Consumer medicine information

CANDESARTAN-GA

Candesartan cilexetil

BRAND INFORMATION

Brand name

Candesartan-GA Tablets

Active ingredient

Candesartan cilexetil

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using CANDESARTAN-GA.

What is in this leaflet

This leaflet answers some common questions about CANDESARTAN-GA.

It does not contain all of the available information. It does not take the place of talking to your doctor or pharmacist.

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

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

Keep this leaflet with your medicine.

You may need to read it again.

What CANDESARTAN-GA is used for

CANDESARTAN-GA belongs to a group of medicines known as angiotensin-II receptor antagonists.

CANDESARTAN-GA is used to treat:

  • high blood pressure, also called hypertension
  • heart failure, usually in combination with other medicines.

Hypertension
Everyone has blood pressure. This pressure helps get your blood all around your body. Your blood pressure may be different at different times of the day, depending on how busy or worried you are. You have hypertension (high blood pressure) which means your blood pressure stays high, even when you are calm and relaxed.

Regular blood pressure checks are the only way of knowing that you have hypertension. There are 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.

CANDESARTAN-GA 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.

CANDESARTAN-GA helps to treat heart failure and may improve your symptoms.

One of the ways CANDESARTAN-GA 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, CANDESARTAN-GA 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 CANDESARTAN-GA and told you what dose to take.

Your doctor may have prescribed CANDESARTAN-GA for another reason.

Ask your doctor if you have any questions about why CANDESARTAN-GA has been prescribed for you.

CANDESARTAN-GA is available only with a doctor's prescription.

Before you take CANDESARTAN-GA

When you must not take it

Do not take CANDESARTAN-GA if you are allergic to medicines containing candesartan cilexetil, other angiotensin II receptor antagonists or any of the ingredients listed at the end of this leaflet.

Symptoms of an allergic reaction can include shortness of breath, wheezing or difficulty breathing, swelling of the face, lips, tongue, or other parts of the body.

Do not take CANDESARTAN-GA if you are pregnant.

CANDESARTAN-GA may affect your developing baby if you take it during pregnancy.

Do not breastfeed if you are taking CANDESARTAN-GA.

It is not known if CANDESARTAN-GA passes into breast milk.

Do not give CANDESARTAN-GA to children.

There is no information about its use in children, so CANDESARTAN-GA is not recommended for children.

Do not take CANDESARTAN-GA if the expiry date (Exp.) printed on the pack has passed.

Do not take CANDESARTAN-GA if the packaging is torn or shows signs of tampering.

Before you start to take it

Tell your doctor if you are allergic to any other medicines, foods, dyes or preservatives.

Tell your doctor if you have, or have had, any medical conditions, especially the following:

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

You may have to take a lower dose of CANDESARTAN-GA if you have these conditions.

If you have not told your doctor about any of the above, tell them before you start taking CANDESARTAN-GA.

Taking other medicines

Tell your doctor if you are taking any other medicines, including any that you buy without a prescription from a pharmacy, supermarket or health food shop.

Some medicines may be affected by CANDESARTAN-GA, or may affect how well it works. These include:

  • fluid tablets or diuretics
  • lithium or lithium containing medicines (eg. Lithicarb)
  • potassium tablets (eg. Span-K, Slow-K, Mag-K)
  • potassium containing salt substitutes (eg. Pressor-K)
  • anti-inflammatory medicines, used to relieve pain, swelling and other symptoms of inflammation, including arthritis. These include nonsteroidal anti-inflammatory agents - NSAIDs (eg. Voltaren, Indocid) and COX-2 inhibitors (eg. Celebrex).

Your doctor can tell you what to do if you are taking any of these medicines.

If you are not sure whether you are taking any of these medicines, check with your doctor or pharmacist.

Your doctor and pharmacist have more information on medicines to be careful with or avoid while taking CANDESARTAN-GA.

How to take CANDESARTAN-GA

How much to take

The usual dose is one 8 mg tablet or one 16 mg tablet taken daily. Sometimes, this may need to be increased to 32 mg taken daily.

Take CANDESARTAN-GA once a day, at about the same time each day.

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

Follow all directions given to you by your doctor and pharmacist carefully.

How to take CANDESARTAN-GA

Swallow the tablets with a glass of water.

It does not matter whether you take CANDESARTAN-GA tablets before or after food.

If you forget to take it

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

Otherwise, take the missed dose as soon as you remember, and then go back to taking your tablets as you would normally.

Do not take a double dose to make up for the dose you missed.

If you are not sure what to do, ask your doctor or pharmacist.

How long to take it for

CANDESARTAN-GA helps control your high blood pressure but does not cure it. To properly control your condition, CANDESARTAN-GA must be taken every day.

Keep taking CANDESARTAN-GA for as long as your doctor recommends.

If you take too much (overdose)

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

You may need urgent medical attention.

If you take too much CANDESARTAN-GA, you may get a headache and feel sick, dizzy and very tired.

While you are taking CANDESARTAN-GA

Things you must do

Before starting any new medicine, tell your doctor or pharmacist that you are taking CANDESARTAN-GA.

Tell all the doctors, dentists and pharmacists who are treating you that you are taking CANDESARTAN-GA.

Tell your doctor immediately if you become pregnant or plan to become pregnant while taking CANDESARTAN-GA.

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

If you plan to have surgery, including dental surgery, that needs a general anaesthetic, tell your doctor or dentist that you are taking CANDESARTAN-GA.

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 (eg blood tests, blood pressure) from time to time. These tests may help to prevent side effects.

Things you must not do

Do not use CANDESARTAN-GA to treat any other conditions unless your doctor tells you to.

Do not give CANDESARTAN-GA to anyone else, even if they have the same condition as you.

Do not stop taking CANDESARTAN-GA unless you have discussed it with your doctor.

Things to be careful of

Be careful driving or operating machinery until you know how CANDESARTAN-GA affects you.

CANDESARTAN-GA may cause drowsiness, dizziness or lightheadedness in some people. If any of these occur, do not drive, operate machinery or do anything else that could be dangerous.

Be careful getting up from a sitting or lying position.

Dizziness, lightheadedness or fainting may occur, especially when you get up quickly. Getting up slowly may help. This problem can be more common if you are also taking a diuretic (fluid tablets). Standing up slowly, especially when you get up from bed or chairs, will help your body get used to the change in position and blood pressure.

If you are taking CANDESARTAN-GA for high blood pressure, make sure you drink enough water during exercise and hot weather when you are taking CANDESARTAN-GA, especially if you sweat a lot.

If you do not drink enough water while taking CANDESARTAN-GA, you may faint or feel light-headed or sick. This is because your body does not have enough fluid and your blood pressure is low. If you continue to feel unwell, tell your doctor.

If you are taking CANDESARTAN-GA 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 CANDESARTAN-GA.

Like all other medicines, CANDESARTAN-GA may have unwanted side effects in some people. Sometimes they are serious, most of the time they are not. You may need medical treatment if you get some of the side effects.

Do not be alarmed by this list of possible side effects.

You may not experience any of them.

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
  • nausea/vomiting
  • back pain
  • dizziness.

These are common side effects. They are generally mild and do not normally require treatment to be interrupted.

The following side effects have been reported very rarely by patients taking CANDESARTAN-GA: palpitations, agitation, anxiety, depression, trouble sleeping (insomnia), drowsiness (somnolence), nervousness, nightmare and sleep disorder. It is not known if these side effects are caused by CANDESARTAN-GA.

Tell your doctor immediately if you notice any of the following:

  • aching muscles, tenderness or weakness in the muscles.

This 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 which may cause difficulty in swallowing or breathing
  • swelling of hands, feet or ankles
  • harsh sounds when breathing
  • signs of frequent infections such as fever, severe chills, sore throat or mouth ulcers
  • jaundice (yellowing of the skin and/or eyes)
  • unusual skin reactions (severe and sudden onset of rash, itchiness, hives (itchy swellings on the skin)
  • easy bruising or bleeding more easily than normal
  • extreme fatigue, tiredness, weakness
  • 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.

These are very rare but serious side effects. You may need urgent medical attention or hospitalisation.

Other side effects not listed above may also occur in some patients. Tell your doctor if you notice anything that is making you feel unwell.

After using CANDESARTAN-GA

Storage

Keep CANDESARTAN-GA where children cannot reach it.

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

Keep your tablets in a cool dry place where the temperature stays below 25°C.

Do not store CANDESARTAN-GA or any other medicine in the bathroom or near a sink.

Do not leave CANDESARTAN-GA in the car or on window sills.

Heat and dampness can destroy some medicines.

Disposal

If your doctor tells you to stop taking CANDESARTAN-GA, or your tablets have passed their expiry date, ask your pharmacist what to do with any that are left over.

Product Description

What it looks like

CANDESARTAN-GA comes in 4 strengths of tablets:

  • CANDESARTAN-GA 4mg - Light pink, round, biconvex tablet with ‘291’ on one side and a break line on the other side
  • CANDESARTAN-GA 8mg - Light pink, round, biconvex tablet with ‘292’ on one side and a break line on the other side
  • CANDESARTAN-GA 16mg - Light pink, round, biconvex tablet with ‘L293’ on one side and a break line on the other side
  • CANDESARTAN-GA 32mg - Light pink, round, biconvex tablet with ‘L294’ on one side and a break line on the other side.

Each PVC/ PE/PVDC/ Aluminium blister pack contains 30 tablets.

Ingredients

The active ingredient in CANDESARTAN-GA is candesartan cilexetil.

  • each CANDESARTAN-GA 4mg tablet contains 4 mg of candesartan cilexetil
  • each CANDESARTAN-GA 8mg tablet contains 8 mg of candesartan cilexetil
  • each CANDESARTAN-GA 16mg tablet contains 16 mg of candesartan cilexetil
  • each CANDESARTAN-GA 32mg tablet contains 32 mg of candesartan cilexetil.

The tablets also contain:

  • lactose
  • carmellose calcium
  • maize starch
  • macrogol 8000
  • hydroxypropylcellulose
  • magnesium stearate
  • Pigment Blend PB-24880 Pink (iron oxide red and lactose).

The tablets do not contain gluten, sucrose, tartrazine or any other azo dyes.

Distributor

Actavis Pty Ltd
Level 5, 117 Harrington St
The Rocks NSW 2000

Australian registration numbers:

  • CANDESARTAN-GA 4mg -
    AUST R 195506
  • CANDESARTAN-GA 8mg -
    AUST R 195491
  • CANDESARTAN-GA 16mg -
    AUST R 195513
  • CANDESARTAN-GA 32mg -
    AUST R 195452

Date of preparation: June 2013
Updated: May 2014

BRAND INFORMATION

Brand name

Candesartan-GA Tablets

Active ingredient

Candesartan cilexetil

Schedule

S4

 

Name of the medicine

Candesartan cilexetil.

Excipients.

Lactose, carmellose calcium, maize starch, macrogol 8000, hydroxypropylcellulose, magnesium stearate and Pigment Blend PB-24880 Pink (ARTG 108327) which contains iron oxide red and lactose. The tablets are gluten free.

Description

Chemical name: (1RS)-1-[[(cyclohexyloxy)carbonyl]oxy] ethyl 2-ethoxy- 1-[[2'-(1H-tetrazol-5-yl) biphenyl-4-yl] methyl]- 1H-benzimadozole- 7-carboxylate. Molecular formula: C33H34N6O6. MW: 611. CAS: 145040-37-5. Candesartan cilexetil is a white or almost white powder and is practically insoluble in water, freely soluble in methylene chloride and slightly soluble in anhydrous ethanol. Three polymorphic forms have been identified; crystal form I, crystal form II and an amorphous form. Crystalline form I is used in Candesartan-GA.

Pharmacology

Pharmacodynamics.

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.
Candesartan cilexetil 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 candesartan. Candesartan does not bind to or block other hormone receptors or ion channels known to be important in cardiovascular regulation.
In hypertension, candesartan 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.
Candesartan 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 hour dosing interval, with a trough/ peak ratio confirming once daily dosing.
Candesartan 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 candesartan.
Candesartan 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. Candesartan reduces urinary protein excretion in hypertensive patients with microalbuminuria or nephropathy of different aetiology. Candesartan 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. Foetotoxicity has been observed in late pregnancy (see Precautions, Use in pregnancy and Use in lactation).

Pharmacokinetics.

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 elimination.

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 Dosage and 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 t1/2 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 t1/2 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.

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 (1/3of the patients); 2) 24 weeks of lisinopril monotherapy (1/3of the patients); 3) 12 weeks of candesartan monotherapy, followed by 12 weeks of candesartan + lisinopril combination therapy (1/6of the patients); and 4) 12 weeks of lisinopril monotherapy, followed by 12 weeks of lisinopril + candesartan combination therapy (1/6of 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, of the patients still in the study were on candesartan monotherapy (n = 49), on lisinopril monotherapy (n = 46), and on combination therapy (candesartan + lisinopril (n = 25); lisinopril + candesartan (n = 24). (See Table 1.)
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 1.)
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%), candesartan cilexetil decreases systemic vascular resistance and pulmonary capillary wedge pressure, increases plasma renin activity and angiotensin II concentration, and decreases aldosterone levels.
Treatment with candesartan cilexetil 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) program comprising 3 studies (CHARM-Alternative, CHARM-Added and CHARM-Preserved). In all 3 studies, patients on optimal baseline therapy were randomised to placebo or candesartan cilexetil (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.
See Table 2.

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.
See Table 3.

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 4.
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: 0.83-1.00, 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 candesartan cilexetil resulted in improved NYHA functional class in CHARM-Alternative and CHARM-Added (p = 0.008 and p = 0.020 respectively).
The beneficial effects of candesartan cilexetil on cardiovascular mortality and CHF hospitalisation were consistent irrespective of age, gender and concomitant medication. Candesartan cilexetil 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.

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.

Contraindications

Hypersensitivity to any component of Candesartan-GA.
Pregnancy and lactation (see Precautions, Use in pregnancy).

Precautions

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 cardiopathy or ischaemic cerebrovascular disease could result in a myocardial infarction or stroke.

Kidney transplantation.

There is no experience regarding the administration of candesartan in patients with a recent kidney transplantation.

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 (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 candesartan in these patients is not recommended.

Hypotension.

Hypotension may occur during treatment with candesartan 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.

Hyperkalaemia.

Based on experience with the use of other drugs that affect the renin angiotensin aldosterone system, concomitant use of candesartan with potassium sparing diuretics, potassium supplements, salt substitutes containing potassium, or other drugs that may increase potassium levels (e.g. heparin) may lead to increases in serum potassium in hypertensive patients. In heart failure patients treated with candesartan, hyperkalaemia may occur. During treatment with Candesartan-GA 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.

Renal impairment.

As with other agents inhibiting the renin angiotensin aldosterone system, changes in renal function may be anticipated in susceptible patients treated with candesartan. When Candesartan-GA 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 end stage 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 Candesartan-GA, monitoring of serum creatinine and potassium is recommended.

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, Candesartan-GA should be carefully titrated with thorough monitoring of blood pressure in patients on haemodialysis (see Dosage and Administration).

Hepatic impairment.

There is no experience in patients with severe hepatic impairment and/or cholestasis; caution is advised in these patients. 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 candesartan.

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.

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.

Use in pregnancy.

(Category D)
The use of Candesartan-GA is contraindicated during pregnancy (see Contraindications). Patients receiving Candesartan-GA 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 Candesartan-GA must be stopped immediately and if appropriate, alternative therapy should be started.
Drugs that act on the renin angiotensin system (RAS) can cause foetal and neonatal morbidity and death when administered to pregnant women. Exposure to angiotensin II receptor antagonist therapy is known to induce human foetotoxicity (decreased renal function, oligohydramnios, skull ossification retardation) and neonatal toxicity (renal failure, hypotension, hyperkalaemia).

Use in lactation.

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 Candesartan-GA is considered essential.

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 1000 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).

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).

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.

Interactions

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 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, nifedipine and enalapril. No pharmacokinetic interactions of clinical significance were identified in these studies.
Attenuation of the antihypertensive effect may occur when simultaneously administering AIIRAs and nonsteroidal anti-inflammatory drugs (NSAIDs; i.e. selective COX-2 inhibitors, acetylsalicylic acid (> 3 g/day) and nonselective NSAIDs).
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.
Candesartan-GA may be administered with other antihypertensive agents.

Adverse Effects

Hypertension.

Candesartan 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. Candesartan was administered as monotherapy 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 5.

Laboratory findings.

In general, there were no clinically important effects of candesartan cilexetil 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 Candesartan-GA. However, in patients with severe renal impairment, periodic monitoring of serum potassium and creatinine levels should be considered.

Heart failure.

The adverse experience profile of candesartan cilexetil 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 candesartan cilexetil 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 as follows.

Vascular disorders.

Hypotension.

Metabolism and nutrition disorders.

Hyperkalaemia.

Renal and urinary disorders.

Renal impairment.

Laboratory findings.

Increases in creatinine, urea and potassium. Periodic monitoring of serum creatinine and potassium is recommended (see Precautions).

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 Precautions).
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.

Dosage and Administration

Candesartan-GA should be taken once daily with or without food.

Paediatrics.

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

Hypertension.

The recommended maintenance dose of candesartan 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 candesartan, combination with a thiazide diuretic is recommended.

Geriatrics.

An initial dose of 8 mg is recommended.

Hepatic insufficiency.

No initial dosage adjustment is necessary in patients with mild to moderately chronic liver disease. No experience is available to date in patients with severely impaired hepatic function (e.g. cirrhotic patients).

Renal insufficiency.

No initial dosage adjustment is necessary in patients with mild to moderate impaired renal function (i.e. creatinine clearance ≥ 30 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 candesartan 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 Precautions).

Special patient populations.

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

Concomitant therapy.

Candesartan can be administered with other heart failure treatment, including ACE inhibitors, beta-blockers, diuretics and digitalis or a combination of these medicines (see also, Pharmacology, Pharmacodynamics).

Overdosage

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.
For information on the management of an overdose, contact the Poisons Information Centre on 131 126 (Australia).

Presentation

Tablets (light pink, mottled, round, biconvex, uncoated, scored), 4 mg (marked 291 on one side), 8 mg (marked 292 on one side), 16 mg (marked L293 on one side), 32 mg (marked L294 on one side): 30's (PVC/PE/PVDC/Al or Al/Al blister pack, HDPE bottle with child resistant PP closure*).
*Not currently marketed in Australia.

Storage

Store below 25°C.

Poison Schedule

S4.