclusions and recommendations when the review is complete, or when the agency has additional information to report.

FDA has recommended that clinicians continue to follow the recommendations in the prescribing information for incretin mimetics. The manufacturer states that if pancreatitis is suspected, promptly discontinue therapy with exenatide or extended-release exenatide and other potentially suspected drugs, perform confirmatory tests (e.g., serum amylase or lipase concentrations, radiologic imaging), and initiate appropriate therapy.

Do not resume exenatide or extended-release exenatide if pancreatitis confirmed.

Safety and efficacy of exenatide or extended-release exenatide not established in patients with a history of pancreatitis; consider other antidiabetic therapies in such patients.

Use with Drugs Known to Cause Hypoglycemia

Increased risk of hypoglycemia with exenatide or extended-release exenatide and concomitant sulfonylurea therapy; may require reduction of sulfonylurea dosage.

If exenatide is used in combination with insulin, consider reduction of insulin dosage in patients at increased risk of hypoglycemia. (See Dosage under Dosage and Administration.) Safety and efficacy of exenatide or extended-release exenatide in combination with prandial insulin not established; manufacturer of exenatide states that such concomitant use not recommended.

Concomitant use of exenatide or extended-release exenatide with other glucose-independent insulin secretagogues (e.g., meglitinides) may increase risk of hypoglycemia.

Renal Effects

Deterioration of renal function (e.g., increased Scr, renal impairment/insufficiency, worsened chronic renal failure, acute renal failure sometimes requiring hemodialysis or kidney transplantation) reported rarely. In some patients, presence of other factors (nausea, vomiting, and/or diarrhea with or without dehydration; concomitant use of other agents known to affect renal function or hydration status [e.g., ACE inhibitors, NSAIAs, diuretics]) may have contributed to development of altered renal function.

Exenatide not directly nephrotoxic in preclinical or clinical studies. Altered renal function may result from diabetes mellitus, independent of any risk associated with exenatide.

Because exenatide or extended-release exenatide may induce nausea and vomiting with transient hypovolemia, this drug may worsen renal function.

Closely monitor patients for signs and symptoms of renal dysfunction; consider discontinuing exenatide if renal dysfunction suspected and cannot be explained by other causes. Renal effects usually reversible with supportive treatment and discontinuance of potentially causative agents, including exenatide. (See Renal Impairment under Cautions and also see Renal Impairment under Dosage and Administration.)

GI Effects

Adverse GI effects (e.g., nausea, vomiting, diarrhea) reported frequently with exenatide or extended-release exenatide; use not recommended in patients with severe GI disease (e.g., gastroparesis).

Immunogenicity

Development of antibodies to exenatide or extended-release exenatide reported. Antibody formation associated with attenuated glycemic response in some patients.

Treatment-emergent cross-reactive antibodies to GLP-1 and/or glucagon not observed in a group of patients with anti-exenatide antibodies in clinical trials.

If worsening glycemic control or failure to achieve targeted glycemic control occurs, consider alternative antidiabetic therapy.

Injection-site Reactions

Serious injection-site reactions (e.g., abscess, cellulitis, necrosis) with or without sub-Q nodules reported in patients receiving extended-release exenatide during postmarketing experience; surgical intervention required in isolated cases.

Risk Associated with Sharing of Injection Pens

Do not share exenatide or extended-release exenatide injection pens among patients, even if the needle has been changed; sharing poses risk for transmission of blood-borne pathogens.

Acute Gallbladder Disease

Cholelithiasis and cholecystitis reported with use of GLP-1 receptor agonists, including extended-release exenatide, during clinical studies. If cholelithiasis is suspected, manufacturer states that gallbladder studies and appropriate clinical follow-up are indicated.

Specific Populations

Pregnancy

Data lacking on the use of exenatide or extended-release exenatide in pregnant women. Animal reproduction studies in mice, rabbits, and rats identified increased adverse fetal and neonatal outcomes from exposure to exenatide or extended-release exenatide during pregnancy and/or lactation. Use during pregnancy only if potential benefit justifies potential risk to the fetus.

Lactation

Distributed into milk in mice; not known whether distributed into human milk. Consider benefits of breast-feeding and importance of exenatide or extended-release exenatide to the woman along with any potential adverse effects on the breast-fed infant from the drug or from the underlying maternal condition.

Pediatric Use

Safety and efficacy of exenatide not established in patients <17 years of age.

Safety and efficacy of extended-release exenatide not established in pediatric patients. Use in this patient population not recommended by manufacturer.

Geriatric Use

No substantial differences in safety and efficacy nor in pharmacokinetics relative to younger adults. Geriatric patients are more likely to have decreased renal function; use caution when initiating drug in such patients.

Hepatic Impairment

Pharmacokinetics of exenatide or extended-release exenatide not evaluated, but impact of hepatic impairment should be minimal.

Renal Impairment

Because exenatide or extended-release exenatide may induce nausea and vomiting with transient hypovolemia, this drug may worsen renal function. (See Renal Effects under Cautions.)

Decreased clearance of exenatide in patients with ESRD receiving dialysis; possible decreased tolerance to therapy due to adverse GI effects. In such patients, single doses of exenatide 5 mcg were not well tolerated due to adverse GI effects. Safety and efficacy of extended-release exenatide not established in patients with ESRD or severe renal impairment.

Do not use exenatide or extended-release exenatide in patients with ESRD or severe renal impairment (Clcr <30 mL/minute for exenatide or eGFR <45 mL/minute per 1.73 m2 for extended-release exenatide); use with caution in patients who have undergone renal transplantation.

Use caution when initiating exenatide or increasing dosage from 5 mcg twice daily to 10 mcg twice daily in patients with moderate renal impairment (Clcr 30–50 mL/minute). Use extended-release exenatide with caution in such patients. (See Elimination: Special Populations, under Pharmacokinetics.)

No adjustment of exenatide or extended-release exenatide dosage required in patients with mild renal impairment (Clcr 50–80 mL/minute). Monitor patients with mild renal impairment who are receiving extended-release exenatide for adverse effects (e.g., nausea and vomiting) that may lead to hypovolemia.

Common Adverse Effects

Exenatide monotherapy or in combination with other oral antidiabetic agents (metformin, a sulfonylurea, and/or a thiazolidinedione) or basal insulin: Hypoglycemia, nausea, vomiting, diarrhea, jittery feeling, dizziness, headache, dyspepsia, asthenia, GERD, hyperhidrosis, constipation, abdominal distention, decreased appetite, flatulence.

Extended-release exenatide monotherapy or in combination with other oral antidiabetic agents (metformin, a sulfonylurea, and/or a thiazolidinedione): Hypoglycemia, nausea, diarrhea, injection-site reactions (pruritus, nodule, erythema, hematoma), vomiting, constipation, headache, viral gastroenteritis, GERD, dyspepsia, fatigue, decreased appetite.

Interactions for Exenatide

GI Absorption of Other Drugs

Possible decreased rate and extent of absorption of concomitantly administered oral drugs; use caution with oral drugs that have a narrow therapeutic index or require rapid GI absorption.

With oral drugs for which efficacy depends on threshold concentrations, administer ≥1 hour before exenatide. If such drugs need to be administered with food, administer them with a meal or snack (e.g., lunch) at a time when exenatide is not administered.

Specific Drugs

Drug

Interaction

Comments

Acetaminophen

Exenatide: Decreased AUC and peak plasma concentration and increased time to peak plasma concentration of acetaminophen when administered simultaneously with or at 1, 2, or 4 hours after exenatide

Exenatide: Acetaminophen AUC, peak plasma concentration, and time to peak plasma concentration not appreciably changed when acetaminophen administered 1 hour before exenatide

Extended-release exenatide: Acetaminophen AUC not appreciably changed but acetaminophen peak plasma concentration decreased (effect greater in fasting than fed state) and time to peak concentration increased; effects generally less than those observed when acetaminophen given with or 1–4 hours after exenatide

Anti-infective agents, oral

Possible decreased rate and extent of anti-infective absorption with concomitant exenatide

Administer oral anti-infective ≥1 hour before exenatide

Digoxin

Decreased peak plasma concentration and delayed time to peak concentration of digoxin when exenatide administered 30 minutes before digoxin; no change in digoxin steady-state AUC and renal clearance

Insulin

Exenatide: Increased risk of hypoglycemia with concurrent insulin; safety and efficacy of concurrent prandial insulin not established

Extended-release exenatide: Safety and efficacy of concurrent prandial insulin not established

Exenatide: Consider reduced concurrent insulin dosage in patients at increased risk of hypoglycemia; concurrent use of prandial insulin not recommended

Insulin secretagogues, insulin independent

Sulfonylureas: Increased risk of hypoglycemia with exenatide or extended-release exenatide

Other glucose-independent insulin secretagogues (e.g., meglitinides): Possible increased risk of hypoglycemia with concomitant exenatide or extended-release exenatide

Sulfonylureas: Consider reduction of concurrent sulfonylurea dosage

Lisinopril

Delayed steady-state time to peak plasma lisinopril concentrations; no change in steady-state AUC or peak plasma lisinopril concentrations or in mean 24-hour SBP and DBP

Lovastatin

Decreased AUC and peak plasma concentration and delayed time to peak plasma concentration of lovastatin when exenatide administered 30 minutes before lovastatin; no consistent changes in lipid profiles

Oral contraceptives

Ethinyl estradiol/levonorgestrel given 30 minutes after exenatide: Decreased peak plasma concentration and delayed time to peak plasma concentration of ethinyl estradiol and levonorgestrel; increased mean trough concentration of ethinyl estradiol; mean trough concentrations of levonorgestrel not altered

Ethinyl estradiol/levonorgestrel given 1 hour before exenatide: Decreased mean peak plasma concentration of ethinyl estradiol; mean peak plasma levonorgestrel concentration not substantially changed

Effect of exenatide on ethinyl estradiol/levonorgestrel pharmacokinetics confounded by possible effect of food

Administer oral contraceptive ≥1 hour before exenatide

Warfarin

Exenatide: Delayed time to peak plasma concentration of warfarin; no clinically important change in AUC or peak plasma warfarin concentrations or INR; however, some reports of increased INR, sometimes associated with bleeding

Extended-release exenatide: Data lacking

Monitor PT more frequently after initiating or altering exenatide therapy; once a stable PT achieved, PT may be monitored at intervals usually recommended for patients receiving warfarin

Monitor INR more frequently after initiating extended-release exenatide therapy; once a stable INR achieved, INR may be monitored at intervals generally recommended for patients receiving warfarin

Exenatide Pharmacokinetics

Absorption

Bioavailability

Following sub-Q administration of exenatide, peak plasma concentration usually attained in 2.1 hours.

Absorption of exenatide is similar when injected into abdomen, thigh, or arm.

Following sub-Q administration of extended-release exenatide, drug is released from the microspheres over approximately 10 weeks. Initial release of surface-bound exenatide is followed by gradual release from microspheres; peak concentrations occur at approximately week 2 and week 6–7.

Steady-state plasma concentrations achieved 6–7 weeks after weekly (once every 7 days) sub-Q administration of extended-release exenatide. Approximately 10 weeks after discontinuance, concentrations generally undetectable.

Special Populations

Extended-release exenatide: Steady-state concentrations not affected by gender or race.

Distribution

Extent

Distributed into milk in mice; not known whether distributed into human milk.

Elimination

Metabolism

Principally proteolytic degradation after glomerular filtration.

Elimination Route

Excreted principally in urine. Clearance of exenatide is independent of dose.

Half-life

Exenatide: 2.4 hours.

Special Populations

Exenatide: Manufacturer states pharmacokinetics are independent of dose, age, gender, race, and BMI.

Exenatide: Decreased clearance and increased exposure in patients with ESRD receiving dialysis. Exposure in patients with mild to moderate renal impairment (Clcr 30–80 mL/minute) similar to that in individuals with normal renal function. (See Renal Impairment under Cautions.)

Extended-release exenatide: Increased exposure in patients with mild or moderate renal impairment; data lacking in patients with severe renal impairment. (See Renal Impairment under Cautions.)

Stability

Storage

Parenteral

Solution for Injection

Exenatide: Before use, 2–8°C in original carton. After first use, ≤25ºC. Do not freeze; protect from light. Discard pen 30 days after first use.

Extended-release exenatide: 2–8°C up to the expiration date or until preparation for use. May store at temperature ≤25°C for 4 weeks, if necessary. Do not freeze; protect from light.

Actions

  • Exenatide, a synthetic analog of a naturally occurring peptide isolated from the saliva of Heloderma suspectum (Gila monster), is a glucagon-like peptide-1 (GLP-1) mimetic (incretin mimetic).

  • Structurally and pharmacologically unrelated to insulin, sulfonylureas, meglitinides, biguanides, thiazolidinediones, and α-glucosidase inhibitors.

  • Lowers fasting and postprandial glucose concentrations in patients with type 2 diabetes mellitus.

  • Improves pancreatic β-cell function by increasing glucose-dependent insulin synthesis, secretion, and acute β-cell responsiveness (i.e., first phase insulin response).

  • Inhibits inappropriately high glucagon secretion (e.g., after a meal) in patients with type 2 diabetes mellitus; does not impair normal glucagon response to hypoglycemia.

  • Slows gastric emptying, which reduces the rate of glucose absorption from a meal, reduces food intake, and is associated with weight loss.

  • Does not appear to be associated with clinically important prolongation of the corrected QT interval (QTc, Bazett's formula).

Advice to Patients

  • Importance of instructing patients on proper use and storage of the exenatide or extended-release exenatide injection pen, including proper reconstitution and injection technique to ensure delivery of a full dose, proper disposal of injection pens and needles using puncture-resistant containers, how and when to set up a new injection pen, and that only one setup step is necessary at initial use of exenatide.

  • Importance of patient reading medication guide and the injection pen user manual before initiating therapy and each time drug is dispensed.

  • Importance of patients not self-administering exenatide or extended-release exenatide if they are blind or unable to see well.

  • Importance of informing patients regarding potential risks and advantages of exenatide or extended-release exenatide therapy and of alternative modes of therapy. Importance of not using exenatide or extended-release exenatide in patients with type 1 diabetes mellitus or diabetic ketoacidosis.

  • Importance of providing instruction regarding diabetes self-management practices, such as regular physical activity, adhering to meal planning, periodic blood glucose monitoring, HbA1c testing, recognition and management of hypoglycemia and hyperglycemia, and assessment of other diabetic complications.

  • Importance of informing patients that extended-release exenatide causes benign and malignant thyroid C-cell tumors in rats and that the relevance of this finding in humans is unknown. Importance of not using extended-release exenatide in patients with a personal or family history of medullary thyroid cancer (MTC) or diagnosis of multiple endocrine neoplasia syndrome type 2 (MEN 2). Importance of advising patients to report symptoms that may be suggestive of thyroid cancer (e.g., lump or swelling in neck, hoarseness, dysphagia, dyspnea).

  • Importance of patients discontinuing exenatide or extended-release exenatide and other suspect drugs and seeking medical assistance immediately if signs and symptoms of a serious hypersensitivity reaction (e.g., anaphylaxis, angioedema) occur. Importance of patients informing their clinician if they have experienced a sensitivity reaction to exenatide or any ingredient in the formulations.

  • Importance of informing patient of the potential risk of acute pancreatitis, which may be severe or fatal. Importance of patient informing clinicians about a history of pancreatitis, gallstones, alcoholism, or high triglyceride levels. Importance of patients discontinuing exenatide or extended-release exenatide and promptly informing clinician if unexplained, persistent, severe abdominal pain that may radiate to the back and may or may not be accompanied by nausea and vomiting occurs. If pancreatitis is suspected, discontinue exenatide or extended-release exenatide; do not restart if pancreatitis confirmed.

  • Importance of informing patients of the potential risk for worsening renal function and about signs and symptoms of altered renal function (e.g., increased Scr; changes in color, frequency, or amount of urination; unexplained swelling in extremities; increases in BP; lethargy; changes in appetite or digestion; dull ache in the middle to lower back). Importance of patient informing clinician about development of nausea, vomiting, or diarrhea, which may contribute to dehydration and consequent altered renal function. Importance of informing patients that chronic conditions such as hypertension or pancreatitis and concomitant therapy with NSAIAs, diuretics, or antihypertensive agents can increase the risk of developing altered renal function with exenatide therapy.

  • Importance of informing patients receiving exenatide that the dosage of concomitant insulin may need to be reduced in those at increased risk of hypoglycemia.

  • Increased risk of hypoglycemia when exenatide or extended-release exenatide is used with an agent that induces hypoglycemia, such as a sulfonylurea or other glucose-independent insulin secretagogue (e.g., meglitinide); lower dosage of sulfonylurea or other insulin secretagogue may be required to reduce risk of hypoglycemia.

  • Importance of reviewing with patients the symptoms, treatment, and conditions that predispose to development of hypoglycemia when initiating exenatide or extended-release exenatide treatment, especially when exenatide is used with a sulfonylurea or insulin; importance of clinician reinforcing instructions for management of hypoglycemia.

  • Importance of advising patient to seek medical advice if symptomatic sub-Q nodules or any signs or symptoms of abscess, cellulitis, or necrosis occur.

  • Importance of informing patients of the potential risk for cholelithiasis or cholecystitis. Importance of instructing patients to contact a clinician for appropriate clinical follow-up if cholelithiasis or cholecystitis is suspected.

  • Importance of informing patients that reduced appetite, food intake, and/or body weight may occur with exenatide or extended-release exenatide therapy but do not require modification of dosage regimen. Importance of informing patient about occurrence of nausea, particularly upon initiation of exenatide or extended-release exenatide therapy, and that nausea decreases over time as the drug is continued.

  • Importance of informing patients that injection pens should not be shared with another person, even if the needle has been changed. Such sharing may pose a risk of transmitting or acquiring infection.

  • Importance of informing patients regarding the timing of exenatide or extended-release exenatide administration with concomitant oral drugs (e.g., oral contraceptives, anti-infective agents) because of slowing of gastric emptying with these exenatide formulations. (See Interactions.)

  • Importance of not mixing exenatide with insulin.

  • Importance of advising patients what to do if a dose of exenatide or extended-release exenatide is missed. (See Administration under Dosage and Administration.)

  • Importance of injecting extended-release exenatide immediately after reconstitution. Importance of not injecting exenatide or extended-release exenatide IV or IM.

  • Importance of informing patient to administer extended-release exenatide at any time on the dosing day, with or without meals. The day of once-weekly administration (once every 7 days) can be changed if necessary, provided the last dose was administered 3 or more days previously.

  • Importance of informing patients to discontinue exenatide once extended-release exenatide is initiated. Importance of informing patients that transient elevations in blood glucose concentrations may occur but generally improve within the first 2 weeks after initiation of extended-release exenatide therapy.

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed. Importance of informing women about enrolling in the pregnancy registry for exenatide or extended-release exenatide if they use the drugs at any time during pregnancy.

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, vitamins, and herbal supplements, as well as any concomitant illnesses (e.g., hypertension, history of liver disease, gastroparesis or serious digestive problems, severe kidney disease or kidney transplant).

  • Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Exenatide

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection, for subcutaneous use

250 mcg/mL

Byetta (available as prefilled cartridge pen)

AstraZeneca

For injection, extended-release, for subcutaneous use

2 mg

Bydureon (available as single-dose, prefilled, dual-chambered injection pen with diluent and as single-dose vial with vial connector and prefilled syringe containing diluent)

AstraZeneca

AHFS DI Essentials™. © Copyright 2021, Selected Revisions November 18, 2019. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

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