5 WARNINGS AND PRECAUTIONS

5.1 Never Share a TOUJEO SoloStar or TOUJEO Max SoloStar Pen Between

Patients

TOUJEO SoloStar or TOUJEO Max SoloStar single-patient-use prefilled pens must never be shared between patients, even if the needle is changed. Pen sharing poses a risk for transmission of blood-borne pathogens.

5.2 Hyperglycemia or Hypoglycemia with Changes in Insulin Regimen

Changes in Insulin Regimen Including Changes to Administration Site

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 (5.3)] 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 unaffected area) has been reported to result in hypoglycemia [see Adverse Reactions (6)].

Make any changes to a patient's insulin regimen under close medical supervision with increased frequency of blood glucose monitoring. Advise patients who have repeatedly injected into areas of lipodystrophy or localized cutaneous amyloidosis to change the injection site to unaffected areas and closely monitor for hypoglycemia. For patients with type 2 diabetes, dosage adjustments of concomitant oral antidiabetic products may be needed.

Changing to TOUJEO from other Insulin Therapies

On a unit-to-unit basis, TOUJEO has a lower glucose lowering effect than LANTUS [see Clinical Pharmacology (12.2)]. In clinical trials, patients who changed to TOUJEO from other basal insulins experienced higher average fasting plasma glucose levels in the first weeks of therapy compared to patients who were changed to LANTUS. Higher doses of TOUJEO were required to achieve similar levels of glucose control compared to LANTUS in clinical trials [see Clinical Studies (14.1)].

The onset of action of TOUJEO develops over 6 hours following an injection. In type 1 diabetes patients treated with IV insulin, consider the longer onset of action of TOUJEO before stopping IV insulin. The full glucose lowering effect may not be apparent for at least 5 days [see Dosage and Administration (2.2) and Clinical Pharmacology (12.2)].

To minimize the risk of hyperglycemia when initiating TOUJEO monitor glucose daily, titrate TOUJEO as described in this prescribing information, and adjust coadministered glucose-lowering therapies per standard of care [see Dosage and Administration (2.2, 2.3)].

5.3 Hypoglycemia

Hypoglycemia is the most common adverse reaction associated with insulin, including TOUJEO. Severe hypoglycemia can cause seizures, may be life- threatening, or cause death. Hypoglycemia can impair concentration ability and reaction time; this may place the patient and others at risk in situations where these abilities are important (e.g., driving, or operating other machinery). Hypoglycemia can happen suddenly, and symptoms may differ in each patient and change over time in the same patient. Symptomatic awareness of hypoglycemia may be less pronounced in patients with longstanding diabetes, in patients with diabetic neuropathy, in patients using drugs that block the sympathetic nervous system (e.g., beta-blockers) [see Drug Interactions (7)], or who experience recurrent hypoglycemia.

The long-acting effect of TOUJEO may delay recovery from hypoglycemia compared to shorter-acting insulins.

Risk Factors for Hypoglycemia

The timing of hypoglycemia usually reflects the time-action profile of the administered insulin formulation. As with all insulins, the glucose lowering effect time course of TOUJEO may vary in different patients or at different times in the same patient and depends on many conditions, including the area of injection as well as the injection site blood supply and temperature [see Clinical Pharmacology (12.2)]. 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 concomitant drugs [see Drug Interactions (7)]. Patients with renal or hepatic impairment may be at higher risk of hypoglycemia [see Use in Specific Populations (8.6, 8.7)].

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. To minimize the risk of hypoglycemia, do not administer TOUJEO intravenously, intramuscularly or in an insulin pump, or dilute or mix TOUJEO with any other insulin products or solutions.

5.4 Hypoglycemia Due to Medication Errors

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

To avoid dosing errors and potential overdose, never use a syringe to remove TOUJEO from the TOUJEO SoloStar or TOUJEO Max SoloStar prefilled pen into a syringe [see Dosage and Administration (2.4) and Warnings and Precautions (5.3)].

5.5 Hypersensitivity Reactions

Severe, life-threatening, generalized allergy, including anaphylaxis, can occur with insulins, including TOUJEO. If hypersensitivity reactions occur, discontinue TOUJEO; treat per standard of care and monitor until symptoms and signs resolve [see Adverse Reactions (6)]. TOUJEO is contraindicated in patients who have had hypersensitivity reactions to insulin glargine or any of the excipients in TOUJEO.

5.6 Hypokalemia

All insulins, including TOUJEO, 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 serum potassium concentrations).

5.7 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, when used in combination with insulin. Fluid retention may lead to or exacerbate heart failure. Patients treated with insulin, including TOUJEO, 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.

6 ADVERSE REACTIONS

The following adverse reactions are discussed elsewhere:

• Hypoglycemia [see Warnings and Precautions (5.3)]
• Hypoglycemia due to medication errors [see Warnings and Precautions (5.4)]
• Hypersensitivity reactions [see Warnings and Precautions (5.5)]
• Hypokalemia [see Warnings and Precautions (5.6)]

6.1 Clinical Trials 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 304 patients with type 1 diabetes to TOUJEO with mean exposure duration of 23 weeks. The type 1 diabetes population had the following characteristics: Mean age was 46 years and mean duration of diabetes was 21 years. Fifty-five percent were male, 86% were Caucasian, 5% were Black or African American, and 5% were Hispanic. At baseline, the mean eGFR was 82 mL/min/1.73 m2 and 35% of patients had eGFR ≥90 mL/min/1.73 m2. The mean BMI was 28 kg/m2. HbA1c at baseline was greater than or equal to 8% in 58% of patients.

The data in Table 2 reflect the exposure of 1242 patients with type 2 diabetes to TOUJEO with mean exposure duration of 25 weeks. The type 2 diabetes population had the following characteristics: Mean age was 59 years and mean duration of diabetes was 13 years. Fifty-three percent were male, 88% were Caucasian, 7% were Black or African American, and 17% were Hispanic. At baseline, mean eGFR was 79 mL/min/1.73 m2 and 27% of patients had an eGFR ≥90 mL/min/1.73 m2. The mean BMI was 35 kg/m2. HbA1c at baseline was greater than or equal to 8% in 66% of patients.

TOUJEO was studied in 233 pediatric patients (6–17 years of age) with type 1 diabetes for a mean duration of 26 weeks [see Clinical Studies (14.1)].

Common adverse reactions (occurring ≥5%) in TOUJEO-treated subjects during clinical trials in adult patients with type 1 diabetes mellitus and type 2 diabetes mellitus are listed in Table 1 and Table 2, respectively. Common adverse reactions for TOUJEO-treated pediatric subjects with type 1 diabetes mellitus were similar to the adverse reactions listed in Table 1. Hypoglycemia is discussed in a dedicated subsection below.

Table 1: Adverse Reactions Occurring ≥5% in Two Pooled Clinical Trials of 26 Weeks and 16 Weeks Duration in Adults with Type 1 Diabetes

	TOUJEO + Mealtime Insulin*, % (n=304)
"mealtime insulin" refers to insulin glulisine, insulin lispro, or insulin aspart.
Nasopharyngitis	12.8
Upper respiratory tract infection	9.5

Table 2: Adverse Reactions Occurring ≥5% in Three Pooled Clinical Trials of 26 Weeks Duration in Adults with Type 2 Diabetes

	TOUJEO*, % (n=1242)
one of the trials in type 2 diabetes included mealtime insulin.
Nasopharyngitis	7.1
Upper respiratory tract infection	5.7

Hypoglycemia

Hypoglycemia is the most commonly observed adverse reaction in patients treated with TOUJEO. 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 TOUJEO with the incidence of hypoglycemia for other products may be misleading and also may not be representative of hypoglycemia rates that will occur in clinical practice.

In the TOUJEO adult program, severe hypoglycemia was defined as an event requiring assistance of another person to administer a resuscitative action. In the pediatric program, severe hypoglycemia was defined as an event with semiconsciousness, unconsciousness, coma and/or convulsions in a patient who had altered mental status and could not assist in his own care, and who may have required glucagon or intravenous glucose.

The incidence of severe hypoglycemia in adult patients with type 1 diabetes receiving TOUJEO as part of a multiple daily injection regimen was 6.6% at 26 weeks. The incidence of hypoglycemia with a glucose level less than 54 mg/dL with or without symptoms was 77.7% at 26 weeks.

The incidence of severe hypoglycemia in pediatric patients with type 1 diabetes receiving TOUJEO as part of a multiple daily injection regimen was 6% at 26 weeks and the incidence of hypoglycemia accompanied by a self-monitored or plasma glucose value less than 54 mg/dL regardless of symptoms was 80.3%.

The incidence of severe hypoglycemia in adult patients with type 2 diabetes was 5% at 26 weeks in patients receiving TOUJEO as part of a multiple daily injection regimen, and 1.0% and 0.9% respectively at 26 weeks in the two studies where patients received TOUJEO as part of a basal-insulin only regimen. The incidence of hypoglycemia accompanied by a self-monitored or plasma glucose value less than 54 mg/dL regardless of symptoms in patients with type 2 diabetes receiving TOUJEO ranged from 9% to 44.6% at 26 weeks and the highest risk was again seen in patients receiving TOUJEO as part of a multiple daily injection regimen.

Insulin Initiation and Intensification of Glucose Control

Intensification or rapid improvement in glucose control has been associated with a transitory, reversible ophthalmologic refraction disorder, worsening of diabetic retinopathy, and acute painful peripheral neuropathy. However, long- term glycemic control decreases the risk of diabetic retinopathy and neuropathy.

Peripheral Edema

Insulin, including TOUJEO, may cause sodium retention and edema, particularly if previously poor metabolic control was improved by intensified insulin therapy.

Lipodystrophy

Long-term use of insulin, including TOUJEO, can cause lipoatrophy (depression in the skin) or lipohypertrophy (enlargement or thickening of tissue) in some patients and may affect insulin absorption [see Dosage and Administration (2.1)].

Weight Gain

Weight gain has occurred with insulins including TOUJEO and has been attributed to the anabolic effects of insulin and the decrease in glucosuria.

Hypersensitivity Reactions

Patients taking TOUJEO experienced erythema, local edema, and pruritus at the site of injection. These conditions were usually self-limiting.

Severe cases of generalized allergy (anaphylaxis) have been reported.

6.2 Immunogenicity

As with all therapeutic proteins, there is potential for immunogenicity.

In a 6-month study of type 1 diabetes patients, 79% of patients who received TOUJEO once daily were positive for anti-insulin antibodies (AIA) at least once during the study, including 62% that were positive at baseline and 44% of patients who developed antidrug antibody (i.e., anti-insulin glargine antibody [ADA]) during the study. Eighty percent of the AIA-positive patients on TOUJEO with antibody test at baseline remained AIA positive at month 6.

In two 6-month studies in type 2 diabetes patients, 25% of patients who received TOUJEO once daily were positive for AIA at least once during the study, including 42% who were positive at baseline and 20% of patients who developed ADA during the study. Ninety percent of the AIA-positive patients on TOUJEO with antibody test at baseline, remained AIA positive at month 6.

The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay and may be influenced by several factors such as: assay methodology, sample handling, timing of sample collection, concomitant medication, and underlying disease. For these reasons, comparison of the incidence of antibodies to TOUJEO with the incidence of antibodies in other studies or to other products may be misleading.

6.3 Postmarketing Experience

The following additional adverse reactions have been identified during postapproval use of TOUJEO. 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.

7 DRUG INTERACTIONS

Table 3 includes clinically significant drug interactions with TOUJEO.

Table 3: Clinically Significant Drug Interactions with TOUJEO

Drugs That May Increase the Risk of Hypoglycemia
Drugs:	Antidiabetic agents, ACE inhibitors, angiotensin II receptor blocking agents, disopyramide, fibrates, fluoxetine, monoamine oxidase inhibitors, pentoxifylline, pramlintide, salicylates, somatostatin analogs (e.g., octreotide), and sulfonamide antibiotics, GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT-2 inhibitors.
Intervention:	Dosage reductions and increased frequency of glucose monitoring may be required when TOUJEO is coadministered with these drugs.
Drugs That May Decrease the Blood Glucose Lowering Effect of TOUJEO
Drugs:	Atypical antipsychotics (e.g., olanzapine and clozapine), corticosteroids, danazol, diuretics, estrogens, glucagon, isoniazid, niacin, oral contraceptives, phenothiazines, progestogens (e.g., in oral contraceptives), protease inhibitors, somatropin, sympathomimetic agents (e.g., albuterol, epinephrine, terbutaline), and thyroid hormones.
Intervention:	Dosage increases and increased frequency of glucose monitoring may be required when TOUJEO is coadministered with these drugs.
Drugs That May Increase or Decrease the Blood Glucose Lowering Effect of TOUJEO
Drugs:	Alcohol, beta-blockers, clonidine, and lithium salts. Pentamidine may cause hypoglycemia, which may sometimes be followed by hyperglycemia.
Intervention:	Dosage adjustment and increased frequency of glucose monitoring may be required when TOUJEO is coadministered with these drugs.
Drugs That May Blunt Signs and Symptoms of Hypoglycemia
Drugs:	Beta-blockers, clonidine, guanethidine, and reserpine.
Intervention:	Increased frequency of glucose monitoring may be required when TOUJEO is coadministered with these drugs.

2 DOSAGE AND ADMINISTRATION

2.1 Important Administration Instructions

• Always check insulin labels before administration [see Warnings and Precautions (5.4)].
• Visually inspect the TOUJEO solution for particulate matter and discoloration prior to administration and only use if the solution is clear and colorless with no visible particles.
• Inject TOUJEO subcutaneously into the abdominal area, thigh, or deltoid.
• Rotate injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. Do not inject into areas of lipodystrophy or localized cutaneous amyloidosis [see Warnings and Precautions (5.2), Adverse Reactions (6)].
• Use TOUJEO with caution in patients with visual impairment who may rely on audible clicks to dial their dose.
• Do not administer TOUJEO intravenously or in an insulin pump.
• Do not dilute or mix TOUJEO with any other insulin products or solutions.
• Never transfer TOUJEO from the cartridges of the TOUJEO SoloStar or TOUJEO Max SoloStar prefilled pen into a syringe for administration [see Warnings and Precautions (5.4)].

2.2 General Dosing Instructions

• TOUJEO is available in 2 single-patient-use prefilled pens:
  • TOUJEO SoloStar contains 450 units of TOUJEO U-300. It delivers doses in 1-unit increments and can deliver up to 80 units in a single injection.
  • TOUJEO Max SoloStar contains 900 units of TOUJEO U-300. It delivers doses in 2-unit increments and can deliver up to 160 units in a single injection. It is recommended for patients requiring at least 20 units per day.
• When changing between TOUJEO SoloStar and TOUJEO Max SoloStar, if the patient's previous dose was an odd number, the dose should be increased or decreased by 1 unit to match the dose increments dialable on each prefilled pen.
• The dose counter of the TOUJEO SoloStar or TOUJEO Max SoloStar prefilled pen shows the number of units of TOUJEO to be injected and no conversion is required.
• Inject TOUJEO subcutaneously once a day at the same time of day.
• During changes to a patient's insulin regimen, increase the frequency of blood glucose monitoring [see Warnings and Precautions (5.2)].
• Individualize and titrate the dosage of TOUJEO based on the patient's metabolic needs, blood glucose monitoring results, and glycemic control goal.
• Titrate the dose of TOUJEO no more frequently than every 3 to 4 days.
• Dosage adjustments may be needed with changes in physical activity, 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 (5.2) and Use in Specific Populations (8.6, 8.7)].

2.3 Starting Dose in Insulin-Naive Pediatric and Adult Patients

Recommended Starting Dosage in Patients with Type 1 Diabetes

• The recommended starting dose of TOUJEO in insulin-naive patients with type 1 diabetes is approximately one-third to one-half of the total daily insulin dose. The remainder of the total daily insulin dose should be given as a short-acting insulin and divided between each daily meal. As a general rule, 0.2 to 0.4 units of insulin per kilogram of body weight can be used to calculate the initial total daily insulin dose in insulin-naive patients with type 1 diabetes.
• The maximum glucose lowering effect of a dose of TOUJEO may take five days to fully manifest and the first TOUJEO dose may be insufficient to cover metabolic needs in the first 24 hours of use [see Clinical Pharmacology (12.2)]. When initiating TOUJEO, monitor glucose daily.

Recommended Starting Dosage in Patients with Type 2 Diabetes

• The recommended starting dose of TOUJEO in insulin-naive patients with type 2 diabetes is 0.2 units per kilogram of body weight once daily.

2.4 Starting Dose in Pediatric and Adult Patients with Either Type 1 or

Type 2 Diabetes Already on Insulin Therapy

Dosage adjustments are recommended to lower the risk of hypoglycemia when switching patients to TOUJEO from another insulin therapy [see Warnings and Precautions (5.3)].

• For patients currently on once-daily long or intermediate-acting insulin, start TOUJEO at the same unit dose as the once-daily long-acting insulin dose. For patients controlled on LANTUS (insulin glargine, 100 units/mL), expect that a higher daily dose of TOUJEO will be needed to maintain the same level of glycemic control [see Clinical Pharmacology (12.2) and Clinical Studies (14.1)].
• For patients currently on twice-daily long or intermediate-acting insulin, start TOUJEO at 80% of the total daily NPH or insulin detemir twice-daily dosage.
• When switching patients to TOUJEO, monitor glucose frequently in the first weeks of therapy [see Warnings and Precautions (5.2) and Clinical Pharmacology (12.2)].

14 CLINICAL STUDIES

14.1 Overview of Clinical Studies

The safety and effectiveness of TOUJEO given once daily was compared to that of once-daily LANTUS in 26-week, open-label, randomized, active-control, parallel studies of 546 adult patients and 463 pediatric patients with type 1 diabetes mellitus and 2,474 patients with type 2 diabetes mellitus (Tables 4 and 5). At trial end, the reduction in glycated hemoglobin (HbA1c) and fasting plasma glucose with TOUJEO titrated to goal was similar to that with LANTUS titrated to goal. At the end of the trial, depending on the patient population and concomitant therapy, patients were receiving a higher dose of TOUJEO than LANTUS.

14.2 Clinical Study in Adult and Pediatric Patients with Type 1 Diabetes

Adult Patients with Type 1 Diabetes

In an open-label, controlled study (Study A), patients with type 1 diabetes (n=546), were randomized to basal-bolus treatment with TOUJEO or LANTUS and treated for 26 weeks. TOUJEO and LANTUS were administered once daily in the morning (time period covering from pre-breakfast until pre-lunch) or in the evening (time period defined as prior to the evening meal until at bedtime). A mealtime insulin analogue was administered before each meal. Mean age was 47years and mean duration of diabetes was 21 years. Fifty-seven percent were male, 85% were Caucasian, 5% Black or African American, and 5% were Hispanic; 32% of patients had GFR >90 mL/min/1.73 m2. The mean BMI was approximately 27.6 kg/m2. At week 26, treatment with TOUJEO provided a mean reduction in HbA1c that met the prespecified noninferiority margin of 0.4% (Table 4). Patients treated with TOUJEO used 18% more basal insulin than patients treated with LANTUS. There were no clinically important differences in glycemic control when TOUJEO was administered once daily in the morning or in the evening. There were no clinically important differences in body weight between treatment groups.

Table 4: Type 1 Diabetes Mellitus – Adult Patients (TOUJEO plus mealtime insulin versus LANTUS plus mealtime insulin)

	TOUJEO + Mealtime Insulin*	LANTUS + Mealtime Insulin*
"mealtime insulin" refers to insulin glulisine, insulin lispro or insulin aspart. † mITT: Modified intention-to-treat population. ‡ Treatment difference: TOUJEO – LANTUS.
Treatment duration	26 weeks
Treatment in combination with	Fast-acting insulin analogue
Number of subjects treated (mITT†)	273	273
HbA1c (%)
Baseline mean	8.13	8.12
Adjusted mean change from baseline	-0.40	-0.44
Adjusted mean difference‡ [95% Confidence Interval]	0.04 [-0.10 to 0.18]
Fasting Plasma Glucose mg/dL
Baseline mean	186	199
Adjusted mean change from baseline	-17	-20
Adjusted mean difference‡ [95% Confidence Interval]	3 [-10 to 16]

Pediatric Patients with Type 1 Diabetes

The efficacy of TOUJEO was evaluated in a 26-week, randomized, open-label, multicenter trial (Study B) in 463 pediatric patients with type 1 diabetes mellitus. Patients were randomized to basal-bolus treatment with TOUJEO or LANTUS and treated for 26 weeks. TOUJEO and LANTUS were administered once daily in the morning or in the evening. A mealtime insulin analogue was administered before each meal.

The mean age of the trial population was 13 years; 31% were <12 years of age, 69% were ages ≥12 years of age. The mean duration of diabetes was 6 years. Of the 463 pediatric patients, 51% were male, 92% were White, 3% were Black or African American, and 30% were Hispanic. The mean baseline BMI percentile was 68.32.

At week 26, the difference in HbA1c reduction from baseline between TOUJEO and LANTUS was 0.02% with a 95% confidence interval (-0.16%; 0.20%) and met the prespecified noninferiority margin (0.3%). The results are presented in Table 5.

Table 5: Type 1 Diabetes Mellitus – Pediatric Patients at 26 weeks (TOUJEO plus mealtime insulin versus LANTUS plus mealtime insulin)

	TOUJEO + Mealtime Insulin*	LANTUS + Mealtime Insulin*
"mealtime insulin" refers to insulin glulisine, insulin lispro or insulin aspart. † ITT: Intention-to-treat: all randomized subjects. ‡ At week 26, change in HbA1c was missing for 3.9% and 4.3% of subjects, and change in FPG was missing for 12.4% and 12.2% of subjects, in TOUJEO and LANTUS respectively. Missing values were imputed with return-to-baseline method for subjects who permanently discontinued the treatment. § Treatment difference: TOUJEO – LANTUS.
Number of subjects (ITT†)	233	230
HbA1c (%)‡
Baseline mean	8.65	8.61
Adjusted Mean change from baseline	-0.386	-0.404
Adjusted Mean difference§ [95% Confidence Interval]	0.018 [-0.159, 0.195]
Fasting Plasma Glucose (mg/dL)‡
Baseline mean	202.70	204.51
Adjusted Mean change from baseline	-10.447	-10.633
Adjusted Mean difference§ [95% Confidence Interval]	0.185 [-18.131, 18.501]

14.3 Clinical Studies in Adult Patients with Type 2 Diabetes

In a 26-week open-label, controlled study (Study C, n=804), adults with type 2 diabetes were randomized to once-daily treatment in the evening with either TOUJEO or LANTUS. Short-acting mealtime insulin analogues with or without metformin were also administered. The average age was 60 years. The majority of patients were White (92%) and 53% were male; 20% of patients had GFR >90 mL/min/1.73 m2. The mean BMI was approximately 36.6 kg/m2. At week 26, treatment with TOUJEO provided a mean reduction in HbA1c that met the prespecified noninferiority margin of 0.4% compared to LANTUS (Table 6). Patients treated with TOUJEO used 11% more basal insulin than patients treated with LANTUS. There were no clinically important differences in body weight between treatment groups.

In two open-label, controlled studies (n=1670), adults with type 2 diabetes mellitus were randomized to either TOUJEO or LANTUS once daily for 26 weeks as part of a regimen of combination therapy with noninsulin antidiabetic drugs. At the time of randomization, 808 patients were treated with basal insulin for more than 6 months (Study D) and 862 patients were insulin-naive (Study E).

In Study D, the average age was 58.2 years. The majority of patients were White (94%) and 46% were male; 33% of patients had GFR >90 mL/min/1.73 m2. The mean BMI was approximately 34.8 kg/m2. At week 26, treatment with TOUJEO provided a mean reduction in HbA1c that met the prespecified noninferiority margin of 0.4% compared to LANTUS (Table 6). Patients treated with TOUJEO used 12% more basal insulin than patients treated with LANTUS. There were no clinically important differences in body weight between treatment groups.

In Study E, the average age was 58 years. The majority of patients were White (78%) and 58% were male; 29% of patients had GFR >90 mL/min/1.73 m2. The mean BMI was approximately 33 kg/m2. At week 26, treatment with TOUJEO provided a mean reduction in HbA1c that met the prespecified noninferiority margin compared to LANTUS (Table 6). Patients treated with TOUJEO used 15% more basal insulin than patients treated with LANTUS. There were no clinically important differences in body weight between treatment groups.

Table 6: Type 2 Diabetes Mellitus – Adult

	Study C	Study D	Study E
m-ITT population: Modified intention-to-treat population. † Treatment difference: TOUJEO – LANTUS.
Treatment duration	26 weeks	26 weeks	26 weeks
Treatment in combination with	Mealtime insulin analog ± metformin	Noninsulin antidiabetic drugs
	TOUJEO	LANTUS	TOUJEO	LANTUS	TOUJEO	LANTUS
Number of patients treated*	404	400	403	405	432	430
HbA1c (%)
Baseline mean	8.13	8.14	8.27	8.22	8.49	8.58
Adjusted mean change from baseline	-0.90	-0.87	-0.73	-0.70	-1.42	-1.46
Adjusted mean difference†	-0.03	-0.03	0.04
[95% Confidence interval]	[-0.14 to 0.08]	[-0.17 to 0.10]	[-0.09 to 0.17]
Fasting Plasma Glucose (mg/dL)
Baseline mean	157	160	149	142	179	184
Adjusted mean change from baseline	-29	-30	-18	-22	-61	-68
Adjusted mean difference†	0.8	3	7
[95% Confidence interval]	[-5 to 7]	[-3 to 9]	[2 to 12]

Cardiovascular Safety

No clinical studies to establish the cardiovascular safety of TOUJEO have been conducted. A cardiovascular outcomes trial, ORIGIN, has been conducted with LANTUS. It is unknown whether the results of ORIGIN can be applied to TOUJEO.

The Outcome Reduction with Initial Glargine Intervention trial (i.e., ORIGIN) was an open-label, randomized, 12,537 patient study that compared LANTUS to standard care on the time to first occurrence of a major adverse cardiovascular event (MACE). MACE was defined as the composite of CV death, nonfatal myocardial infarction, and nonfatal stroke. The incidence of MACE was similar between LANTUS and standard care in ORIGIN (Hazard Ratio [95% CI] for MACE; 1.02 [0.94, 1.11]).

In the ORIGIN trial, the overall incidence of cancer (all types combined) (Hazard Ratio [95% CI]; 0.99 [0.88, 1.11]) or death from cancer (Hazard Ratio [95% CI]; 0.94 [0.77, 1.15]) was also similar between treatment groups.

17 PATIENT COUNSELING INFORMATION

Advise the patient to read the FDA-approved patient labeling (Patient Information and Instructions for Use). There are separate Instructions for Use for TOUJEO SoloStar and TOUJEO Max SoloStar.

Never Share a TOUJEO SoloStar or TOUJEO Max SoloStar Pen Between Patients

Advise patients that they must never share TOUJEO SoloStar or TOUJEO Max SoloStar pen with another person even if the needle is changed. Pen sharing poses a risk for transmission of blood-borne pathogens [see Warnings and Precautions (5.1)].

Hyperglycemia or Hypoglycemia

Inform patients that hypoglycemia is the most common adverse reaction with insulin. Inform patients of the symptoms of hypoglycemia (e.g., impaired ability to concentrate and react). This may present a risk in situations where these abilities are especially important, such as driving or operating other machinery. Advise patients who have frequent hypoglycemia or reduced or absent warning signs of hypoglycemia to use caution when driving or operating machinery [see Warnings and Precautions (5.2, 5.3)].

Advise patients that changes in insulin regimen can predispose to hyperglycemia or hypoglycemia and that changes in insulin regimen should be made under close medical supervision [see Warnings and Precautions (5.2)].

Inform patients that if they change to TOUJEO from other basal insulins they may experience higher average fasting plasma glucose levels in the first weeks of therapy. Advise patients to monitor glucose daily when initiating TOUJEO [see Warnings and Precautions (5.2)].

Hypoglycemia Due to Medication Errors

Instruct patients to always check the insulin label before each injection [see Warnings and Precautions (5.4)]. The "300 units/mL (U-300)" is highlighted in honey gold on the labels of TOUJEO and TOUJEO Max SoloStar single-patient-use prefilled pens.

Inform patients that TOUJEO (insulin glargine) 300 units/mL contains 3 times as much insulin in 1 mL as insulin glargine 100 units/mL. To avoid dosing errors and potential overdose, instruct patients to never use a syringe to remove TOUJEO from the TOUJEO SoloStar or TOUJEO Max SoloStar single-patient- use prefilled pen [see Warnings and Precautions (5.4)].

Inform patients that the dose counter of TOUJEO SoloStar or TOUJEO Max SoloStar single-patient-use prefilled pen shows the number of units of TOUJEO to be injected and no dose recalculation is required [see Dosage and Administration (2.1, 2.4)].

Hypersensitivity Reactions

Advise patients that hypersensitivity reactions have occurred with TOUJEO. Inform patients on the symptoms of hypersensitivity reactions [see Warnings and Precautions (5.5)].