Glem-Lin MXR is a medication that combines three active ingredients:

• Empagliflozin,
• Linagliptin, and
• Metformin in an extended-release form.

The triple combination drug was approved by the FDA on January 28, 2020, for treating type 2 diabetes as TriJardy Xr.

This medication is intended to be used alongside a healthy diet and exercise. However, it is not recommended for people with:

• Type 1 diabetes,
• Diabetic ketoacidosis, or
• pancreatitis.

Glem-Lin MXR comes in four different strengths as:

• 5 mg empagliflozin, 2.5 mg linagliptin, and 1000 mg metformin.
• 10 mg empagliflozin, 5 mg linagliptin, and 1000 mg metformin.
• 12.5 mg empagliflozin, 2.5 mg linagliptin, and 1000 mg metformin.
• 25 mg empagliflozin, 5 mg linagliptin, and 1000 mg metformin.

Glem-Lin MXR Dosage Guidelines

It is indicated in adult patients with type 2 diabetes. The dose can be calculated based on your blood glucose levels and whether the patient has previously been on any of the three ingredients of Glem-Lin MXR or not.

• If you're already taking metformin (with or without linagliptin), you can switch to Glem-Lin MXR 10/5/1000 mg.
• If you're on metformin and empagliflozin (with or without linagliptin), switch to a Glem-Lin MXR dose that matches your current metformin and empagliflozin dosage plus 5 mg linagliptin.

The dose may be adjusted up to a maximum daily dose of 25 mg empagliflozin, 5 mg linagliptin, and 2000 mg metformin.

How to take Glem-Lin MXR?

Take Glem-Lin MXR once daily in the morning with breakfast. Swallow the tablet whole without splitting, crushing, or chewing.

Overdose and Safety!

• Linagliptin: Not effectively removed by dialysis.
• Empagliflozin: No studies on removal by dialysis.
• Metformin: Can cause lactic acidosis in cases of overdose and may be removed through dialysis if necessary.

Use in Pregnancy and Breastfeeding:

• Pregnancy:

The safety of Glem-Lin MXR during pregnancy is unclear. Empagliflozin has been associated with kidney problems in animal studies. It's generally recommended to avoid using this medication during the second and third trimesters.

• Breastfeeding:

Since metformin and empagliflozin can pass into breast milk, it's advised not to use this medication while breastfeeding.

Glem-Lin MXR Dosage Adjustments in Kidney Impairment:

• Dose in Impaired Kidney function:

No adjustment is needed if your eGFR (a measure of kidney function) is above 45 mL/min/1.73m².

Avoid starting treatment if eGFR is below 45 mL/min/1.73m².

Contraindicated if eGFR is below 30 mL/min/1.73m².

• Iodinated contrast procedures:

Temporarily stop Glem-Lin MXR if undergoing certain imaging procedures, especially if you have a history of liver disease, heart failure, or heavy alcohol use.

Glem-Lin MXR Contraindications:

Severe Kidney Impairment:

• Not recommended for patients with an eGFR below 30 mL/min/1.73m².

End-Stage Renal Disease and Dialysis:

• Contraindicated for patients with end-stage renal disease or those on dialysis.

Metabolic Acidosis:

• Avoid use in patients with metabolic acidosis, including diabetic ketoacidosis.

Allergic Reactions:

• Patients with a history of severe allergic reactions (e.g., anaphylaxis, angioedema, or bronchial hyperreactivity) to empagliflozin, linagliptin, or any other component should not use this medication.

Warnings and Precautions:

• Lactic Acidosis:

Metformin-induced lactic acidosis is a serious and potentially fatal condition. Symptoms include malaise, muscle pain, and drowsiness.

It is characterized by high blood lactate levels, metabolic acidosis with an increased anion gap, and elevated plasma metformin levels.

Patients at high risk include those with severe kidney impairment, liver disease, heart failure, or those undergoing major surgery.

• Pancreatitis:

DPP-4 inhibitors like linagliptin have been associated with acute pancreatitis, which can be severe or even fatal. The medication should be avoided in patients with a history of pancreatitis.

• Heart Failure:

There is a risk of heart failure associated with DPP-4 inhibitors. Monitor patients for symptoms like chest pain, shortness of breath, and palpitations.

• Hypotension:

SGLT2 inhibitors can cause volume depletion leading to hypotension, especially in patients on diuretics or ACE inhibitors. Patients should maintain adequate hydration.

• Ketoacidosis:

SGLT2 inhibitors have been linked to diabetic ketoacidosis, even with normal blood sugar levels. Patients should seek medical attention if they experience symptoms such as rapid breathing, shortness of breath, or abdominal pain.

• Acute Kidney Injury:

Empagliflozin may cause intravascular volume depletion, increasing the risk of acute kidney injury. Patients with dehydration, chronic kidney disease, or heart failure should use this medication with caution.

• Urinary Tract Infections:

Empagliflozin may increase the risk of serious urinary tract infections, including pyelonephritis. Patients should report any symptoms promptly.

• Hypoglycemia:

The risk of hypoglycemia is increased when Glem-Lin MXR is used with insulin or insulin secretagogues. Dosage adjustments may be necessary.

• Fournier’s Gangrene:

Empagliflozin has been associated with necrotizing fasciitis of the perineum (Fournier’s Gangrene), a serious and sometimes fatal condition. Immediate medical attention is required for any signs of infection in the genital or perineal area.

• Genital Infections:

SGLT2 inhibitors can cause genital fungal infections. Patients should be monitored and treated as needed.

• Hypersensitivity Reactions:

Linagliptin and empagliflozin have been linked to serious allergic reactions, including angioedema. Patients with a history of hypersensitivity should avoid this medication.

• Vitamin B12 Deficiency:

Metformin can impair the absorption of vitamin B12. Regular monitoring and supplementation may be required.

• Severe Joint Pain:

DPP-4 inhibitors like linagliptin can cause severe joint pain. If this occurs, discontinue the medication and consider alternative treatments.

• Bullous Pemphigoid:

DPP-4 inhibitors may increase the risk of bullous pemphigoid, a skin condition. Patients should discontinue the medication and seek medical advice if symptoms occur.

Final Thoughts:

Glem-Lin MXR is a one-pill solution for most diabetic individuals who require two or more drugs to control their blood glucose.

It reduces the pill burden of the patients especially those with multiple comorbid conditions who require multiple medications such as those with heart diseases, hypertension, dyslipidemia, and stomach problems.

However, it should be avoided in patients with acute or recurrent pancreatitis, diabetic ketoacidosis, severe urinary tract infections, and those who are allergic to it.

Be cautious of lactic acidosis (a rare but serious complication), heart failure, low blood pressure, and acute kidney injury. Always consult with your doctor if you experience unusual symptoms or side effects.

Glem-Lin MXR combines powerful agents to manage blood sugar levels in type 2 diabetes. However, using it under medical guidance is essential due to its potential side effects and interactions with other conditions or medications.