ant change in metformin renal clearance. when administered with metformin, the c max and auc of furosemide were 31% and 12% smaller, respectively, than when administered alone, and the terminal half-life was decreased by 32%, without any significant change in furosemide renal clearance. no information is available about the interaction of metformin and furosemide when co-administered chronically. nifedipine — a single-dose, metformin-nifedipine drug interaction study in normal healthy volunteers demonstrated that co - administration of nifedipine increased plasma metformin c max and auc by 20% and 9%, respectively, and increased the amount excreted in the urine. t max and half-life were unaffected. nifedipine appears to enhance the absorption of metformin. metformin had minimal effects on nifedipine. drugs that reduce metformin clearance- concomitant use of drugs that interfere with common renal tubular transport systems involved in the renal elimination of metformin (e.g., organic cationic transporter-2 [oct2] / multidrug and toxin extrusion [mate] inhibitors such as ranolazine, vandetanib, dolutegravir, and cimetidine) could increase systemic exposure to metformin and may increase the risk for lactic acidosis. consider the benefits and risks of concomitant use. such interaction between metformin and oral cimetidine has been observed in normal healthy volunteers in both single- and multiple-dose, metformin-cimetidine drug interaction studies, with a 60% increase in peak metformin plasma and whole blood concentrations and a 40% increase in plasma and whole blood metformin auc. there was no change in elimination half-life in the single-dose study. metformin had no effect on cimetidine pharmacokinetics. in healthy volunteers, the pharmacokinetics of metformin and propranolol, and metformin and ibuprofen were not affected when coadministered in single-dose interaction studies. metformin is negligibly bound to plasma proteins and is, therefore, less likely to interact with highly protein-bound drugs such as salicylates, sulfonamides, chloramphenicol, and probenecid, as compared to the sulfonylureas, which are extensively bound to serum proteins. other — certain drugs tend to produce hyperglycemia and may lead to loss of glycemic control. these drugs include thiazides and other diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blocking drugs, and isoniazid. when such drugs are administered to a patient receiving metformin, the patient should be observed closely for loss of blood glucose control. when such drugs are withdrawn from a patient receiving metformin, the patient should be observed closely for hypoglycemia. carbonic anhydrase inhibitors – topiramate or other carbonic anhydrase inhibitors (e.g., zonisamide, acetazolamide or dichlorphenamide) frequently cause a decrease in serum bicarbonate and induce non-anion gap, hyperchloremic metabolic acidosis. concomitant use of these drugs with metformin may increase the risk for lactic acidosis. consider more frequent monitoring of these patients. alcohol– alcohol is known to potentiate the effect of metformin on lactate metabolism. warn patients against excessive alcohol intake while receiving metformin.

ntake, and hepatic impairment. steps to reduce the risk of and manage metformin-associated lactic acidosis in these high risk groups are provided (see dosage and administration , contraindications , and precautions ) . if metformin-associated lactic acidosis is suspected, immediately discontinue metformin and institute general supportive measures in a hospital setting. prompt hemodialysis is recommended (see precautions ).

min treated patients with a diagnosis or strong suspicion of lactic acidosis, prompt hemodialysis is recommended to correct the acidosis and remove accumulated metformin (metformin hydrochloride is dialyzable with a clearance of up to 170 ml/min under good hemodynamic conditions). hemodialysis has often resulted in reversal of symptoms and recovery. educate patients and their families about the symptoms of lactic acidosis and, if these symptoms occur, instruct them to discontinue metformin and report these symptoms to their healthcare provider. for each of the known and possible risk factors for metformin-associated lactic acidosis, recommendations to reduce the risk of and manage metformin-associated lactic acidosis are provided below: renal impairment —the postmarketing metformin-associated lactic acidosis cases primarily occurred in patients with significant renal impairment. the risk of metformin accumulation and metformin-associated lactic acidosis increases with the severity of renal impairment because metformin is substantially excreted by the kidney. clinical recommendations based upon the patient’s renal function include (see dosage and administration , clinical pharmacology ): before initiating metformin, obtain an estimated glomerular filtration rate (egfr) metformin is contraindicated in patients with an egfr less than 30 ml/min/1.73 m2 (see contraindications ). initiation of metformin is not recommended in patients with egfr between 30-45 ml/min/1.73 m2. obtain an egfr at least annually in all patients taking metformin. in patients at risk for the development of renal impairment (e.g., the elderly), renal function should be assessed more frequently. in patients taking metformin whose egfr falls below 45 ml/min/1.73 m2, assess the benefit and risk of continuing therapy. drug interactions —the concomitant use of metformin with specific drugs may increase the risk of metformin-associated lactic acidosis: those that impair renal function, result in significant hemodynamic change, interfere with acid-base balance, or increase metformin accumulation. consider more frequent monitoring of patients. age 65 or greater —the risk of metformin-associated lactic acidosis increases with the patient’s age because elderly patients have a greater likelihood of having hepatic, renal, or cardiac impairment than younger patients. assess renal function more frequently in elderly patients. radiologic studies with contrast —administration of intravascular iodinated contrast agents in metformin-treated patients has led to an acute decrease in renal function and the occurrence of lactic acidosis. stop metformin at the time of, or prior to, an iodinated contrast imaging procedure in patients with an egfr between 30 and 60 ml/min/1.73 m2; in patients with a history of hepatic impairment, alcoholism or heart failure; or in patients who will be administered intra-arterial iodinated contrast. re-evaluate egfr 48 hours after the imaging procedure, and restart metformin if renal function is stable. surgery and other procedures —withholding of food and fluids during surgical or other procedures may increase the risk for volume depletion, hypotension, and renal impairment. metformin should be temporarily discontinued while patients have restricted food and fluid intake. hypoxic states —several of the postmarketing cases of metformin-associated lactic acidosis occurred in the setting of acute congestive heart failure (particularly when accompanied by hypoperfusion and hypoxemia). cardiovascular collapse (shock), acute myocardial infarction, sepsis, and other conditions associated with hypoxemia have been associated with lactic acidosis and may cause prerenal azotemia. when such an event occurs, discontinue metformin. excessive alcohol intake —alcohol is known to potentiate the effect of metformin on lactate metabolism. patients, therefore, should be warned against excessive alcohol intake, acute or chronic, while receiving metformin. hepatic impairment —patients with hepatic impairment have developed cases of metformin‑ associated lactic acidosis. this may be due to impaired lactate clearance resulting in higher lactate blood levels. therefore, avoid use of metformin in patients with clinical or laboratory evidence of hepatic disease. vitamin b12 levels —in controlled clinical trials of metformin of 29 weeks duration, a decrease to subnormal levels of previously normal serum vitamin b12 levels, without clinical manifestations, was observed in approximately 7% of patients. such decrease, possibly due to interference with b12 absorption from the b12-intrinsic factor complex, is, however, very rarely associated with anemia and appears to be rapidly reversible with discontinuation of metformin or vitamin b12 supplementation. measurement of hematologic parameters on an annual basis is advised in patients on metformin and any apparent abnormalities should be appropriately investigated and managed (see precautions: laboratory tests ). certain individuals (those with inadequate vitamin b12 or calcium intake or absorption) appear to be predisposed to developing subnormal vitamin b12 levels. in these patients, routine serum vitamin b12 measurements at 2- to 3-year intervals may be useful. hypoglycemia —hypoglycemia does not occur in patients receiving metformin alone under usual circumstances of use, but could occur when caloric intake is deficient, when strenuous exercise is not compensated by caloric supplementation, or during concomitant use with other glucose-lowering agents (such as sulfonylureas and insulin) or ethanol. elderly, debilitated, or malnourished patients, and those with adrenal or pituitary insufficiency or alcohol intoxication are particularly susceptible to hypoglycemic effects. hypoglycemia may be difficult to recognize in the elderly, and in people who are taking beta-adrenergic blocking drugs. macrovascular outcomes —there have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with metformin or any other antidiabetic drug.

d hemoglobin should be measured at intervals of approximately three months. the therapeutic goal should be to decrease both fasting plasma glucose and glycosylated hemoglobin levels to normal or near normal by using the lowest effective dose of metformin hydrochloride tablets, usp either when used as monotherapy or in combination with sulfonylureas or insulin. monitoring of blood glucose and glycosylated hemoglobin will also permit detection of primary failure, i.e., inadequate lowering of blood glucose at the maximum recommended dose of medication, and secondary failure, i.e., loss of an adequate blood glucose lowering response after an initial period of effectiveness. short-term administration of metformin may be sufficient during periods of transient loss of control in patients usually well-controlled on diet alone. recommended dosing schedule adults— the usual starting dose of metformin hydrochloride tablets, usp is 500 mg twice a day or 850 mg once a day, given with meals. in general, clinically significant responses are not seen at doses below 1500 mg per day. dosage increases should be made in increments of 500 mg weekly or 850 mg every 2 weeks, up to a total of 2000 mg per day, given in divided doses. the dosage of metformin hydrochloride tablets, usp must be individualized on the basis of both effectiveness and tolerability. patients can also be titrated from 500 mg twice a day to 850 mg twice a day after 2 weeks. for those patients requiring additional glycemic control, metformin may be given to a maximum daily dose of 2550 mg per day. doses above 2000 mg may be better tolerated given three times a day with meals. pediatrics— the usual starting dose of metformin hydrochloride tablets, usp is 500 mg twice a day, given with meals. dosage increases should be made in increments of 500 mg weekly up to a maximum of 2000 mg per day, given in divided doses. the dosage of metformin must be individualized on the basis of both effectiveness and tolerability. recommendations for use in renal impairment assess renal function prior to initiation of metformin and periodically thereafter. metformin is contraindicated in patients with an estimated glomerular filtration rate (egfr) below 30 ml/min/1.73 m 2 . initiation of metformin in patients with an egfr between 30 – 45 ml/min/1.73 m 2 is not recommended. in patients taking metformin whose egfr later falls below 45 ml/min/1.73 m 2 , assess the benefit risk of continuing therapy. discontinue metformin if the patient’s egfr later falls below 30 ml/min/1.73 m 2 (see warnings and precautions ). discontinuation for iodinated contrast imaging procedures discontinue metformin at the time of, or prior to, an iodinated contrast imaging procedure in patients with an egfr between 30 and 60 ml/min/1.73 m2; in patients with a history of liver disease, alcoholism, or heart failure; or in patients who will be administered intra-arterial iodinated contrast. re-evaluate egfr 48 hours after the imaging procedure; restsart metformin if renal function is stable. concomitant metformin hydrochloride tablets, usp and oral sulfonylurea therapy in adult patients if patients have not responded to four weeks of the maximum dose of metformin hydrochloride tablets, usp monotherapy, consideration should be given to gradual addition of an oral sulfonylurea while continuing metformin hydrochloride tablets, usp at the maximum dose, even if prior primary or secondary failure to a sulfonylurea has occurred. clinical and pharmacokinetic drug-drug interaction data are currently available only for metformin plus glyburide (glibenclamide). with concomitant metformin hydrochloride tablets, usp and sulfonylurea therapy, the desired control of blood glucose may be obtained by adjusting the dose of each drug. in a clinical trial of patients with type 2 diabetes and prior failure on glyburide, patients started on metformin 500 mg and glyburide 20 mg were titrated to 1000/20 mg, 1500/20 mg, 2000/20 mg or 2500/20 mg of metformin and glyburide, respectively, to reach the goal of glycemic control as measured by fpg, hba 1c and plasma glucose response (see clinical pharmacology: clinical studies ). however, attempts should be made to identify the minimum effective dose of each drug to achieve this goal. with concomitant metformin hydrochloride tablets, usp and sulfonylurea therapy, the risk of hypoglycemia associated with sulfonylurea therapy continues and may be increased. appropriate precautions should be taken. (see package insert of the respective sulfonylurea.) if patients have not satisfactorily responded to one to three months of concomitant therapy with the maximum dose of metformin and the maximum dose of an oral sulfonylurea, consider therapeutic alternatives including switching to insulin with or without metformin hydrochloride tablets, usp. concomitant metformin hydrochloride tablets, usp and insulin therapy in adult patients the current insulin dose should be continued upon initiation of metformin hydrochloride tablets, usp therapy. metformin hydrochloride tablets, usp therapy should be initiated at 500 mg once daily in patients on insulin therapy. for patients not responding adequately, the dose of metformin hydrochloride tablets, usp should be increased by 500 mg after approximately 1 week and by 500 mg every week thereafter until adequate glycemic control is achieved. the maximum recommended daily dose is 2500 mg for metformin hydrochloride tablets, usp. it is recommended that the insulin dose be decreased by 10% to 25% when fasting plasma glucose concentrations decrease to less than 120 mg/dl in patients receiving concomitant insulin and metformin hydrochloride tablets, usp. further adjustment should be individualized based on glucose-lowering response. specific patient populations metformin is not recommended for use in pregnancy. metformin hydrochloride tablets, usp are not recommended in patients below the age of 10 years. the initial and maintenance dosing of metformin hydrochloride tablets, usp should be conservative in patients with advanced age, due to the potential for decreased renal function in this population. any dosage adjustment should be based on a careful assessment of renal function.

marketing use of metformin pediatric patients in clinical trials with metformin hydrochloride tablets, usp in pediatric patients with type 2 diabetes, the profile of adverse reactions was similar to that observed in adults. table-7

ant change in metformin renal clearance. when administered with metformin, the c max and auc of furosemide were 31% and 12% smaller, respectively, than when administered alone, and the terminal half-life was decreased by 32%, without any significant change in furosemide renal clearance. no information is available about the interaction of metformin and furosemide when co-administered chronically. nifedipine — a single-dose, metformin-nifedipine drug interaction study in normal healthy volunteers demonstrated that co - administration of nifedipine increased plasma metformin c max and auc by 20% and 9%, respectively, and increased the amount excreted in the urine. t max and half-life were unaffected. nifedipine appears to enhance the absorption of metformin. metformin had minimal effects on nifedipine. drugs that reduce metformin clearance- concomitant use of drugs that interfere with common renal tubular transport systems involved in the renal elimination of metformin (e.g., organic cationic transporter-2 [oct2] / multidrug and toxin extrusion [mate] inhibitors such as ranolazine, vandetanib, dolutegravir, and cimetidine) could increase systemic exposure to metformin and may increase the risk for lactic acidosis. consider the benefits and risks of concomitant use. such interaction between metformin and oral cimetidine has been observed in normal healthy volunteers in both single- and multiple-dose, metformin-cimetidine drug interaction studies, with a 60% increase in peak metformin plasma and whole blood concentrations and a 40% increase in plasma and whole blood metformin auc. there was no change in elimination half-life in the single-dose study. metformin had no effect on cimetidine pharmacokinetics. in healthy volunteers, the pharmacokinetics of metformin and propranolol, and metformin and ibuprofen were not affected when coadministered in single-dose interaction studies. metformin is negligibly bound to plasma proteins and is, therefore, less likely to interact with highly protein-bound drugs such as salicylates, sulfonamides, chloramphenicol, and probenecid, as compared to the sulfonylureas, which are extensively bound to serum proteins. other — certain drugs tend to produce hyperglycemia and may lead to loss of glycemic control. these drugs include thiazides and other diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blocking drugs, and isoniazid. when such drugs are administered to a patient receiving metformin, the patient should be observed closely for loss of blood glucose control. when such drugs are withdrawn from a patient receiving metformin, the patient should be observed closely for hypoglycemia. carbonic anhydrase inhibitors – topiramate or other carbonic anhydrase inhibitors (e.g., zonisamide, acetazolamide or dichlorphenamide) frequently cause a decrease in serum bicarbonate and induce non-anion gap, hyperchloremic metabolic acidosis. concomitant use of these drugs with metformin may increase the risk for lactic acidosis. consider more frequent monitoring of these patients. alcohol– alcohol is known to potentiate the effect of metformin on lactate metabolism. warn patients against excessive alcohol intake while receiving metformin.

ng conditions is approximately 50-60%. studies using single oral doses of metformin hydrochloride tablets, usp of 500 mg to 1500 mg, and 850 mg to 2550 mg, indicate that there is a lack of dose proportionality with increasing doses, which is due to decreased absorption rather than an alteration in elimination. food decreases the extent of and slightly delays the absorption of metformin, as shown by approximately a 40% lower mean peak plasma concentration (c max ), a 25% lower area under the plasma concentration versus time curve (auc), and a 35 minute prolongation of time to peak plasma concentration (t max ) following administration of a single 850 mg tablet of metformin with food, compared to the same tablet strength administered fasting. the clinical relevance of these decreases is unknown. distribution the apparent volume of distribution (v/f) of metformin following single oral doses of 850 mg averaged 654 ± 358 l. metformin is negligibly bound to plasma proteins in contrast to sulfonylureas which are more than 90% protein bound. metformin partitions into erythrocytes, most likely as a function of time. at usual clinical doses and dosing schedules of metformin hydrochloride tablets, usp steady state plasma concentrations of metformin are reached within 24-48 hours and are generally < 1 μg/ml. during controlled clinical trials of metformin, maximum metformin plasma levels did not exceed 5 μg/ml, even at maximum doses. metabolism and elimination intravenous single-dose studies in normal subjects demonstrate that metformin is excreted unchanged in the urine and does not undergo hepatic metabolism (no metabolites have been identified in humans) nor biliary excretion. renal clearance (see table 1 ) is approximately 3.5 times greater than creatinine clearance which indicates that tubular secretion is the major route of metformin elimination. following oral administration, approximately 90% of the absorbed drug is eliminated via the renal route within the first 24 hours, with a plasma elimination half-life of approximately 6.2 hours. in blood, the elimination half-life is approximately 17.6 hours, suggesting that the erythrocyte mass may be a compartment of distribution. specific populations patients with type 2 diabetes in the presence of normal renal function, there are no differences between single or multiple dose pharmacokinetics of metformin between patients with type 2 diabetes and normal subjects (see table 1 ),nor is there any accumulation of metformin in either group at usual clinical doses. renal impairment in patients with decreased renal function, the plasma and blood half-life of metformin is prolonged and the renal clearance is decreased in proportion to the decrease in creatinine clearance (see table 1 ; also see contraindications , warnings , precautions , and dosage and administration ). hepatic impairment no pharmacokinetic studies of metformin have been conducted in patients with hepatic insufficiency (see precautions ). geriatrics limited data from controlled pharmacokinetic studies of metformin in healthy elderly subjects suggest that total plasma clearance of metformin is decreased, the half-life is prolonged, and c max is increased, compared to healthy young subjects. from these data, it appears that the change in metformin pharmacokinetics with aging is primarily accounted for by a change in renal function (see table 1; also see warnings , precautions , and dosage and administration ). a -all doses given fasting except the first 18 doses of the multiple dose studies; b -peak plasma concentration; c -time to peak plasma concentration; d -combined results (average means) of five studies: mean age 32 years (range 23-59 yrs). e -kinetic study done following dose 19, given fasting. f -elderly subjects, mean age 71 years (range 65-81 years). g -cl = creatinine clearance normalized to body surface area of 1.73 m2. pediatrics after administration of a single oral metformin hydrochloride 500 mg tablet with food, geometric mean metformin c max and auc differed less than 5% between pediatric type 2 diabetic patients (12 to 16 years of age) and gender- and weight-matched healthy adults (20 to 45 years of age), all with normal renal function. gender metformin pharmacokinetic parameters did not differ significantly between normal subjects and patients with type 2 diabetes when analyzed according to gender (males = 19, females = 16). similarly, in controlled clinical studies in patients with type 2 diabetes, the antihyperglycemic effect of metformin hydrochloride tablets, usp was comparable in males and females. race no studies of metformin pharmacokinetic parameters according to race have been performed. in controlled clinical studies of metformin hydrochloride tablets, usp in patients with type 2 diabetes, the antihyperglycemic effect was comparable in whites (n=249), blacks (n=51) and hispanics (n=24). table-1

le rats was unaffected by metformin when administered at doses as high as 600 mg/kg/day, which is approximately three times the maximum recommended human daily dose based on body surface area comparisons.

on arm started therapy with metformin hydrochloride 500 mg and glyburide 20 mg. at the end of each week of the first four weeks of the trial, these patients had their dosages of metformin hydrochloride increased by 500 mg if they had failed to reach target fasting plasma glucose. after week four, such dosage adjustments were made monthly, although no patient was allowed to exceed metformin hydrochloride 2500 mg. patients in the metformin hydrochloride only arm (metformin plus placebo) followed the same titration schedule. at the end of the trial, approximately 70% of the patients in the combination group were taking metformin hydrochloride 2000 mg/glyburide 20 mg or metformin hydrochloride 2500 mg/glyburide 20 mg. patients randomized to continue on glyburide experienced worsening of glycemic control, with mean increases in fpg, ppg and hba 1c of 14 mg/dl, 3 mg/dl and 0.2%, respectively. in contrast, those randomized to metformin (up to 2500 mg/day) experienced a slight improvement, with mean reductions in fpg, ppg and hba 1c of 1 mg/dl, 6 mg/dl and 0.4%, respectively. the combination of metformin and glyburide was effective in reducing fpg, ppg and hba 1c levels by 63 mg/dl, 65 mg/dl, and 1.7%, respectively. compared to results of glyburide treatment alone, the net differences with combination treatment were -77 mg/dl, - 68 mg/dl and -1.9%, respectively (see table 3 ). * all patients on glyburide, 20 mg/day, at baseline ** not statistically significant the magnitude of the decline in fasting blood glucose concentration following the institution of metformin hydrochloride tablets, usp therapy is proportional to the level of fasting hyperglycemia. patients with type 2 diabetes with higher fasting glucose concentrations experienced greater declines in plasma glucose and glycosylated hemoglobin. in clinical studies, metformin, alone or in combination with a sulfonylurea, lowered mean fasting serum triglycerides, total cholesterol and ldl cholesterol levels and had no adverse effects on other lipid levels (see table 4 ). in contrast to sulfonylureas, body weight of individuals on metformin tended to remain stable or even decrease somewhat (see tables 2 and 3 ). a 24-week, double blind, placebo-controlled study of metformin hydrochloride tablets, usp plus insulin versus insulin plus placebo was conducted in patients with type 2 diabetes who failed to achieve adequate glycemic control on insulin alone (see table 5 ). patients randomized to receive metformin hydrochloride plus insulin achieved a reduction in hba1c of 2.10%, compared to a 1.56% reduction in hba1c achieved by insulin plus placebo. the improvement in glycemic control was achieved at the final study visit with 16% less insulin, 93.0 u/day vs 110.6 u/day, metformin hydrochloride tablets, usp plus insulin versus insulin plus placebo, respectively, p=0.04. a statistically significant using analysis of covariance with baseline as covariate (p=0.04) not significant using analysis of variance (values shown in table) b statistically significant for insulin (p=0.04) a second double-blind, placebo-controlled study (n=51), with 16 weeks of randomized treatment, demonstrated that in patients with type 2 diabetes controlled on insulin for 8 weeks with an average hba 1c of 7.46 ± 0.97%, the addition of metformin hydrochloride tablets, usp maintained similar glycemic control (hba 1c 7.15 ± 0.61 versus 6.97 ± 0.62 for metformin hydrochloride tablets, usp plus insulin and placebo plus insulin, respectively) with 19% less insulin versus baseline (reduction of 23.68 ± 30.22 versus an increase of 0.43 ± 25.20 units for metformin hydrochloride tablets, usp plus insulin and placebo plus insulin, p<0.01). in addition, this study demonstrated that the combination of metformin hydrochloride tablets, usp plus insulin resulted in reduction in body weight of 3.11 ± 4.30 lbs, compared to an increase of 1.30 ± 6.08 lbs for placebo plus insulin, p=0.01. pediatric clinical studies in a double-blind, placebo-controlled study in pediatric patients aged 10 to 16 years with type 2 diabetes (mean fpg 182.2 mg/dl), treatment with metformin hydrochloride tablets, usp (up to 2000 mg/day) for up to 16 weeks (mean duration of treatment 11 weeks) resulted in a significant mean net reduction in fpg of 64.3 mg/dl, compared with placebo (see table 6 ). a pediatric patients mean age 13.8 years (range 10-16 years) * all patients on diet therapy at baseline ** not statistically significant table-2 table-3 table-4 table-5 table-6

one side and scored on both sides. storage store at controlled room temperature 15°-30°c (59°-86°f). dispense in tight, light resistant container as defined in the usp.

c acidosis or other serious disease. patients should be counseled against excessive alcohol intake, either acute or chronic, while receiving metformin. metformin hydrochloride tablets, usp alone does not usually cause hypoglycemia, although it may occur when metformin is used in conjunction with oral sulfonylureas and insulin. when initiating combination therapy, the risks of hypoglycemia, its symptoms and treatment, and conditions that predispose to its development should be explained to patients and responsible family members. (see patient information printed below.)

mber of medicines taken by mouth, and by insulin shots. before you take metformin, try to control your diabetes by exercise and weight loss. while you take your diabetes medicine, continue to exercise and follow the diet advised for your diabetes. no matter what your recommended diabetes management plan is, studies have shown that maintaining good blood sugar control can prevent or delay complications of diabetes, such as blindness. metformin helps control your blood sugar in a number of ways. these include helping your body respond better to the insulin it makes naturally, decreasing the amount of sugar your liver makes, and decreasing the amount of sugar your intestines absorb. metformin does not cause your body to make more insulin. because of this, when taken alone, they rarely cause hypoglycemia (low blood sugar), and usually do not cause weight gain. however, when they are taken with a sulfonylurea, hypoglycemia is more likely to occur, as is weight gain. tell your doctor if you are pregnant or plan to become pregnant. metformin may not be right for you. talk with your doctor about your choices. you should also discuss your choices with your doctor if you are nursing a child. can metformin hydrochloride tablets, usp be used in children? metformin hydrochloride tablets, usp has been shown to effectively lower glucose levels in children (ages 10 to 16 years) with type 2 diabetes. metformin hydrochloride tablets, usp has not been studied in children younger than 10 years old. metformin hydrochloride tablets, usp has not been studied in combination with other oral glucose-control medicines in children. if you have any questions about the use of metformin hydrochloride tablets in children, talk with your doctor or healthcare provider. how should i take metformin hydrochloride tablets, usp? your doctor will tell you how much medicine to take and when to take it. you will probably start out with a low dose of the medicine. your doctor may slowly increase your dose until your blood sugar is better controlled. you should take metformin with meals. your doctor may have you take other medicines along with metformin to control your blood sugar. these medicines may include insulin shots. taking metformin hydrochloride tablets with insulin may help you better control your blood sugar while reducing the insulin dose. continue your exercise and diet program and test your blood sugar regularly while taking metformin. your doctor will monitor your diabetes and may perform blood tests on you from time to time to make sure your kidneys and your liver are functioning normally. there is no evidence that metformin causes harm to the liver or kidneys. tell your doctor if you have an illness that causes severe vomiting, diarrhea or fever, or if you drink a much lower amount of liquid than normal. these conditions can lead to severe dehydration (loss of water in your body). you may need to stop taking metformin for a short time. plan to have surgery or an x-ray procedure with injection of dye (contrast agent). you may need to stop taking metformin hydrochloride tablets for a short time. start to take other medicines or change how you take a medicine. metformin can affect how well other drugs work, and some drugs can affect how well metformin works. some medicines may cause high blood sugar. what should i avoid while taking metformin hydrochloride tablets, usp? do not drink a lot of alcoholic drinks while taking metformin. this means you should not binge drink for short periods, and you should not drink a lot of alcohol on a regular basis. alcohol can increase the chance of getting lactic acidosis. what are the side effects of metformin? lactic acidosis. metformin, the active ingredient in metformin, can cause a rare but serious condition called lactic acidosis (a buildup of an acid in the blood) that can cause death. lactic acidosis is a medical emergency and must be treated in the hospital. call your doctor right away if you have any of the following symptoms, which could be signs of lactic acidosis: you feel cold in your hands or feet you feel dizzy or lightheaded you have a slow or irregular heartbeat you feel very weak or tired you have unusual (not normal) muscle pain you have trouble breathing you feel sleepy or drowsy you have stomach pains, nausea or vomiting most people who have had lactic acidosis with metformin have other things that, combined with the metformin, led to the lactic acidosis. tell your doctor if you have any of the following, because you have a higher chance for getting lactic acidosis with metformin if you: have severe kidney problems, or your kidneys are affected by certain x-ray tests that use injectable dye have liver problems drink alcohol very often, or drink a lot of alcohol in short-term “binge” drinking get dehydrated (lose a large amount of body fluids). this can happen if you are sick with a fever, vomiting, or diarrhea. dehydration can also happen when you sweat a lot with activity or exercise and do not drink enough fluids have surgery have a heart attack, severe infection or stroke the best way to keep from having a problem with lactic acidosis from metformin is to tell your doctor if you have any of the problems in the list above. your doctor may decide to stop your metformin for a while if you have any of these things. other side effects. common side effects of metformin include diarrhea, nausea, and upset stomach. these side effects generally go away after you take the medicine for a while. taking your medicine with meals can help reduce these side effects. tell your doctor if the side effects bother you a lot, last for more than a few weeks, come back after they’ve gone away, or start later in therapy. you may need a lower dose or need to stop taking the medicine for a short period or for good. about 3 out of every 100 people who take metformin have an unpleasant metallic taste when they start taking the medicine. it lasts for a short time. metformin rarely cause hypoglycemia (low blood sugar) by themselves. however, hypoglycemia can happen if you do not eat enough, if you drink alcohol, or if you take other medicines to lower blood sugar. general advice about prescription medicines if you have questions or problems, talk with your doctor or other healthcare provider. you can ask your doctor or pharmacist for the information about metformin that is written for health care professionals. medicines are sometimes prescribed for purposes other than those listed in a patient information leaflet. do not use metformin for a condition for which it was not prescribed. do not share your medicine with other people. manufactured by: sun pharmaceutical industries ltd. halol-baroda highway, halol-389 350, gujarat, india. distributed by: sun pharmaceutical industries, inc. cranbury, nj 08512 iss. 06/2018