Fiasp

Important Preparation and Administration Instructions

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Always check insulin label before administration [see Warnings and Precautions Adverse Reactions ].

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Train patients using continuous subcutaneous insulin infusion therapy to administer insulin by injection and have alternate insulin therapy available in case of insulin pump failure [see Warnings and Precautions ].

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Change FIASP in the pump reservoir at least every 6 days or replace the PumpCart cartridge at least every 4 days, or according to the pump user manual, whichever is shorter. Follow the FIASP-specific information for in-use time because FIASP-specific information may differ from general insulin pump user manual instructions.

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Change the infusion sets and the infusion set insertion site according to the manufacturers user manual.

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Do not mix with other insulins or diluents in the insulin pump.

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Do not expose FIASP in the pump reservoir to temperatures greater than 37°C (98.6°F).

Intravenous Administration:

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Administer FIASP intravenously only under medical supervision with close monitoring of blood glucose and potassium levels to avoid hypoglycemia and hypokalemia [see Warnings and Precautions ].

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Dilute FIASP to concentrations from 0.5 unit/mL to 1 unit/mL insulin aspart in infusion systems using polypropylene infusion bags.

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FIASP is stable at room temperature at 20°C to 25°C (68°F to 77°F) for 24 hours in 0.9% sodium chloride or 5% dextrose infusion fluids.

Dosage Recommendations

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Individualize the dosage of FIASP based on the route of administration, patient’s metabolic needs, blood glucose monitoring results, and glycemic control goal.

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If converting from another mealtime insulin to FIASP, the initial change can be done on a unit-to-unit basis.

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Dose adjustments may be needed when switching from another insulin, with changes in physical activity, changes in concomitant medications, changes in meal patterns (i.e., macronutrient content or timing of food intake), changes in renal or hepatic function or during acute illness to minimize the risk of hypoglycemia or hyperglycemia [see Warnings and Precautions and Drug Interactions , and Use in Specific Populations ].

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Closely monitor blood glucose when converting insulins used in insulin pumps as individualization of insulin pump parameters may be necessary to minimize the risk of hypoglycemia and hyperglycemia [see Warnings and Precautions and Adverse Reactions ]

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During changes to a patient’s insulin regimen, increase the frequency of blood glucose monitoring [see Warnings and Precautions ].

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Dosage adjustment may be needed when FIASP is co-administered with certain drugs [see Drug Interactions ].

Pregnancy

Risk Summary

There are no available data with FIASP in pregnant women to inform a drug-associated risk for major birth defects and miscarriage. Available information from published randomized controlled trials with insulin aspart use during the second trimester of pregnancy have not reported an association with insulin aspart and major birth defects or adverse maternal or fetal outcomes [see Data]. There are risks to the mother and fetus associated with poorly controlled diabetes in pregnancy [see Clinical Considerations].

In animal reproduction studies, administration of subcutaneous insulin aspart to pregnant rats and rabbits during the period of organogenesis did not cause adverse developmental effects at exposures 8- times and equal to the human subcutaneous dose of 1.0 unit/kg/day, respectively. Pre- and post-implantation losses and visceral/skeletal abnormalities were seen at higher exposures, which are considered secondary to maternal hypoglycemia. These effects were similar to those observed in rats administered regular human insulin [see Data].

The estimated background risk of major birth defects is 6-10% in women with pre-gestational diabetes with a HbA1c >7% and has been reported to be as high as 20-25% in women with a HbA1c >10%. The estimated background risk of miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.

Clinical Considerations

Disease-Associated Maternal and/or Embryo-Fetal Risk

Poorly controlled diabetes in pregnancy increases the maternal risk for diabetic ketoacidosis, preeclampsia, spontaneous abortions, preterm delivery, and delivery complications. Poorly controlled diabetes increases the fetal risk for major birth defects, stillbirth, and macrosomia related morbidity.

Data

Human Data

Published data from 5 randomized controlled trials of 441 pregnant women with diabetes mellitus treated with insulin aspart starting during the late 2nd trimester of pregnancy did not identify an association of insulin aspart with major birth defects or adverse maternal or fetal outcomes. However, these studies cannot definitely establish the absence of any risk because of methodological limitations, including a variable duration of treatment and small size of the majority of the trials.

Animal Data

Fertility, embryo-fetal and pre-and postnatal development studies have been performed with insulin aspart and regular human insulin in rats and rabbits. In a combined fertility and embryo-fetal development study in rats, insulin aspart was administered before mating, during mating, and throughout pregnancy. Further, in a pre- and postnatal development study insulin aspart was given throughout pregnancy and during lactation to rats. In an embryo-fetal development study insulin aspart was given to female rabbits during organogenesis. The effects of insulin aspart did not differ from those observed with subcutaneous regular human insulin. Insulin aspart, like human insulin, caused pre- and post-implantation losses and visceral/skeletal abnormalities in rats at a dose of 200 units/kg/day (approximately 32 times the human subcutaneous dose of 1.0 unit/kg/day, based on human exposure equivalents) and in rabbits at a dose of 10 units/kg/day (approximately three times the human subcutaneous dose of 1.0 unit/kg/day, based on human exposure equivalents). No significant effects were observed in rats at a dose of 50 units/kg/day and in rabbits at a dose of 3 units/kg/day. These doses are approximately 8 times the human subcutaneous dose of 1.0 unit/kg/day for rats and equal to the human subcutaneous dose of 1.0 unit/kg/day for rabbits, based on human exposure equivalents. The effects are considered secondary to maternal hypoglycemia.

Lactation

Risk Summary

There are no data on the presence of FIASP in human milk, the effects on the breastfed infant, or the effect on milk production. One small published study reported that exogenous insulin, including insulin aspart, was present in human milk. However, there is insufficient information to determine the effects of insulin aspart on the breastfed infant and no available information on the effects of insulin aspart on milk production. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for insulin, any potential adverse effects on the breastfed child from FIASP or insulin aspart or from the underlying maternal condition.

Pediatric Use

The safety and effectiveness of FIASP have been established to improve glycemic control in pediatric patients with diabetes mellitus. Use of FIASP for this indication is supported by evidence from an adequate and well-controlled study in 777 pediatric patients with type 1 diabetes mellitus aged 2 to 17 years, and from studies in adults with diabetes mellitus [see Clinical Pharmacology and Clinical Studies ].

Pediatric patients with type 1 diabetes mellitus treated with mealtime and postmeal FIASP reported a higher rate of blood glucose confirmed hypoglycemic episodes compared to patients treated with NovoLog; the imbalance was greater during the nocturnal period. Monitor blood glucose levels closely in pediatric patients [see Warnings and Precautions , Clinical Trial Experience ].

Geriatric Use

In the three controlled clinical studies, 192 of 1219 (16%) FIASP treated patients with type 1 or type 2 diabetes mellitus were ≥ 65 years of age and 24 of 1219 (2%) were ≥ 75 years of age. No overall differences in safety or effectiveness were observed between these elderly patients and younger adult patients.

Nevertheless, caution should be exercised when FIASP is administered to geriatric patients. In elderly patients with diabetes, the initial dosing, dose increments, and maintenance dosage should be conservative to avoid hypoglycemia [see Warnings and Precautions , Adverse Reactions and Clinical Studies ].

Pharmacokinetic/pharmacodynamic study to assess the effect of age on the onset of FIASP action has been performed [see Clinical Pharmacology ].

Renal Impairment

Patients with renal impairment may be at increased risk of hypoglycemia and may require more frequent FIASP dose adjustment and more frequent blood glucose monitoring [see Warnings and Precautions and Clinical Pharmacology ].

Hepatic Impairment

Patients with hepatic impairment may be at increased risk of hypoglycemia and may require more frequent FIASP dose adjustment and more frequent blood glucose monitoring [see Warnings and Precautions and Clinical Pharmacology ].

Never Share a FIASP FlexTouch Pen, PenFill Cartridge or PenFill Cartridge Device Between Patients

FIASP FlexTouch disposable pen, PenFill cartridge and PenFill cartridge devices should never be shared between patients, even if the needle is changed. Patients using FIASP vials should never share needles or syringes with another person. Sharing poses a risk for transmission of blood-borne pathogens.

Hyperglycemia or Hypoglycemia with Changes in Insulin Regimen

Changes in an insulin regimen (e.g., insulin strength, manufacturer, type, injection site or method of administration) may affect glycemic control and predispose to hypoglycemia [see Warnings and Precautions ] or hyperglycemia. Repeated insulin injections into areas of lipodystrophy or localized cutaneous amyloidosis have been reported to result in hyperglycemia; and a sudden change in the injection site (to an unaffected area) has been reported to result in hypoglycemia [see Adverse Reactions ]. Severe hypoglycemia can cause seizures, may lead to unconsciousness, may be life-threatening, or cause death. Hypoglycemia can impair concentration ability and reaction time; this may place an individual and others at risk in situations where these abilities are important (e.g., driving or operating other machinery). FIASP, or any insulin, should not be used during episodes of hypoglycemia [see Contraindications ].

Hypoglycemia can happen suddenly and symptoms may differ in each individual and change over time in the same individual. Symptomatic awareness of hypoglycemia may be less pronounced in patients with longstanding diabetes, in patients with diabetic nerve disease, in patients using medications that block the sympathetic nervous system (e.g., beta-blockers) [see Drug Interactions ], or in patients who experience recurrent hypoglycemia.

Risk Factors for Hypoglycemia

The risk of hypoglycemia after an injection is related to the duration of action of the insulin and, in general, is highest when the glucose lowering effect of the insulin is maximal. The timing of hypoglycemia usually reflects the time-action profile of the administered insulin formulation. As with all insulin preparations, the glucose lowering effect time course of FIASP may vary in different individuals or at different times in the same individual and depends on many conditions, including the area of injection as well as the injection site blood supply and temperature [see Use in Specific Populations , Clinical Pharmacology ].

Other factors which may increase the risk of hypoglycemia include changes in meal pattern (e.g., macronutrient content or timing of meals), changes in level of physical activity, or changes to co-administered medication [see Drug Interactions ]. Patients with renal or hepatic impairment may be at higher risk of hypoglycemia [see Use in Specific Populations ].

Risk Mitigation Strategies for Hypoglycemia

Patients and caregivers must be educated to recognize and manage hypoglycemia. Self-monitoring of blood glucose plays an essential role in the prevention and management of hypoglycemia. In patients at higher risk for hypoglycemia and patients who have reduced symptomatic awareness of hypoglycemia, increased frequency of blood glucose monitoring is recommended.

Hypoglycemia Due to Medication Errors

Accidental mix-ups between insulin products have been reported. To avoid medication errors between FIASP and other insulins, instruct patients to always check the insulin label before each injection.

Hypokalemia

All insulin products, including FIASP, can cause a shift in potassium from the extracellular to intracellular space, possibly leading to hypokalemia. Untreated hypokalemia may cause respiratory paralysis, ventricular arrhythmia and death. Monitor potassium levels in patients at risk for hypokalemia if indicated (e.g., patients using potassium-lowering medications, patients taking medications sensitive to potassium concentrations).

Hypersensitivity and Allergic Reactions

Severe, life-threatening, generalized allergy, including anaphylaxis, can occur with insulin products, including FIASP [see Adverse Reactions ]. If hypersensitivity reactions occur, discontinue FIASP; treat per standard of care and monitor until symptoms and signs resolve. FIASP is contraindicated in patients who have had hypersensitivity reactions to insulin aspart, or any of the excipients in FIASP [see Contraindications ].

Fluid Retention and Heart Failure with Concomitant Use of PPAR-Gamma Agonists

Thiazolidinediones (TZDs), which are peroxisome proliferator-activated receptor (PPAR)-gamma agonists, can cause dose-related fluid retention, particularly when used in combination with insulin. Fluid retention may lead to or exacerbate heart failure. Patients treated with insulin, including FIASP, and a PPAR-gamma agonist should be observed for signs and symptoms of heart failure. If heart failure develops, it should be managed according to current standards of care, and discontinuation or dose reduction of the PPAR-gamma agonist must be considered.

 Hyperglycemia and Ketoacidosis Due to Insulin Pump Device Malfunction

Pump or infusion set malfunctions can lead to a rapid onset of hyperglycemia and ketoacidosis. Prompt identification and correction of the cause of hyperglycemia or ketosis is necessary. Interim therapy with subcutaneous injection of FIASP may be required. Patients using continuous subcutaneous insulin infusion pump therapy must be trained to administer insulin by injection and have alternate insulin therapy available in case of pump failure [see Dosage and Administration , How Supplied/Storage and Handling , and Patient Counseling Information ].

Clinical Trial Experience

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

The data in Table 1 reflect the exposure of 763 adult patients with type 1 diabetes mellitus to FIASP in one clinical trial with a mean exposure duration of 25 weeks [see Clinical Studies ( 14.2)]. The mean age was 44.4 years and the mean duration of diabetes was 19.9 years. 59% were male, 93% were White, and 2% were Black or African American; and 7% were Hispanic or Latino. The mean BMI was 26.7 kg/m2 and the mean HbA1c at baseline was 7.6%.

The data in Table 2 reflect the exposure of 341 adult patients with type 2 diabetes mellitus to FIASP in one clinical trial with a mean exposure duration of 24 weeks [see Clinical Studies ]. The mean age was 59.6 years and the mean duration of diabetes was 13.2 years. 47% were male, 80% were White, and 6% were Black or African American; and 8% were Hispanic or Latino. The mean BMI was 31.5 kg/m2 and the mean HbA1c at baseline was 8.0%.

The data in Table 3 reflect the exposure of 519 pediatric patients with type 1 diabetes mellitus to FIASP in one clinical trial with a mean exposure duration of 26 weeks [see Clinical Studies ]. The mean age was 11.7 years and the mean duration of diabetes mellitus was 4.4 years. 54% were male, 81% were White, 16% were Asian and 2% were Black or African American. The mean BMI was 19.7 kg/m2 and the mean HbA1c at baseline was 7.6%.

Common adverse reactions, excluding hypoglycemia, were defined as events occurring in ≥5% and occurring at the same rate or greater for FIASP-treated patients than comparator-treated patients.

Table 1. Adverse Reactions (%*) in Adult Patients with Type 1 Diabetes Mellitus

*Incidence ≥ 5% and occurring at the same rate or greater with FIASP than comparator

Table 2. Adverse Reactions (%*) in Adult Patients with Type 2 Diabetes Mellitus

*Incidence ≥ 5% and occurring at the same rate or greater with FIASP than comparator

Table 3: Adverse Reactions (%*) in Pediatric Patients with Type 1 Diabetes Mellitus

*Incidence ≥ 5% and occurring at the same rate or greater with FIASP than comparator

Hypoglycemia

Hypoglycemia is the most commonly observed adverse reaction in patients using insulin, including FIASP. The rates of reported hypoglycemia depend on the definition of hypoglycemia used, diabetes type, insulin dose, intensity of glucose control, background therapies, and other intrinsic and extrinsic patient factors. For these reasons, comparing rates of hypoglycemia in clinical trials for FIASP with the incidence of hypoglycemia for other products may be misleading and also, may not be representative of hypoglycemia rates that occur in clinical practice.

Incidence rates for severe hypoglycemia in adults with type 1 and type 2 diabetes mellitus and pediatric patients with type 1 diabetes mellitus treated with FIASP in clinical trials are shown in Table 4 [see Clinical Studies ].

Table 4. Proportion (%) of Patients with Type 1 Diabetes and Type 2 Diabetes Mellitus Experiencing at Least One Episode of Severe Hypoglycemia in Adult and Pediatric Clinical Trials

 

*Severe hypoglycemia: an episode requiring assistance of another person to actively administer carbohydrate, glucagon, or other resuscitative actions

Blood glucose confirmed hypoglycemia was defined as a self-measured glucose calibrated to plasma of less than 56 mg/dL.

In Study D, adult patients with type 1 diabetes mellitus treated with FIASP in a pump reported a higher rate of blood glucose confirmed hypoglycemic episodes within the first hour after a meal compared to patients treated with NovoLog [see Clinical Trials ( 14.5)].

In Study E, pediatric patients with type 1 diabetes mellitus treated with mealtime and postmeal FIASP reported a higher rate of blood glucose confirmed hypoglycemic episodes compared to patients treated with NovoLog; the imbalance was greater during the nocturnal period [see Use in Specific Populations , Clinical Trials ].

Allergic Reactions

Severe, life-threatening, generalized allergy, including anaphylaxis, generalized skin reactions, angioedema, bronchospasm, hypotension, and shock may occur with any insulin, including FIASP, and may be life threatening. In the clinical program, generalized hypersensitivity reactions (manifested by generalized skin rash and facial edema) were reported in 0.4% of adult patients treated with FIASP. Allergic skin manifestations reported with FIASP in 1.7% of adult patients from the clinical program include eczema, rash, rash pruritic, urticaria and dermatitis. In Study D, allergic reactions were reported in 4.2% of adult patients with type 1 diabetes mellitus treated with FIASP. In Study E, allergic reactions were reported in 4% of pediatric patients with type 1 diabetes mellitus treated with FIASP.

Lipodystrophy

Administration of insulin, including FIASP, has resulted in lipohypertrophy (enlargement or thickening of tissue) and lipoatrophy (depression in the skin). In the clinical program, lipodystrophy was reported in 0.4% of adult patients and 2.1% of pediatric patients treated with FIASP [see Dosage and Administration ].

Injection/Infusion Site Reactions

As with other insulin therapy, patients may experience rash, redness, inflammation, pain, bruising or itching at the site of FIASP injection or infusion. These reactions usually resolve in a few days to a few weeks, but in some occasions, may require discontinuation of FIASP. In the clinical program, injection site reactions occurred in 1.6% of adult patients treated with FIASP. In Study A, adult patients with type 1 diabetes mellitus treated with FIASP reported 2.2% injection site reactions. In Study D, infusion site reactions were reported in 10.2% of adult patients with type 1 diabetes mellitus treated with FIASP. In Study E, injection site reactions were reported in 4.2% of pediatric patients with type 1 diabetes mellitus treated with FIASP.

Weight Gain

Weight gain can occur with insulin therapy, including FIASP, and has been attributed to the anabolic effects of insulin and the decrease in glucosuria. In Study A, adult patients with type 1 diabetes mellitus treated with FIASP gained an average of 0.7 kg and in Study B, adult patients with type 2 diabetes mellitus treated with FIASP gained an average of 2.7 kg.

Peripheral Edema

Insulin, including FIASP, may cause sodium retention and edema, particularly if previous poor metabolic control is improved by intensified insulin therapy. In the clinical program, peripheral edema occurred in 0.8% of adult patients treated with FIASP.

Postmarketing Experience

The following additional adverse reactions have been identified during post-approval use of insulin aspart. 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.

Localized cutaneous amyloidosis at the injection site has occurred. Hyperglycemia has been reported with repeated insulin injections into areas of localized cutaneous amyloidosis; hypoglycemia has been reported with a sudden change to an unaffected injection site.

Mechanism of Action

The primary activity of FIASP is the regulation of glucose metabolism. Insulins, including insulin aspart, the active ingredient in FIASP, exert their specific action through binding to insulin receptors. Receptor-bound insulin lowers blood glucose by facilitating cellular uptake of glucose into skeletal muscle and adipose tissue and by inhibiting the output of glucose from the liver. Insulin inhibits lipolysis in the adipocyte, inhibits proteolysis, and enhances protein synthesis.

Pharmacodynamics

The time course of insulin action (i.e., glucose lowering) may vary considerably in different individuals or within the same individual. The average pharmacodynamic profile (i.e., glucose lowering effect measured as glucose infusion rate (GIR) in a euglycemic clamp study) for subcutaneous administration of 0.1, 0.2, and 0.4 unit/kg of FIASP in 46 patients with Type 1 diabetes mellitus is shown in Figure 2 and key characteristics of the timing of the effect are described in Table 6 below.

Table 6. Timing of insulin effect (i.e., mean pharmacodynamic effect) after subcutaneous administration of 0.1, 0.2 and 0.4 unit/kg of FIASP in patients (N=46) with Type 1 Diabetes Mellitus and corresponding to the data shown in Figure 2

Figure 2. Mean insulin effect (i.e., mean pharmacodynamic effect) over time after subcutaneous administration of 0.1, 0.2 and 0.4 unit/kg of FIASP in patients (N=46) with Type 1 Diabetes Mellitus

On average, the pharmacodynamic effects of FIASP, measured as area under the glucose infusion rate-time curve (AUCGIR), was 697 mg/kg, 1406 mg/kg, and 2427 mg/kg following administration of 0.1, 0.2, and 0.4 unit/kg of FIASP.

The day-to-day variability in glucose-lowering-effect of FIASP within patients was ~18% for total glucose lowering (AUCGIR, 0-12h) and ~19% for maximum glucose lowering effect (GIRmax).

Pharmacokinetics

Absorption

Pharmacokinetic results from a euglycemic clamp study in adult patients with type 1 diabetes mellitus (N=51) showed that insulin aspart appeared in the circulation ~2.5 minutes after administration of FIASP (Figure 3). Time to maximum insulin concentrations was achieved ~63 minutes after administration of FIASP.

Figure 3. Mean Insulin Aspart Serum Concentration Profile in Adult Subjects with Type 1 Diabetes Mellitus (N=51) following a single 0.2 unit/kg dose (subcutaneous) of FIASP

Total insulin exposure and maximum insulin concentration increase proportionally with increasing subcutaneous dose of FIASP within the therapeutic dose range.

Distribution

Insulin aspart has a low binding affinity to plasma proteins (<10%), similar to that seen with regular human insulin.

Elimination

The apparent terminal half-life after subcutaneous administration of FIASP is about 1.1 hours.

Specific Populations

Age, gender, BMI, and race did not meaningfully affect the pharmacokinetics and pharmacodynamics of FIASP.

Patients with Renal and Hepatic Impairment

Based on studies conducted with insulin aspart, renal and hepatic impairment is not known to impact the pharmacokinetics of insulin aspart.

Immunogenicity

The observed incidence of anti-drug antibodies is highly dependent on the sensitivity and specificity of the assay. Differences in assay methods preclude meaningful comparisons of the incidence of anti-drug antibodies in the studies described below with the incidence of anti-drug antibodies in other studies, including those of FIASP or of other insulin aspart products.

In a 26-week study in adult subjects with type 1 diabetes mellitus (Study A) [see Clinical Studies ( 14.2)], among the 763 subjects who received FIASP, 97% were positive for cross-reacting anti-insulin antibodies (AIA) at least once during the study, including 90% that were positive at baseline. A total of 25% of patients who received FIASP were positive for anti-drug (insulin aspart) antibodies (ADA) at least once during the study, including 17% that were positive at baseline.

In a 26-week study in pediatric subjects with type 1 diabetes mellitus (Study E) [see Clinical Studies ( 14.3)], among the 519 subjects who received FIASP, 97% were positive for cross-reacting AIA at least once during the study, including 95% that were positive at baseline. A total of 19% of patients who received FIASP were positive for ADA at least once during the study, including 16.0% that were positive at baseline.

There was no identified clinically significant effect of ADA on pharmacokinetics, pharmacodynamics, safety, or effectiveness of FIASP.

Carcinogenesis, Mutagenesis, Impairment of Fertility

In 52-week studies, Sprague-Dawley rats were dosed subcutaneously with insulin aspart at 10, 50, and 200 units/kg/day (approximately 2, 8, and 32 times the human subcutaneous dose of 1.0 units/kg/day, based on units/body surface area, respectively). At a dose of 200 units/kg/day, insulin aspart increased the incidence of mammary gland tumors in females when compared to untreated controls. The incidence of mammary tumors for insulin aspart was not significantly different than for regular human insulin. The relevance of these findings to humans is not known.

Insulin aspart was not genotoxic in the following tests: Ames test, mouse lymphoma cell forward gene mutation test, human peripheral blood lymphocyte chromosome aberration test, in vivo micronucleus test in mice, and in ex vivo UDS test in rat liver hepatocytes.

In fertility studies in male and female rats, at subcutaneous doses up to 200 units/kg/day (approximately 32 times the human subcutaneous dose, based on units/body surface area), no direct adverse effects on male and female fertility, or general reproductive performance of animals was observed.

Overview of Clinical Studies

The efficacy of FIASP was evaluated in 3 randomized, active-controlled trials of 18 to 26 weeks duration in adults and one randomized, active-controlled, treat-to-target trial of 26 weeks duration in pediatric patients.

In total 1,224 adult subjects (N=763 with type 1 diabetes mellitus; N=461 with type 2 diabetes mellitus) and 519 pediatric subjects with type 1 diabetes mellitus were randomized to FIASP. In adult and pediatric patients with type 1 diabetes mellitus, mealtime FIASP and postmeal FIASP led to non-inferior glycemic control compared to mealtime NovoLog, both in combination with basal insulin. In adult patients with type 2 diabetes mellitus, mealtime FIASP provided non-inferior glycemic control compared to mealtime NovoLog, both in combination with metformin. In addition, mealtime FIASP in a basal-bolus regimen with metformin also provided statistically significant improvement in the overall glycemic control compared to basal insulin therapy alone with metformin in adult patients with type 2 diabetes mellitus.

In adults with type 1 diabetes mellitus (N=472), FIASP led to non-inferior glycemic control compared to NovoLog when both were administered by continuous subcutaneous insulin infusion (CSII) pump.

Type 1 Diabetes Mellitus - Adults

Study A (NCT01831765): FIASP added to insulin detemir in adult patients with Type 1 Diabetes Mellitus inadequately controlled at baseline.

The efficacy of FIASP was evaluated in a 26-week, randomized, active controlled, treat-to-target, multicenter trial in 1,143 adult patients with type 1 diabetes mellitus inadequately controlled at baseline. Patients were randomized to either blinded mealtime FIASP (N=381), blinded mealtime NovoLog (N=380), or open-label postmeal FIASP (N=382), all in combination with once or twice daily insulin detemir. At randomization, patients were switched to FIASP on a unit to unit basis. Mealtime FIASP or NovoLog was injected 0-2 minutes before the meal, and postmeal FIASP was injected 20 minutes after the start of the meal.

The mean age of the randomized subjects was 44.4 years and mean duration of diabetes was 19.9 years. 59% were male, 93% were White and 2% were Black or African American; and 7% were Hispanic or Latino. The mean BMI was 26.7 kg/m2.

After 26 weeks of treatment, treatment difference in HbA1c reduction from baseline between mealtime FIASP compared to mealtime NovoLog, and the treatment difference between postmeal FIASP compared to mealtime NovoLog met the pre-specified non-inferiority margin (0.4%). See Table 7. Insulin doses were similar among study arms at baseline and at the end of the trial.

Table 7. Results from Study A: 26-Week Trial of Mealtime FIASP and Postmeal FIASP compared to Mealtime NovoLog Used in Combination with Insulin Detemir in Adults with Type 1 Diabetes Mellitus

Baseline is based on the mean of the observed last available values prior to randomization.

*Tested for non-inferiority

Estimated treatment difference was calculated using mixed model for repeated measurements (MMRM). 

7.6% of subjects on the Mealtime FIASP arm, 7.6% of subjects on the Postmeal FIASP arm, and 5.3% of subjects on the Mealtime NovoLog arm were missing the final HbA1c assessment.

Type 1 Diabetes Mellitus - Pediatric Patients

Study E (NCT02670915): FIASP added to insulin degludec in pediatric patients with Type 1 Diabetes Mellitus.

The efficacy of FIASP was evaluated in a 26-week, randomised, multinational, active controlled, treat-to-target, 3-armed parallel-group trial in 777 pediatric patients with type 1 diabetes mellitus. Patients were randomized to either blinded mealtime FIASP (N=260), blinded mealtime NovoLog (N=258), or open-label postmeal FIASP (N=259), all in combination with once daily insulin degludec. Mealtime FIASP or NovoLog was injected 0-2 minutes before the meal, and postmeal FIASP was injected 20 minutes after the start of the meal.

The mean age of the subjects at baseline was 11.7 years (range 2 to 17 years) and the mean duration of diabetes was 4.4 years. 54% were male, 81% were White, 16% were Asian and 2% were Black or African American. The mean BMI was 19.7 kg/m2.

After 26 weeks of treatment, the treatment difference for change in HbA1c from baseline between mealtime FIASP compared to mealtime NovoLog, and the treatment difference between postmeal FIASP compared to mealtime NovoLog met the pre-specified non-inferiority margin (0.4%). See Table 8. Insulin doses were similar among study arms at baseline and at the end of the trial.

Table 8. Results from Study E: 26-Week Trial of Mealtime FIASP and Postmeal FIASP compared to Mealtime NovoLog Used in Combination with Insulin Degludec in Pediatrics with Type 1 Diabetes Mellitus

Baseline is based on the mean of the observed last available values prior to randomization.

*Tested for non-inferiority

Estimated treatment difference was calculated using ANCOVA.  Week 26, change in HbA1c was missing for 1.5%, 1.9%, and 1.6% of subjects in mealtime FIASP, post-meal FIASP, and NovoLog respectively. Missing values were imputed with a missing at random assumption.

Type 2 Diabetes Mellitus - Adults

Study B (NCT01819129): FIASP added to basal insulin and oral antidiabetics in patients with Type 2 Diabetes Mellitus inadequately controlled at baseline on basal insulin and oral antidiabetics

The efficacy of FIASP was evaluated in a 26-week randomized, double-blind, active controlled, treat-to-target, multicenter, multinational, parallel group trial in 689 adult patients with type 2 diabetes mellitus who were inadequately controlled at baseline on basal insulin and oral antidiabetic therapy and had been on these therapies for at least 6 months. Patients were randomized to either mealtime FIASP or to mealtime NovoLog, both in combination with insulin glargine and metformin in a basal-bolus regimen. Mealtime FIASP or mealtime NovoLog was injected 0-2 minutes before the meal.

The mean age of the randomized subjects was 59.5 years and the mean duration of diabetes was 12.7 years. 49% were male, 81% were White, and 6% were Black or African American; and 6% were Hispanic or Latino. The mean BMI was 31.2 kg/m2.

After 26 weeks of treatment, the treatment difference in HbA1c reduction from baseline between mealtime FIASP and mealtime NovoLog, both in combination with insulin glargine and metformin, met the pre-specified non-inferiority margin (0.4%). See Table 9. Insulin doses were similar among study arms at the end of the trial.

Table 9. Results from Study B: 26-Week Trial of Mealtime FIASP Compared to Mealtime NovoLog, Both used in Combination with Insulin Glargine and Metformin, in Adults with Type 2 Diabetes Mellitus

Baseline is based on the mean of the observed last available values prior to randomization.

*Tested for non-inferiority

Estimated treatment difference was calculated using mixed model for repeated measurements (MMRM). 

11.9% of subjects on the Mealtime FIASP arm and 10.2% of subjects on the Mealtime NovoLog arm were missing the final HbA1c assessment.

Study C (NCT01850615): FIASP added to basal insulin and metformin in patients with Type 2 Diabetes Mellitus inadequately controlled at baseline on basal insulin and metformin

The efficacy of FIASP was evaluated in an 18-week randomized, open-label, parallel group trial in 236 adult patients with type 2 diabetes mellitus who were inadequately controlled on basal insulin and metformin therapy, either with or without other oral antidiabetic therapy, for at least 3 months. Patients were randomized to either mealtime FIASP in addition to basal insulin and metformin or to continuing basal insulin and metformin therapy without FIASP. The basal insulins used in both treatment arms were insulin glargine, insulin detemir or NPH. All patients were also required to be on ≥1000 mg metformin treatment at baseline.

The mean age of the trial population was 57.4 years and the mean duration of diabetes was 11years. 48% were male, 70% were White and 4% were Black or African American; and 37% were Hispanic or Latino. The mean BMI was 30.8 kg/m2.

After 18 weeks of treatment, addition of FIASP to basal insulin and metformin statistically significantly reduced HbA1c compared to continuing basal insulin and metformin therapy without addition of FIASP (Table 10).

Table 10. Results from Study C: 18-Week Trial of Mealtime FIASP in Adults with Type 2 Diabetes Mellitus Inadequately Controlled at Baseline on Basal Insulin and Metformin

Baseline is based on the mean of the observed last available values prior to randomization.

*p<0.0001, 1-sided p-value evaluated at 2.5% level for superiority.

Estimated treatment difference was calculated using mixed model for repeated measurements (MMRM).

6.0% of subjects on the mealtime FIASP arm and 3.3% of subjects on the placebo arm were missing the final HbA1c assessment.

Type 1 Diabetes Mellitus– Adult Continuous Subcutaneous Insulin Infusion (CSII)

Study D (NCT02825251): FIASP in Continuous Subcutaneous Insulin Infusion (CSII) in Adults with Type 1 Diabetes Mellitus

The efficacy and safety of FIASP vs. NovoLog in CSII in adult subjects with type 1 diabetes mellitus (N=472) was evaluated in a randomized, multicenter, multinational, active controlled, treat-to-target, parallel group trial with a 4-week run-in and a 16-week treatment period. Meal-time bolus insulin infusion was initiated 0-2 minutes before a meal.

The mean age of the randomized subjects was 43 years and the mean duration of diabetes was 24 years. 43% were male. 89% were White, 1% were Black or African American, and 1% were Asian; and 3% were Hispanic or Latino. The mean BMI was 26.3 kg/m2.

After 16 weeks of treatment, the treatment difference in HbA1c reduction from baseline between FIASP and NovoLog was 0.10 with 95%CI [0.02, 0.18] (Table 11).

Table 11. Results from Study D: 16-Week Trial FIASP in Adults with Type 1 Diabetes

Baseline is based on the mean of the observed last available values prior to randomization.

*Tested for non-inferiority using a margin of 0.4%.

Estimated treatment difference was calculated using ANCOVA.

2.1% of subjects on the FIASP arm and 2.5% of subjects on the NovoLog arm were missing the final HbA1c assessment. Missing values were imputed using multiple imputation with a mean equal to the baseline value of the corresponding patient.

How Supplied

FIASP (insulin aspart) injection 100 units of insulin aspart per mL (U-100) is available as a clear and colorless solution in the following presentations and packaging configurations:

 

Carton of one 10 mL multiple-dose vials NDC 0169-3201-11

 

Carton of five 3 mL single-patient-use FIASP FlexTouch pens NDC 0169-3204-15

 

Carton of five 3 mL single-patient-use PenFill cartridges* NDC 0169-3205-15

 

Carton of five 1.6 mL single-patient-use PumpCart cartridges** NDC 0169-3206-15

 

The FIASP FlexTouch pen dials in 1 unit increments.

 

* FIASP PenFill cartridges are designed for use with Novo Nordisk insulin delivery devices.

 

** FIASP PumpCart cartridges are designed for use in compatible pumps only.

Recommended Storage

Dispense in the original sealed carton with the enclosed Instructions for Use.

Unused FIASP vials should be stored between 2° to 8°C (36° to 46°F) in a refrigerator, but not in or near a freezing compartment. FIASP should not be exposed to excessive heat or light and must never be frozen. Do not use FIASP if it has been frozen. FIASP should not be drawn into a syringe and stored for later use.

Keep the cap on the pen in order to protect from light. Remove the needle from the FIASP FlexTouch pen after each injection and store without a needle attached. Use a new needle for each injection. Keep unused vials, FIASP FlexTouch, PenFill Cartridges and PumpCart cartridges in the carton so they will stay clean and protected from light.

The storage conditions for vials, FIASP FlexTouch pens, 3 mL PenFill cartridges and 1.6 mL PumpCart cartridges are summarized in Table 12:

Table 12. Storage Conditions for Vial, FIASP FlexTouch, PenFill Cartridges

and PumpCart Cartridges

*Pump Reservoir: The total in use time is 28 days, including 6 days in the pump reservoir

**PumpCart Cartridges: The maximum time at room temperature is 18 days including 4 days in the pump

Storage of FIASP in Insulin Pump:

•

Change FIASP in the pump reservoir at least every 6 days or according to the pump user manual, whichever is shorter.

•

Replace the FIASP PumpCart cartridge at least every 4 days or according to the pump user manual, whichever is shorter.

•

Change FIASP to avoid insulin degradation or after exposure to temperatures that exceed 37°C (98.6°F).

•

The infusion set and infusion set insertion sites should be changed according to the manufacturers’ user manual.

Storage of FIASP in Intravenous Infusion Fluids:
Infusion bags prepared as indicated under Dosage and Administration are stable at room temperature at 20°C to 25°C (68°F to 77°F) for 24 hours.