Moxonidine (Physiotens) for hypertension
Published in NPS RADAR
Date published: About this date
Moxonidine is listed on the Pharmaceutical Benefits Scheme for hypertension when used in combination with other antihypertensive agents.1
Reason for PBS listing
Moxonidine was listed on a cost-minimisation basis compared with clonidine as an add-on therapy for hypertension. The Pharmaceutical Benefits Advisory Committee considered moxonidine to be no worse than clonidine in efficacy and that it appears to be less toxic.
Place in therapy
Moxonidine is similar to clonidine, but with reduced adverse effects. As with other centrally acting antihypertensives it will be useful for a small proportion of patients who are resistant or intolerant to first- and second-line drugs. While moxonidine lowers blood pressure effectively, there have been no large-scale trials to determine its effect on cardiovascular outcomes. In the UK, moxonidine has been available since 1996 but is not widely used.2
Moxonidine may be used as an add-on therapy if first- and second-line agents are insufficient or unsuitable
Moxonidine is a centrally acting antihypertensive that decreases activation of the sympathetic nervous system.3 It is similar to clonidine but is selective for imidazoline I1 receptors over alpha2-adrenergic receptors.4 This selectivity may explain why rebound hypertension appears less common with moxonidine than with clonidine.4
Centrally active agents are only recommended if first- and second-line agents fail to control blood pressure or are contraindicated or not tolerated.5–7 Moxonidine is an alternative to clonidine under these circumstances. A thiazide diuretic is recommended as first-line therapy, except for people with comorbidities that are compelling indications for using another drug class.5,7 Second-line choices include an ACE inhibitor, a beta blocker or a calcium-channel blocker.5–7 Combination therapy with up to three agents may be needed to reduce blood pressure sufficiently in some patients.
Moxonidine has been combined with all classes of first- and second-line antihypertensives. Be aware that combining moxonidine with a beta blocker may increase the likelihood of rebound hypertension on withdrawal of moxonidine (see Moxonidine is less likely to cause rebound hypertension than clonidine)
The effect of moxonidine on cardiovascular morbidity and mortality has not been tested in clinical trials
Clinical trials of moxonidine have been small scale, of up to 6-months’ duration and have not analysed the effect of blood-pressure lowering with moxonidine on cardiovascular morbidity and mortality; in these trials, moxonidine lowered blood pressure as effectively as clonidine and first- and second-line agents.8–13 The lack of large-scale trials means that UK National Institute for Health and Clinical Excellence (NICE) guidelines do not recommend moxonidine for initial treatment of raised blood pressure.5
Moxonidine causes fewer adverse events than clonidine and in small trials was as well tolerated as first- and second-line antihypertensives. Moxonidine is contraindicated for patients with bradycardia (heart rate < 50 beats/minute), severe bradyarrhythmia, malignant arrhythmia, heart failure or severe renal impairment (see Dosing issues). Moxonidine can potentiate the action of benzodiazepines.
Report suspected adverse reactions to the Adverse Drug Reactions Advisory Committee (ADRAC) online or by using the 'Blue Card' distributed with Australian Prescriber. For information about reporting adverse reactions, see the Therapeutic Goods Administration website.
Moxonidine is less likely to cause rebound hypertension than clonidine
No blood pressure rebound effect after sudden discontinuation of moxonidine has been observed in clinical use or in animal models.3,14,15 Nevertheless, moxonidine should be withdrawn over a period of days rather than stopped abruptly.3
The prescribing information states that the likelihood of rebound hypertension when stopping moxonidine may be increased with patients who are also taking a beta blocker. The beta blocker should be stopped first, then moxonidine withdrawn (as above) a few days later, monitoring blood pressure regularly.3 The manufacturer has not provided clinical data to support this recommendation.
Dry mouth and tiredness occur in some patients
Incidence of adverse effects is low, with dry mouth, headache, dizziness and tiredness most common.3 In 2 small trials, the overall incidence of adverse events was less with moxonidine than with clonidine, while blood pressure control was similar.8,9
Do not use moxonidine in people with heart failure of any grade
Moxonidine is contraindicated for people with heart failure, as it appears to worsen outcomes.3 The MOXCON trial in patients with heart failure was stopped early because of a greater number of deaths among participants who took moxonidine rather than placebo.16 Hospitalisation for heart failure, acute myocardial infarction and adverse events was also more frequent in the moxonidine group.16
Initiate moxonidine at 0.2 mg once daily (in the morning). If blood pressure needs further lowering after 2 weeks, increase to 0.4 mg/day (either as a single morning dose or as 2 divided doses, morning and evening). The dose may be increased to a maximum of 0.6 mg/day after a further 2 weeks, if required. Any single dose should not exceed 0.4 mg.3
Reduce the dose in people with renal impairment
If the estimated creatinine clearance is 30–60 mL/min, each single dose should be no more than 0.2 mg and the daily dose no more than 0.4 mg. Moxonidine is contraindicated if the estimated creatinine clearance is < 30 mL/min.3
Information for patients
Advise patients that moxonidine
- has dry mouth as its most common side effect
- may cause tiredness or dizziness, and that they should avoid driving or operating machinery if they are affected
- may increase the effects of alcohol or any benzodiazepine-type medicines
- must not be stopped without medical supervision.
For more detailed information about moxonidine, suggest or provide the Physiotens consumer medicine information (CMI).
- Department of Health and Ageing. March 2006 PBAC outcomes: positive recommendations. http:/
/ www. health. gov. au/ internet/ wcms/ publishing. nsf/ Content/ pbacrec-pbacrecmar06-positive (accessed 27 April 2006).
- Schachter M, Mitchell G, Niziol C, et al. Antihypertensive efficacy of moxonidine in primary care: a 'real-life' study. Int J Clin Pract 2003;57:479–82. [PubMed]
- Solvay Pharmaceuticals. Physiotens product information 28 October 2004
- Bousquet P, Greney H, Bruban V, et al. I1 imidazoline receptors involved in cardiovascular regulation: where are we and where are we going? Ann N Y Acad Sci 2003;1009:228–33. [PubMed]
- National Institute for Clinical Excellence. CG34 Management of hypertension in adults in primary care: partial update. 2006. http:/
/ www. nice. org. uk/ download. aspx?o=CG034fullguideline (accessed 7 July 2006).
- Therapeutic Guidelines: Cardiovascular. Version 4, 2003.
- Australian Medicines Handbook, 2006.
- Plänitz V. Comparison of moxonidine and clonidine HCl in treating patients with hypertension. J Clin Pharmacol 1987;27:46–51. [PubMed]
- Plänitz V. Crossover comparison of moxonidine and clonidine in mild to moderate hypertension. Eur J Clin Pharmacol 1984;27:147–52. [PubMed]
- Vonend O, Marsalek P, Russ H, et al. Moxonidine treatment of hypertensive patients with advanced renal failure. J Hypertens 2003;21:1709–17. [PubMed]
- Jacob S, Klimm HJ, Rett K, et al. Effects of moxonidine vs. metoprolol on blood pressure and metabolic control in hypertensive subjects with type 2 diabetes. Exp Clin Endocrinol Diabetes 2004;112:315–22. [PubMed]
- Prichard BNC, Küster LJ, Hughes PR, et al. Dose relation of blood pressure reduction with moxonidine: findings from three placebo- and active-controlled randomized studies. J Clin Basic Cardiol 2003;6:49–51.
- Frei M, Küster L, Gardosch von Krosigk PP, et al. Moxonidine and hydrochlorothiazide in combination: a synergistic antihypertensive effect. J Cardiovasc Pharmacol 1994;24[Suppl.1]:S25–8. [PubMed]
- Webster J, Koch HF. Aspects of tolerability of centrally acting antihypertensive drugs. J Cardiovasc Pharmacol 1996;27[Suppl.3]:S49–54. [PubMed]
- Rupp H, Maisch B, Brilla CG. Drug withdrawal and rebound hypertension: differential action of the central antihypertensive drugs moxonidine and clonidine. Cardiovasc Drugs Ther 1996;10[Suppl.1]:251–62. [PubMed]
- Cohn JN, Pfeffer MA, Rouleau J, et al. Adverse mortality effect of central sympathetic inhibition with sustained-release moxonidine in patients with heart failure (MOXCON). Eur J Heart Fail 2003;5:659–67. [PubMed]