Consumer medicine information

Reaptan

Perindopril arginine; Amlodipine

BRAND INFORMATION

Brand name

Reaptan

Active ingredient

Perindopril arginine; Amlodipine

Schedule

S4

 

Consumer medicine information (CMI) leaflet

Please read this leaflet carefully before you start using Reaptan.

WHAT IS IN THIS LEAFLET

This leaflet answers some common questions about REAPTAN.

It does not contain all the available information about this medicine.

Reading this leaflet does not take the place of talking to your doctor or pharmacist.

All medicines have risks and benefits. Your doctor has weighed the risks of you taking REAPTAN 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 REAPTAN IS

The name of your medicine is REAPTAN.

The medicine contains the active ingredient perindopril arginine. Perindopril belongs to a group of medicines called angiotensin converting enzyme (ACE) inhibitors.

It also contains the active ingredient amlodipine besilate. Amlodipine belongs to a group of medicines called calcium channel blockers.

Calcium channel blockers do not change the amount of calcium in your blood or bones.

REAPTAN has been prescribed for you by your doctor to replace the separate tablets of perindopril and amlodipine you were taking.

One REAPTAN tablet replaces separate tablets of perindopril and amlodipine.

WHAT REAPTAN IS USED FOR

You have been prescribed REAPTAN if you have high blood pressure, also known as hypertension.

Why REAPTAN is used for high blood pressure

Everyone has blood pressure. This pressure helps get your blood all around the body. Your blood pressure may be different at different times of the day, depending on how busy or stressed you are.

You have high blood pressure when your blood pressure stays higher than is needed, even when you are calm or relaxed.

There are usually no symptoms of high blood pressure. The only way of knowing that you have it is to have your blood pressure checked on a regular basis. If high blood pressure is not treated it can lead to serious health problems. You may feel fine and have no symptoms, but eventually it can cause stroke, heart disease and kidney failure.

The active ingredients in REAPTAN, perindopril arginine and amlodipine help lower your blood pressure.

You may also have been prescribed REAPTAN if you have coronary heart disease.

Why REAPTAN is used for coronary heart disease

Coronary heart disease is narrowing of the vessels carrying blood to the heart.

In patients with coronary artery disease, REAPTAN has been shown to reduce some of the risks, including heart attacks.

HOW REAPTAN WORKS

REAPTAN works by widening your blood vessels, which reduces pressure in the vessel, making it easier for your heart to pump blood around your body

This helps increase the supply of oxygen to your heart, so that when you place extra demands on your heart, such as during exercise, your heart may cope better and you may not get short of breath as easily.

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

REAPTAN is available only with a doctor's prescription.

There is no evidence that REAPTAN is addictive.

BEFORE YOU TAKE REAPTAN

There are some people who shouldn't take REAPTAN. Please read the list below.

If you think any of these situations apply to you or you have any questions, please consult your doctor or pharmacist.

Do not take REAPTAN if:

  • you are allergic to perindopril or amlodipine, or any of the other ingredients of REAPTAN listed at the end of this leaflet.
  • you have had an allergic reaction to any other ACE inhibitors or calcium channel blockers
    Symptoms of an allergic reaction to REAPTAN may include skin rash, itchiness, shortness of breath, swelling of the face, lips or tongue, muscle pain or tenderness or joint pain.
  • are pregnant or trying to become pregnant
    REAPTAN may affect your developing baby if you take it during pregnancy.
  • are breastfeeding or plan to breast-feed
    REAPTAN passes into breast milk and therefore there is a possibility that the breast-fed baby may be affected.
  • are undergoing treatments where your blood is treated outside of the body (also known as extracorporeal treatments) that may increase your risk of allergic reactions, treatments such as:
    - renal dialysis or haemofiltration using polyacrylonitrile membranes
    - low-density lipoprotein (LDL) apheresis, a technique where LDL is 'filtered' out of the blood, using dextran sulphate.
  • you are treated with a blood pressure lowering medicine containing aliskiren and have diabetes or impaired kidney function.
  • you are being treated with sacubitril/valsartan, a medicine for heart failure.
  • have renal artery stenosis (narrowing of the blood vessels to one or both kidneys).
  • have aortic stenosis (narrowing of the main blood vessel leaving from the heart).
  • have severe hypotension (low blood pressure).
  • have unstable angina
    Unstable angina is a pain or uncomfortable feeling in the chest that lasts longer than a few minutes or occurs with rest, and may not be relieved with medication.
  • have cardiogenic shock which is a sudden and severe drop in blood pressure and blood flow through the body because the heart is not pumping normally.
  • have heart failure during the first 28 days after a heart attack (Heart failure means that the heart muscle cannot pump blood strongly enough to supply all the blood needed throughout the body. It does not mean that the heart stops working).
  • have experienced swelling of the face, tongue, lips or throat either spontaneously or in response to another medicine in the past. (This rare condition is known as angio-oedema).
  • the packaging is damaged or shows sign of tampering.
  • the expiry date (EXP) on the pack has passed.

If you think any of these situations apply to you, or you have any doubts or questions about taking REAPTAN speak to your doctor or pharmacist.

For older people and patients with renal impairment

REAPTAN can generally be used safely by elderly people.

Reduced kidney function is often found in elderly people and in this case, the starting dose should always be 2.5 mg of perindopril arginine and 2.5 mg of amlodipine taken as separate tablets.

For children

REAPTAN is not recommended for children.

Driving and using machines

REAPTAN may affect your ability to drive or use machines. If the tablets make you feel sick, dizzy, weak or tired, or give you a headache, do not drive or use machines and contact your doctor immediately.

Tell your doctor straight away if:

  • you are pregnant or become pregnant while taking REAPTAN, as it may cause serious harm to your baby.
  • you are undergoing desensitisation treatment, or have had an allergic reaction during previous desensitisation treatment (e.g. treatments using bee, wasp or ant venom).
  • you are undergoing, or you are intending to undergo, treatments where your blood is treated outside of the body (also known as extracorporeal treatments)you are to undergo anaesthesia and/or surgery.
  • you have recently suffered from diarrhoea or vomiting.
  • you are on a salt restricted diet or use salt substitutes which contain potassium.
  • you have an intolerance to some sugars as REAPTAN contains lactose.
  • you are taking any of the following medicines used to treat high blood pressure:
    - an 'angiotensin II receptor blocker' (also known as ARBs or sartans - for example valsartan, telmisartan, irbesartan), in particular if you have diabetes-related kidney problems
    - aliskiren.
  • you are treated with immunosuppressant therapy or allopurinol or procainamide.
  • you have any other health problems, including:
    - kidney disease or if you are on renal dialysis
    - liver disease
    - high or low levels of potassium, or other problems with salt balance
    - diabetes
    - heart disease, severe increase in blood pressure or other heart problems
    - Systemic lupus erythematous or scleroderma (a disease affecting the skin, joints and kidneys)
    - abnormally increased levels of a hormone called aldosterone in your blood (primary hyperaldosteronism).

If you think any of these situations apply to you, or you have any doubts or questions about taking REAPTAN consult your doctor or pharmacist.

Taking other medicines

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

Taking REAPTAN may change the effect of some medicines, and some medicines may affect how well REAPTAN works. You may need different amounts of your medication or to take different medicines.

The medicines that may interact with REAPTAN include the following:

  • Some treatments where your blood is treated outside of the body, also known as extracorporeal treatments (see also 'Do Not Take REAPTAN If' and 'Tell Your Doctor Straight Away' sections)
  • some antibiotic medicines such as erythromycin, clarithromycin and rifampicin
  • some medicines used to treat fungal infections such as ketoconozole or itracanazole
  • some anti-inflammatory drugs (including high dose aspirin, ibuprofen to relieve pain swelling and other symptoms of inflammation, including arthritis, and gold injections to treat rheumatoid arthritis)
  • medicines used to treat mood swings and some types of depression (lithium, tricyclic antidepressants, antipsychotics)
  • potassium-sparing medicines (spironolactone, triamterene, amiloride, eplerenone), sources of potassium, like potassium tablet and salt substitutes containing potassium, other drugs which can increase potassium in your body (such as heparin and co-trimoxazole also known as trimethoprim/sulfamethoxazole)
  • some medications used to treat high blood pressure (including angiotensin receptor blocker, beta-blockers, alpha-blockers) aliskiren (see also 'Do Not Take REAPTAN If' and 'Tell Your Doctor Straight Away' sections), or diuretics (sometimes called 'fluid' or 'water' tablets because they increase the amount of urine passed each day)
  • vasodilators including nitrates
  • medicines used to treat diabetes (tablets and insulin)
  • muscle relaxants such as baclofen and dantrolene; dantrolene is also used to treat hyperthermia during anaesthesia (symptoms include very high fever and muscle stiffness)
  • medicines used to treat epilepsy such as carbamazepine, phenobarbitone, phenytoin or primidone
  • St. John's Wort
  • medicines which lower your immune system, such as corticosteroids, cyclosporin, tacrolimus or medicines used to treat cancer (including radiation therapy)
  • simvastatin (cholesterol lowering medicine)
  • tetracosactide, a medicine used to treat adrenal insufficiency
  • medicines which may affect the blood cells, such as allopurinol, procainamide
  • medicines affecting the part of the nervous system that controls the activities of the heart and blood vessels, including ephedrine, noradrenaline or adrenaline
  • alpha-blockers used for the treatment of enlarged prostate such as prazosin, alfuzosin, doxazosin, tamsulosin, terazosin
  • amifostine (used to prevent or reduce side effects caused by other medicines or radiation therapy that are used to treat cancer)
  • corticosteroids (used to treat various conditions including severe asthma and rheumatoid arthritis)
  • medicines used to treat HIV infection such as indinavir, ritonavir (also called 'protease inhibitors')
  • mammalian target of rapamycin (mTOR) inhibitors used to avoid rejection of transplanted organs (e.g. temsirolimus, sirolimus, everolimus)Sacubitril/valsartan (used to treat long-term heart failure).

It is a good idea to remind your doctor of all other medicines you take. Your doctor or pharmacist has more information on medicines to be careful with or avoid while taking REAPTAN.

HOW TO TAKE REAPTAN

Follow all directions given to you by your doctor and pharmacist carefully. They may differ from the information contained in this leaflet.

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

How much to take

Your doctor will select a dose when they prescribe REAPTAN for you. The usual dose is one tablet once daily.

How to take it

Swallow your tablet(s) with a glass of water.

Grapefruit juice and grapefruit should not be consumed by people who are taking REAPTAN. This is because grapefruit and grapefruit juice can lead to an increase in the blood levels of the active ingredient amlodipine, which can cause an unpredictable increase in the blood pressure lowering effect of REAPTAN.

When to take it

Take REAPTAN at about the same time each day unless your doctor tells you otherwise.

Taking your tablet at the same time each day will have the best effect. It will also help you remember when to take the tablets.

REAPTAN should be taken in the morning before a meal. 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 it as soon as you remember, and then go back to taking it as you would normally.

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

How long to take it for

REAPTAN helps control your blood pressure and/or treat your coronary heart disease but does not cure it. Continue taking the tablets for as long as your doctor tells you.

If you take too much

Immediately telephone your doctor, or the Poisons Information Centre (telephone 13 11 26 in Australia) if you think you or anyone else may have taken too much REAPTAN. Do this even if there are no signs of discomfort or poisoning.

WHILE YOU ARE TAKING REAPTAN

Things you must do

If you become pregnant while you are taking REAPTAN, tell your doctor.

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

Tell all doctors, dentists and pharmacists involved with your treatment that you are taking REAPTAN.

Take REAPTAN exactly as your doctor has prescribed. Otherwise you may not get the benefits from treatment.

If any of the signs below occur then tell your doctor immediately or go to the Accident and Emergency department at your nearest hospital.

  • swelling of your lips, face, mouth, tongue or throat
  • purple spots with occasional blisters on the front of your arms and legs and/or around your neck and ears (a rare condition known as Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis (TEN))
  • severe blisters, skin rash, itching or other allergic reactions.

These side effects are extremely rare but can become serious.

If you have stopped treatment with REAPTAN due to an allergic reaction you should not start taking REAPTAN again.

Things you must not do

  • do not give REAPTAN to anyone else, even if they have the same condition as you.
  • do not use REAPTAN to treat other complaints unless your doctor tells you to.
  • do not stop taking REAPTAN or change the dosage, without checking with your doctor.
  • do not stop taking your tablets because you are feeling better, unless advised by your doctor.

Things that may help your condition

Some self - help measures suggested below may help your condition. Talk to your doctor or pharmacist about these measures and for more information.

  • Alcohol - your doctor may advise you to limit your alcohol intake
  • Diet - eat a healthy low-fat diet which includes plenty of fresh vegetables, fruit, bread, cereals and fish. Also eat less fat and sugar
  • Exercise - regular exercise helps to reduce blood pressure and helps get the heart fitter, but it is important not to overdo it. Walking is good exercise, but try to find a route that is reasonably flat. Before starting any exercise, ask your doctor about the best kind of program for you
  • Salt - your doctor may advise you to watch the amount of salt in your diet. To reduce your salt intake you should avoid using salt in cooking or at the table
  • Smoking - your doctor may advise you to stop or at least cut down smoking
  • Weight - your doctor may suggest losing some weight to help lower your blood pressure and help lessen the amount of work your heart has to do. Some people may need a dietician's help to lose weight.

SIDE EFFECTS

Angioedema (a severe allergic reaction) has been reported in patients treated with ACE inhibitors, including REAPTAN. This may occur at any time during treatment. If you develop such symptoms described below you should tell your doctor immediately or go to the Accident and Emergency department at your nearest hospital. These side effects are extremely rare but can become serious:

  • swelling of your extremities (limbs, hands or feet), lips, face, mouth, tongue or throat
  • purple spots with occasional blisters on the front of your arms and legs and/or around your neck and ears (a rare condition known as Stevens-Johnson Syndrome)
  • painful red areas, developing large blisters and peeling of layers of skin. This is accompanied by fever and chills
  • red, often itchy spots, similar to the rash of measles, which starts on the limbs and sometimes on the face and the rest of the body
  • difficulty in breathing
  • a fast and irregular heart beat.

Talk to your doctor or pharmacist or nurse if you notice any of the following side effects:

Some of the side effects are usually only identified after blood tests.

Very common (may affect more than 1 in 10 people) side effects can include:

  • dizziness
  • cough, often described as dry and irritating, shortness of breath, discomfort on exertion
  • oedema (fluid retention)
  • swelling of hands, ankles or feet, joint swelling (ankle swelling).

Common (may affect up to 1 in 10 people) side effects can include:

  • chest pain
  • nosebleeds
  • headache, vertigo, pins and needles
  • changes in the rhythm or rate of the heart beat, fast or irregular heart beat
  • feeling tired, lethargic or weak
  • feeling sleepy (somnolence)
  • tinnitus (persistent noise in the ears), vision impairment (including double vision)
  • low blood pressure (and related effects), flushing, impaired peripheral circulation, blood vessel inflammation (vasculitis)
  • nausea, vomiting, taste disturbances, indigestion, diarrhoea, constipation, change of bowel habits, stomach pain or discomfort
  • dry mouth
  • muscle spasms
  • fatigue
  • rash, pruritus (itching), red raised skin rash
  • eczema
  • erectile dysfunction
  • drowsiness
  • chest tightness (dyspnoea), discomfort on exertion.

Uncommon (may affect up to 1 in 100 people) side effects can include:

  • conjunctivitis - discharge with itching of the eyes and crusty eyelids, swollen runny eyes
  • runny or blocked nose, sneezing, facial pressure or pain
  • bleeding or bruising more easily than normal caused by a low blood platelet count (thrombocytopenia)
  • frequent infections such as fever, severe chills, sore throat or mouth ulcers caused by a lack of white blood cells (leukopenia)
  • hyperglycaemia (high blood sugar levels),
  • hypoglycaemia (low blood sugar levels)
  • thirst
  • numbness or weakness of the arms and legs
  • tremor
  • numbness, or reduced sense of touch
  • high levels in the blood of potassium, urea and/or creatinine, low sodium levels in the blood
  • peripheral ischaemia - a condition caused by reduced blood flow to the limbs, hands and feet
  • orthostatic hypertension - dizziness on standing up, especially when getting up from a sitting or lying position
  • mood disturbance, depression, nervousness, depersonalisation, sleep disturbances (difficulty sleeping, abnormal dreams), feeling sleepy or drowsy, fainting
  • difficulty breathing or wheezing
  • decreased appetite
  • difficulty in swallowing
  • flatulence or 'passing wind'
  • bleeding, tender or enlarged gums
  • inflammation of the pancreas (pancreatitis)
  • swelling of the face, lips, mouth, tongue or throat which may cause difficulty in swallowing or breathing
  • unusual hair loss or thinning
  • purpura - unusual bleeding or bruising under the skin, or purple or red-brown spots visible through the skin
  • excessive sweating
  • increased sensitivity of the skin to sun, skin rash or inflammation of the skin often including blisters that weep and become crusted
  • skin discolouration
  • hypersensitivity reactions, mainly skin reactions, in patients with allergies and asthmatic reactions
  • pemphigoid - a skin disease usually affecting older people
  • increase in some white blood cells (eosinophilia).
  • pollakiuria
  • need to urinate during the night
  • passing urine more often than usual
  • sexual dysfunction
  • breast enlargement in men
  • fever or high temperature
  • kidney problems
  • decreased blood sugar levels
  • osteoarthritis
  • aching muscles, not caused by exercise
  • back pain
  • generally feeling unwell
  • falls
  • diplopia, eye pain
  • fast, slow or irregular heart beat
  • peripheral coldness
  • hives or skin rash (urticaria)
  • joint pain
  • malaise, pain, chills
  • blood urea/creatinine increase
  • weight gain/weight decrease.

Rare (may affect up to 1 in 1,000 people) side effects can include:

  • increased appetite
  • confusion, agitation,
  • apathy - lack of interest, enthusiasm, concern
  • loss of memory
  • ataxia - clumsiness and lack of coordination, affecting balance and manner of walking, limb or eye movements and/or speech. Unsteadiness when walking
  • migraine
  • inability to smell
  • unusual muscle stiffness causing poor control of movement
  • muscle weakness
  • blurred vision
  • dry eyes
  • myocardial infarction, angina pectoris (a feeling of tightness, pressure or heaviness in the chest)
  • cardiac failure - disease of the heart with heart failure, symptoms include shortness of breath, swelling of the feet or legs due to fluid build-up
  • gastritis - inflammation of the stomach where symptoms include pain, nausea, vomiting, vomiting blood, blood in the bowel motions
  • red, often itchy spots, similar to the rash of measles, which starts on the limbs and sometimes on the face and the rest of the body
  • dry skin
  • cold and clammy skin
  • dermatitis
  • elevation of bilirubin levels in the blood, increases in liver enzymes
  • hepatitis (liver disease)
  • yellowing of the skin and/or eyes, also called jaundice
  • muscle twitching
  • muscular weakness
  • painful or difficult urination
  • worsening of psoriasis.

Very rare (may affect up to 1 in 10,000 people) side effects can include:

  • hallucination
  • cerebrovascular accident
  • Quicke's oedema
  • Steven Johnson syndrome
  • acute kidney disease
  • eosinophilic pneumonia
  • illnesses resulting from a lack or destruction of red blood cells - (anaemia, pancytopenia)
  • illnesses resulting from a lack of white blood cells (agranulocytosis, neutropenia, pancytopenia)
  • severe flaking or peeling of the skin
  • concentrated urine (dark in colour), feel or are sick, have muscle cramps, confusion and fits which may be due to inappropriate anti-diuretic hormone (ADH) secretion can occur with ACE inhibitors. If you have these symptoms contact your doctor as soon as possible.

Not known (frequency cannot be estimated from the data available):

  • extrapyramidal syndrome - unusual movements, including trembling and shaking of the hands and fingers, rigid posture, mask-like face, slow movements of the body, shuffling unbalanced walk and stiffness of the arms and legs
  • Discolouration, numbness and pain in fingers or toes (Raynaud’s phenomenon).

Consult your doctor, pharmacist or nurse if you experience any of these or notice anything else that is making you feel unwell.

Do not be alarmed by this list of possible side effects. You may not experience any of them. Other uncommon side effects have been reported and you should ask your doctor, pharmacist or nurse if you want to know more.

AFTER TAKING REAPTAN

Storage

Keep your REAPTAN tablets in the bottle until it is time to take them. REAPTAN will not keep as well outside its packaging.

Keep your REAPTAN tablets in a cool, dry place away from light where the temperature stays below 25°C.

Do not store medicines in a bathroom or near a sink. Do not leave them in a car or on a window sill. Heat and dampness can destroy some medicines.

Keep your REAPTAN tablets where children cannot reach them. 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 REAPTAN, or the tablets have passed their expiry date, return any leftover tablets to your pharmacist for disposal.

PRODUCT DESCRIPTION

What it looks like

REAPTAN 5/5 tablets are white and rod-shaped engraved with 5/5 on one face and the Servier Logo on the other face, supplied in a bottle of 30 tablets.

REAPTAN 5/10 tablets are white and square-shaped engraved with 5/10 on one face and the Servier Logo on the other face, supplied in a bottle of 30 tablets.

REAPTAN 10/5 tablets are white and triangular-shaped engraved with 10/5 on one face and the Servier Logo on the other face, supplied in a bottle of 30 tablets.

REAPTAN 10/10 tablets are white and round engraved with 10/10 on one face and the Servier Logo on the other face, supplied in a bottle of 30 tablets.

Thirty (30) tablets are supplied in a white bottle containing desiccant sachets and equipped with a white child-resistant screw-on cap.

Ingredients

Each tablet of REAPTAN 5/5 contains 5 mg perindopril arginine and 5 mg amlodipine, and a number of inactive ingredients.

Each tablet of REAPTAN 5/10 contains 5 mg perindopril arginine and 10 mg amlodipine, and a number of inactive ingredients.

Each tablet of REAPTAN 10/5 contains 10 mg perindopril arginine and 5 mg amlodipine, and a number of inactive ingredients.

Each tablet of REAPTAN 10/10 contains 10 mg perindopril arginine and 10 mg amlodipine, and a number of inactive ingredients.

All tablet doses include the inactive ingredients; lactose monohydrate, microcrystalline cellulose, colloidal anhydrous silica, magnesium stearate.

REAPTAN is registered on the Australian register of Therapeutic Goods.

REAPTAN 5/5: AUST R 170796

REAPTAN 5/10: AUST R 170797

REAPTAN 10/5: AUST R 170798

REAPTAN 10/10: AUST R 170799

Manufacturer

REAPTAN is a product discovered by Servier Research International.

It is distributed in Australia by:

Servier Laboratories (Aust.) Pty Ltd
8 Cato Street
PO Box 196
Hawthorn Victoria 3122

This document was last revised in May 2019

Published by MIMS July 2019

BRAND INFORMATION

Brand name

Reaptan

Active ingredient

Perindopril arginine; Amlodipine

Schedule

S4

 

1 Name of Medicine

Perindopril arginine/ amlodipine besilate.

6.7 Physicochemical Properties

Perindopril arginine.

Perindopril arginine has the chemical name, L-arginine (2S,3aS,7aS)-1-[(2S)-2-[[(1S)-1-(ethoxycarbonyl) butyl] amino] propanoyl] octahydro-1H-indole-2-carboxylate. It is a dipeptide monoacid monoester with a perhydroindole group and no sulphydryl radical. Perindopril arginine is a white powder, readily soluble in purified water, slightly soluble in 95% ethanol and practically insoluble in chloroform. Perindopril has five asymmetric centres. The drug is synthesised stereoselectively so that it is a single enantiomer (all S stereochemistry).
Molecular formula: C19H32N2O5, C6H14N4O2 (MW = 542.7).

Chemical structure.


CAS number.

612548-45-5.

Amlodipine besilate.

Amlodipine besilate is a dihydropyridine derivative, and has the following chemical name: 3-Ethyl 5-methyl (4RS)-2-[(2-aminoethoxy)methyl]-4-(2-chorophenyl)-6-methyl-1,4-dihydropyridine-3,5-dicarboxylate benzenesulfonate. Amlodipine besilate is chiral and present as a racemate. It is a white crystalline powder and is slightly soluble in water and sparingly soluble in ethanol.
Molecular formula: C20H25ClN2O5.C6H6O3S [MW = 567.1 (free base 408.9)].

Chemical structure.


CAS number.

111470-99-6.

2 Qualitative and Quantitative Composition

The active components of Reaptan are perindopril arginine and amlodipine besilate.
Each Reaptan 5/5 tablet contains 5 mg of perindopril arginine and 5 mg of amlodipine (as besilate*).
Each Reaptan 5/10 tablet contains 5 mg of perindopril arginine and 10 mg of amlodipine (as besilate*).
Each Reaptan 10/5 tablet contains 10 mg of perindopril arginine and 5 mg of amlodipine (as besilate*).
Each Reaptan 10/10 tablet contains 10 mg of perindopril arginine and 10 mg of amlodipine (as besilate*).

Excipient with known effect.

Lactose (as monohydrate).
Each Reaptan 5/5 tablet contains 65.23 mg of lactose (as monohydrate).
Each Reaptan 5/10 tablet contains 135.47 mg of lactose (as monohydrate).
Each Reaptan 10/5 tablet contains 137.40 mg of lactose (as monohydrate).
Each Reaptan 10/10 tablet contains 130.47 mg of lactose (as monohydrate).
For the full list of excipients, see Section 6.1 List of Excipients.
* Amlodipine doses are given as active base.

3 Pharmaceutical Form

Reaptan 5/5 is a white, rod-shaped tablet engraved with 5/5 on one face and the Servier company logo on the other face.
Reaptan 5/10 is a white, square-shaped tablet engraved with 5/10 on one face and the Servier company logo on the other face.
Reaptan 10/5 is a white, triangular-shaped tablet engraved with 10/5 on one face and the Servier company logo on the other face.
Reaptan 10/10 is a white, round tablet engraved with 10/10 on one face and the Servier company logo on the other face.

5 Pharmacological Properties

5.1 Pharmacodynamic Properties

Mechanism of action.

Pharmacology of perindopril.

Perindopril (prodrug) following hydrolysis to perindoprilat, inhibits angiotensin converting enzyme (ACE) both in vitro and in vivo. It is thought that ACE inhibitors reduce blood pressure by inhibiting the enzyme which catalyses the conversion of angiotensin I to angiotensin II. Decreased plasma angiotensin II leads to increased plasma renin activity and a decrease in aldosterone. In addition to its effects on circulating ACE, perindopril binds to and inhibits tissue converting enzyme, predominantly in the kidney and vascular wall. The contribution of this mechanism to the overall antihypertensive effect of perindopril is unknown. Animal studies have demonstrated reversal of vascular hypertrophy and an improvement in the ratio of elastin to collagen in the vessel wall. Studies in man have demonstrated an improvement in the visco-elastic properties of large vessels and in compliance. Studies in animals and humans suggest that specific and competitive suppression of the renin-angiotensin-aldosterone system (RAAS) is the main mechanism by which blood pressure is reduced. However, antihypertensive activity has also been observed in patients with low renin activity. Perindopril may also inhibit the degradation of the potent vasodepressor peptide, bradykinin, and this action may contribute to its antihypertensive action. Perindopril appears to reduce peripheral resistance and may influence arterial compliance.
Studies carried out in animal models of hypertension have shown that perindopril is a specific competitive angiotensin I converting enzyme inhibitor. The administration of perindopril to patients with essential hypertension results in a reduction in supine and standing blood pressure without any significant effect on heart rate. Abrupt withdrawal of perindopril has not been associated with a rebound rise in blood pressure. Single dose studies have demonstrated that peak inhibition of ACE activity and peak reduction in blood pressure occurs four to six hours after administration. The durations of these effects are dose related and at the recommended dose range, both effects have been shown to be maintained over a 24-hour period.
In haemodynamic studies carried out in animal models of hypertension, blood pressure reduction after perindopril administration was accompanied by a reduction in peripheral arterial resistance and improved arterial wall compliance. In studies carried out in patients with essential hypertension the reduction in blood pressure was accompanied by a reduction in peripheral resistance with no change, or a small increase in renal blood flow and no change in glomerular filtration rate. An increase in the compliance of large arteries was also observed. When perindopril is administered together with a thiazide-type diuretic, the antihypertensive activity of perindopril may be potentiated in some patients, and this effect is evident after four weeks of treatment. Perindopril, like other ACE inhibitors, may compensate for thiazide-induced hypokalaemia.
In one study of 48 patients in which low-dose perindopril equivalent to perindopril arginine 2.5 mg was compared with correspondingly low doses of enalapril (2.5 mg) or captopril (6.25 mg) in patients with congestive heart failure, significantly different blood pressure responses were noted. Blood pressure fell significantly with captopril and enalapril following the first dose. However, whilst perindopril inhibited plasma ACE comparably with enalapril, the blood pressure changes were insignificant and similar to placebo for up to ten hours of regular observation. Data regarding possibility of a late hypotensive response are not available for perindopril.

Pharmacology of amlodipine.

Amlodipine is a calcium ion influx inhibitor (slow channel blocker or calcium ion antagonist) and inhibits the transmembrane influx of calcium ions into cardiac and vascular smooth muscle.
Experimental data suggest that amlodipine binds to both dihydropyridine and non-dihydropyridine binding sites. The contractile processes of cardiac muscle and vascular smooth muscle are dependent upon the movement of extracellular calcium ions into these cells through specific ion channels. Amlodipine inhibits calcium ion influx across cell membranes selectively, with a greater effect on vascular smooth muscle cells than on cardiac muscle cells. Negative inotropic effects can be detected in vitro but such effects have not been seen in intact animals at therapeutic doses. Serum calcium concentration is not affected by amlodipine. Within the physiologic pH range, amlodipine is an ionized compound (pKa=8.6), and its kinetic interaction with the calcium channel receptor is characterised by a gradual rate of association and dissociation with the receptor binding site, resulting in a gradual onset of effect.
Amlodipine is a peripheral arterial vasodilator that acts directly on vascular smooth muscle to cause a reduction in peripheral vascular resistance and reduction in blood pressure. The precise mechanism by which amlodipine relieves angina has not been fully determined but amlodipine reduces the total ischaemic burden by the following two actions:
Amlodipine dilates peripheral arterioles and thus reduces the total peripheral resistance (afterload) against which the heart works. Since the heart rate remains stable, this unloading of the heart reduces myocardial energy consumption and oxygen requirements.
Amlodipine has been shown to block constriction in main coronary arteries and coronary arterioles, induced by calcium, potassium, adrenaline, serotonin and thromboxane A2 analogue both in normal and in ischaemic regions.
Following administration of therapeutic doses to patients with hypertension, amlodipine produces vasodilation resulting in a reduction of supine and standing blood pressures. These decreases in blood pressure are not accompanied by a significant change in heart rate or plasma catecholamine levels with chronic dosing.
With chronic once daily oral administration, antihypertensive effectiveness is maintained for at least 24 hours. Plasma concentrations correlate with effect in both young and elderly patients.
Amlodipine has shown no harmful effect on lipid levels and is suitable for use in patients with asthma, diabetes and gout.
As with other calcium channel blockers, haemodynamic measurements of cardiac function at rest and during exercise (or pacing) in patients with normal ventricular function treated with amlodipine have generally demonstrated a small increase in cardiac index without significant influence on dP/dt or on left ventricular end diastolic pressure or volume. In haemodynamic studies, amlodipine has not been associated with a negative inotropic effect when administered in the therapeutic dose range to intact animals and man, even when co-administered with beta-blockers to man. Similar findings, however, have been observed in normal or well-compensated patients with heart failure with medicines possessing significant negative inotropic effects.
In patients with hypertension and normal renal function, therapeutic doses of amlodipine resulted in a decrease in renal vascular resistance and an increase in glomerular filtration rate and effective renal plasma flow without change in filtration fraction or proteinuria.

Clinical trials.

Clinical trials using Reaptan consist of three bioequivalence studies and a pharmacokinetic interaction study (see Section 5.2 Pharmacokinetic Properties).
No other clinical trials have been conducted with Reaptan, including trials to assess its long-term effects on cardiovascular morbidity or mortality. However the effects of the individual components of Reaptan have been assessed in clinical trials as detailed below. The combined use of perindopril and amlodipine has been studied in patients with hypertension who have additional cardiovascular risk factors in the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA).

Clinical trials of perindopril.

Stable coronary artery disease.

The effects of perindopril were compared to placebo in patients with stable coronary artery disease with no clinical signs of heart failure. The EUROPA (EUropean trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease) study was a multicentre, international, randomised, double blind, placebo-controlled clinical trial lasting four years. 12,218 patients aged over 18 were randomised: 6110 patients to high dose perindopril, equivalent to perindopril arginine 10 mg and 6108 patients to placebo.
The primary endpoint was the composite of cardiovascular mortality, non-fatal myocardial infarction, and/or cardiac arrest with successful resuscitation.
The trial population had evidence of coronary artery disease documented by previous myocardial infarction at least three months before screening, coronary revascularisation at least six months before screening, angiographic evidence of stenosis (at least 70% narrowing of one or more major coronary arteries), or positive stress test in men with a history of chest pain.
Study medication was added to conventional treatment, including medication used for the management of hyperlipidaemia, hypertension and diabetes mellitus. Patients randomised to perindopril were initiated on doses of perindopril equivalent to perindopril arginine 2.5 mg or perindopril arginine 5 mg for two weeks, and then titrated up to a dose of perindopril equivalent to perindopril arginine 10 mg during the two following weeks. A dose of perindopril equivalent to perindopril arginine 10 mg was then maintained for the whole duration of the study. If this dose was not well tolerated, it could be reduced to a dose of perindopril equivalent to perindopril arginine 5 mg once daily.
Most of the patients also received platelet inhibitors, lipid-lowering medicines and beta-blockers. At the end of the study, the proportions of patients on these combined medicines were 91%, 69% and 63% respectively.
The reduction in the primary composite endpoint was mainly due to a reduction in the number of non-fatal myocardial infarctions. There was no significant reduction in the rate of cardiovascular mortality or total mortality in patients taking perindopril compared to those taking placebo.
After a mean follow-up of 4.2 years, treatment with a dose of perindopril equivalent to perindopril arginine 10 mg once daily resulted in a significant relative risk reduction of 20% (95% CI: 9-29) in the primary combined endpoint: 488 patients (8.0%) reported events in the perindopril group compared to 603 patients (9.9%) in the placebo group (p = 0.0003). Improvements in the primary composite endpoint achieved statistical significance after three years of continuous treatment on perindopril.

Clinical trials of amlodipine.

Electrophysiologic effects.

Amlodipine does not change sinoatrial nodal function or atrioventricular conduction in intact animals or man. In patients with chronic stable angina, intravenous administration of 10 mg of amlodipine and a further 10 mg of amlodipine after a 30 minute interval produced peripheral vasodilation and afterload reduction, but did not significantly alter A-H and H-V conduction and sinus node recovery time after pacing. Similar results were obtained in patients receiving amlodipine and beta-blockers in combination. In clinical studies in which amlodipine was administered in combination with beta-blockers to patients with either hypertension or angina, no adverse events on electrocardiographic parameters were observed. In clinical trials with angina patients alone, amlodipine treatment did not alter electrocardiographic intervals or produce higher degrees of AV block.

Effects in hypertension.

In patients with hypertension once daily dosing provides clinically significant reductions of blood pressure in both the supine and standing positions throughout the 24 hour interval postdose. Due to the slow onset of action, acute hypotension is not a feature of amlodipine administration. The blood pressure effect is maintained over the 24 hour dosing interval, with little difference in peak and trough effect. Tolerance has not been demonstrated in patients studied for up to one year. Effects on diastolic pressure were similar in young and older patients. The effect on systolic pressure was greater in older patients, perhaps because of greater baseline systolic pressure.

Effects in chronic stable angina.

In patients with angina, once daily administration of amlodipine increases total exercise time to angina onset and total work time to 1 mm ST segment depression and decreases both angina attack frequency and nitroglycerine tablet consumption. The sustained efficacy of amlodipine in angina patients has been demonstrated over long-term dosing. In patients with angina there were no clinically significant reductions in blood pressure (4/1 mmHg) or changes in heart rate (+ 0.3 bpm).

Studies in patients with congestive heart failure.

Amlodipine (5-10 mg per day) has been studied in a placebo-controlled trial of 1153 patients with NYHA class III or IV heart failure on stable doses of ACE inhibitor, digoxin and diuretics. Follow-up was at least six months, with a mean of about 14 months. There was no effect on the primary endpoint of the study of all-cause mortality and cardiac morbidity (as defined by life-threatening arrhythmia, acute myocardial infarction, or hospitalisation for worsened heart failure), or on NYHA classification or symptoms of heart failure.
Amlodipine has been compared to placebo in four eight to twelve week studies of patients with NYHA class II/III heart failure, involving a total of 697 patients. In these studies, efficacy in regard to the primary and secondary endpoints was not demonstrated and there was no evidence of worsened heart failure based on measures of exercise tolerance, NYHA classification, symptoms, or LVEF (see Section 4.4 Special Warnings and Precautions for Use).

5.2 Pharmacokinetic Properties

Pharmacokinetics of Reaptan.

Three studies have demonstrated bioequivalence between one tablet of the fixed combination of perindopril/ amlodipine and the co-administration of one tablet of perindopril plus one tablet of amlodipine, at dose ranges equivalent to Reaptan 5/10, Reaptan 10/5 and Reaptan 10/10.
The results of these studies were similar across the different doses and demonstrated that the rate and extent of absorption of perindopril and amlodipine in Reaptan are not significantly different, respectively, from the rate and extent of absorption of perindopril and amlodipine in individual tablet formulations.
A pharmacokinetic interaction study between perindopril arginine 10 mg and amlodipine 10 mg revealed that the extent and rate of bioavailability of perindopril, perindoprilat and amlodipine are similar for perindopril arginine 10 mg or amlodipine 10 mg administered alone or within a co-administration. No pharmacokinetic interaction exists between these two formulations.

Pharmacokinetics of perindopril.

Absorption.

Following oral administration, perindopril is rapidly absorbed with bioavailability of 24%. Elimination is rapid, occurring predominantly via the urine. Plasma half-life is approximately one hour. Bioavailability of the active metabolite perindoprilat is approximately 27%.

Distribution.

Peak plasma concentrations of perindoprilat occur three to four hours after oral administration of perindopril. When perindopril is administered chronically, steady state perindoprilat concentration is reached within four days, and perindoprilat does not accumulate.

Metabolism.

Apart from perindoprilat, the administration of perindopril leads to the formation of five other metabolites, all of which are inactive and exist in very low quantities. One of these is the glucuronoconjugate of perindoprilat, which is formed by a hepatic first-pass effect. This effect does not appear to have any influence on the kinetics of perindoprilat. Food intake may reduce hepatic biotransformation to perindoprilat.

Excretion.

Protein binding of perindoprilat is 20%, principally to angiotensin converting enzyme. Perindoprilat binds to plasma and tissue ACE, and free perindoprilat is eliminated through the urine. The terminal half-life of the unbound fraction is approximately 17 hours. The elimination of perindoprilat is reduced in elderly patients and in patients with cardiac and renal failure.

Pharmacokinetics of amlodipine.

Absorption.

After oral administration of therapeutic doses, amlodipine is well absorbed with peak blood levels between six to twelve hours post-dose. This may reflect significant initial uptake by the liver, followed by a phase of redistribution. This interval is shorter (two to eight hours) in patients with hepatic impairment. Absolute bioavailability has been estimated to be between 64 and 90%.

Distribution.

In vitro studies have shown that approximately 97.5% of circulating amlodipine is bound to plasma proteins.

Metabolism.

Amlodipine is extensively metabolised by the liver to inactive metabolites with 10% of the parent compound and 60% of metabolites excreted in the urine.

Excretion.

The bioavailability of amlodipine is not altered by the presence of food. The volume of distribution is approximately 20 L/kg. The terminal plasma elimination half-life is about 35-50 hours and is consistent with once daily dosing. Steady-state plasma levels are reached after seven to eight days of consecutive dosing. In elderly patients with hypertension (mean age 69 years) there was a decrease in clearance of amlodipine from plasma as compared to young volunteers (mean age 36 years) with a resulting increase in the area under the curve (AUC) of about 60%.

5.3 Preclinical Safety Data

Genotoxicity.

No genotoxicity studies of perindopril in combination with amlodipine have been conducted.

Related to perindopril component.

Results from a broad set of assays for gene mutation and chromosomal damage with perindopril suggest no genotoxic potential at clinical doses.
Perindopril showed no evidence of genotoxicity potential in assays for gene mutation (Ames reverse mutation test, mouse lymphoma thymidine kinase assay), chromosomal damage (mouse micronucleus test, Chinese hamster bone marrow cells in vivo, human lymphocytes in vitro) and other genotoxic effects (gene conversion assay in Saccharomyces cerevisiae, unscheduled DNA synthesis in rat hepatic cells).

Related to amlodipine component.

In animal studies, amlodipine had no teratogenic effects in rats (18 mg/kg) or rabbits (10 mg/kg).

Carcinogenicity.

No carcinogenicity or genotoxicity studies of perindopril in combination with amlodipine have been conducted.

Related to perindopril component.

No evidence of carcinogenic activity was observed in mice and rats when perindopril erbumine was administered via drinking water at levels up to 7.5 mg/kg/day for two years.
At least one ACE inhibitor has caused an increase in the incidence of oxyphilic renal tubular cells and oncocytomas in rats. The potential of the ACE inhibitor class to cause this effect in man is unknown. Moreover, the progression of oxyphilic cells to oncocytomas is rare in humans and when this occurs, it is considered as benign.

Related to amlodipine component.

The carcinogenic potential of amlodipine has not been fully elucidated. Amlodipine did not induce any tumours when tested in rats at oral doses up to 2.5 mg/kg. This dose gave rise to plasma levels that are similar to those achieved clinically.

4 Clinical Particulars

4.1 Therapeutic Indications

Reaptan is indicated as substitution therapy for the treatment of hypertension and/or stable coronary heart disease in patients already controlled with separate doses of perindopril and amlodipine, given concurrently at the same dose level. Treatment should not be initiated with this combination.

4.3 Contraindications

Reaptan is contraindicated:
in patients with a history of previous hypersensitivity to either of the active ingredients; perindopril or amlodipine, ACE inhibitors, dihydropyridines or excipient ingredients present in Reaptan;
during pregnancy and for lactating women.
All contraindications related to the individual components, as listed below, should also apply to the fixed combination of Reaptan.

Related to perindopril component.

In patients with bilateral or unilateral renal artery stenosis (see Section 4.4 Special Warnings and Precautions for Use).
In patients with a history of hereditary and/or idiopathic angioedema or angioedema associated with previous ACE inhibitor treatment (see Section 4.4 Special Warnings and Precautions for Use).
In patients receiving extracorporeal treatments leading to contact of blood with negatively charged surfaces such as dialysis or haemofiltration with certain high-flux membranes (e.g. polyacrylonitrile membranes such as "AN69") and low density lipoprotein apheresis with dextran sulphate due to increased risk of severe anaphylactoid reactions following treatment with ACE inhibitors. This combination should therefore be avoided, either by use of alternative antihypertensive medicines or alternative membranes (e.g. cuprophane or polysulphone PSF) (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
In combination with aliskiren-containing products in patients with diabetes or renal impairment (GFR < 60 mL/min/1.73 m2) (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
Combined use with sacubitril/valsartan fixed dose combinations (see Section 4.4 Special Warnings and Precautions for Use; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Related to amlodipine component.

Severe hypotension.
Shock, including cardiogenic shock.
Obstruction of the outflow-tract of the left ventricle (e.g. high grade aortic stenosis).
Unstable angina pectoris (excluding Prinzmetal's angina).
Heart failure after acute myocardial infarction.

4.4 Special Warnings and Precautions for Use

Related to Reaptan.

Lactose intolerance.

As Reaptan contains lactose monohydrate, patients with rare hereditary problems of galactose intolerance, glucose galactose malabsorption, or total lactase deficiency should not take Reaptan.

Related to perindopril component.

Hyperkalaemia.

Since ACE inhibitors reduce angiotensin II formation resulting in decreased production of aldosterone, increases in serum potassium have been observed in some patients treated with ACE inhibitors including perindopril. Serum electrolytes (including sodium, potassium and urea) should be measured from time to time when ACE inhibitors are given especially in combination with diuretics.
Hyperkalaemia can cause serious, sometimes fatal, arrhythmias. Risk factors for the development of hyperkalaemia include those with renal impairment, worsening of renal function, age (> 70 years), diabetes, intercurrent events, in particular dehydration, acute cardiac decompensation, metabolic acidosis and combined use with potassium-sparing diuretics (e.g. spironolactone, eplerenone, triamterene, amiloride), potassium supplements or potassium-containing salt substitutes; or those patients taking other medicines associated with increases in serum potassium (e.g. heparin, co-trimoxazole also known as trimethoprim/sulfamethoxazole, other ACE-inhibitors, angiotensin receptor blocker, aspirin ≥ 3 g/day, COX-2 inhibitors and other non-selective NSAIDS, immunosuppressant medicines such as cyclosporin or tacrolimus). Combined use of the above-mentioned medicines should be used with caution in combination with ACE inhibitors. Frequent monitoring of serum potassium is needed (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions). In some patients hyponatraemia may co-exist with hyperkalaemia.

Patients with diabetes.

Glycaemic control should be closely monitored during the first month of treatment with an ACE inhibitor in patients with diabetes treated with oral medicines or insulin (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Lithium.

The combination of lithium and perindopril is not recommended (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Potassium sparing medicines, potassium supplements or potassium-containing salt substitutes.

The combination of perindopril and potassium sparing medicines, potassium supplements or potassium containing salt substitutes is not recommended (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Dantrolene.

The combination of dantrolene and perindopril is not recommended (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Angioedema.

ACE inhibitors should not be used in patients with a history of angioedema related to any other medicine as these patients may be at increased risk of angioedema while treated with an ACE inhibitor (see Section 4.3 Contraindications).
Life-threatening angioedema has been reported with most ACE inhibitors. The overall incidence is approximately 0.1-0.2%. The aetiology is thought to be non-immunogenic and may be related to accentuated bradykinin activity. Usually the angioedema is non-pitting oedema of the skin mucous membrane and subcutaneous tissue.
Angioedema of the face, extremities, lips, tongue, mucous membranes, glottis and/or larynx has been reported in patients with ACE inhibitors and has been reported uncommonly with perindopril (see Section 4.8 Adverse Effects (Undesirable Effects)). This may occur at any time during treatment. In such cases treatment should be promptly discontinued and the patient carefully observed until the swelling disappears.
Where such cases have been described with other ACE inhibitors and swelling has been confined to the face and lips, the condition has generally resolved without treatment although antihistamines have been useful in relieving symptoms.
Angioedema associated with laryngeal oedema may be fatal or near fatal. In most cases symptoms occurred during the first week of treatment and the incidence appears to be similar in both sexes or in those with heart failure or hypertension.
Where there is involvement of the tongue, glottis or larynx likely to cause airway obstruction, appropriate treatment (e.g. adrenaline and oxygen) should be given promptly. Treatment of progressive angioedema should be aggressive and failing a rapid response to medical treatment, mechanical methods to secure an airway should be undertaken before massive oedema complicates oral or nasal intubation.
Patients who respond to medical treatment should be observed carefully for a possible rebound phenomenon.
The onset of angioedema associated with use of ACE inhibitors may be delayed for weeks or months.
Patients may have multiple episodes of angioedema with long symptom-free intervals.
Angioedema may occur with or without urticaria.
Intestinal angioedema has been reported rarely in patients treated with ACE inhibitors. These patients presented with abdominal pain (with or without nausea or vomiting); in some cases there was no prior facial angioedema and C-1 esterase levels were normal. The angioedema was diagnosed by procedures including abdominal CT scan, or ultrasound or during surgery and symptoms resolved after stopping the ACE inhibitor. Intestinal angioedema should be included in the differential diagnosis of patients on ACE inhibitors presenting with abdominal pain.
Patients on combined treatment with a mammalian target of rapamycin (mTOR) inhibitor (e.g. temsirolimus, sirolimus, everolimus) may be at increased risk of angioedema (e.g. swelling of the airways or tongue, with or without respiratory impairment) (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
The combined use of Reaptan with sacubitril/valsartan fixed dose combinations is contraindicated due to the increased risk of angioedema (see Section 4.3 Contraindications). Sacubitril/valsartan fixed dose combinations must not be initiated until 36 hours after taking the last dose of Reaptan. If treatment with sacubitril/valsartan fixed dose combinations is stopped, Reaptan must not be initiated until 36 hours after the last dose of sacubitril/valsartan fixed dose combination (see Section 4.3 Contraindications; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions). The combined use of other NEP inhibitors and Reaptan may also increase the risk of angioedema (see Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Anaphylactoid reactions during low-density lipoproteins (LDL) apheresis and haemodialysis.

Rarely, patients treated with ACE inhibitors during apheresis with dextran sulphate have experienced life-threatening anaphylactoid reactions. These reactions were avoided by temporarily withholding ACE inhibitor treatment prior to each apheresis.
Anaphylactoid reactions have been reported in patients dialysed with high flux membranes, who are treated with an ACE inhibitor. Extracorporeal treatments leading to contact of blood with negatively charged surfaces (e.g. polyacrylonitrile membranes such as "AN69") are contraindicated. If such treatment is required, consideration should be given to using a different type of dialysis membrane (e.g. cuprophane or polysulphone PSF) or a different class of antihypertensive medicines (see Section 4.3 Contraindications; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).

Anaphylactic reactions during desensitisation.

Patients treated with ACE inhibitors during desensitisation treatment (e.g. hymenoptera venom) have experienced life-threatening anaphylactoid reactions. In the same patients, these reactions have been avoided when the ACE inhibitors were temporarily withheld, but they reappeared upon inadvertent rechallenge.

Hypotension.

Hypotension has been reported in patients commencing treatment with ACE inhibitors. Symptomatic hypotension is rarely seen in uncomplicated hypertension but is a potential consequence of perindopril use in patients with salt/volume depletion, for example, in patients vigorously treated with diuretics, in patients on dialysis, with impaired renal function, following severe diarrhoea or vomiting, in patients on dietary restrictions or in those with severe renin-dependent hypertension (see Section 4.4 Special Warnings and Precautions for Use; Section 4.8 Adverse Effects (Undesirable Effects)).
Administration of a dose of perindopril equivalent to perindopril arginine 2.5 mg to patients with mild-moderate heart failure was not associated with any significant reduction in blood pressure. In patients with symptomatic heart failure, with or without associated renal impairment, symptomatic hypotension has been observed. This is more likely to occur in those patients with severe heart failure, as reflected by the use of high doses of loop diuretics, hyponatraemia or functional renal impairment. This may be associated with syncope, neurological deficits, oliguria and/or progressive increase in blood nitrogen, and rarely with acute renal failure and/or death. Because of the potential fall in blood pressure in these patients, treatment should be started at low doses under very close supervision. Such patients should be followed closely for the first two weeks of treatment and whenever the dose is increased, or diuretic treatment is commenced or increased.
Patients with ischaemic heart or cerebrovascular disease in whom an excessive fall in blood pressure could result in myocardial infarction or cerebrovascular accident should be closely followed for the first two weeks of treatment and whenever the dose of perindopril and/or the diuretic is increased.
In some patients with congestive heart failure who have normal or low blood pressure, additional lowering of systemic blood pressure may occur with perindopril. This is anticipated and is usually not a reason to discontinue treatment. If symptomatic hypotension occurs, a reduction of dose or discontinuation of perindopril may be necessary.
If hypotension occurs, the patient should be placed in a supine position and if necessary infused with normal saline. A transient hypotensive response is not a contraindication to further doses, which can usually be given without difficulty when blood pressure has increased following volume expansion.

Renovascular hypertension.

If renovascular hypertension is also present, treatment should be started under close medical supervision with low doses and careful dose titration. There is an increased risk of severe hypotension and renal impairment. Since treatment with diuretics may be a contributing factor to the above, they should be discontinued and renal function should be monitored during the first weeks of perindopril treatment. Loss of renal function may occur with only minor changes in serum creatinine even in patients with unilateral renal artery stenosis.

Kidney transplantation.

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

Hepatic failure.

Rarely, ACE inhibitors have been associated with a syndrome that starts with cholestatic jaundice and progresses to fulminant hepatic necrosis and (sometimes) death. The mechanism of this syndrome is not understood. Patients treated with ACE inhibitors who develop jaundice or marked elevations of hepatic enzymes should discontinue the ACE inhibitor and receive appropriate medical follow-up (see Section 4.8 Adverse Effects (Undesirable Effects)).

Ethnicity.

ACE inhibitors cause a higher rate of angioedema in patients of indigenous African origin than in patients of other racial origin. As with other ACE inhibitors, perindopril may be less effective in lowering blood pressure in people of indigenous African origin than in people of other racial origin, possibly because of a higher prevalence of low-renin states in this population. It is unknown if the same observations have been made in patients of indigenous Australian origin.

Patients with diabetes.

In diabetic patients treated with oral antidiabetic agents or insulin, glycaemic control should be closely monitored during the first month of treatment with any ACE inhibitor.

Cough.

A persistent dry (non-productive) irritating cough has been reported with most of the ACE inhibitors. The frequency of reports has been increasing since cough was first recognised as a class-effect of ACE inhibitor treatment with the incidence of cough varying between 2-15% depending upon the ACE inhibitor, dose and duration of use.
The cough is often worse when lying down or at night, and has been reported more frequently in women (who account for two-thirds of the reported cases). Patients who cough may have increased bronchial reactivity compared with those who do not. The observed higher frequency of this side-effect in non-smokers may be due to a higher level of tolerance of smokers to cough.
The cough is most likely due to stimulation of the pulmonary cough reflex by kinins (bradykinin) and/or prostaglandins, which accumulate because of ACE inhibition. Once a patient has developed intolerable cough, an attempt may be made to switch the patient to another ACE inhibitor; the reaction may recur but this is not invariably the case. A change to another class of medicines may be required in severe cases.

Proteinuria.

Perindopril treatment has occasionally been associated with mild or transient proteinuria (< 1 gram/per 24 hours). However in the majority of patients with pre-existing proteinuria treated with perindopril, proteinuria disappeared or remained stable. ACE inhibitors have potential to delay the progression of nephropathy in patients with diabetes or hypertension.

Neutropaenia/agranulocytosis/thrombocytopaenia/anaemia.

Neutropaenia, agranulocytosis, thrombocytopaenia and anaemia have been reported in patients treated with an ACE inhibitor. In patients with normal renal function and no other complicating factors, neutropaenia occurs rarely. Perindopril should be used with extreme caution in patients with collagen vascular disease, immunosuppressant treatment, treatment with allopurinol or procainamide, or a combination of these complicating factors, especially if there is pre-existing renal impairment. Some of these patients developed serious infections, which in a few instances did not respond to intensive antibiotic treatment. If perindopril is used in such patients, periodic monitoring of white blood cell counts is advised and patients should be instructed to report any sign of infection (e.g. sore throat, fever).

Dermatological reactions.

Dermatological reactions characterised by maculo-papular pruritic rashes and sometimes photosensitivity has been reported with another ACE inhibitor. Rare and sometimes severe skin reactions (lichenoid eruptions, psoriasis, pemphigus like rash, rosacea, Stevens-Johnson syndrome, etc.) have been reported following administration of perindopril and may therefore occur. A causal relationship is difficult to assess.
Patients who develop a cutaneous reaction with one ACE inhibitor might not when switched to another medicine of the same class, but there are reports of cross-reactivity.

Taste disturbances (dysgeusia).

Taste disturbances were reported to be common (prevalence up to 12.5%) with high doses of one ACE inhibitor. The actual incidence of taste disturbance is probably low (< 0.5%) but data are scarce and difficult to interpret. Taste disturbances with ACE inhibitors have been described as suppression of taste or a metallic sensation in the mouth. Dysgeusia usually occurs in the first weeks of treatment and may disappear in most cases within one to three months.

Medicines causing renin release.

The effects of perindopril may be enhanced when administered with antihypertensive medicines which cause renin release.

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

As a consequence of inhibiting the renin-angiotensin-aldosterone system, hypotension, syncope, hyperkalaemia, and changes in renal function (including acute renal failure) have been reported in susceptible individuals, especially if combining medicinal products that affect this system. Dual blockade of the RAAS through the combined use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is therefore not recommended (see Section 4.3 Contraindications; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions). If dual blockade treatment is considered absolutely necessary, this should be limited to individually defined cases with frequent close monitoring of renal function, electrolytes and blood pressure.
The combination of perindopril with aliskiren is contraindicated in patients with diabetes or renal impairment (GFR < 60 mL/min/1.73 m2) (see Section 4.3 Contraindications; Section 4.5 Interactions with Other Medicines and Other Forms of Interactions).
ACE inhibitors and angiotensin II receptor blockers should not be used in combination in patients with diabetic nephropathy.

Surgery and anaesthesia.

Perindopril may block angiotensin II formation secondary to compensatory renin release in patients undergoing major surgery or during anaesthesia with medicines that produce hypotension and cause further reduction in blood pressure. Treatment should be discontinued one day prior to the surgery. Perioperative hypotension can be corrected with volume expansion.

Aortic or mitral valve stenosis/ hypertrophic cardiomyopathy.

There has been some concern on theoretical grounds that patients with mitral valve stenosis and obstruction in the outflow of the left ventricle such as aortic stenosis or with hypertrophic cardiomyopathy might be at particular risk of decreased coronary perfusion when treated with vasodilators, including ACE inhibitors. Vasodilators may tend to drop diastolic pressure, and hence coronary perfusion pressure, without producing the concomitant reduction in myocardial oxygen demand that normally accompanies vasodilatation. The true clinical importance of this concern is uncertain.

Stable coronary artery disease.

If an episode of unstable angina pectoris, regardless of severity, occurs during the first month of perindopril treatment, a careful appraisal of the benefits/risks of continuing treatment should be performed.

Primary aldosteronism.

Patients with primary hyperaldosteronism will generally not respond to antihypertensive medicines acting through inhibition of the renin angiotensin system. Therefore, treatment with Reaptan is not recommended.

Related to amlodipine component.

Increased angina.

Rarely patients, particularly those with severe obstructive coronary artery disease, have developed documented increased frequency, duration and/or severity of angina on starting calcium channel blocker treatment or at the time of dosage increase. The mechanism of this effect has not been elucidated.

Outflow obstruction (aortic stenosis).

Amlodipine should be used with caution in the presence of a fixed left ventricular outflow obstruction (aortic stenosis).

Use in patients with congestive heart failure.

Calcium channel blockers, including amlodipine, should be used with caution in patients with congestive heart failure. In a long-term, placebo controlled study of amlodipine in patients with NYHA III and IV heart failure of non-ischaemic aetiology, amlodipine was associated with increased reports of pulmonary oedema despite no significant difference in the incidence of worsening heart failure as compared to placebo (see Section 5.1 Pharmacodynamic Properties).

Peripheral oedema.

Mild to moderate peripheral oedema was the most common adverse event in clinical trials. The incidence of peripheral oedema was dose-dependent and ranged in frequency from 3.0 to 10.8% in 5 to 10 mg dose range. Care should be taken to differentiate this peripheral oedema from the effects of increasing left ventricular dysfunction.

Use in hepatic impairment.

Related to perindopril component.

Biotransformation of perindopril to perindoprilat mainly occurs in the liver. Studies in patients with hepatic impairment have shown that kinetic parameters of perindopril were not modified by hepatic failure. With the exception of bioavailability, which was increased, kinetic parameters of perindoprilat (including Tmax) were also unchanged. The increase in bioavailability could be due to inhibition of the formation of perindopril metabolites other than perindoprilat (see Section 5.2 Pharmacokinetic Properties). The administration of perindopril leads to the formation of a glucuronoconjugate derivative of perindoprilat by a hepatic first-pass effect. The kinetic parameters of perindoprilat glucuronide are not modified by hepatic failure. The small changes in the kinetics of perindoprilat do not justify the need to change the usual dose in most patients with hepatic failure.

Related to amlodipine component.

There are no adequate studies in patients with liver dysfunction and dosage recommendations have not been established. In a small number of patients with mild to moderate hepatic impairment given single doses of 5 mg, amlodipine half-life has been prolonged. Worsening of liver function test values may occur. Amlodipine should, therefore, be administered with caution in these patients and careful monitoring should be performed. A lower starting dose of amlodipine may be required (see Section 4.2 Dose and Method of Administration).

Use in renal impairment.

Related to perindopril component.

As a consequence of inhibiting the RAAS, changes in renal function may be anticipated in susceptible individuals. In patients with severe congestive heart failure whose renal function may depend on RAAS activity, treatment with ACE inhibitors may be associated with oliguria and/or progressive increase in blood nitrogen, and rarely with acute renal failure and/or death.
In patients with symptomatic heart failure, hypotension following the initiation of treatment with ACE inhibitors may lead to further impairment in renal function. Acute renal failure, usually reversible, has been reported in this situation.
ACE inhibitors should be avoided in patients with known or suspected renal artery stenosis (see Section 4.3 Contraindications).
In clinical studies in patients with hypertension with unilateral or bilateral renal artery stenosis, increases in blood urea, nitrogen and serum creatinine were observed in 20% of patients. Acute renal impairment may also occur. These increases are usually reversible upon discontinuation.
Renal function may also be reduced in patients with stenosis of the artery supplying a transplanted kidney. It is believed that renal artery stenosis reduces the pressure in the afferent glomerular arteriole, and transglomerular hydrostatic pressure is then maintained by angiotensin II-induced constriction of the efferent arteriole. When an ACE inhibitor is given, the efferent arteriole relaxes, glomerular filtration pressure falls, and renal failure may result. ACE inhibitors can lead to the thrombotic occlusion of a stenosed renal artery.
Some patients with hypertension and with no apparent pre-existing renovascular disease have developed increases in blood urea, nitrogen and serum creatinine, which are usually minor and transient, particularly when perindopril has been combined with a diuretic. However, increases in blood urea, nitrogen and serum creatinine are more likely to occur in patients with pre-existing renal impairment or in those on diuretics. Dose reduction of the ACE inhibitor and/or discontinuation of the diuretic may be required.
Renal function should always be assessed (see Section 4.2 Dose and Method of Administration). In the case of renal impairment, the initial perindopril dose should be adjusted according to the patient's creatinine clearance (see Section 4.2 Dose and Method of Administration). Routine monitoring of potassium and creatinine are part of normal medical practice for these patients (see Section 4.8 Adverse Effects (Undesirable Effects)). If a deterioration in renal function has occurred after treatment with one ACE inhibitor, then it is likely to be precipitated by another and in these patients use of another class of antihypertensive medicines would be preferable. Patients with unilateral renal artery disease present a special problem as deterioration of function may not be apparent from measurement of blood urea and serum creatinine.
Some ACE inhibitors have been associated with the occurrence of proteinuria (up to 0.7%) and/or decline in renal function in patients with one or more of the following characteristics: old age, pre-existing renal disease, combined use with potassium-sparing diuretics or high doses of other diuretics, limited cardiac reserve, or treatment with a non-steroidal anti-inflammatory medicine (NSAID).
Anaemia has been observed in patients who have had a kidney transplant or have been undergoing dialysis. The reduction in haemoglobin levels is more apparent as initial values were high. This effect does not seem to be dose-dependent but may be linked to the mechanism of action of angiotensin converting enzyme inhibitors. This reduction in haemoglobin is slight, occurs within one to six months, and then remains stable. It is reversible when treatment is stopped. Treatment can be continued with regular haematological testing.
Perindopril is dialysable with a clearance of 70 mL/min.

Related to amlodipine component.

Amlodipine is extensively metabolised to inactive metabolites with 10% excreted as unchanged drug in the urine. Changes in amlodipine plasma concentrations are not correlated with degree of renal impairment. Amlodipine may be used in such patients at normal doses. Amlodipine is not dialysable.

Use in the elderly.

Related to perindopril component.

Renal impairment is commonly observed in elderly people. Care should be taken when prescribing perindopril-containing medicines to elderly patients with hypertension. The initial daily dose in the elderly should always be at a low dose or with one component only, and patients should be monitored closely during the initial stages of treatment (see Section 4.2 Dose and Method of Administration).
In a study of 91 elderly patients with a mean age of 71.9 years, a 6% increase in serum potassium occurred in the first month of treatment and subsequently remained stable. There was no change in the group in blood urea, creatinine or creatinine clearance.
Particular care should be taken in elderly patients with congestive heart failure who have renal and/or hepatic impairment.

Related to amlodipine component.

In elderly patients (> 65 years) clearance of amlodipine is decreased with a resulting increase in AUC. In clinical trials the incidence of adverse reactions in elderly patients was approximately 6% higher than that of younger population (< 65 years). Adverse reactions include oedema, muscle cramps and dizziness. Amlodipine should be used cautiously in elderly patients.

Paediatric use.

Use of Reaptan in children is not recommended as no data establishing safety or effectiveness in children are available.

Effects on laboratory tests.

Reported with perindopril component.

Reduced sodium levels.
Slight increase in urea and in plasma creatinine levels, reversible when treatment is stopped, this increase is more frequent in cases of renal artery stenosis, arterial hypertension treated with diuretics, renal impairment.
Increased levels of potassium, usually transitory.
Elevation of liver enzymes and serum bilirubin have been reported rarely.

Reported with amlodipine component.

Amlodipine treatment has not been associated with clinically significant changes in routine laboratory tests. Hepatic enzymes elevations: ALT, AST (mostly consistent with cholestasis) have been reported very rarely.

4.5 Interactions with Other Medicines and Other Forms of Interactions

Shared by perindopril and amlodipine.

Combined use which requires special care.

Baclofen.

Baclofen may increase the antihypertensive effect of Reaptan. Monitor blood pressure and renal function, and adjust the dose of Reaptan if necessary.

Combined use to be taken into consideration.

Antihypertensive medicines (such as beta-blockers) and vasodilators.

Combined use of these medicines may increase the hypotensive effects of perindopril and amlodipine. Combined use with nitroglycerine and other nitrates or other vasodilators, may further reduce blood pressure and therefore should be considered with caution.

Corticosteroids, tetracosactide.

Reduction in antihypertensive effect (salt and water retention due to corticosteroids).

Alpha-blockers (prazosin, alfuzosin, doxazosin, tamsulosin, terazosin).

Increased antihypertensive effect and increased risk of orthostatic hypotension.

Amifostine.

May potentiate the antihypertensive effect of amlodipine.

Tricyclic antidepressants/antipsychotics/anaesthetics.

Combined use of certain anaesthetics, tricyclic antidepressants and antipsychotics with ACE inhibitors or amlodipine may result in further reduction of blood pressure (see Section 4.4 Special Warnings and Precautions for Use).

Related to perindopril component.

Clinical trial data has shown that dual blockade of the renin-angiotensin-aldosterone system (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).

Medicines inducing hyperkalaemia.

Some medicines or therapeutic classes may increase the occurrence of hyperkalaemia: aliskiren, potassium salts, potassium-sparing diuretics, ACE inhibitors, angiotensin-II receptors antagonists, NSAIDs, heparins, immunosuppressant agents such as ciclosporin or tacrolimus, trimethoprim and fixed dose combination with sulfamethoxazole (co-trimoxazole). The combination of these medicines increases the risk of hyperkalaemia.

Combined use which is contraindicated (see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use).

Aliskiren.

Patients with diabetes or renal impairment (GFR < 60 mL/min/1.73 m2), may be at risk of hypotension, syncope, stroke, hyperkalaemia and changes in renal function (including acute renal failure).

Extracorporeal treatments.

Extracorporeal treatments leading to contact of blood with negatively charged surfaces such as dialysis or haemofiltration with certain high-flux membranes (e.g. polyacrylonitrile membranes such as "AN69") and low density lipoprotein apheresis with dextran sulphate are contraindicated due to increased risk of severe anaphylactoid reactions (see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use). If such treatment is required, consideration should be given to using a different type of dialysis membrane (e.g. cuprophane or polysulphone PSF) or a different class of antihypertensive agent.

Sacubitril-valsartan.

The combined use of Reaptan with sacubitril/valsartan fixed dose combinations is contraindicated as the concomitant inhibition of neprilysin and ACE may increase the risk of angioedema. Sacubitril/valsartan fixed dose combinations must not be started until 36 hours after taking the last dose of Reaptan. Reaptan must not be started until 36 hours after the last dose of sacubitril/valsartan fixed dose combination (see Section 4.3 Contraindications; Section 4.4 Special Warnings and Precautions for Use).

Combined use which is not recommended (see Section 4.4 Special Warnings and Precautions for Use).

Aliskiren.

Patients other than those with diabetes or renal impairment may be at risk of hyperkalaemia, worsening of renal function and cardiovascular morbidity, and an increase in mortality (see Section 4.3 Contraindications).

Combined use with ACE inhibitor and angiotensin-receptor blocker.

It is reported in the literature that in patients with established atherosclerosis, heart failure, or diabetes with end organ damage, combined use with an ACE inhibitor and an angiotensin-receptor blocker is associated with a higher frequency of hypotension, syncope, hyperkalaemia, and worsening renal function (including acute renal failure) as compared to use of a single RAAS medicine. Dual blockade (e.g. by combining an ACE inhibitor with an angiotensin receptor blocker) should be limited to individually defined cases with close monitoring of renal function, serum potassium, and blood pressure.

Co-trimoxazole (trimethoprim/sulfamethoxazole).

Patients on combined treatment with co-trimoxazole (trimethoprim/sulfamethoxazole) may be at increased risk of hyperkalaemia (see Section 4.4 Special Warnings and Precautions for Use).

Medicines inducing hyperkalaemia.

The ACE inhibitor class can attenuate potassium loss caused by thiazide diuretics and increase serum potassium when used alone. Although serum potassium usually remains within normal limits, hyperkalaemia may occur in some patients treated with an ACE inhibitor, the combined use of an ACE inhibitor with a potassium-sparing diuretic (e.g. spironolactone, triamterene, or amiloride), immunosuppressant (e.g. cyclosporin), angiotensin receptor blocker, NSAID, heparin, potassium supplements, or potassium-containing salt substitute can increase the risk of hyperkalaemia. The combination of perindopril with the above mentioned medicines is not recommended (see Section 4.4 Special Warnings and Precautions for Use). If combined use is indicated they should be used with caution and the patient's serum potassium monitored frequently. For combined use with spironolactone in heart failure, see Potassium-sparing diuretics (eplerenone, spironolactone).

Lithium.

Reversible increases in serum lithium concentrations and toxicity have been reported during combined administration of lithium with ACE inhibitors. Combined use of thiazide diuretics may increase the risk of lithium toxicity and enhance the already increased risk of lithium toxicity with ACE inhibitors. Use of perindopril with lithium is not recommended, but if the combination is necessary, careful monitoring of serum lithium levels should be performed (see Section 4.4 Special Warnings and Precautions for Use).

Combined use which requires special care.

Non-steroidal anti-inflammatory medicines (NSAIDs) including aspirin ≥ 3 g/day.

Medicines with prostaglandin synthetase inhibitor properties (e.g. indomethacin) or non-steroidal anti-inflammatory drug (i.e. aspirin at anti-inflammatory dosage regimens, non-selective NSAIDs or COX-2 inhibitor), may diminish the antihypertensive efficacy of co-administered ACE inhibitors. However, clinical studies have not demonstrated any interaction between perindopril or indomethacin or other NSAIDS. Treatment with an NSAID 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 the elderly. Patients should be adequately hydrated and consideration should be given to monitoring renal function after initiation of concomitant therapy, and periodically thereafter.

Antidiabetic agents (insulin, hypoglycaemic sulphonamides).

Reported with captopril and enalapril. The use of ACE inhibitors may increase the hypoglycaemic effect in diabetics receiving treatment with insulin or with hypoglycaemic sulphonylureas. The onset of hypoglycaemic episodes is very rare (improvement in glucose tolerance with a resulting reduction in insulin requirements) and appeared to be more likely to occur during the first weeks of combined treatment and in patients with renal impairment.

Non-potassium-sparing diuretics.

Patients treated with diuretics, especially those who are volume and/or salt depleted, may sometimes experience an excessive reduction of blood pressure after initiation of treatment with an ACE inhibitor. The possibility of hypotensive effects can be reduced by discontinuation of the diuretic or by increasing volume or salt intake prior to commencing treatment with a low and progressive doses of the ACE inhibitor. If it is not possible to discontinue the diuretic, the starting dose of the ACE inhibitor should be reduced. The patient should be closely observed for several hours following the initial dose of the ACE inhibitor and until the blood pressure has stabilised.
In arterial hypertension, when prior diuretic treatment has caused salt/volume depletion, the diuretic must be discontinued before commencing treatment with the ACE inhibitor. The ACE inhibitor must be commenced at a low dose and progressively increased prior to a non-potassium-sparing diuretic being commenced.
In diuretic-treated congestive heart failure, the ACE inhibitor should be initiated at a very low dose, possibly after reducing the dose of the non-potassium-sparing diuretic.
In all cases, renal function (creatinine levels) must be monitored during the first few weeks of ACE inhibitor treatment.

Potassium-sparing diuretics (eplerenone, spironolactone).

As the combination of perindopril and potassium sparing medicines (e.g. eplerenone and spironolactone), potassium supplements or potassium-containing salt substitutes is not recommended:
Ensure patients do not have hyperkalaemia or renal impairment before commencing treatment with this combination.
There is a risk of potentially lethal hyperkalaemia with this combination in patients treated for NYHA Class II-IV heart failure with a reduced ejection fraction, who have been previously treated with ACE inhibitors and loop diuretics. This risk is particularly high when recommendations for use of this combination have not been followed.
Weekly monitoring of serum potassium and creatinine levels is recommended in the first month of the treatment and, monthly thereafter.

Combined use of ACE inhibitors, anti-inflammatory medicines and thiazide diuretics.

The combined use of an ACE inhibiting medicine (ACE inhibitor or angiotensin receptor blocker), an anti-inflammatory medicine (NSAID or COX-2 inhibitor) and a thiazide diuretic increases the risk of renal impairment. This includes use in fixed-combination products. The combination of medicines from these three classes should be used with caution particularly in elderly patients or those with pre-existing renal impairment. Combined use of these medicines should be accompanied by increased monitoring of serum creatinine, particularly at initiation.

Mammalian target of rapamycin (mTOR) inhibitor (e.g. temsirolimus, sirolimus, everolimus).

Patients on combined treatment with an ACE inhibitor and an mTOR inhibitor may be at increased risk of angioedema (see Section 4.4 Special Warnings and Precautions for Use).

Combined use which requires some care.

Gold.

Nitritoid reactions (symptoms include facial flushing, nausea, vomiting and hypotension) have been reported rarely in patients treated with injectable gold (sodium aurothiomalate) and ACE inhibitors including perindopril.

Antihypertensive medicines and vasodilators.

Combined use of these medicines may increase the hypotensive effects of perindopril. Combined use with nitroglycerin and other nitrates, or other vasodilators, may further reduce blood pressure.

Gliptins (e.g. linagliptin, saxagliptin, sitagliptin, vildagliptin).

When an ACE inhibitor and a gliptin are used in combination, there is an increased risk of angioedema due to the decreased activity of the dipeptidyl peptidase IV (DPP-IV).

Aspirin, thrombolytics, beta-blockers, nitrates.

Perindopril may be combined with thrombolytics, aspirin (when used as a thrombolytic), beta-blockers and/or nitrates.

Tetracycline and other medicines that interact with magnesium.

The simultaneous administration of tetracycline with an ACE inhibitor may significantly reduce the absorption of tetracycline, possibly due to the magnesium content in the ACE inhibitor tablets. This interaction should be considered if co-prescribing an ACE inhibitor and tetracycline or other medicines that interact with magnesium.

Medicines affecting sympathetic activity.

As the sympathetic nervous system plays an important part in physiological blood pressure regulation, caution should be exercised with combined administration of a medicine with sympathetic activity and Reaptan. Sympathomimetics may reduce the antihypertensive effects of ACE inhibitors.

Related to amlodipine component.

Amlodipine has been safely administered with thiazide diuretics, beta-blockers, angiotensin converting enzyme inhibitors, long-acting nitrates, sublingual nitroglycerine, non-steroidal anti-inflammatory medicines, antibiotics and oral hypoglycaemic medicines.

Combined use not recommended.

Dantrolene (infusion).

In animals, lethal ventricular fibrillations and CV collapse are observed after administration of verapamil, and intravenous dantrolene. By extrapolation, the combination of calcium channel blockers such as amlodipine, and dantrolene should be avoided especially in patients susceptible to malignant hyperthermia and in the management of malignant hyperthermia.

Combined use which requires special care.

CYP3A4 inducers (rifampicin, Hypericum perforatum (St. John's wort), anticonvulsant medicines, i.e. carbamazepine, phenobarbitone, phenytoin, primidone).

Co-administration of known inducers of the CYP3A4 may lead to reduced plasma concentration of amlodipine due to an increase of the hepatic metabolism of amlodipine by these inducers. Caution should be exercised with this combination and blood pressure should be monitored. The dose of amlodipine should be adjusted if necessary during and after concomitant medication particularly with strong CYP3A4 inducers (e.g. rifampicin, Hypericum perforatum).

CYP3A4 inhibitors (erythromycin in young patients, clarithromycin, verapamil or diltiazem in elderly patients).

Co-administration with strong or moderate CYP3A4 inhibitors (including but not limited to: protease inhibitors like ritonavir, azole antifungals like fluconazole and itraconazole, macrolides like erythromycin or clarithromycin, calcium channel blockers like verapamil or diltiazem) may significantly increase the plasma concentration of amlodipine and consequently its adverse effects. The clinical translation of these PK variations may be more pronounced in the older people. Caution should be exercised when combining amlodipine with strong or moderate CYP3A4 inhibitors and the dose of amlodipine should be adjusted if necessary. Clinical monitoring and dose adjustment may thus be required. There is an increased risk of hypotension in patients receiving clarithromycin with amlodipine. Close observation of patients is recommended when amlodipine is coadministered with clarithromycin.

Combined use which requires some care.

Combined use of amlodipine with other medicines with antihypertensive properties may further reduce blood pressure.

Tacrolimus.

There is a risk of increased tacrolimus blood levels when coadministered with amlodipine. In order to avoid toxicity of tacrolimus, administration of amlodipine in a patient treated with tacrolimus requires monitoring of tacrolimus blood levels and dose adjustment of tacrolimus when appropriate.

Rapamycin (mTOR) inhibitors.

mTOR inhibitors such as sirolimus, temsirolimus, and everolimus are CYP3A substrates. Amlodipine is a weak CYP3A inhibitor. With combined use of mTOR inhibitors, amlodipine may increase exposure of mTOR inhibitors.

Cyclosporin.

No drug interaction studies have been conducted with cyclosporin and amlodipine in healthy volunteers or other populations with the exception of renal transplant patients, where variable increases of trough concentrations of cyclosporin were observed. Consideration should be given to monitoring cyclosporin levels in patients who have undergone renal transplantation and are treated with amlodipine, and cyclosporin dose reductions should be made as necessary.

Simvastatin.

Co-administration of multiple doses of 10 mg of amlodipine with 80 mg simvastatin resulted in an increase in exposure to simvastatin compared to simvastatin alone. Limit the dose of simvastatin in patients on amlodipine to 20 mg daily.

Beta-blockers used in heart failure (bisoprolol, carvedilol, metoprolol).

Risk of hypotension, heart weakness in patients with cardiac heart failure, be it latent or uncontrolled (addition of negative inotrope effect). Furthermore, the beta-blocker may minimise the sympathetic reflex in the case of excessive heamodynamic repercussion.

Antihypertensive medicines (such as beta-blockers) and vasodilators.

Combined use of these medicines may increase the hypotensive effects of perindopril and amlodipine. Combined use with nitroglycerine and other nitrates or other vasodilatators, may further reduce blood pressure and therefore should be considered with caution.

Corticosteroids, tetracosactide.

Reduction in antihypertensive effect (salt and water retention due to corticosteroids).

Alpha-blockers (prazosin, tamsulosin, terazosin, alfuzosin, doxazosin).

Increased antihypertensive effect and increased risk of orthostatic hypotension.

Amifostine.

May potentiate the antihypertensive effect of amlodipine.

Other combined use.

Specific studies conducted with other medicines have shown no influence on amlodipine.

Cimetidine.

Co-administration of amlodipine with cimetidine did not alter the pharmacokinetics of amlodipine.

Sildenafil.

A single 100 mg dose of sildenafil in 16 patients with essential hypertension had no effect on the pharmacokinetic parameters of amlodipine. When amlodipine and sildenafil were used in combination, each medicine independently exerted its own blood pressure lowering effect.

Aluminium/magnesium (antacid).

Co-administration of an aluminium/magnesium antacid with a single dose of amlodipine had no significant effect on the pharmacokinetics of amlodipine.

Grapefruit juice.

Grapefruit juice is known to inhibit the cytochrome P450 system, thereby affecting the pharmacokinetics of medicines such as calcium channel blockers. In a study of 20 healthy volunteers, co-administration of 240 mL of grapefruit juice with a single oral dose of 10 mg amlodipine had no significant effect on the pharmacokinetics of amlodipine. Specific studies conducted with other medicines have shown that amlodipine has no influence on the pharmacokinetics parameters of those medicines.

Atorvastatin.

Co-administration of multiple doses of 10 mg amlodipine with 80 mg of atorvastatin resulted in no significant change in the steady-state pharmacokinetics parameters of atorvastatin.

Digoxin.

Co-administration of amlodipine with digoxin did not change serum digoxin levels or digoxin renal clearance in normal volunteers.

Warfarin.

In healthy male volunteers, the co-administration of amlodipine did not significantly alter the effect of warfarin on prothrombin response time. Co-administration of amlodipine with warfarin did not change the warfarin prothrombin response time.

Alcohol.

Single and multiple 10 mg doses of amlodipine had no significant effect on the pharmacokinetics of ethanol.

4.6 Fertility, Pregnancy and Lactation

Effects on fertility.

No animal studies with Reaptan have been performed.

Related to perindopril component.

The effects of perindopril arginine on fertility have not been investigated. Studies in rats showed no impairment of male or female fertility at oral perindopril erbumine doses up to 10 mg/kg/day.

Related to amlodipine component.

In animal studies, amlodipine did not affect fertility in rats at oral doses up to 18 mg/kg (base).
(Category D)
As this combination contains an ACE inhibitor, Reaptan is contraindicated during pregnancy (see Section 4.3 Contraindications).
No animal studies with Reaptan have been performed.
Reaptan should not be initiated during pregnancy. Patients planning pregnancy should be changed to alternative anti-hypertensive treatments which have an established safety profile for use in pregnancy. When pregnancy is diagnosed, treatment with Reaptan should be stopped immediately, and, if appropriate, alternative treatment should be started.

Related to perindopril component.

The use of ACE inhibitors is contra-indicated during pregnancy (see Section 4.3 Contraindications).
As with all ACE inhibitors, perindopril should not be taken during pregnancy. Pregnancy should be excluded before starting treatment with perindopril and avoided during the treatment. Unless continued treatment with an ACE inhibitor is considered essential, patients planning pregnancy should be changed to alternative anti-hypertensive treatments which have an established safety profile for use in pregnancy. If a patient intends to become pregnant, treatment with ACE inhibitors must be discontinued and replaced by another form of treatment. If a patient becomes pregnant while on ACE inhibitors, she must immediately inform her doctor to discuss a change in medication and further management.
Perindopril or its metabolites have been shown to cross the placenta and distribute to the foetus in pregnant animals. There are no adequate and well-controlled studies of ACE inhibitors in pregnant women, but foetotoxicity is well documented in animal models. Data, however, show that ACE inhibitors cross the human placenta. Post marketing experience with all ACE inhibitors suggests that exposure in utero may be associated with hypotension and decreased renal perfusion in the foetus.
The ACE inhibitor class has also been associated with foetal death in utero.
Epidemiological evidence regarding the risk of teratogenicity following exposure to ACE inhibitors during the first trimester of pregnancy has not been conclusive; however a small increase in risk cannot be excluded.
A historical cohort study in over 29,000 infants born to mothers without diabetes has shown 2.7 times higher risk for congenital malformations in infants exposed to ACE inhibitors during the first trimester compared to no exposure. The risk ratios for cardiovascular and central nervous system malformations were 3.7 times (95% confidence interval 1.89 to 7.3) and 4.4 times (95% confidence interval 1.37 to 14.02) respectively, compared to no exposure.
When ACE inhibitors have been used during the second and third trimesters of pregnancy, there have been reports of foetal and neonatal toxicity, hypotension, hyperkalaemia, renal failure, skull hypoplasia, oligohydramnios and death.
Oligohydramnios has been reported, presumably resulting from decreased foetal renal function; oligohydramnios has been associated with foetal limb contractures, craniofacial deformities, hypoplastic lung development and intra-uterine growth retardation. Prematurity and patent ductus arteriosus have been reported, however it is not clear whether these events were due to ACE inhibitor exposure or to the mother's underlying disease.
Infants exposed in utero to ACE inhibitors should be closely observed for hypotension, oliguria, and hyperkalaemia. Should exposure to ACE inhibitors have occurred from the second trimester of pregnancy, ultrasound check of renal function and skull is recommended. If such complications arise, appropriate medical treatment should be initiated to support blood pressure and renal perfusion.

Related to amlodipine component.

Calcium channel blockers carry the potential to produce foetal hypoxia associated with maternal hypotension. Accordingly they should not be used in pregnant women unless the potential benefit outweighs the risk to the foetus.
The safety of amlodipine in human pregnancy or lactation has not been established. Amlodipine (10 mg/kg as besilate salt, 7 mg/kg base), administered orally to rats at or near parturition induced a prolongation of gestation time, an increase in the number of stillbirths and a decreased postnatal survival.
No animal studies with Reaptan have been performed.

Related to perindopril component.

Alternative treatments with better established safety profiles during breast-feeding are preferable, especially while nursing a newborn or pre-term infant.
Animal studies have shown that perindopril and its metabolites are excreted in milk during lactation, but there are no human data. It is therefore recommended that perindopril should not be given to lactating women as the possible effect on the newborn is unknown.

Related to amlodipine component.

Amlodipine is excreted in human milk. The effect of amlodipine on infants is unknown. Breast-feeding should be discontinued during treatment with amlodipine.

4.8 Adverse Effects (Undesirable Effects)

a. Summary of safety profile.

The most commonly reported adverse reactions with perindopril and amlodipine given separately are: oedema, somnolence, dizziness, headache (especially at the beginning of the treatment), dysgeusia, paraesthesia, visual impairment (including diplopia), tinnitus, vertigo, palpitations, flushing, hypotension (and effects related to hypotension), dyspnoea, cough, abdominal pain, nausea, vomiting, dyspepsia, change of bowel habit, diarrhoea, constipation, pruritus, rash, exanthema, joint swelling (ankle swelling), muscle spasms, fatigue, asthenia.

b. Tabulated list of adverse reactions.

Three bioequivalence studies using doses equivalent to Reaptan 5/10, Reaptan 10/10 and Reaptan 10/5, and one pharmacokinetic interaction study between perindopril arginine 10 mg and amlodipine 10 mg revealed no serious adverse effects. All the reported adverse effects were mild or moderate in intensity.
The following adverse effects have been observed during clinical trials and/or post-marketing use with an amlodipine/perindopril treatment regimen; with perindopril monotherapy; and with amlodipine monotherapy, and ranked under the following frequency: very common (> 10%); common (> 1%, < 10%); uncommon (> 0.1%, < 1%); rare (> 0.01%, < 0.1%); very rare (> 0.001%, < 0.01%); not known (cannot be estimated from the available data). See Table 2.
Cases of Syndrome of inappropriate antidiuretic hormone secretion (SIADH) have been reported with other ACE inhibitors. SIADH can be considered as a very rare but possible complication associated with ACE inhibitor therapy including perindopril.

Withdrawals.

In total 56 of 1,275 patients studied (4.4%) stopped treatment because of adverse reactions. In a specific study of 632 patients in which 36 (5.7%) patients withdrew because of adverse events, a plausible or probable relationship with perindopril treatment was considered to exist in 19 (3%) cases.

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 http://www.tga.gov.au/reporting-problems.

4.2 Dose and Method of Administration

Reaptan (perindopril arginine/ amlodipine) is available in strengths of 5 mg/5 mg, 5 mg/10 mg, 10 mg/5 mg and 10 mg/10 mg as substitution therapy for patients already controlled with separate doses of perindopril (5 or 10 mg) and amlodipine (5 or 10 mg), given concurrently at the dose level as indicated in Table 1. Treatment should not be initiated with this combination.
Food intake may reduce hepatic biotransformation of perindopril to perindoprilat. Recommended treatment is one tablet per day as a single dose, preferably to be taken in the morning and before a meal.
As perindopril and amlodipine may be used for different clinical indications, dose adjustments should be based on clinical judgment and the individual patient profile.
Adjustments can be made by decreasing or increasing the dose of either perindopril and/or amlodipine using separate perindopril and/or amlodipine products within the recommended dose range until clinical stability is re-established. Consult the product information of the individual perindopril and/or amlodipine products being used when adjusting the dose.
In the event that down-titration is required, adjustments using amlodipine 2.5 mg or a dose of perindopril equivalent to perindopril arginine 2.5 mg, as separate products should be considered until clinical stability is re-established.

Patients with impaired renal function and elderly patients.

Elimination of perindoprilat is decreased in the elderly and in patients with renal failure. Therefore, the usual medical follow-up will include frequent monitoring of creatinine and potassium.
Where down-titration is required to achieve clinical stability in patients with a CrCl < 60 mL/min, adjustments using amlodipine 2.5 mg or a dose of perindopril equivalent to perindopril arginine 2.5 mg, as separate products should be considered until clinical stability is re-established. Please consult the product information of the individual perindopril or amlodipine products.
Changes in amlodipine plasma concentrations are not correlated with degree of renal impairment.
Amlodipine is not dialysable.
In elderly patients, adjustments using amlodipine and perindopril as separate products should be considered. Small, fragile or elderly individuals should be started on amlodipine 2.5 mg once daily and care should be taken when increasing the dosage of amlodipine. The initial dose of perindopril in the elderly should always be a dose equivalent to perindopril arginine 2.5 mg daily and patients should be monitored closely during the initial stages of treatment.

Patients with impaired hepatic function.

Dosage recommendations have not been established in patients with mild to moderate hepatic impairment therefore Reaptan should be administered with caution and treatment should start at the lower end of the dosing range (see Section 4.4 Special Warnings and Precautions for Use; Section 5.2 Pharmacokinetic Properties). Dose adjustments can be made by decreasing or increasing the dose of either perindopril and/or amlodipine using separate perindopril and/or amlodipine products within the recommended dose range until an optimal starting and maintenance dose is found. Patients with hepatic impairment should be started on amlodipine 2.5 mg once daily.

4.7 Effects on Ability to Drive and Use Machines

No studies on the effects of Reaptan on the ability to drive and use machines have been performed. The antihypertensive effect in individual cases may be symptomatic. Treatment with any blood pressure lowering medicine may, therefore, affect the ability to drive, cross the road safely or operate machinery, especially at the start of treatment or when changing over from other preparations, or during concomitant use of alcohol. Amlodipine can have minor or moderate influence on the ability to drive and use machinery. If patients suffer from dizziness, headache, fatigue, weariness or nausea, the ability to react may be impaired. Caution is recommended particularly at initiation of treatment with Reaptan.

4.9 Overdose

For information on the management of overdose, contact the Poison Information Centre on 131126 (Australia).
There is no information on overdosage with Reaptan in humans.

Related to perindopril component.

Limited data are available for overdosage in humans. Symptoms associated with overdosage of ACE inhibitors may include hypotension, circulatory shock, electrolyte disturbances, renal failure, hyperventilation, tachycardia, palpitations, bradycardia, dizziness, anxiety, and cough. The recommended treatment of overdosage is intravenous infusion of normal saline solution. If hypotension occurs, the patient should be placed in the shock position. If available, treatment with angiotensin II infusion and/or intravenous catecholamines may also be considered. Perindopril may be removed from the general circulation by haemodialysis (see Section 4.4 Special Warnings and Precautions for Use). Vital signs, serum electrolytes and creatinine concentrations should be monitored continuously. Pacemaker therapy is indicated for treatment resistant bradycardia.

Related to amlodipine component.

Available data suggest that overdosage might be expected to cause excessive peripheral vasodilation with marked hypotension and possibly a reflex tachycardia. Dysrhythmias may occur following overdose with any calcium antagonists. Hypotension and bradycardia are usually seen within one to five hours following overdose. Hypotension can persist for longer than 24 hours despite treatment. Cardiac rhythm disturbances have been noted to persist for up to seven days. Marked and probably prolonged systemic hypotension up to and including shock with fatal outcome have been reported. If massive overdose should occur, active cardiac and respiratory monitoring should be instituted. Frequent blood pressure measurements are essential. Should hypotension occur, cardiovascular support including elevation of the extremities and the judicious administration of fluids should be initiated. If hypotension remains unresponsive to these conservative measures, administration of vasopressors (such as phenylephrine), should be considered with attention to circulating volume and urine output. Intravenous calcium may help to reverse the effects of calcium entry blockade. Administration of activated charcoal to healthy volunteers immediately or up to two hours after ingestion of amlodipine 10 mg has been shown to significantly decrease amlodipine absorption. In patients who are not fully conscious or have impaired gag reflex, consideration should be given to administering activated charcoal via nasogastric tube once the airway is protected. Ipecac-emesis is not recommended since haemodynamic instability and CNS depression may rapidly develop. Since amlodipine is highly protein-bound, dialysis is not likely to be of benefit.

7 Medicine Schedule (Poisons Standard)

S4.

6 Pharmaceutical Particulars

6.1 List of Excipients

Lactose monohydrate, Microcrystalline cellulose, Colloidal anhydrous silica, Magnesium stearate.

6.2 Incompatibilities

Incompatibilities were either not assessed or not identified as part of the registration of this medicine.

6.3 Shelf Life

3 years.

6.4 Special Precautions for Storage

Store in a dry place below 25°C. Keep the container tightly closed and protect from light.

6.5 Nature and Contents of Container

Thirty (30) tablets supplied in a white HDPE bottle equipped with a white induction-sealed child resistant-closure and desiccant sachets.

6.6 Special Precautions for Disposal

In Australia, any unused medicine or waste material should be disposed of by taking it to your local pharmacy.

Summary Table of Changes