Triglide

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Description for Triglide

Triglide (fenofibrate) Tablets, is a lipid regulating agent available as tablets for oral administration. Each tablet contains 160 mg of fenofibrate. The chemical name for fenofibrate is 2-[4-(4-chlorobenzoyl) phenoxy] 2-methyl-propanoic acid, 1-methylethyl ester with the following structural formula:

The empirical formula is C₂₀H₂₁O₄Cl and the molecular weight is 360.83; fenofibrate is insoluble in water. The melting point is 79° to 82°C. Fenofibrate is a white solid which is stable under ordinary conditions.

Inactive Ingredients: Each tablet contains crospovidone, lactose monohydrate, mannitol, maltodextrin, carboxymethylcellulose sodium, egg lecithin, croscarmellose sodium, sodium lauryl sulfate, colloidal silicon dioxide, magnesium stearate, and monobasic sodium phosphate.

Uses for Triglide

Triglide is indicated as adjunctive therapy to diet:

• To reduce triglyceride (TG) levels in adults with severe hypertriglyceridemia (TG greater than or equal to 500 mg/dL).
• To reduce elevated low-density lipoprotein cholesterol (LDL-C) in adults with primary hyperlipidemia when use of recommended LDL-C lowering therapy is not possible.

Limitations Of Use

• Markedly elevated levels of serum triglycerides (e.g., >2,000 mg/dL) may increase the risk of developing pancreatitis. The effect of fenofibrate therapy on reducing this risk has not been determined [see WARNINGS AND PRECAUTIONS].
• Fenofibrate did not reduce coronary heart disease morbidity and mortality in two large, randomized controlled trials of patients with type 2 diabetes mellitus [see WARNINGS AND PRECAUTIONS and Clinical Studies].

Dosage for Triglide

Prior To Initiation Of Triglide

• Assess lipid levels before initiating therapy. Identify other causes (e.g., diabetes mellitus, hypothyroidism, or medications) of high triglyceride levels and manage as appropriate.
• Patients should be placed on an appropriate lipid-lowering diet before receiving Triglide, and should continue this diet during treatment with Triglide.
• In patients with diabetes and fasting chylomicronemia, improve glycemic control prior to considering starting Triglide.

Recommended Dosage And Administration

• The recommended dosage of Triglide is 160 mg orally once daily.
• Administer Triglide as a single dosage at any time of day, with or without food.
• Advise patients to swallow Triglide tablets whole. Do not split, crush, dissolve, or chew tablets [see CLINICAL PHARMACOLOGY].
• Assess TG when clinically appropriate, as early as 4 to 8 weeks after initiating Triglide. Discontinue Triglide in patients who do not have an adequate response after two months of treatment.
• If a dose is missed, advise patients not to take an extra dose. Resume treatment with the next dose.
• Advise patients to take Triglide at least 1 hour before or 4 hours to 6 hours after a bile acid binding resin to avoid impeding its absorption.

Recommendations For Use In Patients With Renal Impairment

• Assess renal function prior to initiation of Triglide and periodically thereafter [see WARNINGS AND PRECAUTIONS].
• Triglide is contraindicated in patients with severe renal impairment (eGFR <30 mL/min), including those with end-stage renal disease (ESRD) and those receiving dialysis [see CONTRAINDICATIONS].
• Triglide is not recommended in patients with mild to moderate renal impairment (eGFR 30 to <60 mL/min) because these patients require a lower dosage of fenofibrate than what is available for Triglide [see Use In Specific Populations].

HOW SUPPLIED

Dosage Forms And Strengths

• 160 mg: Round off-white tablets. Debossed “FH 160”

Storage And Handling

The tablets are supplied as follows:

NDC 70199-013-30: bottles of 30 tablets. 160 mg, off-white round tablets, debossed “FH 160”.

Only dispense Triglide tablets in the original manufacturer bottle with the original desiccant cap. Do not repackage Triglide tablets into standard amber pharmacy vials.

Store at 20°-25°C (68°-77°F); excursions permitted to 15°-30°C (59°-86°F) [See USP Controlled Room Temperature]. Protect from light and moisture. Store tablets only in the moisture protective container.

Manufactured for: Casper Pharma LLC, East Brunswick, NJ 08816 Manufactured by: SkyePharma Production SAS 38070 Saint-Quentin-Fallavier, France Made in France PIB01330-09 © Casper Pharma LLC. All rights reserved. Revised: May 2024

Side Effects for Triglide

The following serious adverse reactions are described below and elsewhere in the labeling:

• Mortality and coronary heart disease morbidity [see WARNINGS AND PRECAUTIONS]
• Hepatoxicity [see WARNINGS AND PRECAUTIONS]
• Myopathy and Rhabdomyolysis [see WARNINGS AND PRECAUTIONS]
• Increases in Serum Creatinine [see WARNINGS AND PRECAUTIONS]
• Cholelithiasis [see WARNINGS AND PRECAUTIONS]
• Increased Bleeding Risk with Coumarin Anticoagulants [see WARNINGS AND PRECAUTIONS]
• Pancreatitis [see WARNINGS AND PRECAUTIONS]
• Hematologic Changes [see WARNINGS AND PRECAUTIONS]
• Hypersensitivity reactions [see WARNINGS AND PRECAUTIONS]
• Venothromboembolic disease [see WARNINGS AND PRECAUTIONS]

Clinical Trials Experience

Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect rates observed in clinical practice.

The safety of Triglide has been established in adults with hypertriglyceridemia or primary hyperlipidemia based on adequate and well-controlled trials of other formulations of fenofibrate, referenced below as “fenofibrate” [see Clinical Studies]. Dosages of fenofibrate used in these trials were comparable to Triglide 160 mg per day [see CLINICAL PHARMACOLOGY].

Adverse reactions reported by 2% or more of patients treated with fenofibrate (and greater than placebo) during double-blind, placebo-controlled trials are listed in Table 1. Adverse reactions led to discontinuation of treatment in 5% of patients treated with fenofibrate and in 3% treated with placebo. Increases in liver function tests were the most frequent events, causing discontinuation of fenofibrate treatment in 1.6% of patients in double-blind trials.

Table 1: Adverse Reactions Reported by 2% or More of Patients Treated with Fenofibrate and Greater than Placebo During the Double-Blind, Placebo-Controlled Trials

Adverse Reaction	Placebo (N = 365)	Fenofibrate (N = 439)
Abnormal Liver Tests	1%	8%
Abdominal Pain	4%	5%
Increased ALT	2%	3%
Increased AST	1%	3%
Increased Creatine Phosphokinase	1%	3%
Constipation	1%	2%
Rhinitis	1%	2%

Urticaria

Urticaria was seen in 1.1 vs. 0%, and rash in 1.4 vs. 0.8% of fenofibrate and placebo patients, respectively, in controlled trials.

Increases In Liver Enzymes

In a pooled analysis of 10 placebo-controlled trials, increases to >3 times the upper limit of normal in ALT occurred in 5.3% of patients taking fenofibrate versus 1.1% of patients treated with placebo. In an 8-week study, the incidence of ALT or AST elevations ≥3 times the upper limit of normal was 13% in patients receiving dosages comparable to 134 mg to 200 mg fenofibrate daily.

Postmarketing Experience

The following adverse reactions have been identified during post approval use of fenofibrate. 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.

Blood Disorders: Anemia

Gastrointestinal Disorders: Pancreatitis

General Disorder: Asthenia

Hepatobiliary Disorders: Increased total bilirubin, hepatitis, cirrhosis

Immune System Disorders: Anaphylaxis, angioedema

Lipid Disorders: Severely depressed HDL-cholesterol levels

Musculoskeletal Disorders: Myalgia, muscle spasms, rhabdomyolysis, arthralgia

Renal and Urinary Disorders: Acute renal failure

Respiratory Disorders: Interstitial lung disease

Skin and Subcutaneous Tissue Disorders: Photosensitivity reactions.

This may occur in patients  who report a prior photosensitivity reaction to ketoprofen.

Drug Interactions for Triglide

Table 2: Clinically Important Drug Interactions with Triglide

Statins
Clinical Impact:	Fibrates may cause myopathy when given alone. The risk of myopathy and rhabdomyolysis is increased with concomitant use of fibrates with statins.
Intervention:	Consider if the benefit of using Triglide concomitantly with statin therapy outweighs the increased risk of myopathy and rhabdomyolysis. If concomitant use is decided, monitor patients for signs and symptoms of myopathy, particularly during initiation of therapy and during upward dosage titration of statin therapy.
Colchicine
Clinical Impact:	Cases of myopathy and rhabdomyolysis have been reported with concomitant use of colchicine with fenofibrates.
Intervention:	Consider if the benefit of using colchicine concomitantly with Triglide outweighs the increased risk of myopathy and rhabdomyolysis. If concomitant use is decided, monitor patients for signs and symptoms of myopathy, particularly during initiation of therapy and during upward dosage titration of colchicine.
Coumarin Anticoagulants
Clinical Impact:	Fibrates may cause potentiation of coumarin-type anticoagulant effects with prolongation of the PT/INR.
Intervention:	Caution should be exercised when coumarin anticoagulants are given in conjunction with Triglide. The dosage of the anticoagulants should be reduced to maintain the PT/INR at the desired level to prevent bleeding complications. Frequent PT/INR determinations are advisable until it has been definitely determined that the PT/INR has stabilized
Immunosuppressants
Clinical Impact:	Immunosuppressants such as cyclosporine and tacrolimus can produce nephrotoxicity with decreases in creatinine clearance and rises in serum creatinine, and because renal excretion is the primary elimination route of fibrate drugs including Triglide, there is a risk that an interaction will lead to deterioration of renal function.
Intervention:	The benefits and risks of using Triglide with immunosuppressants and other potentially nephrotoxic agents should be carefully considered, and the lowest effective dosage employed and renal function monitored.
Bile-Acid Binding Resins
Clinical Impact:	Bile-acid binding resins may bind other drugs given concurrently.
Intervention:	In patients taking a bile acid resins, administer Triglide at least 1 hour before or 4 to 6 hours after the bile acid resins to avoid impeding its absorption.

Warnings for Triglide

Included as part of the PRECAUTIONS section.

Precautions for Triglide

Mortality And Coronary Heart Disease Morbidity

Fenofibrate did not reduce cardiovascular disease morbidity or mortality in two large, randomized controlled trials of patients with type 2 diabetes mellitus [see Clinical Studies].

Because of chemical, pharmacological, and clinical similarities between Triglide, pemafibrate, clofibrate, and gemfibrozil, findings in 5 large randomized, placebo-controlled clinical trials with these other fibrate drugs may also apply to Triglide.

Pemafibrate did not reduce cardiovascular disease morbidity or mortality in a large, randomized, placebo-controlled trial of patients with type 2 diabetes mellitus on background statin therapy [see Clinical Studies].

In the Coronary Drug Project, a large trial conducted from 1965 to 1985 in men post myocardial infarction, there was no difference in mortality or nonfatal myocardial infarction between the clofibrate group and the placebo group after 5 years of treatment (NCT00000482).

In a trial conducted by the World Health Organization (WHO) from 1965 to 1976, men without known coronary artery disease were treated with placebo or clofibrate for 5 years and followed for an additional one year. There was a statistically significant, higher age-adjusted all-cause mortality in the clofibrate group compared with the placebo group (5.70% vs. 3.96%, p = <0.01). Excess mortality was due to a 33% increase in non-cardiovascular causes, including malignancy, post-cholecystectomy complications, and pancreatitis.

The Helsinki Heart Study, conducted from 1982 to 1987, was a large (n=4,081) study of middle-aged men without a history of coronary artery disease. Subjects received either placebo or gemfibrozil for 5 years, with a 3.5 years open extension afterward. Total mortality was numerically but not statistically higher in the gemfibrozil randomization group versus placebo [95% confidence interval (CI) of the hazard ratio (HR) 0.91 to 1.64].

A secondary prevention component of the Helsinki Heart Study treated middle-aged men with gemfibrozil or placebo for 5 years. The HR for cardiac deaths was 2.2, 95% CI, 0.94 to 5.05.

Hepatotoxicity

Serious drug-induced liver injury (DILI), including liver transplantation and death, has been reported postmarketing with Triglide. DILI has been reported within the first few weeks of treatment or after several months of therapy and in some cases has reversed with discontinuation of Triglide treatment. Patients with DILI have experienced signs and symptoms including dark urine, abnormal stool, jaundice, malaise, abdominal pain, myalgia, weight loss, pruritus, and nausea. Many patients had concurrent elevations of total bilirubin, serum alanine transaminase (ALT), and aspartate transaminase (AST). DILI has been characterized as hepatocellular, chronic active, and cholestatic hepatitis, and cirrhosis has occurred in association with chronic active hepatitis.

In clinical trials, fenofibrate has been associated with increases in serum AST or ALT. The incidence of increases in transaminases may be dose related [see ADVERSE REACTIONS].

Triglide is contraindicated in patients with active liver disease, including those with unexplained persistent liver function abnormalities [see CONTRAINDICATIONS]. Monitor patient’s liver function, including serum ALT, AST, and total bilirubin, at baseline and periodically for the duration of therapy with Triglide. Discontinue Triglide if signs or symptoms of liver injury develop or if elevated enzyme levels persist (ALT or AST >3 times the upper limit of normal, or if accompanied by elevation of bilirubin). Do not restart Triglide in these patients if there is no alternative explanation for the liver injury.

Myopathy And Rhabdomyolysis

Triglide may cause myopathy [muscle pain, tenderness, or weakness associated with elevated creatine kinase (CK)] and rhabdomyolysis.

Risk Factors For Myopathy

Risk factors for myopathy include age 65 years or greater, uncontrolled hypothyroidism, renal impairment, and concomitant use with certain other drugs [see DRUG INTERACTION and Uses In Specific Populations].

Steps To Prevent Or Reduce The Risk Of Myopathy And Rhabdomyolysis

Data from observational studies indicate that the risk for rhabdomyolysis is increased when fibrates are co-administered with a statin. Avoid concomitant use unless the benefit of further alterations in TG levels is likely to outweigh the increased risk of this drug combination [see DRUG INTERACTIONS and CLINICAL PHARMACOLOGY .

Cases of myopathy, including rhabdomyolysis, have been reported with Triglide co-administered with colchicine. Consider whether the benefit of using colchicine concomitantly with Triglide outweighs the increased risk of myopathy [see DRUG INTERACTIONS].

Discontinue Triglide if markedly elevated CK levels occur or if myopathy is either diagnosed or suspected. Muscle symptoms and CK elevations may resolve if Triglide is discontinued. Temporarily discontinue Triglide in patients experiencing an acute or serious condition at high risk of developing renal failure secondary to rhabdomyolysis (e.g., sepsis; shock; severe hypovolemia; major surgery; trauma; severe metabolic, endocrine, or electrolyte disorders; or uncontrolled epilepsy).

Inform patients of the risk of myopathy and rhabdomyolysis when starting or increasing the Triglide dosage. Instruct patients to promptly report any unexplained muscle pain, tenderness or weakness, particularly if accompanied by malaise or fever.

Increases In Serum Creatinine

Increases in serum creatinine have been reported in patients on Triglide. These increases tend to return to baseline following discontinuation of Triglide. The clinical significance of this finding is unknown. Monitor renal function in patients with renal impairment taking Triglide. Renal monitoring should also be considered for patients taking Triglide at risk for renal insufficiency such as the elderly and patients with diabetes. Triglide is not recommended in patients with mild or moderate renal impairment. Triglide is contraindicated in patients with severe renal impairment, including those with end-stage renal disease (ESRD) and those receiving dialysis [see CONTRAINDICATIONS, Use In Specific Populations, and CLINICAL PHARMACOLOGY].

Cholelithiasis

Fenofibrate may increase cholesterol excretion into the bile, leading to cholelithiasis. If cholelithiasis is suspected, gallbladder studies are indicated. Triglide therapy should be discontinued if gallstones are found. Triglide is contraindicated in patients with preexisting gallbladder disease.

Increased Bleeding Risk With Coumarin Anticoagulants

Caution should be exercised when anticoagulants are given in conjunction with Triglide because of the potentiation of coumarin-type anti-coagulant effects in prolonging the prothrombin time/International Normalized Ration (PT/INR). The dosage of the anticoagulant should be reduced to maintain the PT/INR at the desired level to prevent bleeding complications. Frequent PT/INR determinations are advisable until it has been definitely determined that the PT/INR has stabilized [see DRUG INTERACTIONS].

Pancreatitis

Pancreatitis has been reported in patients taking Triglide. This occurrence may represent a failure of efficacy in patients with severe hypertriglyceridemia, a direct drug effect, or a secondary phenomenon mediated through biliary tract stone or sludge formation with obstruction of the common bile duct.

Hematologic Changes

Mild to moderate hemoglobin, hematocrit, and white blood cell decreases have been observed in patients following initiation of Triglide. However, these levels stabilize during long-term administration. Thrombocytopenia and agranulocytosis have been reported in individuals treated with Triglide. Periodic monitoring of red and white cell counts is recommended during the first 12 months of Triglide administration.

Hypersensitivity Reactions

Acute Hypersensitivity

Anaphylaxis and angioedema have been reported postmarketing with fenofibrate. In some cases, reactions were life-threatening and required emergency treatment. If a patient develops signs or symptoms of an acute hypersensitivity reaction, advise them to seek immediate medical attention and discontinue Triglide. Triglide is contraindicated in patients with a hypersensitivity to fenofibrate, fenofibric acid, or any of the ingredients in Triglide.

Delayed Hypersensitivity

Severe cutaneous adverse drug reactions (SCAR), including Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis, and Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), have been reported postmarketing, occurring days to weeks after initiation of Triglide. The cases of DRESS were associated with cutaneous reactions (such as rash or exfoliative dermatitis) and a combination of eosinophilia, fever, systemic organ involvement (renal, hepatic, or respiratory). Discontinue fenofibrate and treat patients appropriately if SCAR is suspected.

Venothromboembolic Disease

In the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) trial, pulmonary embolus (PE) and deep vein thrombosis (DVT) were observed at higher rates in the fenofibrate-than the placebo-treated group. Of 9,795 patients enrolled in FIELD, there were 4,900 in the placebo group and 4,895 in the fenofibrate group. For DVT, there were 48 events (1%) in the placebo group and 67 (1.4%) in the fenofibrate group (p = 0.074); and for PE, there were 32 (0.7%) events in the placebo group and 53 (1.1%) in the fenofibrate group (p = 0.022).

In the Coronary Drug Project, a higher proportion of the clofibrate group experienced definite or suspected fatal or nonfatal pulmonary embolism or thrombophlebitis than the placebo group (5.2% vs. 3.3% at five years; p <0.01).

In the cardiovascular outcome trial with pemafibrate, pulmonary embolism was reported for 37 (0.7%) subjects in the pemafibrate group and 16 (0.3%) subjects in the placebo group. Deep vein thrombosis was reported for 36 (0.7%) subjects in the pemafibrate group and 13 (0.2%) subjects in the placebo group.

Paradoxical Decrease In HDL Cholesterol Levels

There have been postmarketing and clinical trial reports of severe decreases in HDL cholesterol levels (as low as 2 mg/dL) occurring in patients with and without diabetes initiated on fibrate therapy. The decrease in HDL-C is mirrored by a decrease in apolipoprotein A1. This decrease has been reported to occur within 2 weeks to years after initiation of fibrate therapy. The HDL-C levels remain depressed until fibrate therapy has been withdrawn; the response to withdrawal of fibrate therapy is rapid and sustained. The clinical significance of this decrease in HDL-C is unknown. Check HDL-C levels within the first few months after initiation of Triglide. If a severely depressed HDL-C level is detected, discontinue Triglide and monitor HDL-C until it has returned to baseline. Triglide should not be re-initiated.

Nonclinical Toxicology

Carcinogenesis, Mutagenesis, Impairment Of Fertility

Carcinogenesis

Two dietary carcinogenicity studies have been conducted in rats with fenofibrate. In the first 24-month study, Wistar rats were dosed with fenofibrate at 10 mg/kg/day, 45 mg/kg/day and 200 mg/kg/day, approximately 0.3 times, 1 time, and 6 times the maximum recommended human dose (MRHD), based on body surface area comparisons (mg/m²). At a dose of 200 mg/kg/day (at 6 times MRHD), the incidence of liver carcinoma was significantly increased in both sexes. A statistically significant increase in pancreatic carcinomas was observed in males at 1 and 6 times the MRHD; an increase in pancreatic adenomas and benign testicular interstitial cell tumors was observed in males at 6 times the MRHD. In a second 24-month study in a different strain of rats (Sprague-Dawley), doses of 10 mg/kg/day and 60 mg/kg/day (0.3 times and 2 times the MRHD) produced significant increases in the incidence of pancreatic acinar adenomas in both sexes and increases in testicular interstitial cell tumors in males at 2 times the MRHD.

A 117-week carcinogenicity study was conducted in rats comparing three drugs: fenofibrate 10 mg/kg/day and 60 mg/kg/day (0.3 and 2 times the MRHD), clofibrate (400 mg/kg; 2 times the human dose), and gemfibrozil (250 mg/kg; 2 times the human dose, based on mg/m² surface area). Fenofibrate increased pancreatic acinar adenomas in both sexes. Clofibrate increased hepatocellular carcinomas in males and hepatic neoplastic nodules in females. Gemfibrozil increased hepatic neoplastic nodules in males and females, while all three drugs increased testicular interstitial cell tumors in males.

In a 21-month study in CF-1 mice, fenofibrate 10 mg/kg/day, 45 mg/kg/day and 200 mg/kg/day (approximately 0.2 times, 1 time, and 3 times the MRHD on the basis of mg/m² surface area) significantly increased the liver carcinomas in both sexes at 3 times the MRHD. In a second 18-month study at 10 mg/kg/day, 60 mg/kg/day and 200 mg/kg/day, fenofibrate significantly increased the liver carcinomas in male mice and liver adenomas in female mice at 3 times the MRHD.

Electron microscopy studies have demonstrated peroxisomal proliferation following fenofibrate administration to the rat. An adequate study to test for peroxisome proliferation in humans has not been done, but changes in peroxisome morphology and numbers have been observed in humans after treatment with other members of the fibrate class when liver biopsies were compared before and after treatment in the same individual.

Mutagenesis

Fenofibrate has been demonstrated to be devoid of mutagenic potential in the following tests: Ames, mouse lymphoma, chromosomal aberration and unscheduled DNA synthesis in primary rat hepatocytes.

Impairment Of Fertility

In fertility studies rats were given oral dietary doses of fenofibrate, males received 61 days prior to mating and females 15 days prior to mating through weaning which resulted in no adverse effect on fertility at doses up to 300 mg/kg/day (approximately 10 times the MRHD, based on mg/m² surface area comparisons).

Use In Specific Populations

Pregnancy

Risk Summary

Limited available data with fenofibrate use in pregnant women are insufficient to determine a drug-associated risk of major birth defects, miscarriage or adverse maternal or fetal outcomes. In animal reproduction studies, no evidence of embryo-fetal toxicity was observed with oral administration of fenofibrate in rats and rabbits during organogenesis at doses less than or comparable to the maximum recommended clinical dose of 160 mg daily, based on body surface area (mg/m²). Adverse reproductive outcomes occurred at higher doses in the presence of maternal toxicity [see Data]. Fenofibrate tablets should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.

Data

Animal Data

In pregnant rats given oral dietary doses of 14 mg/kg/day, 127 mg/kg/day, and 361 mg/kg/day from gestation day 6 to 15 during the period of organogenesis, no adverse developmental findings were observed at 14 mg/kg/day (less than the clinical exposure at the maximum recommended human dose [MRHD] of 300 mg fenofibrate daily, comparable to 160 mg Triglide tablets daily, based on body surface area comparisons). Increased fetal skeletal malformations were observed at maternally toxic doses (361 mg/kg/day, corresponding to 12 times the clinical exposure at the MRHD) that significantly suppressed maternal body weight gain.

In pregnant rabbits given oral gavage doses of 15 mg/kg/day, 150 mg/kg/day, and 300 mg/kg/day from gestation day 6 to 18 during the period of organogenesis and allowed to deliver, no adverse developmental findings were observed at 15 mg/kg/day (a dose that approximates the clinical exposure at the MRHD, based on body surface area comparisons). Aborted litters were observed at maternally toxic doses (≥150 mg/kg/day, corresponding to ≥10 times the clinical exposure at the MRHD) that suppressed maternal body weight gain.

In pregnant rats given oral dietary doses of 15 mg/kg/day, 75 mg/kg/day, and 300 mg/kg/day from gestation day 15 through lactation day 21 (weaning), no adverse developmental effects were observed at 15 mg/kg/day (less than the clinical exposure at the MRHD, based on body surface area comparisons), despite maternal toxicity (decreased weight gain). Post-implantation loss was observed at ≥75 mg/kg/day (≥2 times the clinical exposure at the MRHD) in the presence of maternal toxicity (decreased weight gain). Decreased pup survival was noted at 300 mg/kg/day (10 times the clinical exposure at the MRHD), which was associated with decreased maternal body weight gain/maternal neglect.

Lactation

Risk Summary

There is no available information on the presence of fenofibrate in human milk, effects of the drug on the breastfed infant, or the effects on milk production. Fenofibrate is present in the milk of rats, and is therefore likely to be present in human milk. Because of the potential for serious adverse reactions in breastfed infants, such as disruption of infant lipid metabolism, women should not breastfeed during treatment with fenofibrates tablets and for 5 days after the final dose [see CONTRAINDICATIONS].

Pediatric Use

The safety and effectiveness of Triglide have not been established in pediatric patients with severe hypertriglyceridemia or primary hyperlipidemia.

Geriatric Use

Assess renal function in elderly patients and follow contraindications and dosing recommendations for patients with renal impairment [see CONTRAINDICATIONS, WARNINGS AND PRECAUTIONS, and Use In Specific Populations]. While fenofibric acid exposure is not influenced by age, elderly patients are more likely to have renal impairment, and fenofibric acid is substantially excreted by the kidney [see CLINICAL PHARMACOLOGY].

Consider monitoring renal function in elderly patients taking Triglide.

Renal Impairment

Triglide is contraindicated in patients with severe renal impairment (eGFR <30 mL/min), including those with end-stage renal disease (ESRD) and those receiving dialysis [see CONTRAINDICATIONS]. Triglide is not recommended for use in patients with mild or moderate renal impairment (eGFR 30 to <60 mL/min) because these patients require a lower dosage of fenofibrate than what is available for Triglide. Patients with severe renal impairment have 2.7-fold higher exposure of fenofibric acid and increased accumulation of fenofibric acid during chronic dosing compared with healthy volunteers. Renal impairment is a risk factor for myopathy and rhabdomyolysis [see WARNINGS AND PRECAUTIONS, and CLINICAL PHARMACOLOGY].

Hepatic Impairment

The use of Triglide has not been evaluated in subjects with hepatic impairment. Triglide is contraindicated in patients with active liver disease, including those with unexplained persistent liver function abnormalities [see CONTRAINDICATIONS and CLINICAL PHARMACOLOGY].

Overdose Information for Triglide

In the event of an overdose of Triglide, consider contacting the Poison Help line (1-800-222-1222) or a medical toxicologist for additional overdosage management recommendations. There is no specific treatment for overdose with Triglide. General supportive care of the patient is indicated, including monitoring of vital signs and observation of clinical status, should an overdose occur. If indicated, elimination of unabsorbed drug should be achieved by emesis or gastric lavage; usual precautions should be observed to maintain the airway. Because fenofibrate is highly bound to plasma proteins, hemodialysis should not be considered.

Contraindications for Triglide

Triglide is contraindicated in the following conditions:

• Severe renal impairment, including those with end-stage renal disease (ESRD) and those receiving dialysis [see CLINICAL PHARMACOLOGY].
• Active liver disease, including those with unexplained persistent liver function abnormalities [see WARNINGS AND PRECAUTIONS].
• Preexisting gallbladder disease [see WARNINGS AND PRECAUTIONS].
• Hypersensitivity to fenofibrate, fenofibric acid, or any of the excipients in Triglide. Serious hypersensitivity reactions including anaphylaxis and angioedema have been reported with fenofibrate [see WARNINGS AND PRECAUTIONS].

Clinical Pharmacology for Triglide

Mechanism Of Action

The active moiety of Triglide is fenofibric acid. The pharmacological effects of fenofibric acid in both animals and humans have been studied through oral administration of fenofibrate.

The lipid-modifying effects of fenofibric acid seen in clinical practice have been explained in vivo in transgenic mice and in vitro in human hepatocyte cultures by the activation of PPAR alpha receptor. Through this mechanism, fenofibrate increases lipolysis and elimination of triglyceride-rich particles from plasma by activating lipoprotein lipase and reducing production of apoprotein C-III (an inhibitor of lipoprotein lipase activity).

Pharmacodynamics

Fenofibric acid, the active metabolite of fenofibrate, produces reductions in total cholesterol, total triglycerides, and triglyceride rich lipoprotein (VLDL) in treated patients with severe hypertriglyceridemia.

Pharmacokinetics

Triglide 160 mg tablet was shown to have comparable bioavailability to a single dose of 200 mg fenofibrate capsule, micronized. Fenofibrate is a pro-drug of the active chemical moiety fenofibric acid. Fenofibrate is converted by ester hydrolysis in the body to fenofibric acid which is the active constituent measurable in the circulation.

Absorption

The absolute bioavailability of fenofibrate cannot be determined as the compound is virtually insoluble in aqueous media suitable for injection. Fenofibrate is insoluble in water and its bioavailability is optimized when taken with meals. However, after fenofibrate is dissolved, fenofibrate is well absorbed from the gastrointestinal tract. Following oral administration in healthy volunteers, approximately 60% of a single dose of radiolabelled fenofibrate appeared in urine, primarily as fenofibric acid and its glucuronate conjugate, and 25% was excreted in the feces. Peak plasma levels of fenofibric acid occur an average of 3 hours after administration.

Effect Of Food

The extent of absorption of Triglide (AUC) is comparable between fed and fasted conditions. High-fat meal increases the rate of absorption of Triglide approximately 55%.

Distribution

In healthy volunteers, steady-state plasma levels of fenofibric acid were shown to be achieved within a week of dosing and did not demonstrate accumulation across time following multiple dose administration. Serum protein binding was approximately 99% in normal and hyperlipidemic subjects.

Elimination

Metabolism

Following oral administration, fenofibrate is rapidly hydrolyzed by esterases to the active metabolite, fenofibric acid; no unchanged fenofibrate is detected in plasma. Fenofibric acid is primarily conjugated with glucuronic acid and then excreted in urine. A small amount of fenofibric acid is reduced at the carbonyl moiety to a benzhydrol metabolite which is, in turn, conjugated with glucuronic acid and excreted in urine. In vivo metabolism data indicate that neither fenofibrate nor fenofibric acid undergo oxidative metabolism (e.g., cytochrome P450) to a significant extent.

Excretion

After absorption, fenofibrate is mainly excreted in the urine in the form of metabolites, primarily fenofibric acid and fenofibric acid glucuronide. After administration of radio-labelled fenofibrate, approximately 60% of the dose appeared in the urine and 25% was excreted in the feces. Fenofibric acid is eliminated with a half-life of approximately 16 hours, allowing once daily dosing.

Specific Populations

Geriatric Patients

In elderly volunteers aged 77 to 87 years, the oral clearance of fenofibric acid following a single oral dose of fenofibrate was 1.2 L/h, which compares to 1.1 L/h in young adults. This indicates that a similar dosage regimen can be used in the elderly, without increasing accumulation of the drug or metabolites.

Pediatric Patients

Pharmacokinetics of Triglide has not been studied in pediatric patients.

Male And Female Patients

No pharmacokinetic difference between males and females has been observed for fenofibrate.

Racial And Ethnic Groups

The influence of race on the pharmacokinetics of fenofibrate has not been studied; however, fenofibrate is not metabolized by enzymes known for exhibiting inter-ethnic variability.

Patients With Renal Impairment

The pharmacokinetics of fenofibric acid was examined in patients with mild, moderate, and severe renal impairment. Patients with severe renal impairment (creatinine clearance [CrCl ≤30 mL/min] <30 mL/min or estimated glomerular filtration rate [eGFR] <30 mL/min) showed 2.7-fold increase in exposure for fenofibric acid and increased accumulation of fenofibric acid during chronic dosing compared to that of healthy subjects. Patients with mild to moderate renal impairment (CrCl 30 mL/min to 80 mL/min or eGFR 30 mL/min to 59 mL/min) had similar exposure but an increase in the half-life for fenofibric acid compared to that of healthy subjects.

Patients With Hepatic Impairment

No pharmacokinetic studies have been conducted in patients having hepatic impairment.

Drug-Drug Interaction Studies

In vitro studies using human liver microsomes indicate that fenofibrate and fenofibric acid are not inhibitors of cytochrome (CYP) P450 isoforms CYP3A4, CYP2D6, CYP2E1, or CYP1A2. They are weak inhibitors of CYP2C8, CYP2C19 and CYP2A6, and mild-to-moderate inhibitors of CYP2C9 at therapeutic concentrations.

Table 3 describes the effects of co-administered drugs on fenofibric acid systemic exposure. Table 4 describes the effects of fenofibrate on co-administered drugs.

Table 3: Effects of Co-Administered Drugs on Fenofibric Acid Systemic Exposure from Fenofibrate Administration

Co-Administered Drug	Dosage Regimen of CoAdministered Drug	Dosage Regimen of Fenofibrate	Changes in Fenofibric Acid Exposure
			AUC	Cmax
Lipid-lowering agents
Atorvastatin	20 mg once daily for 10 days	Fenofibrate 160 mg1 once daily for 10 days	↓2%	↓4%
Pravastatin	40 mg as a single dose	Fenofibrate 3 x 67 mg2 as a single dose	↓1%	↓2%
Fluvastatin	40 mg as a single dose	Fenofibrate 160 mg1 as a single dose	↓2%	↓10%
Anti-diabetic agents
Glimepiride	1 mg as a single dose	Fenofibrate 145 mg1 once daily for 10 days	↑1%	↓1%
Metformin	850 mg three times daily for 10 days	Fenofibrate 54 mg1 three times daily for 10 days	↓9%	↓6%
Rosiglitazone	8 mg once daily for 5 days	Fenofibrate 145 mg1 once daily for 14 days	↑10%	↑3%
1 TriCor (fenofibrate) oral tablet 2 TriCor (fenofibrate) oral micronized capsule

Table 4: Effects of Fenofibrate on Systemic Exposure of Co-Administered Drugs

Dosage Regimen of Fenofibrate	Dosage Regimen of CoAdministered Drug	Change in Co-Administered Drug Exposure
		Analyte	AUC	Cmax
Lipid-lowering agents
Fenofibrate 160 mg1 once daily for 10 days	Atorvastatin, 20 mg once daily for 10 days	Atorvastatin	↓17%	0%
Fenofibrate 3 x 67 mg2 as a single dose	Pravastatin, 40 mg as a single dose	Pravastatin	↑13%	↑13%
		3a-Hydroxyl-iso- pravastatin	↑26%	↑29%
Fenofibrate 160 mg1 as a single dose	Fluvastatin, 40 mg as a single dose	(+)-3R, 5S-Fluvastatin	↑15%	↑16%
Anti-diabetic agents
Fenofibrate 145 mg1 once daily for 10 days	Glimepiride, 1 mg as a single dose	Glimepiride	↑35%	↑18%
Fenofibrate 54 mg1 three times daily for 10 days	Metformin, 850 mg three times daily for 10 days	Metformin	↑3%	↑6%
Fenofibrate 145 mg1 once daily for 14 days	Rosiglitazone, 8 mg once daily for 5 days	Rosiglitazone	↑6%	↓1%
1 TriCor (fenofibrate) oral tablet 2 TriCor (fenofibrate) oral micronized capsule

Clinical Studies

Overview Of Clinical Trials

The effectiveness of Triglide has been established in adults with hypertriglyceridemia or primary hyperlipidemia based on adequate and well-controlled trials of other formulations of fenofibrate, referenced below as “fenofibrate.” Dosages of fenofibrate used in these trials were comparable to Triglide 160 mg per day [see CLINICAL PHARMACOLOGY].

Clinical Trials In Adults With Hypertriglyceridemia

The effects of fenofibrate on serum triglycerides were studied in two randomized, double-blind, placebo-controlled clinical trials of 147 patients with hypertriglyceridemia. Patients were treated for eight weeks under protocols that differed only in that one entered patients with baseline triglyceride (TG) levels of 500 to 1500 mg/dL, and the other TG levels of 350 to 500 mg/dL. In patients with hypertriglyceridemia and normal cholesterolemia with or without hyperchylomicronemia, treatment with fenofibrate decreased primarily very low-density lipoprotein (VLDL) triglycerides and VLDL cholesterol. Treatment of patients with elevated triglycerides often results in an increase of low-density lipoprotein (LDL) cholesterol (see Table 5).

Table 5: Effects of Fenofibrate in Patients with Hypertriglyceridemia

Study 1			Macebo		Fenofibrate**
Baseline TG levels 350 to 499 mg/dL	N	Baseline (Mean)	Endpoint (Mean)	% Change (Mean)	N	Baseline (Mean)	Endpoint (Mean)	% Change (Mean)
Triglycerides	28	449	450	-0.5	27	432	223	-46.2*
VLDL Triglycerides	19	367	350	2.7	19	350	178	-44.1*
Total Cholesterol	28	255	261	2.8	27	252	227	-9.1*
HDL Cholesterol	28	35	36	4	27	34	40	19.6*
LDL Cholesterol	28	120	129	12	27	128	137	14.5
VLDL Cholesterol	27	99	99	5.8	27	92	46	-44.7*
Study 2			Placebo		Fenofibrate**
Baseline TG levels 500 to 1500 mg/dL	N	Baseline (Mean)	Endpoint (Mean)	% Change (Mean)	N	Baseline (Mean)	Endpoint (Mean)	% Change (Mean)
Triglycerides	44	710	750	7.2	48	726	308	-54.5*
Study 1	Placebo				Fenofibrate**
VLDL Triglycerides	29	537	571	18.7	33	543	205	-50.6*
Total Cholesterol	44	272	271	0.4	48	261	223	-13.8*
HDL Cholesterol	44	27	28	5	48	30	36	22.9*
LDL Cholesterol	42	100	90	-4.2	45	103	131	45*
VLDL Cholesterol	42	137	142	11	45	126	54	-49.4*
* =p<0.05 vs. placebo ** Dosage comparable to 160 mg Triglide

Clinical Trials In Adults With Primary Hyperlipidemia

The effects of fenofibrate were assessed in four randomized, placebo-controlled, double-blind, parallel-group trials in patients with hyperlipidemia and mixed dyslipidemia. Fenofibrate therapy reduced LDL-C, Total-C, and triglycerides, and increased HDL-C (see Table 6).

Table 6: Mean Percent Change in Lipid Parameters at End of Treatment*

Treatment Group	Total-C	LDL-C	HDL-C	TG
Mean baseline lipid values (n = 646)	306.9 mg/dL	213.8 mg/dL	52.3 mg/dL	191 mg/dL
All fenofibrate (n = 361)	-18.7%†	-20.6%†	+11%†	-28.9%†
Placebo (n = 285)	-0.4%	-2.2%	+0.7%	+7.7%
* Duration of study treatment was 3 to 6 months. † p=<0.05 vs. placebo

Lack Of Efficacy In Cardiovascular Outcomes Trials

Fenofibrate did not reduce cardiovascular disease morbidity or mortality in two large, randomized controlled trials of patients with type 2 diabetes mellitus.

The Action to Control Cardiovascular Risk in Diabetes Lipid (ACCORD Lipid) (NCT00000620) trial was a randomized placebo-controlled trial of 5,518 patients (2,765 assigned to receive fenofibrate) with type 2 diabetes mellitus on background statin therapy treated with fenofibrate. The mean age at baseline was 62 years and 31% were female. Overall, 68% were White, 15% were Black or African American; 7% identified as Hispanic or Latino. The mean duration of follow-up was 4.7 years. The primary outcome of major adverse cardiovascular events (MACE), a composite of non-fatal myocardial infarction, non-fatal stroke, and cardiovascular disease death was a HR of 0.92 (95% CI, 0.79 to 1.08) for fenofibrate plus statin combination therapy as compared to statin monotherapy.

The Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study was a 5-year randomized, placebo-controlled trial of 9,795 patients (4,895 assigned to receive fenofibrate) with type 2 diabetes mellitus treated with fenofibrate. The mean age at baseline was 62 years, 37% were female, and 93% were White. The primary outcome of coronary heart disease events was a HR of 0.89 (95% CI, 0.75 to 1.05) with fenofibrate compared to placebo. The HR for total and coronary heart disease mortality, respectively, was 1.11 (95% CI, 0.95 to 1.29) and 1.19 (95% CI, 0.90 to 1.57)with fenofibrate as compared to placebo.

Because of chemical, pharmacological, and clinical similarities between fenofibrate and pemafibrate, findings in a large randomized, placebo-controlled clinical trial with pemafibrate are relevant for Triglide.

Pemafibrate did not reduce cardiovascular disease morbidity or mortality in a large, randomized, placebo-controlled trial of patients with type 2 diabetes mellitus on background statin therapy (NCT03071692). The trial was a randomized placebo-controlled trial of 10,497 patients (5,240 assigned to receive pemafibrate) with type 2 diabetes mellitus on background lipid-lowering therapy. The median age at baseline was 64 years and 28% were female. Overall, 86% were White, 5% were Asian, 3% were Black or African American; 19% identified as Hispanic or Latino. The median duration of follow-up was 3.4 years. The primary outcome of major adverse cardiovascular events (MACE), a composite of non-fatal myocardial infarction, non-fatal ischemic stroke, coronary revascularization, and death from cardiovascular causes, was a HR of 1.03 (95% CI, 0.91 to 1.15) for pemafibrate plus statin combination therapy as compared to statin monotherapy.

Patient Information for Triglide

Hepatotoxicity

Inform patients that Triglide may cause liver enzyme elevations and possibly liver failure. Advise patients to promptly report fatigue, anorexia, right upper abdominal discomfort, dark urine or jaundice [see CONTRAINDICATIONS, WARNINGS AND PRECAUTIONS].

Myopathy And Rhabdomyolysis

Advise patients that Triglide may cause myopathy and rhabdomyolysis. Inform patients that the risk is also increased when taking certain types of medication and they should discuss all medication, both prescription and over the counter, with their healthcare provider. Instruct patients to inform other healthcare providers prescribing a new medication or increasing the dosage of an existing medication that they are taking Triglide. Instruct patients to promptly report any unexplained muscle pain, tenderness, or weakness particularly if accompanied by malaise or fever [see WARNINGS AND PRECAUTIONS and DRUG INTERACTIONS].

Hypersensitivity Reactions

Inform patients that serious hypersensitivity reactions, such as anaphylaxis and angioedema, have been reported with fibrates. Advise patients to report immediately any signs or symptoms suggesting allergic reaction, and to discontinue drug until they have consulted prescribing physicians [see WARNINGS AND PRECAUTIONS].

Pregnancy

Advise patients to inform their healthcare provider of a known or suspected pregnancy to discuss if Triglide should be discontinued [see Use In Specific Populations]. Lactation Advise patients that breastfeeding during treatment with Triglide is not recommended [see Use In Specific Populations].

Missed Doses

If a dose is missed, advise patients not take an extra dose and to resume treatment with the next dose.