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Acarbose Side Effects
Common Side Effects of Acarbose
Tell your doctor if any of the following side effects become severe or don't go away:
- Mild stomach pain, gas, or bloating
- Mild diarrhea
- Mild itching or skin rash
Serious Side Effects of Acarbose
Call your doctor right away if you experience any of the following serious side effects:
- Signs of an allergic reaction, which include hives; difficulty breathing; or swelling of the face, lips, tongue, or throat
- Severe itching
- Severe stomach pain
- Severe constipation
- Diarrhea that's watery or bloody
- Unusual bleeding
- Easy bruising
- Purple or red pinpoint spots under your skin
- Upper stomach pain, nausea, or loss of appetite
- Dark urine or clay-colored stools
- Yellowing of the eyes or skin (jaundice)
What is acarbose, and how does it work?
- Acarbose is a prescription oral drug that is used to control blood glucose (sugar) levels in people type 2 diabetes in conjunction with diet, exercise, and other diabetes drugs, for example, metformin (Glucophage) or insulin. It belongs to a class of drugs called alpha-glucosidase inhibitors, which also includes miglitol (Glyset).
- Carbohydrates that are eaten are digested by enzymes in the intestine into smaller sugars which are absorbed into the body and increase blood sugar levels. The process of carbohydrate digestion requires the pancreas to release into the intestine alpha-amylase enzymes, which digest the large carbohydrates into smaller carbohydrates called oligosaccharides. The cells lining the small intestine then release alpha-glucosidase enzymes that further digest the oligosaccharides into smaller sugars, like glucose, that can be absorbed. Acarbose is a man-made oligosaccharide designed to slow down the actions of alpha-amylase and alpha-glucosidase enzymes, thereby slowing the appearance of sugar in the blood after a meal.
What happens if I miss a dose?
Take the missed dose as soon as you remember (be sure to take it with a meal). If it has been longer than 15 minutes since you started your meal, you may still take acarbose but it may be less effective than taking it with the first bite of the meal. Do not take acarbose between meals, and do not take extra medicine to make up a missed dose.
What should I avoid while taking acarbose?
Avoid drinking alcohol. It can lower your blood sugar.
Avoid taking a digestive enzyme such as pancreatin, amylase, or lipase at the same time you take acarbose. These enzymes can make it harder for your body to absorb acarbose. Products that contain digestive enzymes include Arco-Lase, Cotazym, Donnazyme, Pancrease, Creon, and Ku-Zyme.
Acarbose Dosage and Administration
Individualize treatment and adjust target blood glucose and glycosylated hemoglobin A1c (HbA1c) concentrations based on patient’s understanding and adherence to the treatment regimen, the risk of severe hypoglycemia, and other factors that may increase risk or decrease benefit (e.g., very young or old age, comorbid conditions, other diseases that materially shorten life expectancy).1 62
Goal of therapy is to reduce both postprandial blood (or plasma) glucose and hemoglobin values to normal or near normal using lowest effective dosage of acarbose as monotherapy or combined with a sulfonylurea antidiabetic agent, metformin, or insulin.1 (Plasma glucose concentrations generally 10–15% higher than those in whole blood and may vary according to method and laboratory used.)63 During therapy initiation and dosage titration, obtain 1-hour postprandial glucose concentration to determine therapeutic response and minimum effective dosage.1 14 23 52 62 Monitor HbA1c values at approximately every 3 months to evaluate long-term glycemic control.1 14 23 52 62 Monitor glucose concentrations 1–2 hours after the start of a meal in those who have elevated HbA1c despite adequate preprandial glucose concentrations.62
Administer orally at the beginning (with the first bite) of each main meal.1 23 If a dose is missed, take the next dose at the next meal.108 Do not take a double dose to make up for the missed dose.108
AdultsDiabetes Mellitus Oral
Initially, 25 mg 3 times daily at the beginning of each main meal.1 23 In patients with adverse GI effects,2 12 23 34 initiate at 25 mg once daily and increase dosage gradually as necessary to 25 mg 3 times daily.1
Once dosage of 25 mg 3 times daily has been reached, increase dosage at intervals of 4–8 weeks as tolerated to achieve the desired 1-hour postprandial glucose concentration (i.e., <180 mg/dL).1 23 34 41 52 62 Maintenance dosage ranges from 50–100 mg 3 times daily.1 6 47
Dosages higher than 100 mg 3 times daily are not recommended since such dosages have been associated with an increased risk of elevated serum aminotransferase concentrations.1 10 18 19 20 22 23 25 27 30 37 43 52 If no further therapeutic benefit occurs at the maximum recommended dosage, consider lowering the dosage.1
AdultsDiabetes Mellitus Oral
Patients ≤60 kg: maximum 50 mg 3 times daily.1 23 34 41 52
Patients >60 kg: maximum 100 mg 3 times daily.1
Cautions for Acarbose
Known hypersensitivity to the drug.1
Inflammatory bowel disease, colonic ulceration, existing partial intestinal obstruction or predisposition to this condition.1
Chronic intestinal diseases associated with marked disorders of digestion or absorption.1
Co-existing conditions that may deteriorate as a result of increased intestinal gas formation.1
General PrecautionsMetabolic Effects
Should not cause hypoglycemia when administered alone in the fasted or postprandial state.1 However, hypoglycemia (rarely hypoglycemic shock) may occur when used concomitantly with a sulfonylurea antidiabetic agent and/or insulin.1 If hypoglycemia occurs, adjust dosage of these agents appropriately.1 Use oral glucose (dextrose) for the treatment of mild to moderate hypoglycemia instead of sucrose (table sugar);1 the absorption of oral glucose is not inhibited by acarbose.1 Severe hypoglycemia may require the use of either IV glucose or parenteral glucagon.1
Insulin may be required for correction of temporary hyperglycemia that is not controlled by dietary regulation or oral antidiabetic agents during periods of severe stress (e.g., acute infection, trauma, surgery, fever).1 57 59Hepatic Effects
Elevations in serum aminotransferase (i.e., ALT, AST) concentrations and, in rare instances, hyperbilirubinemia may occur, particularly with dosages exceeding 150 mg daily (50 mg 3 times daily).1 23 Jaundice and fatal hepatitis reported during postmarketing experience.1
Determine serum aminotransferase concentrations every 3 months during the first year of therapy and periodically thereafter.1 If elevations in serum aminotransferase concentrations occur, reduce dosage.1 May be necessary to withdraw the drug, particularly if elevated serum aminotransferase concentrations persist.1Adherence to Prescribed Diet
If prescribed diet not followed closely, adverse GI effects may be intensified.1 108 To minimize adverse GI effects, avoid rich foods, sauces, and certain beverages, including beer and carbonated soft drinks.108 Limit intake of gas-producing foods such as beans, nuts, bran cereals, broccoli, and cabbage.108 Consume low-fat meals and snacks.108 Drink plenty of water, especially in the early morning, midmorning, and afternoon.108 Avoid overeating; food portions should be small to moderate in size.108 Eat food slowly and chew thoroughly.108 Keep food diary to identify problem foods.108
Distributed into milk in rats.1 Not known whether distributed into human milk.1 Use not recommended in nursing women.1Pediatric Use
Safety and efficacy in children <18 years of age not established.1 23Geriatric Use
Safety and efficacy in those ≥65 years of age similar to that in younger adults.1 (See Special Populations under Pharmacokinetics: Absorption.)Hepatic Impairment
Contraindicated in patients with cirrhosis.1 23 52 Not studied in other conditions associated with hepatic impairment.1 23 52Renal Impairment
Not recommended for use in diabetic patients with appreciable renal impairment (Scr >2 mg/dL).1 23
Common Adverse Effects
Flatulence, diarrhea, abdominal discomfort/pain.1
acarbose Side Effects
Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.
Check with your doctor as soon as possible if any of the following side effects occur:Rare
- Yellow eyes or skin
Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:More common
- Abdominal or stomach pain
- bloated feeling or passing of gas
Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.
Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.
Indications and Usage for Acarbose
Acarbose Tablets are indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Acarbose Tablets or any other anti-diabetic drug.Hypoglycemia
Because of its mechanism of action, Acarbose Tablets when administered alone should not cause hypoglycemia in the fasted or postprandial state. Sulfonylurea agents or insulin may cause hypoglycemia. Because Acarbose Tablets given in combination with a sulfonylurea or insulin will cause a further lowering of blood glucose, it may increase the potential for hypoglycemia. Hypoglycemia does not occur in patients receiving metformin alone under usual circumstances of use, and no increased incidence of hypoglycemia was observed in patients when Acarbose Tablets were added to metformin therapy.
Oral glucose (dextrose), whose absorption is not inhibited by Acarbose Tablets, should be used instead of sucrose (cane sugar) in the treatment of mild to moderate hypoglycemia. Sucrose, whose hydrolysis to glucose and fructose is inhibited by Acarbose Tablets, is unsuitable for the rapid correction of hypoglycemia. Severe hypoglycemia may require the use of either intravenous glucose infusion or glucagon injection.Elevated Serum Transaminase Levels
In long-term studies (up to 12 months, and including Acarbose Tablets doses up to 300 mg t.i.d.) conducted in the United States, treatment-emergent elevations of serum transaminases (AST and/or ALT) above the upper limit of normal (ULN), greater than 1.8 times the ULN, and greater than 3 times the ULN occurred in 14%, 6%, and 3%, respectively, of Acarbose Tablets-treated patients as compared to 7%, 2%, and 1%, respectively, of placebo-treated patients. Although these differences between treatments were statistically significant, these elevations were asymptomatic, reversible, more common in females, and, in general, were not associated with other evidence of liver dysfunction. In addition, these serum transaminase elevations appeared to be dose related. In US studies including Acarbose Tablets doses up to the maximum approved dose of 100 mg t.i.d., treatment-emergent elevations of AST and/or ALT at any level of severity were similar between Acarbose Tablets-treated patients and placebo-treated patients (p ≥ 0.496).
In approximately 3 million patient-years of international postmarketing experience with Acarbose Tablets, 62 cases of serum transaminase elevations > 500 IU/L (29 of which were associated with jaundice) have been reported. Forty-one of these 62 patients received treatment with 100 mg t.i.d. or greater and 33 of 45 patients for whom weight was reported weighed < 60 kg. In the 59 cases where follow-up was recorded, hepatic abnormalities improved or resolved upon discontinuation of Acarbose Tablets in 55 and were unchanged in two. Cases of fulminant hepatitis with fatal outcome have been reported; the relationship to Acarbose is unclear.Loss of Control of Blood Glucose
When diabetic patients are exposed to stress such as fever, trauma, infection, or surgery, a temporary loss of control of blood glucose may occur. At such times, temporary insulin therapy may be necessary.
Information for Patients
Patients should be told to take Acarbose Tablets orally three times a day at the start (with the first bite) of each main meal. It is important that patients continue to adhere to dietary instructions, a regular exercise program, and regular testing of urine and/or blood glucose.
Acarbose Tablets itself does not cause hypoglycemia even when administered to patients in the fasted state. Sulfonylurea drugs and insulin, however, can lower blood sugar levels enough to cause symptoms or sometimes life-threatening hypoglycemia. Because Acarbose Tablets given in combination with a sulfonylurea or insulin will cause a further lowering of blood sugar, it may increase the hypoglycemic potential of these agents. Hypoglycemia does not occur in patients receiving metformin alone under usual circumstances of use, and no increased incidence of hypoglycemia was observed in patients when Acarbose Tablets were added to metformin therapy. The risk of hypoglycemia, its symptoms and treatment, and conditions that predispose to its development should be well understood by patients and responsible family members. Because Acarbose Tablets prevent the breakdown of table sugar, patients should have a readily available source of glucose (dextrose, D-glucose) to treat symptoms of low blood sugar when taking Acarbose Tablets in combination with a sulfonylurea or insulin.
If side effects occur with Acarbose Tablets, they usually develop during the first few weeks of therapy. They are most commonly mild-to-moderate gastrointestinal effects, such as flatulence, diarrhea, or abdominal discomfort, and generally diminish in frequency and intensity with time.
Therapeutic response to Acarbose Tablets should be monitored by periodic blood glucose tests. Measurement of glycosylated hemoglobin levels is recommended for the monitoring of long-term glycemic control.
Acarbose Tablets, particularly at doses in excess of 50 mg t.i.d., may give rise to elevations of serum transaminases and, in rare instances, hyperbilirubinemia. It is recommended that serum transaminase levels be checked every 3 months during the first year of treatment with Acarbose Tablets and periodically thereafter. If elevated transaminases are observed, a reduction in dosage or withdrawal of therapy may be indicated, particularly if the elevations persist.
Monitoring glycemic control with 1,5-AG assay is not recommended as measurements of 1,5-AG are unreliable in assessing glycemic control in patients taking Acarbose. Use alternative methods to monitor for glycemic control.
Plasma concentrations of Acarbose Tablets in renally impaired volunteers were proportionally increased relative to the degree of renal dysfunction. Long-term clinical trials in diabetic patients with significant renal dysfunction (serum creatinine > 2 mg/dL) have not been conducted. Therefore, treatment of these patients with Acarbose Tablets is not recommended.
Certain drugs tend to produce hyperglycemia and may lead to loss of blood glucose control. These drugs include the thiazides and other diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel-blocking drugs, and isoniazid. When such drugs are administered to a patient receiving Acarbose Tablets, the patient should be closely observed for loss of blood glucose control. When such drugs are withdrawn from patients receiving Acarbose Tablets in combination with sulfonylureas or insulin, patients should be observed closely for any evidence of hypoglycemia.Patients Receiving Sulfonylureas or Insulin
Sulfonylurea agents or insulin may cause hypoglycemia. Acarbose Tablets given in combination with a sulfonylurea or insulin may cause a further lowering of blood glucose and may increase the potential for hypoglycemia. If hypoglycemia occurs, appropriate adjustments in the dosage of these agents should be made. Very rarely, individual cases of hypoglycemic shock have been reported in patients receiving Acarbose Tablets therapy in combination with sulfonylureas and/or insulin.
Intestinal adsorbents (e.g., charcoal) and digestive enzyme preparations containing carbohydrate-splitting enzymes (e.g., amylase, pancreatin) may reduce the effect of Acarbose Tablets and should not be taken concomitantly.
Acarbose Tablets have been shown to change the bioavailability of digoxin when they are coadministered, which may require digoxin dose adjustment. (See CLINICAL PHARMACOLOGY, Drug-Drug Interactions).
Carcinogenesis, Mutagenesis, and Impairment of Fertility
Eight carcinogenicity studies were conducted with Acarbose. Six studies were performed in rats (two strains, Sprague-Dawley and Wistar) and two studies were performed in hamsters.
In the first rat study, Sprague-Dawley rats received Acarbose in feed at high doses (up to approximately 500 mg/kg body weight) for 104 weeks. Acarbose treatment resulted in a significant increase in the incidence of renal tumors (adenomas and adenocarcinomas) and benign Leydig cell tumors. This study was repeated with a similar outcome. Further studies were performed to separate direct carcinogenic effects of Acarbose from indirect effects resulting from the carbohydrate malnutrition induced by the large doses of Acarbose employed in the studies.
In one study using Sprague-Dawley rats, Acarbose was mixed with feed but carbohydrate deprivation was prevented by the addition of glucose to the diet. In a 26-month study of Sprague-Dawley rats, Acarbose was administered by daily postprandial gavage so as to avoid the pharmacologic effects of the drug. In both of these studies, the increased incidence of renal tumors found in the original studies did not occur. Acarbose was also given in food and by postprandial gavage in two separate studies in Wistar rats. No increased incidence of renal tumors was found in either of these Wistar rat studies. In two feeding studies of hamsters, with and without glucose supplementation, there was also no evidence of carcinogenicity.
Acarbose did not induce any DNA damage in vitro in the CHO chromosomal aberration assay, bacterial mutagenesis (Ames) assay, or a DNA binding assay. In vivo, no DNA damage was detected in the dominant lethal test in male mice, or the mouse micronucleus test.
Fertility studies conducted in rats after oral administration produced no untoward effect on fertility or on the overall capability to reproduce.
Pregnancy Category B
The safety of Acarbose Tablets in pregnant women has not been established. Reproduction studies have been performed in rats at doses up to 480 mg/kg (corresponding to 9 times the exposure in humans, based on drug blood levels) and have revealed no evidence of impaired fertility or harm to the fetus due to Acarbose. In rabbits, reduced maternal body weight gain, probably the result of the pharmacodynamic activity of high doses of Acarbose in the intestines, may have been responsible for a slight increase in the number of embryonic losses. However, rabbits given 160 mg/kg Acarbose (corresponding to 10 times the dose in man, based on body surface area) showed no evidence of embryotoxicity and there was no evidence of teratogenicity at a dose 32 times the dose in man (based on body surface area). There are, however, no adequate and well-controlled studies of Acarbose Tablets in pregnant women. Because animal reproduction studies are not always predictive of the human response, this drug should be used during pregnancy only if clearly needed. Because current information strongly suggests that abnormal blood glucose levels during pregnancy are associated with a higher incidence of congenital anomalies as well as increased neonatal morbidity and mortality, most experts recommend that insulin be used during pregnancy to maintain blood glucose levels as close to normal as possible.
A small amount of radioactivity has been found in the milk of lactating rats after administration of radiolabeled Acarbose. It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, Acarbose Tablets should not be administered to a nursing woman.
Safety and effectiveness of Acarbose Tablets in pediatric patients have not been established.
Of the total number of subjects in clinical studies of Acarbose Tablets in the United States, 27% were 65 and over, while 4% were 75 and over. No overall differences in safety and effectiveness were observed between these subjects and younger subjects. The mean steady-state area under the curve (AUC) and maximum concentrations of Acarbose were approximately 1.5 times higher in elderly compared to young volunteers; however, these differences were not statistically significant.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Precose: 25 mg, 50 mg, 100 mg
Generic: 25 mg, 50 mg, 100 mg
Brand Names U.S.
Dosing Renal Impairment
Serum creatinine ≤2 mg/dL or CrCl ≥25 mL/ minute/1.73 m2: There are no dosage adjustments provided in the manufacturer’s labeling.
Serum creatinine >2 mg/dL or CrCl <25 ml/minute/1.73 m2: Use is not recommended; systemic AUC increased 6-fold in patients with CrCl <25 mL/ minute/1.73 m2.
Pregnancy Risk Factor B Pregnancy Considerations
Adverse events have not been observed in animal reproduction studies. Less than 2% of an oral dose of acarbose is absorbed systemically, which should limit fetal exposure.
In women with diabetes, maternal hyperglycemia can be associated with congenital malformations as well as adverse effects in the fetus, neonate, and the mother (ACOG 2005; ADA 2017c; Kitzmiller 2008; Metzger 2007). To prevent adverse outcomes, prior to conception and throughout pregnancy, maternal blood glucose and HbA1c should be kept as close to target goals as possible but without causing significant hypoglycemia (ACOG 2013; ADA 2017c; Blumer 2013; Kitzmiller 2008). Agents other than acarbose are currently recommended to treat diabetes in pregnant women (ADA 2017c).
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience abdominal pain, flatulence, diarrhea, or bloating. Have patient report immediately to prescriber signs of low blood sugar (dizziness, headache, fatigue, feeling weak, shaking, tachycardia, confusion, increased hunger, or sweating), or signs of liver problems (dark urine, fatigue, lack of appetite, nausea, abdominal pain, light-colored stools, vomiting, or jaundice) (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.
PRECOSE is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.
Gastrointestinal symptoms are the most common reactions to PRECOSE. In U.S. placebo-controlled trials, the incidences of abdominal pain, diarrhea, and flatulence were 19%, 31%, and 74% respectively in 1255 patients treated with PRECOSE 50–300 mg t.i.d., whereas the corresponding incidences were 9%, 12%, and 29% in 999 placebo-treated patients.
In a one-year safety study, during which patients kept diaries of gastrointestinal symptoms, abdominal pain and diarrhea tended to return to pretreatment levels over time, and the frequency and intensity of flatulence tended to abate with time. The increased gastrointestinal tract symptoms in patients treated with PRECOSE are a manifestation of the mechanism of action of PRECOSE and are related to the presence of undigested carbohydrate in the lower GI tract.
If the prescribed diet is not observed, the intestinal side effects may be intensified. If strongly distressing symptoms develop in spite of adherence to the diabetic diet prescribed, the doctor must be consulted and the dose temporarily or permanently reduced.
Elevated Serum Transaminase Levels
Other Abnormal Laboratory Findings
Small reductions in hematocrit occurred more often in PRECOSE-treated patients than in placebo-treated patients but were not associated with reductions in hemoglobin. Low serum calcium and low plasma vitamin B6 levels were associated with PRECOSE therapy but are thought to be either spurious or of no clinical significance.
Postmarketing Adverse Event Reports
Additional adverse events reported from worldwide postmarketing experience include fulminant hepatitis with fatal outcome, hypersensitive skin reactions (for example rash, erythema, exanthema and uticaria), edema, ileus/subileus, jaundice and/or hepatitis and associated liver damage, thrombocytopenia, and pneumatosis cystoides intestinalis (see PRECAUTIONS).
Pneumatosis Cystoides Intestinalis
There have been rare postmarketing reports of pneumatosis cystoides intestinalis associated with the use of alpha-glucosidase inhibitors, including Precose. Pneumatosis cystoides intestinalis may present with symptoms of diarrhea, mucus discharge, rectal bleeding, and constipation. Complications may include pneumoperitoneum, volvulus, intestinal obstruction, intussusception, intestinal hemorrhage, and intestinal perforation. If pneumatosis cystoides intestinalis is suspected, discontinue Precose and perform the appropriate diagnostic imaging.
Unlike sulfonylureas or insulin, an overdose of PRECOSE will not result in hypoglycemia. An overdose may result in transient increases in flatulence, diarrhea, and abdominal discomfort which shortly subside. In cases of overdosage the patient should not be given drinks or meals containing carbohydrates (polysaccharides, oligosaccharides and disaccharides) for the next 4–6 hours.
Acarbose is a prescription medication used to treat type 2 diabetes.
Acarbose belongs to a group of drugs called alpha-glucosidase inhibitors. These work by slowing the action of certain chemicals that digest food, which prevents glucose from being released into the blood stream too quickly after a meal.
This medication comes in tablet form and is taken three times a day, with the first bite of each main meal.
Common side effects of acarbose include abdominal pain, diarrhea, and flatulence.
In combination with other medications to treat diabetes, acarbose can also cause hypoglycemia (low blood sugar), which can cause blurred vision and dizziness. Do not drive or operate heavy machinery until you know how acarbose affects you.
Take acarbose exactly as prescribed.
Acarbose comes in tablet form and is taken three times daily, with the first bite of each main meal.
If you miss a dose, take the missed dose as soon as you remember. If it is almost time for the next dose, skip the missed dose and take your next dose at the regular time. Do not take two doses of acarbose at the same time.
- Store acarbose at room temperature.
- Keep this and all medicines out of the reach of children.
Liver Dose Adjustments
Use with caution
If elevated transaminase levels develop: Dose reduction or withdrawal of therapy may be necessary, especially if elevations persist.
Data not available