Lopid® (gemfibrozil tablets, USP) is a lipid regulating agent. It is available as tablets for oral administration. Each tablet contains 600 mg gemfibrozil. Each also contains calcium stearate, NF; candelilla wax FCC; microcrystalline cellulose, NF; hydroxypropyl cellulose, NF: hydroxypropyl methylcellulose, USP; methylparaben, NF; Opaspray white; polyethylene glycol, NF; polysorbate 80, NF; propylparaben, NF; colloidal silicon dioxide, NF; pregelatinized starch, NF. The chemical name is 5-(2,5-dimethylphenoxy)-2,2-dimethylpentanoic acid with the following structural formula:

The empirical formula is C ₁₅ H ₂₂ O ₃ and the molecular weight is 250.35; the solubility in water and acid is 0.0019% and in dilute base it is greater than 1%. The melting point is 58°-61°C. Gemfibrozil is a white solid which is stable under ordinary conditions.

Lopid (gemfibrozil tablets, USP) is a lipid regulating agent which decreases serum triglycerides and very low density lipoprotein (VLDL) cholesterol, and increases high density lipoprotein (HDL) cholesterol. While modest decreases in total and low density lipoprotein (LDL) cholesterol may be observed with Lopid therapy, treatment of patients with elevated triglycerides due to Type IV hyperlipoproteinemia often results in a rise in LDL-cholesterol. LDL-cholesterol levels in Type IIb patients with elevations of both serum LDL-cholesterol and triglycerides are, in general, minimally affected by Lopid treatment; however, Lopid usually raises HDL-cholesterol significantly in this group. Lopid increases levels of high density lipoprotein (HDL) subfractions HDL ₂ and HDL ₃ , as well as apolipoproteins AI and AII. Epidemiological studies have shown that both low HDL-cholesterol and high LDL-cholesterol are independent risk factors for coronary heart disease.

In the primary prevention component of the Helsinki Heart Study (refs. 1,2), in which 4081 male patients between the ages of 40 and 55 were studied in a randomized, double-blind, placebo-controlled fashion, Lopid therapy was associated with significant reductions in total plasma triglycerides and a significant increase in high density lipoprotein cholesterol. Moderate reductions in total plasma cholesterol and low density lipoprotein cholesterol were observed for the Lopid treatment group as a whole, but the lipid response was heterogeneous, especially among different Fredrickson types. The study involved subjects with serum non-HDL-cholesterol of over 200 mg/dL and no previous history of coronary heart disease. Over the 5-year study period, the Lopid group experienced a 1.4% absolute (34% relative) reduction in the rate of serious coronary events (sudden cardiac deaths plus fatal and nonfatal myocardial infarctions) compared to placebo, p = 0.04 (see Table I). There was a 37% relative reduction in the rate of nonfatal myocardial infarction compared to placebo, equivalent to a treatment-related difference of 13.1 events per thousand persons. Deaths from any cause during the double-blind portion of the study totaled 44 (2.2%) in the Lopid randomization group and 43 (2.1%) in the placebo group.

Among Fredrickson types, during the 5-year double-blind portion of the primary prevention component of the Helsinki Heart Study, the greatest reduction in the incidence of serious coronary events occurred in Type IIb patients who had elevations of both LDL-cholesterol and total plasma triglycerides. This subgroup of Type IIb gemfibrozil group patients had a lower mean HDL-cholesterol level at baseline than the Type IIa subgroup that had elevations of LDL-cholesterol and normal plasma triglycerides. The mean increase in HDL-cholesterol among the Type IIb patients in this study was 12.6% compared to placebo. The mean change in LDL-cholesterol among Type IIb patients was -4.1% with Lopid compared to a rise of 3.9% in the placebo subgroup. The Type IIb subjects in the Helsinki Heart Study had 26 fewer coronary events per thousand persons over 5 years in the gemfibrozil group compared to placebo. The difference in coronary events was substantially greater between Lopid and placebo for that subgroup of patients with the triad of LDL-cholesterol >175 mg/dL (>4.5 mmol), triglycerides >200 mg/dL (>2.2 mmol), and HDL-cholesterol <35 mg/dL (<0.90 mmol) (see Table I).

Further information is available from a 3.5 year (8.5 year cumulative) follow-up of all subjects who had participated in the Helsinki Heart Study. At the completion of the Helsinki Heart study, subjects could choose to start, stop, or continue to receive Lopid; without knowledge of their own lipid values or double-blind treatment, 60% of patients originally randomized to placebo began therapy with Lopid and 60% of patients originally randomized to Lopid continued medication. After approximately 6.5 years following randomization, all patients were informed of their original treatment group and lipid values during the 5 years of the double-blind treatment. After further elective changes in Lopid treatment status, 61% of patients in the group originally randomized to Lopid were taking drug; in the group originally randomized to placebo, 65% were taking Lopid. The event rate per 1000 occurring during the open-label follow-up period is detailed in Table II.

Lopid (gemfibrozil tablets, USP) is indicated as adjunctive therapy to diet for:

1. Treatment of adult patients with very high elevations of serum triglyceride levels (Types IV and V hyperlipidemia) who present a risk of pancreatitis and who do not respond adequately to a determined dietary effort to control them. Patients who present such risk typically have serum triglycerides over 2000 mg/dL and have elevations of VLDL-cholesterol as well as fasting chylomicrons (Type V hyperlipidemia). Subjects who consistently have total serum or plasma triglycerides below 1000 mg/dL are unlikely to present a risk of pancreatitis. Lopid therapy may be considered for those subjects with triglyceride elevations between 1000 and 2000 mg/dL who have a history of pancreatitis or of recurrent abdominal pain typical of pancreatitis. It is recognized that some Type IV patients with triglycerides under 1000 mg/dL may, through dietary or alcoholic indiscretion, convert to a Type V pattern with massive triglyceride elevations accompanying fasting chylomicronemia, but the influence of Lopid therapy on the risk of pancreatitis in such situations has not been adequately studied. Drug therapy is not indicated for patients with Type I hyperlipoproteinemia, who have elevations of chylomicrons and plasma triglycerides, but who have normal levels of very low density lipoprotein (VLDL). Inspection of plasma refrigerated for 14 hours is helpful in distinguishing Types I, IV, and V hyperlipoproteinemia (ref. 5).
2. Reducing the risk of developing coronary heart disease only in Type IIb patients without history of or symptoms of existing coronary heart disease who have had an inadequate response to weight loss, dietary therapy, exercise, and other pharmacologic agents (such as bile acid sequestrants and nicotinic acid, known to reduce LDL- and raise HDL-cholesterol and who have the following triad of lipid abnormalities: low HDL-cholesterol levels in addition to elevated LDL-cholesterol and elevated triglycerides (see , PRECAUTIONS , and ). The National Cholesterol Education Program has defined a serum HDL-cholesterol value that is consistently below 35 mg/dL as constituting an independent risk factor for coronary heart disease (ref. 6). Patients with significantly elevated triglycerides should be closely observed when treated with gemfibrozil. In some patients with high triglyceride levels, treatment with gemfibrozil is associated with a significant increase in LDL-cholesterol. BECAUSE OF POTENTIAL TOXICITY SUCH AS MALIGNANCY, GALLBLADDER DISEASE, ABDOMINAL PAIN LEADING TO APPENDECTOMY AND OTHER ABDOMINAL SURGERIES, AN INCREASED INCIDENCE IN NONCORONARY MORTALITY, AND THE 44% RELATIVE INCREASE DURING THE TRIAL PERIOD IN AGE-ADJUSTED ALL-CAUSE MORTALITY SEEN WITH THE CHEMICALLY AND PHARMACOLOGICALLY RELATED DRUG, CLOFIBRATE, THE POTENTIAL BENEFIT OF GEMFIBROZIL IN TREATING TYPE IIA PATIENTS WITH ELEVATIONS OF LDL-CHOLESTEROL ONLY IS NOT LIKELY TO OUTWEIGH THE RISKS. LOPID IS ALSO NOT INDICATED FOR THE TREATMENT OF PATIENTS WITH LOW HDL-CHOLESTEROL AS THEIR ONLY LIPID ABNORMALITY.

In a subgroup analysis of patients in the Helsinki Heart Study with above-median HDL-cholesterol values at baseline (greater than 46.4 mg/dL), the incidence of serious coronary events was similar for gemfibrozil and placebo subgroups (see Table I).

The initial treatment for dyslipidemia is dietary therapy specific for the type of lipoprotein abnormality. Excess body weight and excess alcohol intake may be important factors in hypertriglyceridemia and should be managed prior to any drug therapy. Physical exercise can be an important ancillary measure, and has been associated with rises in HDL-cholesterol. Diseases contributory to hyperlipidemia such as hypothyroidism or diabetes mellitus should be looked for and adequately treated. Estrogen therapy is sometimes associated with massive rises in plasma triglycerides, especially in subjects with familial hypertriglyceridemia. In such cases, discontinuation of estrogen therapy may obviate the need for specific drug therapy of hypertriglyceridemia. The use of drugs should be considered only when reasonable attempts have been made to obtain satisfactory results with nondrug methods. If the decision is made to use drugs, the patient should be instructed that this does not reduce the importance of adhering to diet

CONTRAINDICATIONS

1. Hepatic or severe renal dysfunction, including primary biliary cirrhosis.
2. Preexisting gallbladder disease (see ).
3. Hypersensitivity to gemfibrozil.

1. Because of chemical, pharmacological, and clinical similarities between gemfibrozil and clofibrate, the adverse findings with clofibrate in two large clinical studies may also apply to gemfibrozil. In the first of those studies, the Coronary Drug Project, 1000 subjects with previous myocardial infarction were treated for 5 years with clofibrate. There was no difference in mortality between the clofibrate-treated subjects and 3000 placebo-treated subjects, but twice as many clofibrate-treated subjects developed cholelithiasis and cholecystitis requiring surgery. In the other study, conducted by the World Health Organization (WHO), 5000 subjects without known coronary heart disease were treated with clofibrate for 5 years and followed one year beyond. There was a statistically significant, 44%, higher age-adjusted total mortality in the clofibrate-treated than in a comparable placebo-treated control group during the trial period. The excess mortality was due to a 33% increase in noncardiovascular causes, including malignancy, post-cholecystectomy complications, and pancreatitis. The higher risk of clofibrate-treated subjects for gallbladder disease was confirmed.
   Because of the more limited size of the Helsinki Heart Study, the observed difference in mortality from any cause between the Lopid and placebo group is not statistically significantly different from the 29% excess mortality reported in the clofibrate group in the separate WHO study at the 9 year follow-up (see ). Noncoronary heart disease related mortality showed an excess in the group originally randomized to Lopid primarily due to cancer deaths observed during the open-label extension.
   During the 5 year primary prevention component of the Helsinki Heart Study mortality from any cause was 44 (2.2%) in the Lopid group and 43 (2.1%) in the placebo group; including the 3.5 year follow-up period since the trial was completed, cumulative mortality from any cause was 101 (4.9%) in the Lopid group and 83 (4.1%) in the group originally randomized to placebo (hazard ratio 1.20 in favor of placebo). Because of the more limited size of the Helsinki Heart Study, the observed difference in mortality from any cause between the Lopid and placebo groups at year-5 or at year-8.5 is not statistically significantly different from the 29% excess mortality reported in the clofibrate group in the separate WHO study at the 9 year follow-up. Noncoronary heart disease related mortality showed an excess in the group originally randomized to Lopid at the 8.5 year follow-up (65 Lopid versus 45 placebo noncoronary deaths).
   The incidence of cancer (excluding basal cell carcinoma) discovered during the trial and in the 3.5 years after the trial was completed was 51 (2.5%) in both originally randomized groups. In addition, there were 16 basal cell carcinomas in the group originally randomized to Lopid and 9 in the group randomized to placebo (p = 0.22). There were 30 (1.5%) deaths attributed to cancer in the group originally randomized to Lopid and 18 (0.9%) in the group originally randomized to placebo (p = 0.11). Adverse outcomes, including coronary events, were higher in gemfibrozil patients in a corresponding study in men with a history of known or suspected coronary heart disease in the secondary prevention component of the Helsinki Heart Study. (See .)
   A comparative carcinogenicity study was also done in rats comparing three drugs in this class: fenofibrate (10 and 60 mg/kg; 0.3 and 1.6 times the human dose), clofibrate (400 mg/kg; 1.6 times the human dose), and gemfibrozil (250 mg/kg; 1.7 times the human dose). Pancreatic acinar adenomas were increased in males and females on fenofibrate; hepatocellular carcinoma and pancreatic acinar adenomas were increased in males and hepatic neoplastic nodules in females treated with clofibrate; hepatic neoplastic nodules were increased in males and females treated with gemfibrozil while testicular interstitial cell (Leydig cell) tumors were increased in males on all three drugs.
2. A gallstone prevalence substudy of 450 Helsinki Heart Study participants showed a trend toward a greater prevalence of gallstones during the study within the Lopid treatment group (7.5% vs 4.9% for the placebo group, a 55% excess for the gemfibrozil group). A trend toward a greater incidence of gallbladder surgery was observed for the Lopid group (17 vs 11 subjects, a 54% excess). This result did not differ statistically from the increased incidence of cholecystectomy observed in the WHO study in the group treated with clofibrate. Both clofibrate and gemfibrozil may increase cholesterol excretion into the bile leading to cholelithiasis. If cholelithiasis is suspected, gallbladder studies are indicated. Lopid therapy should be discontinued if gallstones are found.
3. Since a reduction of mortality from coronary heart disease has not been demonstrated and because liver and interstitial cell testicular tumors were increased in rats, Lopid should be administered only to those patients described in the section. If a significant serum lipid response is not obtained, Lopid should be discontinued.
4. Concomitant Anticoagulants--Caution should be exercised when anticoagulants are given in conjunction with Lopid. The dosage of the anticoagulant should be reduced to maintain the prothrombin time at the desired level to prevent bleeding complications. Frequent prothrombin determinations are advisable until it has been definitely determined that the prothrombin level has stabilized.
5. Concomitant therapy with Lopid and Mevacor® (lovastatin) has been associated with rhabdomyolysis, markedly elevated creatine kinase (CK) levels and myoglobinuria, leading in a high proportion of cases to acute renal failure. IN VIRTUALLY ALL PATIENTS WHO HAVE HAD AN UNSATISFACTORY LIPID RESPONSE TO EITHER DRUG ALONE, ANY POTENTIAL LIPID BENEFIT OF COMBINED THERAPY WITH LOVASTATIN AND GEMFIBROZIL DOES NOT OUTWEIGH THE RISKS OF SEVERE MYOPATHY, RHABDOMYOLYSIS, AND ACUTE RENAL FAILURE (see Drug Interactions). The use of fibrates alone, including Lopid, may occasionally be associated with myositis. Patients receiving Lopid and complaining of muscle pain, tenderness, or weakness should have prompt medical evaluation for myositis, including serum creatine kinase level determination. If myositis is suspected or diagnosed, Lopid therapy should be withdrawn.
6. Cataracts--Subcapsular bilateral cataracts occurred in 10% and unilateral in 6.3% of male rats treated with gemfibrozil at 10 times the human dose.

PRECAUTIONS

  1. Initial Therapy-- Laboratory studies should be done to ascertain that the lipid levels are consistently abnormal. Before instituting Lopid therapy, every attempt should be made to control serum lipids with appropriate diet, exercise, weight loss in obese patients, and control of any medical problems such as diabetes mellitus and hypothryroidism that are contributing to the lipid abnormalities.

 2. Continued Therapy-- Periodic determination of serum lipids should be obtained, and the drug withdrawn if lipid response is inadequate after 3 months of therapy.

 3. Drug Interactions--(A) HMG-CoA reductase inhibitors: Rhabdomyolysis has occurred with combined gemfibrozil and lovastatin therapy. It may be seen as early as 3 weeks after initiation of combined therapy or after several months. In most subjects who have had an unsatisfactory lipid response to either drug alone, the possible benefit of combined therapy with lovastatin (or other HMG-CoA reductase inhibitors) and gemfibrozil does not outweigh the risks of severe myopathy, rhabdomyolysis, and acute renal failure. There is no assurance that periodic monitoring of creatine kinase will prevent the occurrence of severe myopathy and kidney damage.

(B) Anticoagulants: CAUTION SHOULD BE EXERCISED WHEN ANTICOAGULANTS ARE GIVEN IN CONJUNCTION WITH LOPID. THE DOSAGE OF THE ANTICOAGULANT SHOULD BE REDUCED TO MAINTAIN THE PROTHROMBIN TIME AT THE DESIRED LEVEL TO PREVENT BLEEDING COMPLICATIONS. FREQUENT PROTHROMBIN DETERMINATIONS ARE ADVISABLE UNTIL IT HAS BEEN DEFINITELY DETERMINED THAT THE PROTHROMBIN LEVEL HAS STABILIZED.

 4. Carcinogenesis, Mutagenesis, Impairment of Fertility-- Long-term studies have been conducted in rats at 0.2 and 1.3 times the human exposure (based on AUC). Based on two-week toxicokinetic studies, exposure (AUC) of the dose groups was estimated to be 0.2 and 1.3 times the human exposure. The incidence of benign liver nodules and liver carcinomas was significantly increased in high dose male rats. The incidence of liver carcinomas increased also in low dose males, but this increase was not statistically significant (p=0.1). Male rats had a dose-related and statistically significant increase of benign Leydig cell tumors. The higher dose female rats had a significant increase in the combined incidence of benign and malignant liver neoplasms.

Long-term studies have been conducted in mice at 0.1 and 0.7 times the human exposure (based on AUC). There were no statistically significant differences from controls in the incidence of liver tumors, but the doses tested were lower than those shown to be carcinogenic with other fibrates.

Electron microscopy studies have demonstrated a florid hepatic peroxisome proliferation following Lopid administration to the male rat. An adequate study to test for peroxisome proliferation has not been done in humans, but changes in peroxisome morphology have been observed. Peroxisome proliferation has been shown to occur in humans with either of two other drugs of the fibrate class when liver biopsies were compared before and after treatment in the same individual.

Administration of approximately 0.6 and 2 times the human dose (based on surface area) to male rats for 10 weeks resulted in a dose-related decrease of fertility. Subsequent studies demonstrated that this effect was reversed after a drug-free period of about eight weeks, and it was not transmitted to the offspring.

 5. Pregnancy Category C-- Lopid has been shown to produce adverse effects in rats and rabbits at doses between 0.5 and 3 times the human dose (based on surface area). There are no adequate and well-controlled studies in pregnant women. Lopid should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Administration of Lopid to female rats at 0.6 and 2 times the human dose (based on surface area) before and throughout gestation caused a dose-related decrease in conception rate and, at the high dose, an increase in stillborns and a slight reduction in pup weight during lactation. There were also dose-related increased skeletal variations. Anophthalmia occurred, but rarely.

Administration of 0.6 and 2 times the human dose (based on surface area) of Lopid to female rats from gestation day 15 through weaning caused dose-related decreases in birth weight and suppressions of pup growth during lactation.

Administration of 1 and 3 times the human dose (based on surface area) of Lopid to female rabbits during organogenesis caused a dose-related decrease in litter size and, at the high dose, an increased incidence of parietal bone variations.

 6. Nursing Mothers-- It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for tumorigenicity shown for Lopid in animal studies, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

 7. Hematologic Changes-- Mild hemoglobin, hematocrit and white blood cell decreases have been observed in occasional patients following initiation of Lopid therapy. However, these levels stabilize during long-term administration. Rarely, severe anemia, leukopenia, thrombocytopenia, and bone marrow hypoplasia have been reported. Therefore, periodic blood counts are recommended during the first 12 months of Lopid administration.

 8. Liver Function-- Abnormal liver function tests have been observed occasionally during Lopid administration, including elevations of AST (SGOT), ALT (SGPT), LDH, bilirubin, and alkaline phosphatase. These are usually reversible when Lopid is discontinued. Therefore periodic liver function studies are recommended and Lopid therapy should be terminated if abnormalities persist.

 9. Kidney Function-- There have been reports of worsening renal insufficiency upon the addition of Lopid therapy in individuals with baseline plasma creatinine >2.0 mg/dL. In such patients, the use of alternative therapy should be considered against the risks and benefits of a lower dose of Lopid.

10. Use in Pediatric Patients-- Safety and efficacy in pediatric patients have not been established.

ADVERSE REACTIONS

In the double-blind controlled phase of the primary prevention component of the Helsinki Heart Study, 2046 patients received Lopid for up to 5 years. In that study, the following adverse reactions were statistically more frequent in subjects in the Lopid group:

Adverse events reported by more than 1% of subjects, but without a significant difference between groups:

Gallbladder surgery was performed in 0.9% of Lopid and 0.5% of placebo subjects in the primary prevention component, a 64% excess, which is not statistically different from the excess of gallbladder surgery observed in the clofibrate compared to the placebo group of the WHO study. Gallbladder surgery was also performed more frequently in the Lopid group compared to placebo (1.9% vs 0.3%, p = 0.07) in the secondary prevention component. A statistically significant increase in appendectomy in the gemfibrozil group was seen also in the secondary prevention component (6 on gemfibrozil vs 0 on placebo, p = 0.014).

Nervous system and special senses adverse reactions were more common in the Lopid group. These included hypesthesia, paresthesias, and taste perversion. Other adverse reactions that were more common among Lopid treatment group subjects but where a causal relationship was not established include cataracts, peripheral vascular disease, and intracerebral hemorrhage.

From other studies it seems probable that Lopid is causally related to the occurrence of MUSCULOSKELETAL SYMPTOMS (see ), and to ABNORMAL LIVER FUNCTION TESTS and HEMATOLOGIC CHANGES (see PRECAUTIONS).

Reports of viral and bacterial infections (common cold, cough, urinary tract infections) were more common in gemfibrozil treated patients in other controlled clinical trials of 805 patients. Additional adverse reactions that have been reported for gemfibrozil are listed below by system. These are categorized according to whether a causal relationship to treatment with Lopid is probable or not established:

DOSAGE AND ADMINISTRATION

The recommended dose for adults is 1200 mg administered in two divided doses 30 minutes before the morning and evening meal (see ).

OVERDOSAGE

There have been reported cases of overdosage with Lopid. In one case a 7 year old child recovered after ingesting up to 9 grams of Lopid. Symptomatic supportive measures should be taken should an overdose occur.

HOW SUPPLIED

Lopid (Tablet 737), white, elliptical, film-coated, scored tablets, each containing 600 mg gemfibrozil, are available as follows:

N 0071-0737-20: Bottles of 60

N 0071-0737-30: Bottles of 500

Parcode No. 737

Storage:   Store at controlled room temperature 20°-25° C (68°-77° F) [see USP]. Protect from light and humidity.

PRODUCT PHOTO(S):

REFERENCES

1. Frick MH, Elo O, Haapa K, et al: Helsinki Heart Study: Primary prevention trial with gemfibrozil in middle-aged men with dyslipidemia. N Engl J Med 1987; 317:1237-1245.
2. Manninen V, Elo O, Frick MH, et al: Lipid alterations and decline in the incidence of coronary heart disease in the Helsinki Heart Study. JAMA 1988; 260:641-651.
3. Frick MH, Heinonen OP, et al: Efficacy of Gemfibrozil in Dyslipidemic Subjects with Suspected Heart Disease. An Ancillary Study in the Helsinki Heart Study Frame Population. Annals of Medicine 1993; 25:41-45.
4. Data on file. Parke-Davis; Morris Plains, NJ
5. Nikkila EA: Familial lipoprotein lipase deficiency and related disorders of chylomicron metabolism. In Stanbury J.B. et al. (eds.): The Metabolic Basis of Inherited Disease, 5th ed., McGraw-Hill, 1983, Chap. 30, pp. 622-642.
6. Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol. Arch Int Med 1988;148:36-69.

Rx only

Revised May 1999

Manufactured by:

Parke Davis Pharmaceuticals, Ltd.

Vega Baja, PR 00694

Distributed by:

PARKE-DAVIS

Div of Warner-Lambert Co

Morris Plains, NJ 07950 USA

©1997-'99, PDPL

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