ORLISTAT - Xenical 120 mg Capsules | Fat Shredder

XENICAL® (orlistat) Capsules

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84 Capsules

Weight Management Formula

Orlistat is a weight loss medication that works by blocking the absorption of dietary fat in the intestines. It inhibits the enzyme lipase, which is responsible for breaking down fat. About 30% of the fat you eat is prevented from being absorbed and is instead eliminated in the stool.
Brand names include Xenical (prescription, 120 mg) and Alli (over-the-counter, 60 mg). It is intended for adults with a body mass index (BMI) of 30 or higher, or 27 or higher if other weight-related health conditions (like diabetes or high blood pressure) are present.
Orlistat should be taken up to three times a day, with each fat-containing meal or within one hour after eating. If you skip a meal or eat a fat-free meal, you can skip the dose.
Common side effects are gastrointestinal, such as oily or fatty stools, frequent or urgent bowel movements, flatulence with discharge, and abdominal discomfort. These effects are more likely when your diet is high in fat. To reduce side effects, limit your fat intake to about 15 grams per meal.
Because Orlistat reduces the absorption of fat-soluble vitamins (A, D, E, and K), a multivitamin supplement is recommended daily, taken at least 2 hours before or after an Orlistat dose.
Orlistat is not suitable for people with chronic malabsorption syndromes, cholestasis, or for use during pregnancy.

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DESCRIPTION

XENICAL (orlistat) is a lipase inhibitor for obesity management that acts by inhibiting the absorption of dietary fats. Orlistat is (S)-2-formylamino-4-methyl-pentanoic acid (S)-1-[[(2S, 3S)-3-hexyl-4-oxo-2 oxetanyl] methyl]-dodecyl ester. Its empirical formula is C29H53NO5, and its molecular weight is 495.7. It is a single diastereomeric molecule that contains four chiral centers, with a negative optical rotation in ethanol at 529 nm.

Orlistat is a white to off-white crystalline powder. Orlistat is practically insoluble in water, freely soluble in chloroform, and very soluble in methanol and ethanol. Orlistat has no pKa within the physiological pH range. XENICAL is available for oral administration in dark-blue, hard-gelatin capsules, with light-blue imprinting. Each capsule contains 120 mg of the active ingredient, orlistat.

The capsules also contain the inactive ingredients microcrystalline cellulose, sodium starch glycolate, sodium lauryl sulfate, povidone, and talc. Each capsule shell contains gelatin, titanium dioxide, and FD&C Blue No. 1, with printing of pharmaceutical glaze NF, titanium dioxide, and FD&C Blue No. 1 aluminum lake.

CLINICAL PHARMACOLOGY

Mechanism of Action

Orlistat is a reversible inhibitor of lipases. It exerts its therapeutic activity in the lumen of the stomach and small intestine by forming a covalent bond with the active serine residue site of gastric and pancreatic lipases. The inactivated enzymes are thus unavailable to hydrolyze dietary fat in the form of triglycerides into absorbable free fatty acids and monoglycerides.

As undigested triglycerides are not absorbed, the resulting caloric deficit may have a positive effect on weight control. Systemic absorption of the drug is therefore not needed for activity. At the recommended therapeutic dose of 120 mg three times a day, orlistat inhibits dietary fat absorption by approximately 30%.

Pharmacokinetics

Absorption Systemic exposure to orlistat is minimal. Following oral dosing with 360 mg 14C-orlistat, plasma radioactivity peaked at approximately 8 hours; plasma concentrations of intact orlistat were near the limits of detection (<5 ng/mL). In therapeutic studies involving monitoring of plasma samples, detection of intact orlistat in plasma was sporadic and concentrations were low (<10 ng/mL or 0.02 μM), without evidence of accumulation, and consistent with minimal absorption.

The average absolute bioavailability of intact orlistat was assessed in studies with male rats at oral doses of 150 and 1000 mg/kg/day and in male dogs at oral doses of 100 and 1000 mg/kg/day and found to be 0.12%, 0.59% in rats and 0.7%, 1.9% in dogs, respectively.

Distribution In vitro orlistat was >99% bound to plasma proteins (lipoproteins and albumin were major binding proteins). Orlistat minimally partitioned into erythrocytes. Metabolism Based on animal data, it is likely that the metabolism of orlistat occurs mainly within the gastrointestinal wall. Based on an oral 14C-orlistat mass balance study in obese patients, two metabolites, M1 (4-member lactone ring hydrolyzed) and M3 (M1 with N-formyl leucine moiety cleaved), accounted for approximately 42% of total radioactivity in plasma.

M1 and M3 have an open β-lactone ring and extremely weak lipase inhibitory activity (1000- and 2500-fold less than orlistat, respectively). In view of this low inhibitory activity and the low plasma levels at the therapeutic dose (average of 26 ng/mL and 108 ng/mL for M1 and M3, respectively, 2 to 4 hours after a dose), these metabolites are considered pharmacologically inconsequential.

The primary metabolite M1 had a short half-life (approximately 3 hours) whereas the secondary metabolite M3 disappeared at a slower rate (half-life approximately 13.5 hours). In obese patients, steady-state plasma levels of M1, but not M3, increased in proportion to orlistat doses.

Elimination Following a single oral dose of 360 mg 14C-orlistat in both normal weight and obese subjects, fecal excretion of the unabsorbed drug was found to be the major route of elimination. Orlistat and its M1 and M3 metabolites were also subject to biliary excretion. Approximately 97% of the administered radioactivity was excreted in feces; 83% of that was found to be unchanged orlistat.

The cumulative renal excretion of total radioactivity was <2% of the given dose of 360 mg 14C-orlistat. The time to reach complete excretion (fecal plus urinary) was 3 to 5 days. The disposition of orlistat appeared to be similar between normal weight and obese subjects. Based on limited data, the half-life of the absorbed orlistat is in the range of 1 to 2 hours.

Special Populations Because the drug is minimally absorbed, studies in special populations (geriatric, different races, patients with renal and hepatic insufficiency) were not conducted. Pediatrics Plasma concentrations of orlistat and its metabolites M1 and M3 were similar to those found in adults at the same dose level.

Daily fecal fat excretions were 27% and 7% of dietary intake in orlistat and placebo treatment groups, respectively. Drug-Drug Interactions Drug-drug interaction studies indicate that XENICAL had no effect on pharmacokinetics and/or pharmacodynamics of alcohol, digoxin, glyburide, nifedipine (extended-release tablets), oral contraceptives, phenytoin, pravastatin, or warfarin.

Alcohol did not affect the pharmacodynamics of orlistat. Other Short-term Studies Adults. In several studies of up to 6 weeks duration, the effects of therapeutic doses of XENICAL on gastrointestinal and systemic physiological processes were assessed in normal weight and obese subjects.

Postprandial cholecystokinin plasma concentrations were lowered after multiple doses of XENICAL in two studies but not significantly different from placebo in two other experiments. There were no clinically significant changes observed in gallbladder motility, bile composition or lithogenicity, or colonic cell proliferation rate, and no clinically significant reduction of gastric emptying time or gastric acidity.

In addition, no effects on plasma triglyceride levels or systemic lipases were observed with the administration of XENICAL in these studies. In a 3-week study of 28 healthy male volunteers, XENICAL (120 mg three times a day) did not significantly affect the balance of calcium, magnesium, phosphorus, zinc, copper, and iron.

Pediatrics In a 3-week study of 32 obese adolescents aged 12 to 16 years, XENICAL (120 mg three times a day) did not significantly affect the balance of calcium, magnesium, phosphorus, zinc, or copper. The iron balance was decreased by 64.7 μmole/24 hours and 40.4 μmole/24 hours in orlistat and placebo treatment groups, respectively.

Dose-response Relationship A simple maximum effect (Emax) model was used to define the dose-response curve of the relationship between XENICAL daily dose and fecal fat excretion as representative of gastrointestinal lipase inhibition. The dose-response curve demonstrated a steep portion for doses up to approximately 400 mg daily, followed by a plateau for higher doses. At doses greater than 120 mg three times a day, the percentage increase in effect was minimal.

CLINICAL STUDIES

Observational epidemiologic studies have established a relationship between obesity and visceral fat and the risks for cardiovascular disease, type 2 diabetes, certain forms of cancer, gallstones, certain respiratory disorders, and an increase in overall mortality. These studies suggest that weight loss, if maintained, may produce health benefits for obese patients who have or are at risk of developing weight-related comorbidities. The long-term effects of orlistat on morbidity and mortality associated with obesity have not been established.

The effects of XENICAL on weight loss, weight maintenance, and weight regain and on a number of comorbidities (eg, type 2 diabetes, lipids, blood pressure) were assessed in the 4-year XENDOS study and in seven long-term (1- to 2-years duration) multicenter, double-blind, placebo-controlled clinical trials. During the first year of therapy, the studies of 2-year duration assessed weight loss and weight maintenance.

During the second year of therapy, some studies assessed continued weight loss and weight maintenance, and others assessed the effect of orlistat on weight regain. These studies included over 2800 patients treated with XENICAL and 1400 patients treated with placebo.

The majority of these patients had obesity-related risk factors and comorbidities. In the XENDOS study, which included 3304 patients, the time to onset of type 2 diabetes was assessed in addition to weight management. In all these studies, treatment with XENICAL and placebo designates treatment with XENICAL plus diet and placebo plus diet, respectively.

During the weight loss and weight maintenance period, a well-balanced, reduced-calorie diet that was intended to result in an approximate 20% decrease in caloric intake and provide 30% of calories from fat was recommended to all patients. In addition, all patients were offered nutritional counseling. One-year Results: Weight Loss, Weight Maintenance, and Risk Factors Weight loss was observed within 2 weeks of initiation of therapy and continued for 6 to 12 months.

Pooled data from five clinical trials indicated that the overall mean weight loss from randomization to the end of 6 months and 1 year of treatment in the intent-to-treat population were 12.4 lbs and 13.4 lbs in the patients treated with XENICAL and 6.2 lbs and 5.8 lbs in the placebo-treated patients, respectively.

During the 4-week placebo lead-in period of the studies, an additional 5 to 6 lb weight loss was also observed in the same patients. Of the patients who completed 1 year of treatment, 57% of the patients treated with XENICAL (120 mg three times a day) and 31% of the placebo-treated patients lost at least 5% of their baseline body weight.

The diet utilized during year 1 was a reduced-calorie diet. Treatment designates XENICAL 120 mg three times a day plus diet or placebo plus diet †. Last observation carried forward ‡ All studies, with the exception of 14161, was conducted at centers specialized in treating obesity and complications of obesity. Study 14161 was conducted with primary care physicians.

The relative changes in risk factors associated with obesity following 1-year o,f therapy with XENICAL and placebo are presented for the population as a whole and for the population with abnormal values at randomization. Population as a Whole The changes in metabolic, cardiovascular and anthropometric risk factors associated with obesity based on pooled data for five clinical studies, regardless of the patient’s risk factor status at randomization, are presented.

In the population with abnormal blood pressure at baseline (systolic BP ≥ 140 mm Hg), the change in SBP from randomization to 1 year was greater for XENICAL (-10.89 mm Hg) than placebo (-5.07 mm Hg). For patients with a diastolic blood pressure ≥ 90 mm Hg, XENICAL patients decreased by 7.9 mm Hg while the placebo patients decreased by -5.5 mm Hg. Fasting insulin decreased more for XENICAL than placebo (-39 vs -16 pmol/L) from randomization to 1 year in the population with abnormal baseline values (≥ 120 pmol/L).

A greater reduction in waist circumference for XENICAL vs placebo (-7.29 vs -4.53 cm) was observed in the population with abnormal baseline values (≥ 100 cm). Effect on Weight Regain Three studies were designed to evaluate the effects of XENICAL compared to placebo in reducing weight regain after a previous weight loss achieved following either diet alone (one study, 14302) or prior treatment with XENICAL (two studies, 14119C and 14185).

The diet utilized during the 1-year weight regain portion of the studies was a weightmaintenance diet, rather than a weight-loss diet, and patients received less nutritional counseling than patients in weight-loss studies. For studies 14119C and 14185, patients’ previous weight loss was due to 1 year of treatment with XENICAL in conjunction with a mildly hypocaloric diet.

Study 14302 was conducted to evaluate the effects of 1 year of treatment with XENICAL on weight regain in patients who had lost 8% or more of their body weight in the previous 6 months on diet alone. In study 14119C, patients treated with placebo regained 52% of the weight they had previously lost while the patients treated with XENICAL regained 26% of the weight they had previously lost (p<0.001).

In study 14185, patients treated with placebo regained 63% of the weight they had previously lost while the patients treated with XENICAL regained 35% of the weight they had lost (p<0.001). In study 14302, patients treated with placebo regained 53% of the weight they had previously lost while the patients treated with XENICAL regained 32% of the weight that they had lost (p<0.001). Two-year

Results: Long-term Weight Control and Risk Factors The treatment effects of XENICAL were examined for 2 years in four of the five 1-year weight management clinical studies previously discussed (see Table 1). At the end of year 1, the patients’ diets were reviewed and changed where necessary. The diet prescribed in the second year was designed to maintain patient’s current weight. XENICAL was shown to be more effective than placebo in long-term weight control in four large, multicenter, 2-year double-blind, placebo-controlled studies.

Pooled data from four clinical studies indicate that 40% of all patients treated with 120 mg three times a day of XENICAL and 24% of patients treated with placebo who completed 2 years of the same therapy had ≥ 5% loss of body weight from randomization. Pooled data from four clinical studies indicate that the relative weight loss advantage between XENICAL 120 mg three times a day and placebo treatment groups was the same after 2 years as for 1 year, indicating that the pharmacologic advantage of XENICAL was maintained over 2 years.

In the same studies cited in the One-year Results (see Table 1), the percentages of patients achieving a ≥ 5% and ≥ 10% weight loss after 2 years are maintenance and not weight loss.

Treatment designates XENICAL 120 mg three times a day plus diet or placebo plus diet † Last observation carried forward ‡ All studies, with the exception of 14161 were conducted at centers specializing in treating obesity or complications of obesity. Study 14161 was conducted with primary care physicians.

The relative changes in risk factors associated with obesity following 2 years of therapy were also assessed in the population as a whole and the population with abnormal risk factors at randomization. Population as a Whole The relative differences in risk factors between treatment with XENICAL and placebo were similar to the results following 1 year of therapy for total cholesterol, LDLcholesterol, LDL/HDL ratio, triglycerides, fasting glucose, fasting insulin, diastolic blood pressure, waist circumference, and hip circumference.

The relative differences between treatment groups for HDL cholesterol and systolic blood pressure were less than that observed in the year one results. Population With Abnormal Risk Factors at Randomization The relative differences in risk factors between treatment with XENICAL and placebo were similar to the results following 1 year of therapy for LDL- and HDL-cholesterol, triglycerides, fasting insulin, diastolic blood pressure, and waist circumference.

The relative differences between treatment groups for LDL/HDL ratio and isolated systolic blood pressure were less than that observed in the year one results. Four-year Results: Long-term Weight Control and Risk Factors In the 4-year double-blind, placebo-controlled XENDOS study, the effects of orlistat in delaying the onset of type 2 diabetes and on body weight were compared to placebo in 3304 obese patients who had either normal or impaired glucose tolerance at baseline.

Thirty-four percent of the 1655 patients who were randomized to the placebo group and 52% of the 1649 patients who were randomized to the orlistat group completed the 4-year study. At the end of the study, the mean percent weight loss in the placebo group was -2.75% compared with -5.17% in the orlistat group (p<0.001) (see Figure 1).

Forty-five percent 8 of the placebo patients and 73% of the orlistat patients lost ≥ 5% of their baseline body weight, and 21% of the placebo patients and 41% of the orlistat patients lost ≥ 10% of their baseline body weight following the first year of treatment.

Following 4 years of treatment, 28% of the placebo patients and 45% of the orlistat patients lost ≥ 5% of their baseline body weight and 10% of the placebo patients and 21% of the orlistat patients lost ≥ 10% of their baseline body weight. Mean Change from Baseline Body Weight (Kgs) Over Time.

The relative changes from baseline in risk factors associated with obesity following 4 years of therapy were assessed in the XENDOS study population (see Table 4). 9 Table 4 Mean Change in Risk Factors From Randomization Following 4-Years Treatment* Risk Factor XENICAL 120 mg† Placebo† Metabolic: Total Cholesterol -7.02% -2.03% LDL-Cholesterol -11.66% -3.85% HDL-Cholesterol +5.92% +7.01% LDL/HDL -0.53 -0.33 Triglycerides +3.64% +1.30 Fasting Glucose, mmol/L +0.12 +0.23 Fasting Insulin, pmol/L -24.93 -15.71

Cardiovascular: Systolic Blood Pressure, mm Hg -4.12 -2.60 Diastolic Blood Pressure, mm Hg -1.93 -0.87 Anthropometric: Waist Circumference, cm -5.78 -3.99 *Treatment designates XENICAL 120 mg three times a day plus diet or placebo plus diet †Intent-to-treat population Study of Patients With Type 2 Diabetes A 1-year double-blind, placebo-controlled study in type 2 diabetics (N=321) stabilized on sulfonylureas was conducted.

Thirty percent of patients treated with XENICAL achieved at least a 5% or greater reduction in body weight from randomization compared to 13% of the placebo-treated patients (p<0.001). Table 5 describes the changes over 1 year of treatment with XENICAL compared to placebo, in sulfonylurea usage and dose reduction as well as in hemoglobin HbA1c, fasting glucose, and insulin.

Mean Changes in Body Weight and Glycemic Control From Randomization Following 1-Year Treatment in Patients With Type 2 Diabetes XENICAL 120 mg* (n=162) Placebo* (n=159) Statistical Significance % patients who discontinued dose of oral sulfonylurea % patients who decreased dose of oral sulfonylurea 11.7% 31.5% 7.5% 21.4% † Average reduction in sulfonylurea medication dose -22.8% -9.1% † Body weight change (lbs) -8.9 -4.2 † HbA1c -0.18% +0.28% † Fasting glucose, mmol/L -0.02 +0.54 † Fasting insulin, pmol/L -19.68 -18.02 ns.

Statistical significance based on intent-to-treat population, last observation carried forward. * Treatment designates XENICAL 120 mg three times a day plus diet or placebo plus diet † Statistically significant (p ≤ 0.05) based on intent-to-treat, last observation carried forward ns nonsignificant, p>0.05 In addition, XENICAL (n=162) compared to placebo (n=159) was associated with significant lowering for total cholesterol (-1.0% vs +9.0%, p ≤ 0.05), LDL-cholesterol ( 3.0% vs +10.0%, p ≤ 0.05), LDL/HDL ratio (-0.26 vs -0.02, p ≤ 0.05) and triglycerides (+2.54% vs +16.2%, p ≤ 0.05), respectively. For HDL cholesterol, there was a +6.49% increase on XENICAL and +8.6% increase on placebo, p>0.05. Systolic blood pressure increased by +0.61 mm Hg on XENICAL and increased by +4.33 mm Hg on placebo, p>0.05. Diastolic blood pressure decreased by -0.47 mm Hg for XENICAL and by -0.5 mm Hg for placebo, p>0.05. Glucose Tolerance in Obese Patients.

Two-year studies that included oral glucose tolerance tests were conducted in obese patients not previously diagnosed or treated for type 2 diabetes and whose baseline oral glucose tolerance test (OGTT) status at randomization was either normal, impaired, or diabetic.

The progression from a normal OGTT at randomization to a diabetic or impaired OGTT following 2 years of treatment with XENICAL (n=251) or placebo (n=207) were compared. Following treatment with XENICAL, 0.0% and 7.2% of the patients progressed from normal to diabetic and normal to impaired, respectively, compared to 1.9% and 12.6% of the placebo treatment group, respectively.

Patients found to have an impaired OGTT at randomization, the percent of patients improving to normal or deteriorating to diabetic status following 1 and 2 years of treatment with XENICAL compared to placebo are presented. After 1 year of treatment, 45.8% of the placebo patients and 73% of the XENICAL patients had a normal oral glucose tolerance test while 10.4% of the placebo patients and 2.6% of the XENICAL patients became diabetic.

After 2 years of treatment, 50% of the placebo patients and 71.7% of the XENICAL patients had a normal oral glucose tolerance test while 7.5% of placebo patients were found to be diabetic and 1.7% of XENICAL patients were found to be diabetic after treatment.

Onset of Type 2 Diabetes in Obese Patients In the XENDOS trial, in the overall population, orlistat delayed the onset of type 2 diabetes such that at the end of four years of treatment the cumulative incidence rate of diabetes was 8.3% for the placebo group compared to 5.5% for the orlistat group, p=0.01 (see Table 6). This finding was driven by a statistically-significant reduction in the incidence of developing type 2 diabetes in those patients who had impaired glucose tolerance at baseline (Table 6 and Figure 2). Orlistat did not reduce the risk for the development of diabetes in patients with normal glucose tolerance at baseline.

The effect of XENICAL to delay the onset of type 2 diabetes in obese patients with IGT is presumably due to weight loss, and not to any independent effects of the drug on glucose or insulin metabolism. The effect of orlistat on weight loss is adjunctive to diet and exercise. Table 6 Incidence Rate of Diabetes at Year 4 by OGTT Status at Baseline* OGTT at baseline Normal Impaired All Treatment Placebo Orlistat Placebo Orlistat Placebo Orlistat Number of patients.

Based on patients with a baseline and at least one follow-up OGTT measurement †Rate adjusted for dropouts †† Computed as (1- hazard ratio). For current labeling information, please visit https://www.fda.gov/drugsatfda Figure 2 Percentage of Patients Without Diabetes Over Time Pediatric Clinical Studies The effects of XENICAL on body mass index (BMI) and weight loss were assessed in a 54-week multicenter, double-blind, placebo-controlled study in 539 obese adolescents (357 receiving XENICAL 120 mg three times a day, 182 receiving placebo), aged 12 to 16 years.

All study participants had a baseline BMI that was 2 units greater than the US weighted mean for the 95th percentile based on age and gender. Body mass index was the primary efficacy parameter because it takes into account changes in height and body weight, which occur in growing children.

During the study, all patients were instructed to take a multivitamin containing fatsoluble vitamins at least 2 hours before or after ingestion of XENICAL. Patients were also maintained on a well-balanced, reduced-calorie diet that was intended to provide 30% of calories from fat. In addition, all patients were placed on a behavior modification program and offered exercise counseling.

Approximately 65% of patients in each treatment group completed the study. Following one year of treatment, BMI decreased by an average of 0.55 kg/m2 in the XENICAL-treated patients and increased by an average of 0.31 kg/m2 in the placebotreated patients (p=0.001). The percentages of patients achieving ≥ 5% and ≥ 10% reduction in BMI and body weight after 52 weeks of treatment for the intent-to-treat population are presented.

Treatment designates XENICAL 120 mg three times a day plus diet or placebo plus diet † Last observation carried forward INDICATIONS AND USAGE XENICAL is indicated for obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet. XENICAL is also indicated to reduce the risk for weight regain after prior weight loss. XENICAL is indicated for obese patients with an initial body mass index (BMI) ≥ 30 kg/m2 or ≥ 27 kg/m2 in the presence of other risk factors (eg, hypertension, diabetes, dyslipidemia).

Conversion Factors: Weight in lbs ÷ 2.2 = weight in kilograms (kg) Height in inches × 0.0254 = height in meters (m) 1 foot = 12 inches 14 This label may not be the latest approved by FDA. For current labeling information, please visit https://www.fda.gov/drugsatfda HEIGHT (ft/in) This label may not be the latest approved by FDA. For current labeling information, please visit https://www.fda.gov/drugsatfda CONTRAINDICATIONS XENICAL is contraindicated in patients with chronic malabsorption syndrome or cholestasis, and in patients with known hypersensitivity to XENICAL or to any component of this product.

WARNINGS Miscellaneous Organic causes of obesity (eg, hypothyroidism) should be excluded before prescribing XENICAL. Preliminary data from a XENICAL and cyclosporine drug interaction study indicate a reduction in cyclosporine plasma levels when XENICAL was coadministered with cyclosporine.

Therefore, XENICAL and cyclosporine should not be coadministered. To reduce the chance of a drug-drug interaction, cyclosporine should be taken at least 2 hours before or after XENICAL in patients taking both drugs. In addition, in those patients whose cyclosporine levels are being measured, more frequent monitoring should be considered.

PRECAUTIONS

General Patients should be advised to adhere to dietary guidelines . Gastrointestinal events may increase when XENICAL is taken with a diet high in fat (>30% total daily calories from fat). The daily intake of fat should be distributed over three main meals. If XENICAL is taken with any one meal very high in fat, the possibility of gastrointestinal effects increases.

Patients should be strongly encouraged to take a multivitamin supplement that contains fat-soluble vitamins to ensure adequate nutrition because XENICAL has been shown to reduce the absorption of some fat-soluble vitamins and beta-carotene. In addition, the levels of vitamin D and beta-carotene may be low in obese patients compared with non-obese subjects. The supplement should be taken once a day at least 2 hours before or after the administration of XENICAL, such as at bedtime.

All patients were treated with vitamin supplementation throughout the course of the study † Treatment designates placebo plus diet or XENICAL plus diet There have been rare postmarketing reports of severe liver injury with hepatocellular necrosis or acute hepatic failure in patients treated with orlistat with some of these cases resulting in liver transplant or death.

Patients should be instructed to report any symptoms of hepatic dysfunction (anorexia, pruritus, jaundice, dark urine, light colored stools, or right upper quadrant pain) while taking orlistat. When these symptoms occur, orlistat and other suspect medications should be discontinued immediately and liver function tests and ALT and AST levels obtained.

Some patients may develop increased levels of urinary oxalate following treatment with XENICAL. Caution should be exercised when prescribing XENICAL to patients with a history of hyperoxaluria or calcium oxalate nephrolithiasis. Weight-loss induction by XENICAL may be accompanied by improved metabolic control in diabetics, which might require a reduction in dose of oral hypoglycemic medication (eg, sulfonylureas, metformin) or insulin.

Substantial weight loss can increase the risk of cholelithiasis. In a clinical trial of XENICAL for the prevention of type 2 diabetes, the rates of cholelithiasis as an adverse event were 2.9% (47/1649) for patients randomized to XENICAL and 1.8% (30/1655) for patients randomized to placebo. In this trial, the incidence of cholelithiasis was similar for XENICAL and placebo at similar amounts of weight loss. An increase in cholelithiasis with XENICAL was not seen in trials that were not evaluating the prevention of type 2 diabetes.

Misuse Potential As with any weight-loss agent, the potential exists for misuse of XENICAL in inappropriate patient populations (eg, patients with anorexia nervosa or bulimia). See INDICATIONS AND USAGE for recommended prescribing guidelines. Information for Patients Patients should read the Patient Information before starting treatment with XENICAL and each time their prescription is renewed.

Drug Interactions Alcohol In a multiple-dose study in 30 normal-weight subjects, coadministration of XENICAL and 40 grams of alcohol (eg, approximately 3 glasses of wine) did not result in alteration of alcohol pharmacokinetics, orlistat pharmacodynamics (fecal fat excretion), or systemic exposure to orlistat. Cyclosporine Preliminary data from a XENICAL and cyclosporine drug interaction study indicate a reduction in cyclosporine plasma levels when XENICAL was coadministered with cyclosporine.

Digoxin In 12 normal-weight subjects receiving XENICAL 120 mg three times a day for 6 days, XENICAL did not alter the pharmacokinetics of a single dose of digoxin. Fat-soluble Vitamin Supplements and Analogues A pharmacokinetic interaction study showed a 30% reduction in beta-carotene supplement absorption when concomitantly administered with XENICAL.

XENICAL inhibited absorption of a vitamin E acetate supplement by approximately 60%. The effect of orlistat on the absorption of supplemental vitamin D, vitamin A, and nutritionallyderived vitamin K is not known at this time. Glyburide In 12 normal-weight subjects receiving orlistat 80 mg three times a day for 5 days, orlistat did not alter the pharmacokinetics or pharmacodynamics (blood glucoselowering) of glyburide.

Levothyroxine Hypothyroidism has been reported in patients treated concomitantly with orlistat and levothyroxine postmarketing (see ADVERSE REACTIONS: Other Clinical Studies or Postmarketing Surveillance). Patients treated concomitantly with orlistat and levothyroxine should be monitored for changes in thyroid function. Administer levothyroxine and orlistat at least 4 hours apart. Nifedipine (extended-release tablets).

In 17 normal-weight subjects receiving XENICAL 120 mg three times a day for 6 days, XENICAL did not alter the bioavailability of nifedipine (extended-release tablets). Oral Contraceptives In 20 normal-weight female subjects, the treatment of XENICAL 120 mg three times a day for 23 days resulted in no changes in the ovulation-suppressing action of oral contraceptives.

Phenytoin In 12 normal-weight subjects receiving XENICAL 120 mg three times a day for 7 days, XENICAL did not alter the pharmacokinetics of a single 300-mg dose of phenytoin. Pravastatin In a 2-way crossover study of 24 normal-weight, mildly hypercholesterolemic patients receiving XENICAL 120 mg three times a day for 6 days, XENICAL did not affect the pharmacokinetics of pravastatin. Warfarin In 12 normal-weight subjects, administration of XENICAL 120 mg three times a day for 16 days did not result in any change in either warfarin pharmacokinetics (both R- and Senantiomers) or pharmacodynamics (prothrombin time and serum Factor VII).

Although undercarboxylated osteocalcin, a marker of vitamin K nutritional status, was unaltered with XENICAL administration, vitamin K levels tended to decline in subjects taking XENICAL. Therefore, as vitamin K absorption may be decreased with XENICAL, patients on chronic stable doses of warfarin who are prescribed XENICAL should be monitored closely for changes in coagulation parameters. Carcinogenesis, Mutagenesis, Impairment of Fertility.

Carcinogenicity studies in rats and mice did not show a carcinogenic potential for orlistat at doses up to 1000 mg/kg/day and 1500 mg/kg/day, respectively. For mice and rats, these doses are 38 and 46 times the daily human dose calculated on an area under concentration vs time curve basis of total drug-related material. Orlistat had no detectable mutagenic or genotoxic activity as determined by the Ames test, a mammalian forward mutation assay (V79/HPRT), an in vitro clastogenesis assay in peripheral human lymphocytes, an unscheduled DNA synthesis assay (UDS) in rat hepatocytes in culture, and an in vivo mouse micronucleus test.

When given to rats at a dose of 400 mg/kg/day in a fertility and reproduction study, orlistat had no observable adverse effects. This dose is 12 times the daily human dose calculated on a body surface area (mg/m2 ) basis. Pregnancy Teratogenic Effects: Pregnancy Category B. Teratogenicity studies were conducted in rats and rabbits at doses up to 800 mg/kg/day.

Neither study showed embryotoxicity or teratogenicity. This dose is 23 and 47 times the daily human dose calculated on a body surface area (mg/m2 ) basis for rats and rabbits, respectively. The incidence of dilated cerebral ventricles was increased in the mid- and high-dose groups of the rat teratology study. These doses were 6 and 23 times the daily human dose calculated on a body surface area (mg/m2 ) basis for the mid- and high-dose levels, respectively.

This finding was not reproduced in two additional rat teratology studies at similar doses. There are no adequate and well-controlled studies of XENICAL in pregnant women. Because animal reproductive studies are not always predictive of human response, XENICAL is not recommended for use during pregnancy. Nursing Mothers It is not known if orlistat is secreted in human milk.

Therefore, XENICAL should not be taken by nursing women. Pediatric Use The safety and efficacy of XENICAL have been evaluated in obese adolescent patients aged 12 to 16 years. Use of XENICAL in this age group is supported by evidence from adequate and well-controlled studies of XENICAL in adults with additional data from a 54-week efficacy and safety study and a 21-day mineral balance study in obese adolescent patients aged 12 to 16 years.

Patients treated with XENICAL had a mean reduction in BMI of 0.55 kg/m2 compared with an average increase of 0.31 kg/m2 in placebo-treated patients (p=0.001). In both adolescent studies, adverse effects were generally similar to those described in adults and included fatty/oily stool, oily spotting, and oily evacuation.

In a subgroup of 152 orlistat and 77 placebo patients from the 54 week study, changes in body composition measured by DEXA were similar in both treatment groups with the exception of fat mass, which was significantly reduced in patients treated with XENICAL compared to patients treated with placebo (-2.5 kg vs 0.6 kg, p=0.033). Because XENICAL can interfere with the absorption of fat-soluble vitamins, all patients should take a daily multivitamin that contains vitamins A, D, E, K, and beta-carotene.

The supplement should be taken at least 2 hours before or after XENICAL: Other Short-term Studies; CLINICAL STUDIES: Pediatric Clinical Studies; ADVERSE REACTIONS: Pediatric Patients). XENICAL has not been studied in pediatric patients below the age of 12 years. 19 Geriatric Use Clinical studies of XENICAL did not include sufficient numbers of patients aged 65 years and older to determine whether they respond differently from younger patients.

ADVERSE REACTIONS Commonly Observed (based on first year and second year data - XENICAL 120 mg three times a day versus placebo): Gastrointestinal (GI) symptoms were the most commonly observed treatment-emergent adverse events associated with the use of XENICAL in the seven double-blind, placebocontrolled clinical trials and are primarily a manifestation of the mechanism of action. (Commonly observed is defined as an incidence of ≥ 5% and an incidence in the XENICAL 120 mg group that is at least twice that of placebo.)

Increased Defecation 10.8 4.1 2.6 0.8 Fecal Incontinence 7.7 0.9 1.8 0.2 * Treatment designates XENICAL three times a day plus diet or placebo plus diet These and other commonly observed adverse reactions were generally mild and transient, and they decreased during the second year of treatment. In general, the first occurrence of these events was within 3 months of starting therapy.

Overall, approximately 50% of all episodes of GI adverse events associated with orlistat treatment lasted for less than 1 week, and a majority lasted for no more than 4 weeks. However, GI adverse events may occur in some individuals over a period of 6 months or longer.

Discontinuation of Treatment In controlled clinical trials, 8.8% of patients treated with XENICAL discontinued treatment due to adverse events, compared with 5.0% of placebo-treated patients. For XENICAL, the most common adverse events resulting in discontinuation of treatment were gastrointestinal. Incidence in Controlled Clinical Trials

The following table lists other treatment-emergent adverse events from seven multicenter, double-blind, placebo-controlled clinical trials that occurred at a frequency of ≥ 2% among patients treated with XENICAL 120 mg three times a day and with an incidence that was greater than placebo during year 1 and year 2, regardless of relationship to study medication. 20 This label may not be the latest approved by FDA.

Other Treatment-Emergent Adverse Events From Seven Placebo-Controlled Clinical Trials Body System/Adverse Event Year 1 Year 2 XENICAL* % Patients (N=1913) Placebo* % Patients (N=1466) XENICAL* % Patients (N=613) Placebo* % Patients (N=524) Gastrointestinal System Abdominal Pain/Discomfort Nausea Infectious Diarrhea Rectal Pain/Discomfort.

Tooth Disorder Gingival Disorder Vomiting Respiratory System Influenza Upper Respiratory Infection Lower Respiratory Infection Ear, Nose & Throat Symptoms Musculoskeletal System Back Pain Pain Lower Extremities Arthritis Myalgia Joint Disorder Tendonitis Central Nervous System Headache Dizziness Body as a Whole Fatigue Sleep Disorder.

Skin & Appendages Rash Dry Skin Reproductive, Female Menstrual Irregularity Vaginitis Urinary System Urinary Tract Infection Psychiatric Disorder Psychiatric Anxiety Depression Hearing & Vestibular Disorders Otitis Cardiovascular Disorders Pedal Edema.

Treatment designates XENICAL 120 mg three times a day plus diet or placebo plus diet – None reported at a frequency ≥ 2% and greater than placebo. In the 4-year XENDOS study, the general pattern of adverse events was similar to that reported for the 1- and 2-year studies with the total incidence of gastrointestinal-related adverse events occurring in year 1 decreasing each year over the 4-year period.

Other Clinical Studies or Postmarketing Surveillance Rare cases of increase in transaminases and in alkaline phosphatase and hepatitis that may be serious have been reported. There have been reports of hepatic failure observed with the use of XENICAL in postmarketing surveillance with some of these cases resulting in liver transplant or death. Rare cases of hypersensitivity have been reported with the use of XENICAL.

Signs and symptoms have included pruritus, rash, urticaria, angioedema, bronchospasm and anaphylaxis. Very rare cases of bullous eruption have been reported. Reports of decreased prothrombin, increased INR and unbalanced anticoagulant treatment resulting in change of hemostatic parameters have been reported in patients treated concomitantly with orlistat and anticoagulants.

Hypothyroidism has been reported in patients treated concomitantly with orlistat and levothyroxine. Pancreatitis has been reported with the use of XENICAL in postmarketing surveillance. No causal relationship or physiopathological mechanism between pancreatitis and obesity therapy has been definitively established.

In clinical trials in obese diabetic patients, hypoglycemia and abdominal distension were also observed. Preliminary data from a XENICAL and cyclosporine drug interaction study indicate a reduction in cyclosporine plasma levels when XENICAL was coadministered with cyclosporine (see WARNINGS).

Pediatric Patients In clinical trials with XENICAL in adolescent patients ages 12 to 16 years, the profile of adverse reactions was generally similar to that observed in adults. OVERDOSAGE Single doses of 800 mg XENICAL and multiple doses of up to 400 mg three times a day for 15 days have been studied in normal weight and obese subjects without significant adverse findings.

Should a significant overdose of XENICAL occur, it is recommended that the patient be observed for 24 hours. Based on human and animal studies, systemic effects attributable to the lipase-inhibiting properties of orlistat should be rapidly reversible.

DOSAGE AND ADMINISTRATION

The recommended dose of XENICAL is one 120-mg capsule three times a day with each main meal containing fat (during or up to 1 hour after the meal).

The patient should be on a nutritionally balanced, reduced-calorie diet that contains approximately 30% of calories from fat. The daily intake of fat, carbohydrate, and protein should be distributed over three main meals.

If a meal is occasionally missed or contains no fat, the dose of XENICAL can be omitted. Because XENICAL has been shown to reduce the absorption of some fat-soluble vitamins and beta-carotene, patients should be counseled to take a multivitamin containing fat-soluble vitamins to ensure adequate nutrition (see PRECAUTIONS: General).

The supplement should be taken at least 2 hours before or after the administration of XENICAL, such as at bedtime. For patients receiving both orlistat and levothyroxine therapy, administer levothyroxine and orlistat at least 4 hours apart. Doses above 120 mg three times a day have not been shown to provide additional benefit. Based on fecal fat measurements, the effect of XENICAL is seen as soon as 24 to 48 hours after dosing.

Upon discontinuation of therapy, fecal fat content usually returns to pretreatment levels within 48 to 72 hours. The safety and effectiveness of XENICAL beyond 4 years have not been determined at this time. HOW SUPPLIED XENICAL is a dark-blue, hard-gelatin capsule containing pellets of powder. XENICAL 120 mg Capsules: Dark-blue, two-piece, No. 1 opaque hard-gelatin capsule imprinted with Roche and XENICAL 120 in light-blue ink — bottle of 90 (NDC 0004 0256-52).

Storage Conditions Store at 25°C (77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Keep bottle tightly closed. XENICAL should not be used after the given expiration date. XENICAL is a registered trademark of Roche Laboratories Inc.

TO PHARMACIST: PLEASE PROVIDE THIS INFORMATION TO THE PATIENT.

Important Patient Information Patient Information about XENICAL® (orlistat) Capsules XENICAL (zen′ i-cal) Generic Name: orlistat Rx only Please read this information before you start taking XENICAL and each time you renew your prescription. This important information may help you successfully lose weight and maintain your weight loss while taking XENICAL.

This patient information is a summary and is not intended to take the place of discussions with your doctor. It does not list all benefits and risks of XENICAL. The medication described here can only be prescribed and dispensed by a licensed health care professional, who has information about your medical condition and more information about the drug, including how to take it, what to expect, and potential side effects. If you have any questions about XENICAL, talk with your doctor.

What is XENICAL? XENICAL is an oral prescription weight loss medication used to help obese people lose weight and keep this weight off. XENICAL works in your intestines, where it blocks some of the fat you eat from being absorbed. This undigested fat is then eliminated in your bowel movements. XENICAL should be used together with a reduced-calorie diet that your doctor will recommend.

Excess weight has been proven to contribute to an increased risk of developing many medical problems, including high blood pressure, high cholesterol, heart disease, and diabetes. The consumption of excess fatty food and calories plays a significant role in the development of excess weight. While fat is an important component of a balanced diet, the consumption of excess fat contributes to excess body weight, since fat provides twice the number of calories per gram of weight as carbohydrates and protein. Reduction of dietary fat intake is one potential way of losing weight.

How does XENICAL work? If you eat an excess amount of fat or calories, the excess is stored as fat by the body resulting in weight gain. When you eat fat, your body breaks it down into its simplest components so that it can be absorbed. Enzymes in your intestinal tract, called lipases, help digest (or break down) fat. When you take XENICAL with meals, XENICAL attaches to the lipases and blocks them from breaking down some of the fat you have eaten.

The undigested fat cannot be absorbed and is eliminated in your bowel movements. By working this way, XENICAL helps block about 30% of the fat eaten in food from being absorbed by your body. Information for adult obese patients Following one year of treatment, XENICAL in combination with diet was shown to be more effective in reducing weight than diet alone. In most cases, weight loss was gradual.

Patients treated with XENICAL and a reduced-calorie diet for one year lost an average of 13.4 pounds while those on a reduced-calorie diet alone lost 5.8 pounds. Information for adolescent obese patients Following one year of treatment, XENICAL in combination with diet was shown to be more effective in reducing Body Mass Index (BMI) than diet alone. A reduction in Body Mass Index is a better indicator of weight loss in children because it takes into account changes in weight related to growing children. Who should use XENICAL?

A weight loss program that includes a reduced-calorie diet and appropriate physical activity may be adequate in some patients. You should discuss with your doctor or other health care provider whether XENICAL should be added to such a program. XENICAL may be right for you if you are considerably overweight (at least 30% above ideal weight or a body mass index of 30 or greater). XENICAL may also be right for you if you are overweight (at least 20% above ideal weight or a body mass index of 27 or greater) and also have other risk factors such as high blood pressure, high cholesterol, heart disease, or diabetes.

How to determine your body mass index (BMI): The chart below illustrates BMI according to a variety of weights and heights. The BMI is calculated by dividing your weight in kilograms by your height in meters squared. To use this chart: • Find the height closest to your height in the left-hand column. • Then move across the top row to find the weight closest to your weight. •

Who should not use XENICAL?

Those who: • consistently have problems absorbing food (chronic malabsorption); or • have gallbladder problems; or • are pregnant or are breastfeeding a child; or • have ever had an allergic reaction to orlistat or any of the inactive ingredients in XENICAL. What should I tell my doctor before taking XENICAL? Before beginning treatment with XENICAL, make sure your doctor knows if you are: • allergic to any medicines, foods, or dyes; • taking any other weight-loss medication; • taking cyclosporine; • taking thyroid medicine; • taking any other medicines (including those not prescribed by your doctor); • taking any dietary supplements, including herbal products; • planning to become pregnant; or • anorexic or bulimic.

This information will help you and your physician decide if the expected advantages of XENICAL are greater than any possible disadvantages. 3 This label may not be the latest approved by FDA. For current labeling information, please visit https://www.fda.gov/drugsatfda HEIGHT (ft/in) How should I take XENICAL? The recommended dose is one 120 mg capsule by mouth with liquid at each main meal that contains fat. You can take XENICAL in conjunction with a mildly reduced-calorie diet up to 3 times a day. Each time you take XENICAL, your meal should contain no more than about 30% of calories from fat.

Take XENICAL during meals or up to one hour after a meal. If you occasionally miss a meal or have a meal without fat, you can omit your dose of XENICAL. Doses greater than 120 mg three times a day have not been shown to provide an additional weight loss benefit. You should use XENICAL together with a nutritionally balanced, mildly reduced-calorie diet that contains no more than about 30% of calories from fat.

You should evenly divide your daily intake of fat, carbohydrates, and protein over 3 main meals. You should try to follow a healthy eating plan such as the one developed by the American Heart Association. Following this eating plan will help you lose weight while decreasing some of the possible gastrointestinal effects you may experience

XENICAL has been shown to reduce the absorption of certain vitamins. You should take a multivitamin containing vitamins D, E, K, and beta-carotene once a day at least 2 hours before or after the administration of XENICAL, such as at bedtime. • Some patients taking XENICAL may develop an increased risk for the development of kidney stones. Promptly report any symptoms of back pain or blood in the urine. • Some patients prescribed XENICAL may already be at increased risk for the formation of gall stones. Weight loss with XENICAL can increase the risk of gall stones. Promptly report any symptoms of pain in the upper right portion of the abdomen. The pain may be accompanied by nausea and vomiting. •

There have been rare reports of severe liver injury in patients taking XENICAL. Promptly discontinue XENICAL and contact your healthcare provider if you develop symptoms suggestive of liver impairment, such as loss of appetite, itching, yellowing of the skin, dark urine, light colored stools, or right upper quadrant pain. Can I take XENICAL while taking other medications? Be sure to discuss with your doctor all medications (including herbal products) you are currently taking, including medicines you can get without a prescription (over-the- 4

XENICAL can be taken in addition to these medications. If you are taking cyclosporine, XENICAL and cyclosporine should be taken at least 2 hours apart. If your cyclosporine levels are being measured, more frequent monitoring may be necessary. If you are taking levothyroxine, XENICAL and levothyroxine should be taken at least 4 hours apart. How long should I use XENICAL? The use of XENICAL for more than 4 years has not been studied. You and your doctor should discuss how long you should use XENICAL. What are the most common side effects of XENICAL?

Because XENICAL works by blocking the absorption of dietary fat, it is likely that you will experience some changes in bowel habits. These generally occur during the first weeks of treatment; however, they may continue throughout your use of XENICAL. These changes may include oily spotting, gas with discharge, urgent need to go to the bathroom, oily or fatty stools, an oily discharge, increased number of bowel movements, and inability to control bowel movements. Due to the presence of undigested fat, the oil seen in a bowel movement may be clear or have a coloration such as orange or brown.

These bowel changes are a natural effect of blocking the fat from being absorbed and indicate that XENICAL is working. They generally occur early in treatment, particularly after meals containing higher amounts of fat than are recommended. These symptoms are often temporary and may lessen or disappear as you continue treatment and keep to your recommended diet of meals containing no more than about 30% fat. However, these side effects may occur in some individuals over a period of 6 months or longer.

In obese adolescent patients treated with XENICAL, the side effects reported were similar to those observed in adults. If you are concerned about these or any other side effects you experience while taking XENICAL, talk to your doctor or pharmacist. What lifestyle changes should I consider when taking XENICAL? You must use XENICAL with a recommended mildly reduced-calorie diet. You should also follow a program of regular physical activity, such as walking. However, before you undertake any activity or exercise program, be sure to speak with your doctor or health care professional. How can I reduce dietary fat? To help you get started on reducing the fat in your diet to around 30%, read the labels on all the foods you buy.

You should avoid foods that contain more than 30% fat while you are taking XENICAL. • When eating meat, poultry or fish, limit your portion to 2 or 3 ounces (roughly the size of a deck of cards). Choose lean cuts of meat and remove the skin from poultry. Fill up your meal plate by including more grains, fruits, and vegetables. • Replace whole-milk products with nonfat or 1% milk and nonfat, reduced-fat, or lowfat dairy items. 5 This label may not be the latest approved by FDA. For current labeling information, please visit https://www.fda.gov/drugsatfda • Cook with less fat.

Use vegetable oil spray when cooking. Salad dressings, many baked items, and prepackaged, processed, and fast foods are usually high in fat. Use the low- or non-fat versions and/or cut back on serving sizes. • When dining out, ask how foods are prepared and request that they be prepared with little or no added fat.