Consumer medicine information

Atacand

Candesartan cilexetil

BRAND INFORMATION

Brand name

Atacand Tablets

Active ingredient

Candesartan cilexetil

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Atacand.

What is in this leaflet

This leaflet answers some of the common questions people ask about ATACAND. It does not contain all the information that is known about ATACAND.

It does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor will have weighed the risks of you taking ATACAND against the benefits they expect it will have for you.

If you have any concerns about taking this medicine, ask your doctor or pharmacist.

Keep this leaflet with the medicine.

You may need to read it again.

What ATACAND is used for

ATACAND is a type of medicine called an angiotensin II receptor antagonist (or blocker).

ATACAND is used to treat high blood pressure, also called hypertension.

ATACAND is also used to treat heart failure. It is used in combination with other medicines to treat your condition.

Hypertension:
All people have blood pressure. This pressure helps to push blood all around your body. Your blood pressure changes during the day, depending on how busy you are or how you are feeling.

You have hypertension (high blood pressure) when your blood pressure stays higher than is needed, even when you are calm and relaxed.

Regular blood pressure checks are the only way of knowing that you have hypertension. There are usually no symptoms of hypertension and you may feel fine. If hypertension is not treated, serious health problems such as stroke or heart attack and heart or kidney failure may occur.

ATACAND lowers blood pressure by dilating (expanding) small blood vessels from the heart, letting the blood be pumped around the body more easily.

Heart Failure:
Heart failure means that the heart muscle cannot pump blood strongly enough to supply all the blood needed throughout the body. Heart failure is not the same as heart attack and does not mean that the heart stops working.

Heart failure may start off with no symptoms, but as the condition progresses, patients may feel short of breath or may get tired easily after light physical activity such as walking. Some patients may wake up short of breath at night. Fluid may collect in different parts of the body, often first noticed as swollen ankles and feet.

ATACAND helps to treat heart failure and may improve your symptoms.

One of the ways ATACAND helps heart failure is that it widens the blood vessels, so that the heart does not have to pump as hard to move the blood around the body. This also means that when you place extra demands on your heart, such as during exercise, the heart may cope better so you may not get short of breath as easily.

When used to treat heart failure, ATACAND is almost always used with other medicines called diuretics or fluid tablets. These medicines help the kidney get rid of excess fluid from the body.

Your doctor will have explained why you are being treated with ATACAND and told you what dose to take.

Ask your doctor if you have any questions about why this medicine has been prescribed for you.

Your doctor may prescribe this medicine for another reason.

ATACAND is not addictive.

Before you use ATACAND

When you must not use it

Do not use ATACAND if you have an allergy to:

  • any medicine containing candesartan cilexetil
  • any ingredient listed at the end of this leaflet
  • any medicine containing an angiotensin II receptor antagonist (or blocker)

Some of the symptoms of an allergic reaction may include:

  • shortness of breath
  • wheezing or difficulty breathing
  • swelling of the face, lips, tongue, or other parts of the body
  • rash, itching or hives on the skin

Do not use ATACAND if you have:

  • severe liver disease and/or conditions associated with impaired bile flow (cholestasis)

Do not use ATACAND if you are taking blood pressure medicine containing aliskiren, especially if you have diabetes mellitus or have kidney problems.

Do not use ATACAND if you are pregnant or planning to become pregnant.

It may affect your baby if you take it during pregnancy.

Do not use ATACAND if you are breastfeeding.

It is not known if ATACAND passes into breast milk.

Do not give ATACAND to children.

There is no information about its use in children, so ATACAND is not recommended for children.

Do not use ATACAND after the use by (expiry) date printed on the pack or if the packaging is torn or shows signs of tampering

If it has expired or is damaged, return it to your pharmacist for disposal.

If you are not sure whether you should take this medicine, talk to your doctor.

Before you start to use it

Tell your doctor if you have allergies to any other medicines, foods, dyes or preservatives.

Tell your doctor if you have any of the following medical conditions:

  • kidney problems
  • liver problems
  • heart problems
  • recent excessive vomiting or diarrhoea
  • a condition called primary hyperaldosteronism

You may have to take a lower dose of ATACAND if you have these conditions.

Taking other medicines

Tell your doctor if you are taking any other medicines, including any that you buy at the chemist, supermarket or health food shop.

Some medicines and ATACAND may interfere with each other. These include:

  • Any medicines containing potassium, including salt substitutes
  • Diuretics (fluid tablets)
  • Lithium, a medicine used to treat mood swings and some types of depression
  • Non-steroidal anti-inflammatory drugs (NSAIDs), medicines used to relieve pain, swelling and other symptoms of inflammation, including arthritis
  • Angiotensin-converting-enzyme (ACE) inhibitors, medicines used to help lower blood pressure, especially if you have diabetes-related kidney problems
  • Mineralocorticoid receptor antagonists (MRAs), such as spironolactone and eplerenone, medicines used to treat heart failure

These medicines may be affected by ATACAND or may affect the way ATACAND works. You may need different amounts of your medicines, or you may need to take different medicines.

It may be necessary to have regular blood tests done if you take any of these medicines.

Your doctor and pharmacist have more information on medicines to be careful with or avoid while taking this medicine.

How to take ATACAND

Follow all directions given to you by your doctor carefully.

They may differ from the information contained in this leaflet.

If you do not understand the instructions on the box, ask your doctor or pharmacist for help.

How to take it

The usual dose is one 8 mg tablet or one 16 mg tablet taken daily. Sometimes an increase in dose to 32 mg once daily is needed. Your doctor will tell you the dose of ATACAND you should take.

Take ATACAND once a day, at about the same time each day.

Keeping a regular time for taking ATACAND will help to remind you to take it.

It does not matter whether you take ATACAND with food or on an empty stomach.

How long to take it

Continue taking this medicine for as long as your doctor tells you.

This medicine controls your condition, but does not cure it. It is important to keep taking your medicine even if you feel well.

If you forget to take it

If you forget to take a dose, take it as soon as you remember, as long as it is at least 12 hours before your next dose is due.

Then go back to taking it as you would normally.

If it is almost time for your next dose, skip the dose you missed and take your next dose when you are meant to.

Do NOT double the dose.

If you have trouble remembering when to take your medicine, ask your pharmacist for some hints.

If you take too much (overdose)

Immediately telephone your doctor or the Poisons Information Centre (13 11 26) or go to Accident and Emergency at your nearest hospital immediately if you think that you or anyone else may have taken too much ATACAND, even if there are no signs of discomfort or poisoning.

If you take too many ATACAND you may get a headache, feel sick (nausea), dizzy and very tired.

While you are using ATACAND

Things you must do

Take ATACAND exactly as your doctor has told you to.

Your blood pressure will not be well controlled if you do not.

If you are about to be started on any new medicine, remind your doctor and pharmacist that you are taking ATACAND.

Tell all doctors, dentists and pharmacists who are treating you that you are taking ATACAND.

Tell your doctor immediately if you become pregnant or plan to become pregnant while you are taking ATACAND.

You should not use ATACAND if you are pregnant or thinking about becoming pregnant. Your doctor can discuss different treatment options with you.

If you plan to have surgery (even at the dentist) that needs a general anaesthetic, tell your doctor or dentist that you are taking ATACAND.

Be sure to keep all of your doctor's appointments so that your progress can be checked.

Your doctor will check your progress and may want to take some tests (e.g. blood tests, blood pressure) from time to time. These tests may help to prevent side effects.

Things you must not do

Do not use it to treat any other complaints unless your doctor says to.

Do not give this medicine to anyone else, even if they have the same condition as you.

Do not stop taking ATACAND unless you have discussed it with your doctor.

Things to be careful of

Move slowly when getting out of bed or standing up if you feel faint, dizzy or light-headed.

Be careful driving or operating machinery until you know how ATACAND affects you.

You may feel dizzy when you start taking ATACAND.

If you are taking ATACAND for high blood pressure, drink plenty of water during exercise and hot weather, especially if you sweat a lot. If you do not drink enough water while taking ATACAND, you may faint or feel light-headed or sick. This is because your body doesn't have enough fluid and your blood pressure is low. If you continue to feel unwell, tell your doctor.

If you are taking ATACAND for heart failure, restricted fluid intake is generally recommended. Speak with your doctor about how much water you should drink.

Please talk to your doctor or pharmacist about these possibilities if you think they may bother you.

Side effects

Tell your doctor or pharmacist as soon as possible if you do not feel well while you are taking ATACAND.

ATACAND helps most people, but it may have unwanted side effects in a few people.

All medicines can have side effects. Sometimes they are serious, most of the time they are not. You may need medical treatment if you get some of the side effects.

Ask your doctor or pharmacist to answer any questions you may have.

Tell your doctor if you notice any of the following and they worry you:

  • headache
  • chest or throat infection
  • flu-like symptoms
  • feeling sick (nausea, vomiting)
  • back pain
  • dizziness

These side effects are usually mild.

Tell your doctor as soon as possible if you notice any of the following:

  • aching muscles, tenderness or weakness in the muscle

The above list includes serious side effects that may require medical attention. Serious side effects are rare.

If any of the following happen, tell your doctor immediately or go to Accident and Emergency at your nearest hospital:

  • swelling of the face, lips, tongue or throat
  • swelling of the hands, feet or ankles.
  • harsh sounds when breathing
  • rash, itching or hives
  • yellowing of the skin and/or eyes
  • easy bruising or bleeding more easily than normal
  • extreme fatigue, tiredness, weakness
  • signs of frequent infections such as fever, severe chills, sore throat or mouth ulcers
  • worsening of the kidney function including passing little or no urine, drowsiness, nausea, vomiting, breathlessness, loss of appetite and weakness (especially in patients with existing kidney problems or heart failure)
  • changes in your potassium, sodium and red or white blood cell levels may occur. Such changes are usually detected by a blood test
  • symptoms that may indicate high potassium levels in the blood include nausea, diarrhoea, muscle weakness and changes in heart rhythm

The above list includes very serious side effects. You may need urgent medical attention or hospitalisation.

These side effects are very rare.

Tell your doctor if you notice anything else that is making you feel unwell.

Other side effects not listed above may occur in some people.

After using ATACAND

Storage

Keep your tablets in the blister pack until it is time to take them.

If you take ATACAND out of the blister pack it will not keep well.

Keep it in a cool, dry place where the temperature stays below 30°C.

Do not store it or any other medicine in the bathroom or near a sink. Do not leave it on a window sill or in the car.

Heat and dampness can destroy some medicines.

Keep it where young children cannot reach it.

A locked cupboard at least one-and-a-half metres above the ground is a good place to store medicines.

Disposal

If your doctor tells you to stop taking them, or the tablets have passed their expiry date, ask your pharmacist what to do with any ATACAND tablets you have left over.

Product description

What ATACAND looks like

ATACAND 4 mg tablets are round white tablets, 7 mm in diameter. They are scored and marked A/CF on one side with 004 on the other.

ATACAND 8 mg tablets are round light pink tablets 7 mm in diameter. They are scored and marked A/CG on one side with 008 on the other.

ATACAND 16 mg tablets are round pink tablets 7 mm in diameter. They are scored and marked A/CH on one side with 016 on the other.

ATACAND 32 mg tablets are round pink biconvex tablets. They are scored and marked A/CL on one side with 032 on the other side.

All strengths are available in blister packs of 7 or 30 tablets.

Ingredients

Each ATACAND tablet contains candesartan cilexetil 4, 8, 16 or 32 mg as the active ingredient, plus:

Carmellose calcium

Hyprolose

Iron oxide red (E 172) (8 mg, 16 mg and 32 mg tablets only)

Lactose monohydrate

Magnesium stearate (E 572)

Maize starch

Macrogol 8000

ATACAND does not contain gluten.

BRAND INFORMATION

Brand name

Atacand Tablets

Active ingredient

Candesartan cilexetil

Schedule

S4

 

1 Name of Medicine

Candesartan cilexetil.

2 Qualitative and Quantitative Composition

Atacand (candesartan cilexetil) is available in 4 mg, 8 mg, 16 mg and 32 mg tablets.

Excipients with known effect.

Sugars as lactose monohydrate.
For the full list of excipients, see Section 6.1 List of Excipients.

3 Pharmaceutical Form

Atacand 4 mg tablets are round (diameter 7 mm), white tablets with a score and marked "A/CF" on one side and 004 on the other side.
Atacand 8 mg tablets are round (diameter 7 mm), light pink tablets with a score and marked "A/CG" on one side and marked 008 on the other side.
Atacand 16 mg tablets are round (diameter 7 mm), pink tablets with a score and marked "A/CH" on one side and marked 016 on the other side.
Atacand 32 mg tablets are round, pink, biconvex tablets, with a score and marked "A/CL" on one side and marked 032 on the other side.

4 Clinical Particulars

4.1 Therapeutic Indications

Treatment of hypertension.
Treatment of patients with heart failure and impaired left ventricular systolic function (left ventricular ejection fraction ≤ 40%) as add-on therapy to ACE inhibitors or when ACE inhibitors are not tolerated.

4.2 Dose and Method of Administration

Atacand should be taken once daily with or without food.

Hypertension.

The recommended maintenance dose of Atacand is 8 mg or 16 mg once daily. The maximal antihypertensive effect is attained within 4 weeks following initiation of treatment. For those patients who start on 8 mg and require further blood pressure reduction, a dose increase to 16 mg is recommended. An initial dose of 16 mg is also well tolerated. Some patients may receive an additional benefit by increasing the dose to 32 mg once daily.
In patients with less than optimal blood pressure reduction on Atacand, combination with a thiazide diuretic is recommended.

Special patient populations.

Use in the elderly.

An initial dose of 8 mg is recommended.

Hepatic impairment.

Dose titration is recommended in patients with mild to moderate chronic liver disease, and a lower initial dose of 4 mg should be considered.
Atacand should not be used in patients with severe hepatic impairment and/or cholestasis (see Section 4.3 Contraindications).

Renal impairment.

No initial dosage adjustment is necessary in patients with mild to moderate impaired renal function (i.e. creatinine clearance 30-80 mL/min/1.73 m2 BSA). In patients with severely impaired renal function (i.e. creatinine clearance < 30 mL/min/1.73 m2 BSA) including patients on haemodialysis, a lower initial dose of 4 mg should be considered.

Heart failure.

The usual recommended initial dose of Atacand is 4 mg once daily. Up titration to the target dose of 32 mg once daily or the highest tolerated dose is performed by doubling the dose at intervals of at least 2 weeks (see Section 4.4 Special Warnings and Precautions for Use).

Special patient populations.

No initial dose adjustment is necessary for elderly patients or in patients with renal or hepatic impairment.

Concomitant therapy.

Atacand can be administered with other heart failure treatment, including ACE inhibitors, betablockers, diuretics and digitalis or a combination of these medicines (see Section 4.4 Special Warnings and Precautions for Use; Section 5.1 Pharmacodynamic Properties).

Paediatrics.

The safety and efficacy of Atacand have not been established in children.

4.3 Contraindications

Hypersensitivity to any component of Atacand.
Pregnancy and lactation (see Section 4.6 Fertility, Pregnancy and Lactation).
Severe hepatic impairment and/or cholestasis.
The use of Atacand in combination with aliskiren containing medicines in patients with diabetes mellitus (type I or II) or with moderate to severe renal impairment (GFR < 60 mL/min/1.73 m2).

4.4 Special Warnings and Precautions for Use

General.

In patients whose vascular tone and renal function depend predominantly on the activity of the renin angiotensin aldosterone system (e.g. patients with severe congestive heart failure or underlying renal disease, including renal artery stenosis), treatment with drugs that affect this system has been associated with acute hypotension, azotaemia, oliguria or, rarely, acute renal failure. As with any antihypertensive agent, excessive blood pressure decrease in patients with ischaemic heart disease or atherosclerotic cerebrovascular disease could result in a myocardial infarction or stroke.

Kidney transplantation.

There is limited clinical experience regarding Atacand use in patients who have undergone renal transplant.

Renal artery stenosis.

Other drugs that affect the renin angiotensin aldosterone system, i.e. angiotensin converting enzyme (ACE) inhibitors, may increase blood urea and serum creatinine in patients with bilateral renal artery stenosis or stenosis of the artery to a solitary kidney. A similar effect may be anticipated with angiotensin II receptor antagonists.

Aortic and mitral valve stenosis or obstructive hypertrophic cardiomyopathy.

As with other vasodilators, special caution is indicated in patients suffering from haemodynamically relevant aortic or mitral valve stenosis, or obstructive hypertrophic cardiomyopathy.

Primary hyperaldosteronism.

Patients with primary hyperaldosteronism will not generally respond to antihypertensive drugs acting through inhibition of the renin angiotensin aldosterone system. Therefore, the use of Atacand in these patients is not recommended.

Hypotension.

Hypotension may occur during treatment with Atacand in heart failure patients. As described for other agents acting on the renin angiotensin aldosterone system, it may also occur in hypertensive patients with intravascular volume depletion. Caution should be observed when initiating therapy and correction of hypovolaemia should be attempted.

Dual blockade of the renin angiotensin aldosterone system (RAAS).

There is evidence that the concomitant use of ACE inhibitors, angiotensin II receptor blockers or aliskiren increases the risk of hypotension, hyperkalaemia and decreased renal function (including acute renal failure). Dual blockade of RAAS through the combined use of Atacand with an ACE inhibitor or aliskiren is therefore not recommended (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
If dual blockade therapy is considered necessary, this should only occur under specialist supervision and subject to frequent close monitoring of renal function, electrolytes and blood pressure.
ACE inhibitors and angiotensin II receptor blockers should not be used concomitantly in patients with diabetic nephropathy. The use of Atacand with aliskiren is contraindicated in patients with diabetes mellitus (type I or II) or moderate to severe renal impairment (GFR < 60 mL/min/1.73 m2) (see Section 4.3 Contraindications).

Use in heart failure.

Triple combination of Atacand with an ACE inhibitor and a mineralocorticoid receptor antagonist used in heart failure is also not recommended. Use of these combinations should be under specialist supervision and subject to frequent close monitoring of renal function, electrolytes and blood pressure.

Hyperkalaemia.

Based on experience with the use of other drugs that affect the renin angiotensin aldosterone system, concomitant use of Atacand with potassium sparing diuretics, potassium supplements, salt substitutes containing potassium, or other drugs that may increase potassium levels (e.g. heparin, trimethoprim/ sulfamethoxazole) may lead to increases in serum potassium in hypertensive patients. In heart failure patients treated with Atacand, hyperkalaemia may occur. During treatment with Atacand in patients with heart failure, periodic monitoring of serum potassium is recommended, especially when taken concomitantly with ACE inhibitors and potassium sparing diuretics such as spironolactone.

Haemodialysis.

During dialysis the blood pressure may be particularly sensitive to AT1-receptor blockade as a result of reduced plasma volume and activation of the renin angiotensin aldosterone system. Therefore, Atacand should be carefully titrated with thorough monitoring of blood pressure in patients on haemodialysis (see Section 4.2 Dose and Method of Administration).

Anaesthesia and surgery.

Hypotension may occur during anaesthesia and surgery in patients treated with angiotensin II antagonists due to blockade of the renin angiotensin system. Very rarely, hypotension may be severe such that it may warrant the use of intravenous fluids and/or vasopressors.

Combination use of ACE inhibitors or angiotensin receptor antagonists, anti-inflammatory drugs and thiazide diuretics.

The use of an ACE inhibiting drug (ACE inhibitor or angiotensin receptor antagonist), an anti-inflammatory drug (NSAID or COX-2 inhibitor) and a thiazide diuretic at the same time increases the risk of renal impairment. This includes use in fixed combination products containing more than one class of drug. Combined use of these medications should be accompanied by increased monitoring of serum creatinine, particularly at the institution of the combination. The combination of drugs from these three classes should be used with caution particularly in elderly patients or those with pre-existing renal impairment.

Use in hepatic impairment.

There is limited clinical experience in patients with severe hepatic impairment and/or cholestasis. Use in patients with severe hepatic impairment is contraindicated. Caution is advised in patients with mild to moderate hepatic impairment. There have been reports of clinically significant liver disease occurring with other angiotensin II receptor antagonists. No such cases have been reported to date with Atacand.

Use in renal impairment.

As with other agents inhibiting the renin angiotensin aldosterone system, changes in renal function may be anticipated in susceptible patients treated with Atacand. When Atacand is used in hypertensive patients with severe renal impairment, periodic monitoring of serum potassium and creatinine levels should be considered. There is very limited experience in patients with very severe or endstage renal impairment (i.e. creatinine clearance < 15 mL/min/1.73 m2 BSA). Evaluation of patients with heart failure should include periodic assessments of renal function. During dose titration of Atacand, monitoring of serum creatinine and potassium is recommended.

Use in the elderly.

See Section 4.2 Dose and Method of Administration, Use in the elderly; Section 4.4 Special Warnings and Precautions for Use, Combination use of ACE inhibitors or angiotensin receptor antagonists, anti-inflammatory drugs and thiazide diuretics; Section 5.2 Pharmacokinetic Properties, Pharmacokinetics in special populations.

Paediatric use.

No data available.

Effects on laboratory tests.

Hypertension.

In general there were no clinically important effects of Atacand on routine laboratory variables. As for other inhibitors of the renin-angiotensin-aldosterone system, small decreases in haemoglobin have been seen. Increases in creatinine, urea or potassium and decreases in sodium have been observed. In clinical trials, elevations of ALT occurred in 1.3% of candesartan-treated patients and 0.5% of those treated with placebo. The incidence of AST elevation was 0.4% with candesartan and 0% with placebo. No routine monitoring of laboratory variables is usually necessary for patients receiving Atacand. However, in patients with severe renal impairment, periodic monitoring of serum potassium and creatinine levels should be considered.

Heart failure.

Increases in creatinine, urea and potassium. Periodic monitoring of serum creatinine and potassium is recommended (see Section 4.4 Special Warnings and Precautions for Use, Use in heart failure).

4.5 Interactions with Other Medicines and Other Forms of Interactions

Dual blockade of the renin angiotensin aldosterone system (RAAS).

The combination of Atacand with aliskiren containing medicine is contraindicated in patients with diabetes mellitus (type I or II) or moderate to severe renal impairment (GFR < 60 mL/min/1.73 m2) and is not recommended in other patients. Clinical trial data has shown that dual blockade of the RAAS through the combined use of ACE inhibitors, angiotensin II receptor blockers or aliskiren is associated with a higher frequency of adverse events such as hypotension, hyperkalaemia and decreased renal function (including acute renal failure) compared to the use of a single RAAS acting agent (see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use).

Food.

Food increases the rate of absorption of candesartan, however, the extent of absorption of candesartan is not affected by food.

Lithium.

Reversible increases in serum lithium concentrations and toxicity have been reported during concomitant administration of lithium with ACE inhibitors. A similar effect may occur with angiotensin II receptor antagonists (AIIRAs) and careful monitoring of serum lithium levels is recommended during concomitant use.

Other drugs.

Compounds which have been investigated in clinical pharmacokinetic studies include hydrochlorothiazide, warfarin, digoxin, oral contraceptives (i.e. ethinyloestradiol/ levonorgestrel), glibenclamide and nifedipine and enalapril. No pharmacokinetic interactions of clinical significance were identified in these studies.
The antihypertensive effect of angiotensin II receptor antagonists, including candesartan, may be attenuated by NSAIDs, including COX-2 inhibitors and acetylsalicylic acid.
As with ACE inhibitors, concomitant use of AIIRAs and NSAIDs may lead to an increased risk of worsening of renal function, including possible acute renal failure, and an increase in serum potassium, especially in patients with poor pre-existing renal function. The combination should be administered with caution, especially in older patients and in volume depleted patients. Patients should be adequately hydrated and consideration should be given to monitoring renal function after initiation of concomitant therapy and periodically thereafter.
Candesartan is eliminated only to a minor extent by hepatic metabolism (CYP2C9). Available interaction studies indicate no effect on CYP2C9 and CYP3A4 but the effect on other cytochrome P450 isoenzymes is presently unknown.
Atacand may be administered with other antihypertensive agents.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

Candesartan cilexetil had no adverse effects on the reproductive performance of male or female rats at oral doses up to 300 mg/kg/day.
(Category D)
The use of Atacand is contraindicated during pregnancy (see Section 4.3 Contraindications). Patients receiving Atacand should be made aware of that before contemplating a possibility of becoming pregnant so that they can discuss appropriate options with their treating physician. When pregnancy is diagnosed, treatment with Atacand must be stopped immediately and if appropriate, alternative therapy should be started.
Drugs that act on the renin angiotensin system (RAS) can cause fetal and neonatal morbidity and death when administered to pregnant women. Exposure to angiotensin II receptor antagonist therapy is known to induce human fetotoxicity (decreased renal function, oligohydramnios, skull ossification retardation) and neonatal toxicity (renal failure, hypotension, hyperkalaemia).
It is not known whether candesartan is excreted in human milk. However, candesartan is excreted in the milk of lactating rats. Because of the potential for adverse effects on the nursing infant, breastfeeding should be discontinued if the use of Atacand is considered essential.

4.7 Effects on Ability to Drive and Use Machines

When driving vehicles or operating machines, it should be taken into account that dizziness or weariness may occur during treatment.

4.8 Adverse Effects (Undesirable Effects)

Hypertension.

Atacand was well tolerated in clinical studies showing an adverse event profile comparable to that of placebo. Generally adverse events were mild and transient. The overall incidence of adverse effects showed no association with dose, age or gender. Withdrawals from treatment due to adverse events were similar with candesartan cilexetil (3.1%) and placebo (3.2%).
Information on adverse events was obtained from 39 phase I to phase III clinical studies, involving a total of 5,464 subjects. Atacand was administered as mono or combination therapy to 2,061 hypertensive patients. The crude frequency of the most commonly occurring adverse events, irrespective of causality, reported for those patients and the 573 placebo comparators are given in Table 1.

Heart failure.

The adverse experience profile of Atacand in heart failure patients was consistent with the pharmacology of the drug and the health status of the patients. In the CHARM clinical programme, comparing Atacand in doses up to 32 mg (n = 3,803) to placebo (n = 3,796), 21.0% of the candesartan cilexetil group and 16.1% of the placebo group discontinued treatment because of adverse events. Adverse reactions commonly (≥ 1/100, < 1/10) seen were:

Vascular disorders.

Hypotension.

Metabolism and nutrition disorders.

Hyperkalaemia.

Renal and urinary disorders.

Renal impairment.

Postmarketing.

The following adverse reactions have been reported very rarely (< 0.01%) in postmarketing experience.

Blood and lymphatic system disorders.

Leukopenia, neutropenia and agranulocytosis.

Metabolism and nutrition disorders.

Hyperkalaemia, hyponatraemia.

Hepatobiliary disorders.

Increased liver enzymes, abnormal hepatic function or hepatitis.

Skin and subcutaneous tissue disorders.

Angioedema, rash, urticaria, pruritus.

Musculoskeletal, connective tissue and bone disorders.

Back pain, myalgia.

Renal and urinary disorders.

Renal impairment, including renal failure in susceptible patients (see Section 4.4 Special Warnings and Precautions for Use).
Rare reports of rhabdomyolysis have been reported in patients receiving angiotensin II receptor blockers.
Although causality to candesartan has not been established, the following neuropsychiatric and cardiovascular adverse reactions have been very rarely reported during postmarketing surveillance. These were agitation, anxiety, depression, insomnia, somnolence, nervousness, nightmare, sleep disorder and palpitations.

Reporting suspected adverse effects.

Reporting suspected adverse reactions after registration of the medicinal product is important. It allows continued monitoring of the benefit-risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions at www.tga.gov.au/reporting-problems.

4.9 Overdose

Symptoms.

Based on pharmacological considerations, the main manifestation of an overdose is likely to be symptomatic hypotension and dizziness. In single case reports of overdose (up to 672 mg candesartan cilexetil) patient recovery was uneventful.

Management.

If symptomatic hypotension should occur, symptomatic treatment should be instituted and vital signs monitored. The patients should be placed supine with the legs elevated. If this is not sufficient, plasma volume should be increased by the infusion of, for example, isotonic saline solution. Sympathomimetic drugs may be administered if the abovementioned measures are not sufficient.
Candesartan is not removed by haemodialysis. Contact the Poisons Information Centre for advice on management.
For information on the management of overdose, contact the Poison Information Centre on 131126 (Australia).

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

Angiotensin II is the primary vasoactive hormone of the renin angiotensin aldosterone system and plays a significant role in the pathophysiology of hypertension, heart failure and other cardiovascular disorders. It also has an important role in the pathogenesis of end organ hypertrophy and damage. The major physiological effects of angiotensin II, such as vasoconstriction, aldosterone stimulation, regulation of salt and water homeostasis and stimulation of cell growth, are mediated via the type 1 (AT1) receptor.
Atacand is a prodrug suitable for oral use. It is rapidly converted to the active drug, candesartan, by ester hydrolysis during absorption from the gastrointestinal tract. Candesartan is an angiotensin II receptor antagonist, selective for AT1 receptors, with tight binding to and slow dissociation from the receptor. It has no agonist activity.
Candesartan does not inhibit angiotensin converting enzyme (ACE), which converts angiotensin I to angiotensin II and degrades bradykinin. Since there is no effect on ACE and no potentiation of bradykinin or substance P, angiotensin II receptor antagonists are unlikely to be associated with cough. This has been confirmed in controlled clinical studies with Atacand. Candesartan does not bind to or block other hormone receptors or ion channels known to be important in cardiovascular regulation.
In hypertension, Atacand causes a dose dependent, long lasting reduction in arterial blood pressure. The antihypertensive action is due to decreased systemic peripheral resistance, while heart rate, stroke volume and cardiac output are not affected. There is no indication of serious or exaggerated first dose hypotension or rebound effect after cessation of treatment.
Atacand is effective in hypertension. After administration of a single dose, onset of antihypertensive effect generally occurs within two hours. With continuous treatment, the maximum reduction in blood pressure with any dose is generally attained within four weeks and is sustained during long-term treatment. It provides effective and smooth blood pressure reduction over the 24 hours dosing interval, with a trough/ peak ratio confirming once daily dosing.
Atacand can be used as monotherapy or in combination with other antihypertensive drugs, such as thiazide diuretics, calcium antagonists and lisinopril, for improved blood pressure control. Age and gender have no influence on the efficacy of Atacand.
Atacand has favourable renal haemodynamic effects. It increases renal blood flow and maintains or increases glomerular filtration rate while renal vascular resistance and filtration fraction are reduced. Atacand reduces urinary protein excretion in hypertensive patients with microalbuminuria or nephropathy of different aetiology. Atacand has no adverse effect on blood glucose or lipid profile. In a variety of preclinical safety studies conducted in several species, expected exaggerated pharmacological effects (e.g. renal changes leading to juxtaglomerular cell hypertrophy, adrenal gland zona glomerulosa atrophy and reduced heart weight related to reduced afterload), due to modification of the renin angiotensin aldosterone system homeostasis, have been observed. The incidence and severity of the effects induced were dose and time related and have been shown to be reversible in adult animals. Fetotoxicity has been observed in late pregnancy (see Section 4.6 Fertility, Pregnancy and Lactation).

Clinical trials.

Hypertension.

The Candesartan and Lisinopril Microalbuminuria (CALM) study was a 24 week double blind, parallel group trial (n = 199) to evaluate the effects of candesartan and lisinopril alone and in combination on urinary albumin excretion (UAE) in patients with type II diabetes mellitus, hypertension and microalbuminuria. Patients were randomly allocated to four treatment regimens: 1) 24 weeks of candesartan monotherapy (1/3 of the patients); 2) 24 weeks of lisinopril monotherapy (1/3 of the patients); 3) 12 weeks of candesartan monotherapy, followed by 12 weeks of candesartan + lisinopril combination therapy (1/6 of the patients); and 4) 12 weeks of lisinopril monotherapy, followed by 12 weeks of lisinopril + candesartan combination therapy (1/6 of the patients). Thus, after 12 weeks, half of the patients were treated with candesartan monotherapy (n = 99) and half with lisinopril monotherapy (n = 98). After 24 weeks, 1/3 of the patients still in the study were on candesartan monotherapy (n = 49), 1/3 on lisinopril monotherapy (n = 46), and 1/3 on combination therapy (candesartan + lisinopril (n = 25); lisinopril + candesartan (n = 24)). (See Table 2).
Significant reduction in urinary albumin/ creatinine ratio (UACR), in both monotherapy treatment groups was observed, although no significant difference between treatment groups was seen. Combination therapy following monotherapy for 12 weeks showed significantly greater reduction in UACR (mean reduction of 50%) than candesartan cilexetil 16 mg monotherapy (mean reduction in UACR 24%) and numerically greater reduction than lisinopril 20 mg monotherapy (mean reduction in UACR 39%).
All treatment regimens reduced both systolic and diastolic blood pressure significantly. The blood pressure reductions were significantly greater with combination therapy than with monotherapy, whether lisinopril was added to candesartan, or candesartan was added to lisinopril (see Table 2).
The antihypertensive effects of candesartan cilexetil and losartan potassium at their highest recommended doses administered once daily were compared in two randomised, double blind trials. In a total of 1,268 patients with mild to moderate hypertension who were not receiving other antihypertensive therapy, candesartan cilexetil 32 mg lowered systolic and diastolic blood pressure by 2 to 3 mmHg on average more than losartan potassium 100 mg, when measured at the time of either peak or trough effect.

Heart failure.

In patients with chronic heart failure (CHF) and depressed left ventricular systolic function (left ventricular ejection fraction, LVEF ≤ 40%), Atacand decreases systemic vascular resistance and pulmonary capillary wedge pressure, increases plasma renin activity and angiotensin II concentration, and decreases aldosterone levels.
Treatment with Atacand reduces mortality and hospitalisation due to CHF and improves symptoms as shown in the Candesartan in Heart failure - Assessment of Reduction in Mortality and morbidity (CHARM) programme comprising 3 studies (CHARM-Alternative, CHARM-Added and CHARM-Preserved). In all 3 studies, patients on optimal baseline therapy were randomised to placebo or Atacand (titrated from 4 mg or 8 mg once daily to 32 mg once daily or the highest tolerated dose, mean dose 24 mg) and followed for a median of 37.7 months.

CHARM-Alternative.

CHARM-Alternative was a multinational, randomised, double blind placebo controlled study in CHF patients (NYHA class II-IV, n = 2,028) with a LVEF ≤ 40% not treated with an ACE inhibitor because of intolerance.
Effect of candesartan versus placebo on composite endpoints and their components in CHARM-Alternative. See Table 3.

CHARM-Added.

CHARM-Added was a multinational, randomised, double blind placebo controlled study in CHF patients (NYHA class II-IV, n = 2,548) with a LVEF ≤ 40% treated with ACE inhibitors.
Effect of candesartan versus placebo on composite endpoints and their components in CHARM-Added. See Table 4.

CHARM-Preserved.

CHARM-Preserved was a multinational, randomised, double blind placebo controlled study in CHF patients (n = 3,023, NYHA class II-IV) with a LVEF > 40%, approximately 20% of whom received an ACE inhibitor. In the CHARM-Preserved study there was no effect of candesartan upon mortality. See Table 5.
All cause mortality was also assessed in pooled populations, CHARM-Alternative and CHARM-Added (HR 0.88, 95% CI: 0.79-0.98, p = 0.018) and all three studies (HR 0.91, 95% CI: 0.83 to 1.00, p = 0.055). This corresponds to a relative risk reduction of 12% and 9% respectively and an absolute risk reduction of 2.9 and 1.6% respectively.
Treatment with Atacand resulted in improved NYHA functional class in CHARM-Alternative and CHARM-Added (p = 0.008 and p = 0.020 respectively).
The beneficial effects of Atacand on cardiovascular mortality and CHF hospitalisation were consistent irrespective of age, gender and concomitant medication. Atacand was effective also in patients taking both beta-blockers and ACE inhibitors at the same time, and the benefit was obtained whether or not patients were taking ACE inhibitors at the target dose recommended by treatment guidelines.

5.2 Pharmacokinetic Properties

Absorption and distribution.

Following oral administration, candesartan cilexetil is converted to the active drug candesartan. The absolute bioavailability of candesartan is approximately 40% after an oral solution of candesartan cilexetil. The relative bioavailability of the tablet formulation compared with the same oral solution is approximately 34%, with little variability. The absolute bioavailability of candesartan following administration of the tablet is approximately 14%. The mean peak serum concentration (Cmax) is reached 3-4 hours after taking a tablet. The candesartan serum concentrations increase linearly with increasing doses in the therapeutic dose range. The area under the serum concentration versus time curve (AUC) of candesartan is not significantly affected by food. The peak concentration (Cmax) is increased by 26% and the rate of absorption is increased when taken with food. These changes are unlikely to result in clinically significant effects.
Candesartan is highly bound to plasma protein (more than 99%). The apparent volume of distribution (Vss) of candesartan is 0.1 L/kg.

Metabolism and excrettion.

Candesartan is mainly eliminated unchanged via urine and bile and is eliminated by hepatic metabolism only to a minor extent. The terminal half-life of candesartan is approximately 9 hours. There is no accumulation following multiple doses.
Total plasma clearance of candesartan is about 0.37 mL/min/kg, with a renal clearance of about 0.19 mL/min/kg. The renal elimination of candesartan is both by glomerular filtration and active tubular secretion. Following an oral dose of 14C-labelled candesartan cilexetil about 30% and 70% of the total radioactivity is recovered in the urine and faeces, respectively.

Pharmacokinetics in special populations.

In the elderly (over 65 years) both Cmax and AUC of candesartan are increased in comparison to young subjects. An initial dose of 8 mg is recommended (see Section 4.2 Dose and Method of Administration).
In patients with mild to moderate renal impairment Cmax and AUC of candesartan increased during repeated dosing by approximately 50% and 70%, respectively, but t½ was not altered, compared to patients with normal renal function. The corresponding changes in patients with severe renal impairment was approximately 50% and 110%, respectively. The terminal t½ of candesartan was approximately doubled in patients with severe renal impairment. AUC of candesartan in patients undergoing haemodialysis was similar to that in patients with severe renal impairment.
In patients with mild to moderate hepatic impairment, there was a 23% increase in the AUC of candesartan. No initial dosage adjustment is necessary in these patients.

5.3 Preclinical Safety Data

Genotoxicity.

Candesartan showed no evidence of genotoxic potential in a series of assay for gene mutations (Salmonella typhimurium, Escherichia coli, Mouse L5178Y cells and CHO cells), chromosomal aberrations (mouse nucleus assay) and unscheduled DNA synthesis. The active metabolite, candesartan, caused an increase in chromosomal aberrations in vitro (CHL cells) but not in vivo (mouse micronucleus assay).

Carcinogenicity.

There was no evidence of carcinogenicity when candesartan cilexetil was orally administered to mice and rats for up to 104 weeks at doses up to 100 and 1,000 mg/kg/day, respectively. Rats received the drug by gavage whereas mice received the drug by dietary administration. These (maximally tolerated) doses of candesartan cilexetil provided systematic exposures to candesartan (AUCs) that were, in mice, approximately 7 times and, in rats, more than 70 times the exposure in man at the maximum recommended daily human dose (32 mg).

6 Pharmaceutical Particulars

6.1 List of Excipients

In addition to candesartan cilexetil, Atacand also contains carmellose calcium, hyprolose, iron oxide - red (8 mg, 16 mg and 32 mg tablets only), lactose monohydrate, magnesium stearate, maize starch and macrogol 8000.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine. See Section 4.5 Interactions with Other Medicines and Other Forms of Interactions.

6.3 Shelf Life

In Australia, information on the shelf life can be found on the public summary of the Australian Register of Therapeutic Goods (ARTG). The expiry date can be found on the packaging.

6.4 Special Precautions for Storage

Store below 30°C.

6.5 Nature and Contents of Container

Blister foil (PVC/PVDC/Al) in cartons of 7*, 28* and 30 tablets.
*Not all pack sizes may be available in Australia.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of in accordance with local requirements.

6.7 Physicochemical Properties

Chemical structure.

It is a white to off white powder and is practically insoluble in water. Three polymorphic forms have been identified; crystal form I, crystal form II and an amorphous form. Crystalline form I is used in Atacand.
The chemical name for candesartan cilexetil is (±)-1-(cyclohexyloxycarbonyl-oxy) ethyl 2-ethoxy-1-[[2'-(1H-tetrazol-5-yl)biphenyl-4-yl] methyl]-1H-benzimadozole-7-carboxylate.
The molecular weight is 610.7.
The molecular formula is C33H34N6O6.

CAS number.

The CAS number is 145040-37-5.

7 Medicine Schedule (Poisons Standard)

Prescription only medicine (Schedule 4).

Summary Table of Changes