Cilazapril 1mg Film-Coated Tablets
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Cilazapril 1 mg, film-coated tablets
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
One 1 mg film-coated tablet contains 1 mg of CILAZAPRIL (as CILAZAPRIL monohydrate).
Excipient(s) with known effect:
One 1 mg film-coated tablet contains 122.000 mg of lactose monohydrate For a full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Film-coated tablet
Pink, oblong presenting a one sided score, with the mark C1 engraved on one side, weighing approximately 200 mg, film coated tablets.
The tablet can be divided into equal halves
4 CLINICAL PARTICULARS
4.1 Therapeutic indications Hypertension
Treatment of essential hypertension.
Heart failure
Treatment of symptomatic heart failure
4.2 Posology and method of administration
CILAZAPRIL should be administered orally in a single daily dose. As with all other medicinal products taken once daily, it should be taken at approximately the same time each day. The absorption of CILAZAPRIL is not affected by food.
The maintenance does should be individualized according to patient profile and blood pressure response (see section 4.4).
Essential hypertension
CILAZAPRIL may be used as monotherapy or in combination with other classes of antihypertensive medicinal products (see sections 4.3, 4.4, 4.5 and 5.1).
Hypertensive patients receiving diuretics
Starting dose
The initial recommended dose is 1 mg once a day. Patients with a strongly activated renin- angiotensin-aldosterone system (in particular, renovascular hypertension, salt and/or volume depletion, cardiac decompensation, or severe hypertension) may experience an excessive blood pressure fall following the initial dose. The initiation of treatment should take place under medical supervision.
Maintenance dose
The usual daily dose is 2.5 mg to a maximum of 5 mg administered in a single dose. In general if the desired therapeutic effect cannot be achieved in a period of 3 to 4 weeks on a certain dose level, the dose can be further increased.
If the blood pressure is not adequately controlled with 5 mg CILAZAPRIL once daily, a low dose of a non-potassium-sparing diuretic may be administered concomitantly to enhance the anti-hypertensive effect.
Hypertensive patients being treated with concomitant diuretic therapy:
Symptomatic hypotension may occur following initiation of therapy with CILAZAPRIL. This is more likely in patients who are being treated currently with diuretics, especially in patients with heart failure, elderly patients (over 75 years) and patients with renal dysfunction. Caution is recommended therefore, since these patients may be volume and/or salt depleted. If possible, the diuretic should be discontinued 2 to 3 days before beginning therapy with CILAZAPRIL. In hypertensive patients in whom the diuretic cannot be discontinued, and especially in those on high-dose diuretic therapy, therapy with CILAZAPRIL should be initiated with a 0.5 mg dose.
Renal function and serum potassium should be monitored. The subsequent dosage of CILAZAPRIL should be adjusted according to blood pressure response. If required, diuretic therapy may be resumed (see section 4.4 and section 4.5). When treatment is initiated in a patient already taking diuretics, it is recommended that the treatment with CILAZAPRIL is started under medical supervision for several hours and until blood pressure is stabilised.
Heart failure
In patients with symptomatic heart failure, CILAZAPRIL should be used as adjunctive therapy to diuretics and, where appropriate, digitalis.
The recommended initial dose is 0.5 mg once daily, initiated under close medical supervision.
If the initial dose is well tolerated, patients should then be titrated to the lowest maintenance dose of 1 mg daily based on clinical response. Further titration within the usual maintenance dose of 1 to 2.5 mg daily should be carried out based on the patient's response, clinical status and tolerability.
The usual maximum dose is 5 mg once daily.
Results from clinical trials showed that clearance of cilazaprilat in patients with chronic heart failure is correlated with creatinine clearance. Thus, in patients with
chronic heart failure and impaired renal function, special dosage recommendations as given under "Impaired renal function" should be followed.
The appearance of hypotension after the initial dose should not preclude careful dose titration of CILAZAPRIL, following effective management of the hypotension.
Patients at high risk of symptomatic hypotension e.g. patients with salt depletion with or without hyponatraemia, patients with hypovolaemia or patients who have been receiving vigorous diuretic therapy should have these conditions corrected, if possible, prior to therapy with CILAZAPRIL. Renal function and serum potassium should be monitored (see section 4.4).
Impaired renal function
Reduced dosages may be required in patients with renal impairment, depending on their creatinine clearance.
The following dose schedules of CILAZAPRIL are recommended:
|
Creatinine clearance |
Initial dose |
Maximal dose |
|
> 40 ml/min |
1 mg once daily |
5 mg once daily |
|
10 - 40 ml/min |
0.5 mg once daily |
2.5 mg once daily |
|
< 10ml/min |
Not recommended | |
Haemodialysis
In patients requiring haemodialysis, CILAZAPRIL should not be administered on days when dialysis is performed, and the dosage should be adjusted according to blood pressure response.
Hepatic impairment
Should patients with liver cirrhosis require treatment with CILAZAPRIL, it should be initiated with caution at a dose of 0.5 or 0.25 mg once daily, because significant hypotension may occur (see sections 4.4 and 5.2).
Elderly
In the treatment of hypertension CILAZAPRIL should be initiated with between 0.5 mg and 1.0 mg once daily. Thereafter, the maintenance dose may be increased according to individual response.
In the treatment of chronic heart failure CILAZAPRIL should be initiated with a dose of 0.5 mg once daily. The maintenance dose is 1.0 mg to 2.5 mg according to individual tolerability, response and clinical status.
In elderly patients with chronic heart failure the recommended daily starting dose of CILAZAPRIL 0.5 mg must be strictly followed due to the risk of symptomatic hypotension.
Children and adolescents
CILAZAPRIL is not recommended for use in children and adolescents below the age of 18 years, due to insufficient data on the safety and efficacy of this medicinal product.
4.3 Contraindications
• Hypersensitivity to the active substance or to any of the excipients listed in section 6.1 or any other angiotensin-converting enzyme (ACE) inhibitor
• Hereditary or idiopathic angioneurotic oedema
• History of angioedema associated with previous ACE inhibitors therapy
• Second and third trimesters of pregnancy (see section 4.4 and 4.6)
• The concomitant use of CILAZAPRIL with aliskiren-containing products is contraindicated in patients with diabetes mellitus or renal impairment (GFR 60 ml/min/1.73m2) (see sections 4.5 and 5.1).
4.4 Special warnings and precautions for use
Symptomatic hypotension
Symptomatic hypotension is seen rarely in uncomplicated hypertensive patients. In hypertensive patients receiving CILAZAPRIL, hypotension is more likely to occur if the patient has been volume-depleted e.g. by diuretic therapy, dietary salt restriction, dialysis, diarrhoea or vomiting, or has severe renin-dependent hypertension (see section 4.5 and section 4.8). In patients with heart failure, with or without associated renal insufficiency, symptomatic hypotension has been observed. This is most likely to occur in those patients with more severe degrees of heart failure, as reflected by the use of high doses of loop diuretics, hyponatraemia or functional renal impairment. In patients at increased risk of symptomatic hypotension, initiation of therapy and dose adjustment should be closely monitored. Similar considerations apply to patients with ischaemic heart or cerebrovascular disease in whom an excessive fall in blood pressure could result in a myocardial infarction or cerebrovascular accident.
If hypotension occurs, the patient should be placed in the supine position and, if necessary, should receive an intravenous infusion of sodium chloride 9 mg/ml (0.9%) solution. A transient hypotensive response is not a contraindication to further doses, which can be given usually without difficulty once the blood pressure has increased after volume expansion.
In some patients with heart failure who have normal or low blood pressure, additional lowering of systemic blood pressure may occur with CILAZAPRIL. This effect is anticipated and is not usually a reason to discontinue treatment. If hypotension becomes symptomatic, a reduction of dose or discontinuation of CILAZAPRIL may be necessary.
Dual blockade of the renin-angiotensin-aldosterone system (RAAS)
There is evidence that the concomitant use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren increases the risk of hypotension, hyperkalaemia and decreased renal function (including acute renal failure). Dual blockade of RAAS through the combined use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is therefore not recommended (see section 4.5 and 5.1).
If dual blockade therapy is considered absolutely necessary, this should only occur under specialist supervision and subject to frequent close monitoring of renal function, electrolytes and blood pressure.
ACE-inhibitors and angiotensin II receptor blockers should not be used concomitantly in patients with diabetic nephropathy.
Aortic and mitral valve stenosis / hypertrophic cardiomyopathy
As with other angiotensin-converting enzyme (ACE) inhibitors, CILAZAPRIL should be given with caution to patients with mitral valve stenosis and obstruction in the outflow of the left ventricle such as aortic stenosis or hypertrophic cardiomyopathy.
Renal function impairment
In cases of renal impairment, the dosage of CILAZAPRIL should be adjusted according to creatinine clearance (see section 4.2). Routine monitoring of potassium and creatinine is part of normal medical practice for these patients.
In patients with heart failure, hypotension following the initiation of therapy with ACE inhibitors may lead to some further impairment in renal function. Acute renal failure, usually reversible, has been reported in this situation.
In some patients with bilateral renal artery stenosis or with a stenosis of the artery to a solitary kidney, who have been treated with ACE inhibitors, increases in blood urea and serum creatinine, usually reversible upon discontinuation of therapy, have been seen. This is especially likely in patients with renal insufficiency. If renovascular hypertension is also present there is an increased risk of severe hypotension and renal insufficiency. In these patients, treatment should be started under close medical supervision with low doses and careful dose titration. Since treatment with diuretics may be a contributory factor to the above, they should be discontinued and renal function should be monitored during the first weeks of therapy with CILAZAPRIL.
Some hypertensive patients with no apparent pre-existing renal vascular disease have developed increases in blood urea and serum creatinine, usually minor and transient, especially when CILAZAPRIL has been given concomitantly with a diuretic. This is more likely to occur in patients with pre-existing renal impairment. Dosage reduction and/or discontinuation of the diuretic and/or ACE inhibitor may be required.
Proteinuria
In patients with pre-existing renal impairment proteinuria may occur in rare cases. In clinically relevant proteinuria (greater than 1 g/day) CILAZAPRIL should only be used after a very critical benefit/risk evaluation and with regular monitoring of the clinical and laboratory chemical parameters.
Hypersensitivity / angioedema
Angioedema of the face, extremities, lips, tongue, glottis and/or larynx has been reported rarely in patients treated with ACE inhibitors, including CILAZAPRIL. This may occur at any time during therapy.
In such cases, CILAZAPRIL should be discontinued promptly and appropriate treatment and monitoring should be instituted to ensure complete resolution of symptoms prior to dismissing the patients. Even in those instances where swelling of only the tongue is involved, without respiratory distress, patients may require prolonged observation since treatment with antihistamines and corticosteroids may not be sufficient.
Very rarely, fatalities have been reported due to angioedema associated with laryngeal oedema or tongue oedema. Patients with involvement of the tongue, glottis or larynx, are likely to experience airway obstruction, especially those with a history of airway surgery. In such cases emergency therapy should be administered promptly. This may include the administration of adrenaline and/or the maintenance of a patent airway. The patient should be under close medical supervision until complete and sustained resolution of symptoms has occurred.
ACE inhibitors cause a higher rate of angioedema in Black patients than in non-Black patients.
Patients with a history of angioedema unrelated to ACE inhibitor therapy may be at increased risk of angioedema while receiving an ACE inhibitor (see section 4.3).
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-l esterase levels were normal. The angioedema was diagnosed by procedures including abdominal CT scan, or ultrasound or at 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 (see section 4.8).
Anaphylactoid reactions in haemodialysis patients
Anaphylactoid reactions have been reported in patients dialysed with high flux membranes (e.g. AN 69) and treated concomitantly with an ACE inhibitor. In these patients consideration should be given to using a different type of dialysis membrane or different class of antihypertensive agent.
Anaphylactoid reactions during low-density lipoproteins (LDL) apheresis
Rarely, patients receiving ACE inhibitors during LDL apheresis with dextran sulphate have experienced life-threatening anaphylactoid reactions. These reactions were avoided by temporarily withholding ACE inhibitor therapy prior to each apheresis.
Desensitisation
Patients receiving ACE inhibitors during desensitisation treatment (e.g. hymenoptera venom) have sustained anaphylactoid reactions. In the same patients, these reactions have been avoided when ACE inhibitors were temporarily withheld but they have reappeared upon inadvertent re-administration of the medicinal product.
Hepatic failure
High CILAZAPRIL plasma concentrations might occur in patients with impaired hepatic function. Very rarely, ACE inhibitors have been associated with a syndrome that starts with cholestatic jaundice or hepatitis and progresses to fulminant necrosis and (sometimes) death. The mechanism of this syndrome is not understood. Patients receiving CILAZAPRIL who develop jaundice or marked elevations of hepatic enzymes should discontinue CILAZAPRIL and receive appropriate medical followup.
Neutropenia/Agranulocytosis
Neutropenia/agranulocytosis, thrombocytopenia and anaemia have been reported in patients receiving ACE inhibitors. In patients with normal renal function and no other complicating factors, neutropenia occurs rarely. Neutropenia and agranulocytosis are reversible after discontinuation of the ACE inhibitor. ACE inhibitors should be used with extreme caution in patients with collagen vascular disease, immunosuppressant therapy, treatment with allopurinol or procainamide, or a combination of these complicating factors, especially if there is pre-existing impaired renal function. Some of these patients developed serious infections, which in a few instances did not respond to intensive antibiotic therapy. If CILAZAPRIL 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.”
Race
As with other ACE inhibitors, CILAZAPRIL may be less effective in lowering blood pressure in Black patients than in non-Blacks, possibly because of a higher prevalence of low-renin states in the Black hypertensive population.
Cough
Cough has been reported with the use of ACE inhibitors. Characteristically, the cough is non- productive, persistent and resolves after discontinuation of therapy. ACE inhibitor-induced cough should be considered as part of the differential diagnosis of cough.
Surgery / anaesthesia
In patients undergoing major surgery or during anaesthesia with agents that produce hypotension, CILAZAPRIL may block angiotensin II formation secondary to compensatory renin release. If hypotension occurs and is considered to be due to this mechanism, it can be corrected by volume expansion.
Hyperkalaemia
Elevations in serum potassium have been observed in some patients treated with ACE inhibitors, including CILAZAPRIL. Patients at risk for the development of hyperkalaemia include those with renal insufficiency, or worsening renal function, diabetes mellitus, acute cardiac decompensation, metabolic acidosis, intercurrent events, in particular dehydration, the elderly (age > 70 years) or those using concomitant potassium-sparing diuretics, potassium supplements or potassium-containing salt substitutes, (especially in those with renal impairment, in whom combined use may lead to significant increases in serum potassium), or those patients taking other medicinal products associated with increases in serum potassium (e.g. heparin). Hyperkalaemia can cause serious, sometimes fatal arrhythmias. If concomitant use of the above-mentioned products is deemed appropriate, caution and regular monitoring of serum potassium are recommended (see section 4.5).
Diabetic patients
In diabetic patients treated with oral antidiabetic agents or insulin, glycaemic control should be closely monitored during the first month of treatment with an ACE inhibitor (see section 4.5).
Lithium
The combination of lithium and CILAZAPRIL is generally not recommended (see section 4.5).
Pregnancy
ACE inhibitors should not be initiated during pregnancy. Unless continued ACE inhibitor therapy is considered essential, 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 ACE inhibitors should be stopped immediately, and, if appropriate, alternative therapy should be started (see sections 4.3 and 4.6).
Lactose monohydrate content
This medicinal product contains lactose monohydrate. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicinal product.
4.5 Interaction with other medicinal products and other forms of interaction
Diuretics
When a diuretic is added to the therapy of a patient receiving CILAZAPRIL, the antihypertensive effect is usually additive.
Patients already on diuretics and especially those in whom diuretic therapy was recently instituted may occasionally experience an excessive reduction of blood pressure when CILAZAPRIL is added. The possibility of symptomatic hypotension with CILAZAPRIL can be minimised by discontinuing the diuretic prior to initiation of treatment with CILAZAPRIL (see section 4.4).
Potassium supplements, potassium-sparing diuretics, potassium-containing salt substitutes, or other medicinal products associated with increases in serum potassium (e.g. heparin) (see section 4.4, Hyperkalaemia)
Although in clinical trials, serum potassium usually remained within normal limits, hyperkalaemia did occur in some patients. Risk factors for the development of hyperkalaemia include renal insufficiency, diabetes mellitus, and concomitant use of potassium-sparing diuretics (e.g., spironolactone, triamterene or amiloride), potassium supplements, potassium- containing salt substitutes or other medicinal products associated with increases in serum potassium (e.g. heparin).
The use of the above-mentioned products, particularly in patients with impaired renal function, may lead to a significant increase in serum potassium.
If CILAZAPRIL is given with a potassium-losing diuretic, diuretic-induced hypokalaemia may be ameliorated.
Lithium
Reversible increases in serum lithium concentrations and toxicity have been reported during concomitant administration of lithium with ACE inhibitors. Concomitant use of thiazide diuretics may increase the risk of lithium toxicity and enhance the already increased lithium toxicity with ACE inhibitors. Use of CILAZAPRIL with lithium is not recommended, but if the combination proves necessary, careful monitoring of serum lithium levels should be performed (see section 4.4).
Non steroidal anti-inflammatory medicinal products (NSAIDs) including acetylsalicylic acid > 3 g/day
Chronic administration of NSAIDs (including acetylsalicylic acid at antiinflammatory doses, COX-2 inhibitors and non-selective NSAIDs) may reduce the antihypertensive effect of an ACE inhibitor. NSAIDs and ACE inhibitors exert an additive effect on the increase in serum potassium and may result in a deterioration of renal function, 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.
Other antihypertensive agents
Combination with other antihypertensive agents such as beta-blockers, methyldopa, calcium antagonists, and diuretics may increase the anti-hypertensive efficacy. Concomitant use with glyceryl trinitrate and other nitrates, or other vasodilators, may further reduce blood pressure.
Tricyclic antidepressants /Antipsychotics /Anaesthetics
Concomitant use of certain anaesthetic medicinal products, tricyclic antidepressants and antipsychotics with ACE inhibitors may result in further reduction of blood pressure (see section 4.4).
Sympathomimetics
Sympathomimetics may reduce the antihypertensive effects of ACE inhibitors.
Antidiabetics
Epidemiological studies have suggested that concomitant administration of ACE inhibitors and antidiabetic medicinal products (insulins, oral hypoglycaemic agents) may cause an increased blood glucose lowering effect with risk of hypoglycaemia. This phenomenon appeared to be more likely to occur during the first weeks of combined treatment and in patients with renal impairment.
Acetylsalicylic acid, thrombolytics, beta-blockers, nitrates
CILAZAPRIL may be used concomitantly with acetylsalicylic acid (at cardiological doses), thrombolytics, beta-blockers and/or nitrates.
Immunosuppressants, cytostatics, systemic corticosteroids or procainamide, allopurinol
The combination of CILAZAPRIL with immunosuppressant medicinal products and/or medicinal products that can cause leucopenia should be avoided.
Alcohol
Alcohol enhances the hypotensive effect of CILAZAPRIL.
Antacids
Antacids (e.g. aluminium hydroxide, magnesium hydroxide, simeticone) may impair absorption of CILAZAPRIL and so the administration of both medicinal products should be separated by at least 2 hours.
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 sections 4.3, 4.4 and 5.1).
4.6 Fertility, pregnancy and lactation
Pregnancy
The use of ACE inhibitors is not recommended during the first trimester of pregnancy (see section 4.4). The use of ACE inhibitors is contra-indicated during the second and third trimesters of pregnancy (see sections 4.3 and 4.4)
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. Unless continued ACE inhibitor therapy is considered essential, 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 ACE inhibitors should be stopped immediately, and, if appropriate, alternative therapy should be started.
Exposure to ACE inhibitor therapy during the second and third trimesters is known to induce human fetotoxicity (decreased renal function, oligohydramnios, skull ossification retardation) and neonatal toxicity (renal failure, hypotension, hyperkalaemia) (see also section 5.3). Should exposure to an ACE inhibitor have occurred from the second trimester of pregnancy, ultrasound check of renal function and skull is recommended. Infants whose mothers have taken ACE inhibitors should be closely observed for hypotension (see also section 4.3 and 4.4).
Breastfeeding
Because no information is available regarding the use of CILAZAPRIL during breastfeeding, CILAZAPRIL is not recommended and alternative treatments with better established safety profiles during breastfeeding are preferable, especially while nursing a newborn or preterm infant.
4.7 Effects on ability to drive and use machines
Cilazapril has no or negligible influence on the ability to drive and use machines.
Although cilazapril is not expected to directly affect the ability to drive or use machines, adverse reactions such as hypotension, dizziness and vertigo may interfere it.
This occurs especially at the start of treatment, when increasing the dosage, when changing over from other preparations and during concomitant use of alcohol, depending on the individual's susceptibility.
4.8 Undesirable effects
The following adverse reactions have been observed during treatment with CILAZAPRIL or other ACE inhibitors (marked with an asterisk) and are ranked under the following frequency convention:
Very common (>1/10); common (>1/100, <1/10); uncommon (>1/1,000, <1/100); rare (>1/10,000, <1/1,000); very rare (<1/10,000), not known (cannot be estimated from the available data).
|
Blood and lymphatic system disorders | |
|
Very rare |
Decreased haemoglobin or haematocrit levels, bone marrow depression*, anaemia*, thrombocytopenia*, leucopenia, neutropenia*, agranulocytosis (see section 4.4), haemolytic anaemia*, lymphadenopathy |
|
Immune system disorders | |
|
Very rare |
Auto-immune disease* |
|
Metabolism and nutrition disorders | |
|
Very rare |
Hypoglycaemia* |
|
Nervous system disorders | |
|
Common |
Headache, dizziness |
|
Uncommon |
Mood changes*, syncope*, sleep disturbances |
|
Rare |
Depression, paresthesia, confusion, taste disturbances |
|
Very rare |
Neuropathy |
|
Cardiovascular disorders | |
|
Common |
Hypotension, orthostatic or otherwise (including hypotension)* (see section 4.4) |
|
Uncommon |
Myocardial infarction, cerebrovascular accident, possibly secondary to significant drop in blood pressure in high-risk |
|
patients (see section 4.4)*, palpitations, tachycardia*, Raynaud's phenomenon* | |
|
Very rare |
Vasculitis |
|
Respiratory, thoracic and mediastinal disorders | |
|
Common |
Cough |
|
Uncommon |
Rhinitis, chest pain |
|
Rare |
Dyspnoea, sinusitis*, bronchitis, allergic alveolitis / eosinophilic pneumonitis*, bronchospasm |
|
Gastrointestinal disorders | |
|
Common |
Nausea, diarrhoea*, vomiting* |
|
Uncommon |
Abdominal pain, dyspepsia, digestive disorders* |
|
Rare |
Dry mouth, glossitis |
|
Very rare |
Pancreatitis, intestinal angioedema* |
|
Hepato-biliary disorders | |
|
Very rare |
Hepatocellular or cholestatic hepatitis with or without necrosis (severe forms have been observed in exceptional cases), jaundice, hepatic failure* |
|
Skin and subcutaneous tissue disorders | |
|
Common |
Rash |
|
Uncommon |
Exanthema, pruritus* |
|
Rare |
Hypersensitivity / angioedema: angioedema of the face, extremities, lips, tongue, epiglottis and / or larynx (see section 4.4), urticaria*, alopecia*, psoriasis* |
|
Very rare |
Diaphoresis*, pemphigus*, toxic epidermal necrolysis*, Stevens-Johnson syndrome*, erythema multiforme* |
|
A symptom complex involving one or more of the following has been reported with ACE inhibitors: fever, vasculitis, myalgia, arthralgia / arthritis, positive antinuclear antibody (ANA) test, increased sedimentation rate (SR), eosinophilia and leucocytosis. Rash, photosensitisation or other dermatological disorders may occur. | |
|
Musculoskeletal and connective tissue disorders | |
|
Rare |
Myalgia, arthralgia |
|
Renal and urinary disorders | |
|
Rare |
Renal impairment, uraemia* |
|
Very rare |
Acute renal failure, oliguria / anuria* |
|
Reproductive system and breast disorders | |
|
Uncommon |
Impotence* |
|
Very rare |
Gynaecomastia |
|
General disorders and administration site conditions | |
|
Common |
Tiredness |
|
Uncommon |
Asthenia* |
|
Investigations | |
|
Uncommon |
Moderately increased plasma urea and creatinine levels, reversible on discontinuation of treatment and most frequently observed in patients with renal artery stenosis, diuretic-treated hypertension, renal impairment. Usually transient hyperkalaemia. |
Proteinuria in patients with glomerular nephropathy, increased serum bilirubin, increased liver enzyme levels (transaminases, bilirubin, alkaline phosphatase, gamma GT), hyponatraemia*_
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation 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 via:
Yellow Card Scheme, website: www.mhra.gov.uk/yellowcard
4.9 Overdose
While single doses of up to 160 mg Cilazapril have been administered to normal healthy volunteers without untoward effects on blood pressure, only a few data on overdose are available in patients.
Symptoms
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 overdose is intravenous infusion of normal saline solution.
Treatment
After ingestion of an overdose, the patient should be kept under close supervision, preferably in an intensive care unit. Serum electrolytes and creatinine should be monitored frequently. Therapeutic measures depend on the nature and severity of the symptoms. Measurements to prevent absorption of the drugs (such as gastric lavage, administration of adsorbents and sodium sulphate within 30 minutes after the ingestion of an overdose), and to hasten elimination should be applied if ingestion is recent. If hypotension occurs, the patient should be placed in the shock position and salt and volume supplementation should be given rapidly.
Treatment with angiotensin II should be considered. Bradycardia or extensive vagal reactions should be treated by administering atropine. The use of a pacemaker may be considered. ACE inhibitors may be removed from the circulation by haemodialysis. The use of high-flux polyacrylonitrile membranes should be avoided.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
Pharmacotherapeutic group: angiotensin convertase inhibitors, ATC code: C09 AA08
CILAZAPRIL is a selective, long-acting angiotensin-converting enzyme (ACE) inhibitor which suppresses the renin-angiotensin-aldosterone system and the conversion of the inactive angiotensin I to angiotensin II which is a potent vasoconstrictor. At recommended doses, the effect of CILAZAPRIL in hypertensive patients and in patients with chronic heart failure is maintained for up to 24 hours.
In patients with normal renal function, serum potassium usually remains within the normal range during CILAZAPRIL treatment. In patients concomitantly taking potassium-sparing diuretics, potassium levels may rise.
Two large randomised, controlled trials (ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial), VA NEPHRON-D (The Veterans Affair Nephropathy in Diabetes) have examined the use of combination of an ACE-inhibitor with angiotensin II receptor blocker. ONTARGET was a study conducted in patients with a history of cardiovascular or cerebrovascular disease, or type 2 diabetes mellitus accompanied by evidence of end-organ damage. VA NEPHRON-D was a study in patients with type 2 diabetes mellitus and diabetic nephropathy.
These studies have shown no significant beneficial effect on renal and/ or cardiovascular outcomes and mortality, while an increased risk of hyperkalaemia, acute kidney injury and/or hypotension as compared to monotherapy was observed.
Given their similar pharmaodynamic properties, these results are also relevant for other ACE-inhibitors and angiotensin II receptor blockers.
ACE-inhibitors and angiotensin II receptor blockers should therefore not be used concomitantly in patients with diabetic nephropathy.
ALTITUDE (Aliskiren Trial in Type 2 Diabetes Using Cardiovascular and Renal Disease Endpoints) was a study designed to test the benefit of adding aliskiren to a standard therapy of an ACE-inhibitor or an angiotensin II receptor blocker in patients with type 2 diabetes mellitus and chronic kidney disease, cardiovascular disease, or both. The study was terminated early because of an increased risk of adverse outcomes. CV death and stroke were both numerically more frequent in the aliskiren group than in the placebo group and adverse events and serious adverse events of interest (hyperkalaemia, hypotension and renal dysfunction) were more frequently reported in the aliskiren group than in the placebo group.
The concomitant use of aliskiren with an ACE-inhibitor or an angiotensin II receptor blocker is contraindicated in patients with type 2 diabetes mellitus or renal impairment (GFR 60ml/min/1.73m2).
Hypertension
CILAZAPRIL induces a reduction of both supine and standing systolic and diastolic blood pressure, usually with no orthostatic component. CILAZAPRIL is effective in all degrees of essential hypertension as well as in renal hypertension. The antihypertensive effect of CILAZAPRIL is usually apparent within the first hour after administration, with maximum effect observed between three and seven hours after dosing. In general the heart rate (pulse) remains unchanged. Reflex tachycardia is not induced by the drug, although small, clinically insignificant alterations of heart rate may occur. In some patients the anti-hypertensive effect of the drug diminishes toward the end of the dosage interval.
The initial dosage seldom achieves the desired therapeutic response. Blood pressure values should be assessed and dosage gradually increased as required. If the maximum recommended dose is not sufficient, it can be combined with nonpotassium-sparing diuretics.
The anti-hypertensive effect of CILAZAPRIL is maintained during long-term therapy. No rapid increases in blood pressure have been observed after abrupt withdrawal of CILAZAPRIL.
In hypertensive patients with moderate or severe renal impairment, the glomerular filtration rate and renal blood flow remain in general unchanged with CILAZAPRIL despite a clinically significant blood pressure reduction.
The blood pressure-lowering effect of CILAZAPRIL in Black patients may be less pronounced than in non-Blacks. However, racial differences in response are no longer evident when CILAZAPRIL is administered in combination with hydrochlorothiazide.
Chronic heart failure
In patients with chronic heart failure the renin-angiotensin-aldosterone and the sympathetic nervous systems are generally excessively activated leading to systemic vasoconstriction and to the promotion of sodium and water retention. By suppressing the renin-angiotensin- aldosterone system, CILAZAPRIL improves loading conditions in the failing heart by reducing systemic vascular resistance (afterload) and pulmonary capillary wedge pressure (preload) in patients on diuretics and/or digitalis.
Furthermore, the exercise tolerance of these patients increases significantly thus showing an improvement in quality of life. The haemodynamic and clinical effects occur promptly and persist during the treatment.
5.2 Pharmacokinetic properties
Cilazapril is efficiently absorbed and rapidly converted to the active form, cilazaprilat. Ingestion of food immediately prior to Cilazapril
administration, delays and reduces the absorption to a minor extent which, however, is therapeutically irrelevant. The bioavailability of cilazaprilat after oral administration of cilazapril approximates 60% based on urinary recovery data. Maximum serum concentrations are reached within two hours after drug administration and are directly related to dosage.
Cilazaprilat is eliminated unchanged by the kidneys with an effective half-life of nine hours after once-daily dosing with cilazapril. In patients with renal impairment, higher plasma concentrations of cilazaprilat are observed than in patients with normal renal function, since drug clearance is reduced when creatinine clearance is lower. There is no elimination in patients with complete renal failure, but haemodialysis reduces concentrations of cilazapril and cilazaprilat to a limited extent.
In elderly patients whose renal function is normal for age, plasma concentrations of cilazaprilat may be up to 40% higher, and the clearance up to 20% lower than in younger patients. Similar changes in the pharmacokinetics occur in patients with moderate to severe liver cirrhosis.
In patients with chronic heart failure the clearance of cilazaprilat is correlated with the creatinine clearance. Thus, dosage adjustments do not go beyond those recommended for patients with impaired renal functions (see section 4.2) should not be necessary.
5.3 Preclinical safety data
Preclinical data reveal no special hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicity, genotoxicity and carcinogenic potential.
In chronic oral toxicity studies (rats and monkeys), the target organ is the kidney, with reversible damage.
In fertility and general reproduction performance testing in rats, dosing with 50 mg/kg/day of CILAZAPRIL resulted in greater implantation losses, less viable fetuses, smaller pups, and dilatation of the renal pelvis in the pups. No teratogenic effects or adverse effects on post- natal pup development were observed in rats and Cynomolgus monkeys during embryotoxicity testing. In the rats, however, at a dose of 400 mg/kg/day, renal cavitation was observed in the pups. In peri- and post-natal toxicity testing in rats, dosing with 50 mg/kg/day resulted in greater pup mortality, smaller pups, and delayed unfolding of the pinna. On administration of 14C-CILAZAPRIL to pregnant mice, rats and monkeys, radioactivity was measured in the foetuses.
ACE inhibitors, as a class, have been shown to induce adverse effect on late foetal development, resulting in foetal death and congenital effects in rodents and rabbits: renal lesions and an increase in peri- and post-natal mortality have been observed.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Tablet core Lactose monohydrate Maize starch Hypromellose 3cp Talc
Sodium stearyl fumarate Film -Coating
Opadry pink 03B23719: hypromellose 6cp, talc, titanium dioxide (E171), Macrogol 400, iron oxide red (E172), iron oxide yellow (E172).
6.2 Incompatibilities
Not applicable.
Shelf life
6.3
3 years.
6.4 Special precautions for storage
Do not store above 25°C.
6.5 Nature and contents of container
Aluminium/Aluminium blisters in a cardboard box.
30 tablets
6.6 Special precautions for disposal
No special requirements
7 MARKETING AUTHORISATION HOLDER
Activase Pharmaceuticals Limited,
11 Boumpoulinas, 3rd Floor,
P.C. 1060, Nicosia Cyprus
8 MARKETING AUTHORISATION NUMBER(S)
PL 28444/0115
DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
02/06/2009
10
DATE OF REVISION OF THE TEXT
30/12/2014