Losartan Potassium 12.5mg Film-Coated Tablets
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Losartan Potassium 12.5 mg Film-Coated Tablets
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Losartan Potassium 12.5 mg Film-Coated Tablets Each tablet contains 12.5 mg of losartan potassium.
For a full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Film-Coated Tablet
Losartan Potassium 12.5 mg Film-Coated Tablet is supplied as white, round, biconvex, non-scored film-coated tablet.
4 CLINICAL PARTICULARS
4.1 Therapeutic indications
Treatment of essential hypertension
Treatment of renal disease in patients with hypertension and type 2 diabetes mellitus with proteinuria > 0.5g/day as part of an antihypertensive treatment.
Treatment of chronic heart failure (in patients > 60 years), when treatment with ACE inhibitors is not considered suitable due to incompatibility, especially cough, or contraindication. Patients who have been stabilised with an ACE inhibitor should not be switched to losartan. The patients should have a left ventricular ejection fraction < 40% and should be stabilised under the treatment of the chronic heart failure.
Reduction in the risk of stroke in hypertensive patients with left ventricular hypertrophy documented by ECG (see section 5.1 Pharmacodynamic studies, Hypertension studies, Race)
4.2 Posology and method of administration
Losartan Potassium may be administered with or without food.
Losartan Tablets should be swallowed with a glass of water.
Losartan Potassium may be administered with other antihypertensive agents, especially with diuretics (e.g. hydrochorthiazide). (See sections 4.3, 4.4, 4.5 and 5.1).
Hypertension:
The usual starting and maintenance dose is 50mg once daily for most patients. The maximal antihypertensive effect is attained 3-6 weeks after initiation of therapy. Some patients may receive an additional benefit by increasing the dose to 100mg once daily (in the morning).
Paediatric hypertension:
There are limited data on the efficacy and safety of Losartan Potassium in children and adolescents aged 6-16 years for the treatment of hypertension (see 5.1 “Pharmacodynamic Properties”). Limited pharmacokinetic data are available in hypertensive children above one month of age (see 5.2 “Pharmacokinetic Properties”). For patients who are able to swallow tablets, the recommended dose is 25mg once daily in patients >20 to <50kg. In exceptional cases the dose can be increased to a maximum of 50mg once daily. Dosage should be adjusted according to blood pressure response.
In patients >50kg, the usual dose is 50mg once daily. In exceptional cases the dose can be increased to a maximum of 100mg once daily. Doses above 1.4mg/kg (or in excess of 100mg) daily have not been studied in paediatric patients.
Losartan Potassium is not recommended for use in children under 6 years old as limited data are available in these patient groups.
Losartan Potassium is not recommended in children with glomerular filtration <30ml/min/1.73m2 as no data are available (see also section 4.4).
Losartan Potassium is also not recommended in children with hepatic impairment (see also section 4.4).
Hypertensive type II diabetic patients with proteinuria >0.5g/day:
The usual starting dose is 50mg once daily. The dose may be increased to 100mg once daily according to blood pressure response from one month after initiation of therapy onwards. Losartan Potassium may be administered with other antihypertensive agents (e.g. diuretics, calcium channel blockers, alpha- or beta-blockers and centrally acting agents) as well as with insulin and other commonly used hypoglycaemic agents (e.g. sulfonylureas, glitazones and glucosidase inhibitors).
Heart Failure:
The usual initial dose of Losartan Potassium in patients with heart failure is 12.5mg once daily. The dose should generally be titrated at weekly intervals (i.e. 12.5mg daily, 25mg daily, 50mg daily) to the usual maintenance dose of 50mg once daily, as tolerated by the patient.
Reduction in the risk of stroke in hypertensive patients with left ventricular hypertrophy documented by ECG:
The usual starting dose is 50mg of Losartan Potassium once daily. A low dose of hydrochlorothiazide may be added and/or the dose of Losartan Potassium may be increased to 100mg once daily based on blood pressure response.
Use in the patients with intravascular volume depletion:
For patients who have intravascular volume depletion (e.g. those treated with high-dose diuretics), a starting dose of 25mg once daily should be considered (see section 4.4 “Special warnings and precautions for use”).
Use in renal impairment and haemodialysis patients:
No initial dose adjustment is necessary in patients with renal impairment and in haemodialysis patients.
Use in patients with hepatic impairment:
A lower dose should be considered for patients with a history of hepatic impairment. There is no therapeutic experience in patients with severe hepatic impairment. Therefore Losartan Potassium is contraindicated in patients with severe hepatic impairment, (see sections 4.3 and 4.4).
Use in the elderly:
Although consideration should be given to initiating therapy with 25mg in patients over 75 years of age, dosage adjustment is not usually necessary for the elderly.
4.3 Contraindications
Hypersensitivity to any of the ingredients of this product (see sections
4.4 and 6.1).
Second and third trimesters of pregnancy (see sections 4.4 and 4.6). Severe hepatic impairment.
The concomitant use of Losartan Potassium with aliskiren-containing products is contraindicated in patients with diabetes mellitus or renal impairment (GFR < 60ml/min/1.73 m ) (see sections 4.5 and 5.1).
4.4 Special warnings and special precautions for use
Hypersensitivity:
Angioedema. Patients with a history of angioedema (swelling of the face, lips, throat, and/or tongue) should be closely monitored (see section 4.8 “Undesirable effects”).
Hypotension and electrolyte/fluid imbalance:
Symptomatic hypotension, especially after the first dose and after increasing the dose, may occur in patients who are volume depleted and/or sodium depleted (e.g. by high dose diuretic therapy, dietary salt restriction, diarrhoea or vomiting). These conditions should be corrected prior to administration of Losartan Potassium, or a lower starting dose should be used (see section 4.2 “Posology and method of administration”). This also applies to children.
Electrolyte imbalances:
Electrolyte imbalances are common in patients with renal impairment, with or without diabetes, and should be addressed. In a clinical study conducted in type 2 diabetic patients with nephropathy, the incidence of hyperkalaemia was higher in the group treated with Losartan Potassium as compared to the placebo group (see section 4.8 “Undesirable effects” - Hypertension and type 2 diabetes with renal disease - investigations and Post-marketing experience -investigations). Therefore, the plasma concentrations of potassium as well as creatinine clearance values should be closely monitored, especially in patients with heart failure and a creatinine clearance between 30-50ml/min.
The concomitant use of potassium sparing diuretics, potassium supplements and potassium containing salt substitutes with Losartan Potassium is not recommended (see section 4.5).
Liver function impairment:
Based on pharmacokinetic data which demonstrate significantly increased plasma concentrations of losartan in cirrhotic patients, a lower dose should be considered for patients with a history of hepatic impairment. There is no therapeutic experience with losartan in patients with severe hepatic impairment. Therefore losartan must not be administered in patients with severe hepatic impairment (see sections 4.2, 4.3 and 5.2).
Losartan is also not recommended in children with hepatic impairment (see section 4.2).
Renal function impairment:
As a consequence of inhibiting the renin-angiotensin system, changes in renal function including renal failure have been reported (in particular, in patients whose renal function is dependent on the renin-angiotensin-aldosterone system such as those with severe cardiac insufficiency or pre-existing renal dysfunction).
As with other drugs that affect the renin-angiotensin-aldosterone system, increases in blood urea and serum creatinine have also been reported in patients with bilateral renal artery stenosis or stenosis of the artery to a solitary kidney; these changes in renal function may be reversible upon discontinuation of therapy. Losartan Potassium should be used with caution in patients with bilateral renal artery stenosis or stenosis of the artery to a solitary kidney.
Use in paediatric patients with renal function impairment:
Losartan is not recommended in children with a glomerular filtration rate < 30ml/min/1.73m2 as no data are available (see section 4.2).
Renal function should be regularly monitored during treatment with losartan as it may deteriorate. This applies particularly when losartan is given in the presence of other conditions (fever, dehydration) likely to impair renal function.
Concomitant use of losartan and ACE inhibitors has been shown to impair renal function. Concomitant use is therefore not recommended.
Renal transplantation:
There is no experience in patients with recent kidney transplantation. Primary hyperaldosteronism:
Patients with primary hyperaldosteronism generally will not respond to antihypertensive drugs acting through inhibition of the renin-angiotensin system. Therefore, the use of Losartan Potassium tablets is not recommended.
Coronary heart disease and cerebrovascular disease:
As with any anti-hypertensive agent, excessive blood pressure decrease in patients with ischaemic cardiovascular and cerebrovascular disease could result in a myocardial infarction or stroke.
Heart Failure:
In patients with heart failure, with or without renal impairment, there is, as with other drugs acting on the renin-angiotensin system, a risk of severe arterial hypotension, and (often acute) renal impairment.
There is insufficient therapeutic experience with losartan in patients with heart failure and concomitant severe renal impairment, in patients with severe heart failure (NYHA class IV), as well as in patients with heart failure and symptomatic life threatening cardiac arrhythmias. Therefore losartan should be used with caution in these patient groups. The combination of losartan with a beta-blocker should be used with caution (see section 5.1).
Aortic and mitral valve stenosis, obstructive hypertrophic cardiomyopathy:
As with other vasodilators, special caution is indicated in patients suffering from aortic and mitral valve stenosis, or obstructive hypertrophic cardiomyopathy.
Pregnancy:
Losartan should not be initiated during pregnancy. Unless continued losartan 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 Losartan should be stopped immediately, and, if appropriate, alternative therapy should be started (see sections 4.3 and 4.6).
Other warnings and precautions:
As observed for angiotensin converting enzyme inhibitors, losartan and other angiotensin antagonists are apparently less effective in lowering blood pressure in black people than in non-blacks, possibly because of a higher prevalence of low-renin states in black hypertensive population.
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.
4.5 Interactions with other medicinal products and other forms of interaction
Other antihypertensive agents may increase the hypotensive effect of losartan. Concomitant use with these drugs that lower blood pressure, as a main or side-effect, may increase the risk of hypotension.
Losartan is predominantly metabolised by cytochrome P450 (CYP) 2C9 to the active carboxy-acid metabolite. In a clinical trial it was found that fluconazole (inhibitor of CYP2C9) decreases the exposure to the active metabolite by approximately 50%. It was found that concomitant treatment of losartan with rifampicin (inducer of metabolic enzymes) resulted in a 40% reduction in plasma level of the active metabolite. The clinical relevance of this effect is not known. No difference in exposure was found with concomitant treatment with fluvastatin (weak inhibitor of CYP2C9).
As with other drugs that block angiotensin II or its effects, concomitant use of other drugs which retain potassium (e.g. potassium-sparing diuretics such as amiloride, triamterene, spironolactone) or may increase potassium levels (e.g. heparin, potassium supplements or salt substitutes containing potassium) may lead to increases in serum potassium. Co-medication is not advisable.
Reversible increases in serum lithium concentrations and toxicity have been reported during concomitant administration of lithium with ACE inhibitors. Very rare cases have also been reported with angiotensin II receptor antagonists. Co-administration of lithium and Losartan Potassium should be undertaken with caution. If this combination is essential, serum lithium level monitoring is recommended during concomitant use.
Combination with NSAIDs : When angiotensin II antagonists are administered simultaneously with non-steroidal anti-inflammatory medicinal products (e.g. selective COX-2 inhibitors, acetylsalicylic acid at anti-inflammatory doses and non-selective NSAIDs), attenuation of the anti-hypertensive effect may occur. Concomitant use of angiotensin II antagonists, or diuretics, and NSAIDs may lead to an increased risk of worsening of renal function, including possible acute renal failure, and an increase in serum potassium, especially in patients with poor pre-existing renal function. The combination should be administered with caution, especially in the elderly. Patients should be adequately hydrated and consideration should be given to monitoring renal function after initiation of concomitant therapy, and periodically thereafter.
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 AIIRAs is not recommended during the first trimester of pregnancy (see section 4.4). The use of AIIRAs 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. Whilst there are no controlled epidemiological data on the risk with Angiotensin II Receptor Inhibitors (AIIRAs), similar risks may exist for this class of drugs. Unless continued AIIRA 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 AIIRAs should be stopped immediately, and if appropriate, alternative therapy should be started (see section 4.3).
Exposure to AIIRAs 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 section 5.3)
Should exposure to losartan have occurred from the second trimester of pregnancy, ultrasound checks of renal function and skull are recommended. Infants whose mothers have taken AIIRAs should be closely observed for hypotension (see sections 4.3 and 4.4).
Lactation:
Because no information is available regarding the use of Losartan Potassium Tablets during breastfeeding, Losartan Potassium 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
No studies on the effects on the ability to drive and use machines have been performed. However, when driving vehicles or operating machinery it must be borne in mind that dizziness or drowsiness may occasionally occur when taking antihypertensive therapy, in particular during initiation of treatment or when dose is increased.
4.8 Undesirable effects
Adverse drug reactions are listed below by system organ class and frequency. Frequencies are defined as: 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) including isolated reports.
In controlled clinical trials for essential hypertension, hypertensive patients with left ventricular hypertrophy, chronic heart failure, as well as, for hypertension and type 2 diabetes mellitus with renal disease, the most common adverse event, was dizziness.
Hypertension
In controlled clinical trials for essential hypertension with losartan the following adverse reactions were reported:
Nervous system disorders:
Common: dizziness, vertigo
Uncommon: somnolence, headache, sleep disorders
Cardiac disorders:
Uncommon: palpitations angina pectoris Vascular disorders:
Uncommon: symptomatic hypotension (especially in patients with intravascular volume depletion, e.g. patients with severe heart failure or under treatment with high dose diuretics), dose-related orthostatic effects, rash.
Gastro-intestinal disorders:
Uncommon: abdominal pain, constipation
General disorders and administration site conditions:
Uncommon: asthenia, fatigue, oedema
Hypertensive patients with left ventricular hypertrophy
In controlled clinical trials in hypertensive patients with left ventricular hypertrophy the following adverse reactions were reported:
Nervous system disorders:
Common: dizziness
Ear and labyrinth disorders:
Common: vertigo
General disorders and administration site conditions:
Common: asthenia/fatigue
Chronic heart failure
In a controlled clinical trial in patients with cardiac insufficiency the following adverse events were reported:
Nervous system disorders:
Uncommon: dizziness, headache Rare: paraesthesia
Cardiac disorders:
Rare: syncope, atrial fibrillation, cerebrovascular accident
Vascular disorders:
Uncommon: hypotension, including orthostatic hypotension
Respiratory, thoracic and mediastinal disorders:
Uncommon: dyspnoea
Gastro-intestinal disorders:
Uncommon: diarrhoea, nausea, vomiting
Skin and sub-Cutaneous tissue disorders:
Uncommon: urticaria, pruritus, rash
General disorders and administration site conditions:
Uncommon: asthenia/fatigue
Hypertension and type 2 diabetes with renal disease
In a controlled clinical trial in type 2 diabetic patients with proteinuria (RENAAL study, see section 5.1) the most common drug-related adverse events which reported for losartan are as follows:
Nervous system disorders:
Common: dizziness
Vascular disorders:
Common: hypotension
General disorders and administration site conditions:
Common: asthenia/fatigue
Investigations:
Common: hypoglycaemia, hyperkalaemia
The following adverse events occurred more often in patients receiving losartan than placebo:
Blood and lymphatic system disorders:
Not known: anaemia
Cardiac disorders:
Not known: syncope, palpitations
Vascular disorders:
Not known: orthostatic hypotension
Gastro-intestinal disorders:
Not known: diarrhoea
Musculoskeletal and connective tissue disorders:
Not known: back pain
Renal and urinary disorders:
Not known: urinary tract infections
General disorders and administration site conditions:
Not known: flu-like symptoms
Post-marketing experience
The following adverse events have been reported in post-marketing experience:
Blood and lymphatic system disorders:
Not known: anaemia, thrombocytopenia
Immune system disorders:
Rare: hypersensitivity - anaphylactic reactions, angioedema including
swelling of the larynx and glottis causing airway obstruction and/or swelling of the face, lips, pharynx, and/or tongue (in some of these patients angioedema had been reported in the past in connection with administration of other medicines including ACE inhibitors); vasculitis including Henoch-Schonlein purpura.
Nervous system disorders:
Not known: migraine
Respiratory, thoracic and mediastinal disorders:
Not known: cough
Gastro-intestinal disorders:
Not known: diarrhoea
Hepatobiliary disorders:
Rare: hepatitis
Not known: liver function abnormalities
Skin and sub-cutaneous tissue disorders:
Not known: urticaria, pruritus, rash
Musculoskeletal and connective tissue disorders:
Not known: myalgia, arthralgia
Renal disorders:
As a consequence of inhibiting the renin-angiotensin-aldosterone system, changes in renal function including renal failure have been reported in patients at risk; these changes in renal function may be reversible upon discontinuation of therapy (see section 4.4).
Investigations:
In controlled clinical trials, clinically important changes in standard laboratory parameters were rarely associated with administration of Losartan Potassium. Elevations of ALT occurred rarely and usually resolved upon discontinuation of therapy. Hyperkalaemia (serum potassium >5.5mmol/l) occurred in 1.5% of patients in hypertension clinical trials. In a study conducted in type 2 diabetic patients with nephropathy, 9.9% of patients treated with Losartan Potassium and 3.4% of patients treated with placebo developed hyperkalaemia >5.5mEq/l (see section 4.4, “Warnings and special precautions for use” - electrolyte imbalances).
In a controlled clinical trial on patients with cardiac insufficiency, increase in blood urea, serum creatinine and serum potassium has been reported.
The adverse experience profile for paediatric patients appears to be similar to that seen in adult patients. Data in the paediatric population are limited.
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 the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard.
4.9 Overdose
Symptoms of intoxication:
There is no experience with overdose in man so far. The most likely symptoms, depending on the extent of overdosage would be hypotension, tachycardia and possibly bradycardia.
Treatment of intoxication:
Measures should depend on the time of drug intake and kind and severity of symptoms. Stabilisation of the circulatory system should be given priority. After oral intake the administration of a sufficient dose of activated charcoal is indicated. Thereafter, close monitoring of the vital parameters should be performed. Vital parameters should be corrected if necessary.
Neither losartan nor the active metabolite can be removed by haemodialysis.
5.1 Pharmacodynamic properties
ATC code: CO9CA01. Pharmacotherapeutic Group: Angiotensin II Receptor Antagonists.
Losartan is a synthetic oral, angiotensin II receptor (type AT1) antagonist. Angiotensin II, a potent vasoconstrictor, is the primary active hormone of the renin-angiotensin system and an important determinant of the pathophysiology of hypertension.
Angiotensin II binds to the ATi receptor found in many tissues (e.g. vascular smooth muscle, adrenal gland, kidneys and the heart) and elicits several important biological actions, including vasoconstriction and the release of aldosterone. Angiotensin II also stimulates smooth-muscle cell proliferation.
Losartan selectively blocks the AT1 receptor. In vitro and in vitro, both losartan and its pharmacologically active carboxylic acid metabolite E-3174 block all physiologically relevant actions of angiotensin II, regardless of the source or route of synthesis.
Losartan does not have an agonist effect nor does it block other hormone receptors or ion channels important in cardiovascular regulation. Furthermore Losartan does not inhibit ACE (kinase II), the enzyme that degrades bradykinin. Consequently, there is no potentiation of undesirable bradykinin-mediated effects.
During losartan administration, removal of angiotensin II negative feedback of renin secretion leads to increased plasma renin activity (PRA). Increase in PRA leads to an increase in angiotensin II in plasma. Even with these increases, antihypertensive activity and suppression of plasma aldosterone concentration are maintained, indicating effective angiotensin II receptor blockade. After discontinuation of Losartan, PRA and angiotensin II values fell within three days to baseline values.
Both Losartan and its principal active metabolite have a far greater affinity for the AT1-receptor than for the AT2-receptor. The active metabolite is 10 to 40 times more active than Losartan on a weight for weight basis.
Hypertension studies:
In controlled clinical studies, once daily administration of Losartan to patients with mild to moderate essential hypertension produced statistically significant reductions in systolic and diastolic blood pressure. Measurement of blood pressure 24 hours post-dose relative to 5-6 hours post-dose demonstrated blood pressure reduction over 24 hours; the natural diurnal rhythm was retained. Blood pressure reduction at the end of the dosing interval was 70-80% of the effect seen 5-6 hours post-dose. Discontinuation of losartan in hypertensive patients did not result in an abrupt rise in blood pressure (rebound).
Despite the significant decrease in blood pressure, administration of Losartan potassium had no clinically significant effect on heart rate.
Losartan is equally effective in males and females, and in younger (below 65 years of age) and older hypertensive patients.
LIFE-study
The Losartan Intervention for Endpoint Reduction In Hypertension [LIFE] study was a randomised triple-blind, active-controlled study in 9193 hypertensive patients aged 55 to 80 years with ECG-documented left ventricular hypertrophy. Patients were randomised to once daily Losartan 50mg or once daily atenolol 50mg. If target blood pressure (<140/90mmHg) was not reached, hydrochlorothiazide 12.5mg was added first and, if needed, the dose of Losartan or atenolol was increased to 100mg once daily. Other antihypertensives (excluding ACE-inhibitors), angiotensin II antagonists or beta-blockers were added if necessary to reach the target blood pressure.
The mean length of follow up was 4.8 years.
The primary end-point was the composite of cardiovascular morbidity and mortality as measured by a reduction in the combined incidence of cardiovascular death, stroke and myocardial infarction. Blood pressure was significantly lowered to similar levels in the two groups.
Treatment with Losartan resulted in a 13.0% risk reduction (p=0.021, 95% confidence interval 0.77-0.98) compared with atenolol for patients reaching the primary composite endpoints. This was mainly attributable to a reduction of the incidence of stroke. Treatment with Losartan reduced the risk of stroke by 25% relative to atenolol (p=0.001, 95% confidence interval 0.63-0.89). The rates of cardiovascular death and myocardial infarction were not significantly different between the treatment groups.
Race:
In the LIFE-study, black patients treated with Losartan had a higher risk of suffering the primary combined endpoint i.e. a cardiovascular event (e.g. cardiac infarction, cardiovascular death) and especially stroke, than the black patients treated with atenolol. Therefore the results observed for losartan in comparison with atenolol, regarding cardiovascular morbidity/mortality, do not apply for black patients with hypertension and left ventricular hypertrophy.
RENAAL-study:
The Reduction of Endpoints in NIDDM with the Angiotensin II Receptor Antagonist Losartan RENAAL study was a controlled study, conducted worldwide, of 1513 Type 2 diabetic patients with proteinuria (with or without hypertension), 751 patients were treated with Losartan. The objective of the study was to demonstrate a nephroprotective effect of losartan potassium over and above the benefit of lowering blood pressure. Patients with proteinuria and a serum creatinine of 1.3 - 3.0mg/dl were randomised to receive Losartan 50mg once daily, titrated if necessary, to achieve blood pressure response, or to placebo, on a background of conventional hypertensive therapy (excluding ACE-inhibitors and angiotensin II antagonists). Investigators were instructed to titrate the study medication to 100mg daily as appropriate (72% of patients received 100mg daily the majority of the time). Other anti-hypertensive agents (diuretics, calcium antagonists, alpha- and beta-receptor blockers and also centrally acting anti-hypertensives) were permitted as supplementary treatment, depending on the requirement in both groups. Patients were followed up for up to 4.6 years (3.4 years on average).
The primary endpoint of the study was a composite endpoint of doubling of the serum creatinine end-stage renal failure (need for dialysis or transplantation) or death.
The results showed that treatment with losartan (327 events) as compared with placebo (359 events) resulted in a 16.1% risk reduction (p=0.022) in the number of patients reaching the primary composite endpoint. For the following individual and combined components of the primary end point, the results showed significant risk reduction in the group treated with losartan: 25.3% risk reduction for doubling of serum creatinine (p=0.006); 28.6% risk reduction for end-stage renal disease (p=0.002); 19.9% risk reduction for end-stage renal failure or death (p=0.009); 21.0% risk reduction for doubling of serum creatinine or end-stage renal failure (p=0.01).
All-cause mortality rate was not significantly different between the two treatment groups. In this study losartan was generally well tolerated, as shown by a therapy discontinuation rate on account of adverse events that was comparable to the placebo group.
ELITE I and ELITE II Study
In the ELITE Study carried out over 48 weeks in 722 patients with heart failure (NYHA Class II-IV), no difference was observed between patients treated with losartan and those treated with captopril with regard to the primary endpoint of a long term change in renal function. The observation of the ELITE I Study, that, compared with captopril, Losartan reduced the mortality risk, was not confirmed in the subsequent ELITE II Study which is described in the following-
In the ELITE II Study, Losartan 50mg once daily (starting dose 12.5mg, increased to 25mg, then 50mg once daily) was compared with captopril 50mg three times daily (starting dose 12.5mg, increased to 25mg, then 50mg three times daily). The primary endpoint of this prospective study was the all-cause mortality.
In this study 3152 patients with heart failure (NYHA Class II -IV) were followed for almost two years (median: 1.5 years) in order to determine whether Losartan is superior to captopril in reducing allcause mortality. The primary endpoint did not show any statistically significant difference between Losartan and captopril in reducing allcause mortality.
In both comparator-controlled (not placebo controlled) clinical studies on patients with heart failure, the tolerability of Losartan was superior to that of captopril, measured on the basis of a significantly lower rate of discontinuations of therapy on account of adverse events and a significantly lower frequency of cough.
An increased mortality was observed in ELITE II in the small subgroup (22% of all HF patients) taking beta-blockers at baseline.
Paediatric Hypertension
The antihypertensive effect of losartan was established in a clinical study involving 177 hypertensive paediatric patients 6 to 16 years of age, with a body weight > 20kg and a glomerular filtration rate > 30ml/min/1.73m2. Patients who weighed >20kg to <50kg received either 2.5, 25 or 50mg of losartan daily and patients who weighed >50kg received either 5, 50 or 100mg of losartan daily. At the end of three weeks, losartan administration once daily lowered trough blood pressure in a dose-dependent manner.
Overall, there was a dose response; the dose-response relationship became very obvious in the low dose group compared to the middle dose group (period I; -6.2mmHg vs. -11.65mmHg), but was attenuated when comparing the middle dose group with the high dose group (period I; -11.65mmHg vs.-12.21mmHg). The lowest doses studied (2.5mg and 5mg), corresponding to an average daily dose of 0.07mg/kg, did not appear to offer consistent antihypertensive efficacy.
These results were confirmed during period II of the study where patients were randomised to continue losartan or placebo after three weeks of treatment. The difference in blood pressure increase as compared to placebo was largest in the middle group (6.70mmHg middle dose vs. 5.38mmHg high dose). The rise in trough diastolic blood pressure was the same in patients receiving placebo and in those continuing losartan at the lowest dose in each group, again suggesting that the lowest dose in each group did not have significant antihypertensive effect.
Long-term effects of losartan on growth, puberty and general development have not been studied. The long-term efficacy of antihypertensive therapy with losartan in childhood to reduce cardiovascular morbidity and mortality has also not been established.
Two large randomised, controlled trials (ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) and VA NEPHRON-D (The Veterans Affairs Nephropathy in Diabetes)) have examined the use of combination of an ACE-inhibitor with an 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 pharmacodynamic 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 < 60 ml/min/1.73 m ).
5.2 Pharmacokinetic properties
Absorption
Following oral administration, losartan is well absorbed and undergoes first-pass metabolism, forming an active carboxylic acid metabolite and other inactive metabolites. The systemic bioavailability of Losartan Potassium tablets is approximately 33%. Mean peak concentrations of losartan and its active metabolite are reached in 1 hour and in 3-4 hours, respectively.
Distribution
Both losartan and its active metabolite are >99% bound to plasma proteins, primarily albumin. The volume of distribution of losartan is 34 litres.
Biotransformation
Around 14% of an intravenously or orally-administered dose of losartan is converted to its active metabolite. Following oral and intravenous administration of 14C-labelled losartan potassium, circulating plasma radioactivity is attributed primarily to losartan and its active metabolite. Minimal conversion of losartan to its active metabolite was seen in about 1% of individuals studied.
In addition to the active metabolite, inactive metabolites are formed. Elimination
Plasma clearance of losartan and its active metabolite is about 600 ml/min and 50 ml/min, respectively. Renal clearance of losartan and its active metabolite is about 74 ml/min and 26 ml/min, respectively. When losartan is administered orally, about 4% of the dose is excreted unchanged in the urine, and about 6% of the dose is excreted in the urine as active metabolite. The pharmacokinetics of losartan and its active metabolite are linear with oral losartan potassium doses of up to 200 mg.
Following oral administration, plasma concentrations of losartan and its active metabolite decline polyexponentially with a terminal half-life of about 2 hours and 6-9 hours, respectively. During once-daily dosing with 100 mg, neither losartan nor its active metabolite accumulates significantly in plasma.
Both biliary and urinary excretion contribute to the elimination of losartan and its metabolites. Following an oral dose/intravenous administration of 14C-labelled losartan in man, about 35%/43% of radioactivity is recovered in the urine and 58%/50% in the faeces.
Characteristics in patients
In elderly hypertensive patients the plasma concentrations of losartan and its active metabolite do not differ essentially from those found in young hypertensive patients.
In female hypertensive patients the plasma levels of losartan were up to twice as high as in male hypertensive patients, while the plasma levels of the active metabolite did not differ between men and women.
In patients with mild to moderate alcohol-induced hepatic cirrhosis, the plasma levels of losartan and its active metabolite after oral administration were, respectively, 5 and 1.7 times higher than those seen in young male volunteers (see section 4.2 and 4.4).
Plasma concentrations of losartan are not altered in patients with creatinine clearance above 10 ml/min. Compared to patients with normal renal function, the AUC for losartan is approximately 2 times higher than in haemodialysis patients. Plasma concentrations of the active metabolite are not altered in patients with renal impairment or in haemodialysis patients. Neither losartan nor the active metabolite can be removed by haemodialysis.
Pharmacokinetics in paediatric patients
The pharmacokinetics of losartan have been investigated in 50 hypertensive paediatric patients >1 month to <16 years of age following once daily oral administration of approximately 0.54 to 0.77 mg/kg Losartan Potassium (mean doses). The results showed that the active metabolite is formed from losartan in all age groups. The results showed roughly similar pharmacokinetic parameters of losartan following oral administration in infants and toddlers, preschool children, school age children and adolescents. The pharmacokinetic parameters for the metabolite differed to a greater extent between the age groups. When comparing pre-school children with adolescents these differences became statistically significant. Exposure in infants/toddlers was comparatively high.
5.3 Preclinical safety data
Preclinical data reveal no special hazard for humans based on conventional studies of general pharmacology, genotoxicity and carcinogenic potential. In repeat dose toxicity studies, the administration of losartan induced a decrease in red blood cell parameters (erythrocytes, haemoglobin, haematocrit), a rise in urea-N in the serum and occasional rises in serum creatinine, a decrease in heart weight (without histological correlate) and gastrointestinal changes (mucous membrane lesions, ulcers, erosions, haemorrhages). Like other substances that directly affect the renin-angiotensin system, losartan has been shown to induce adverse effects on late foetal development, resulting in foetal death and malformations.
6.1 List of excipients
Each Losartan Potassium 12.5 mg Film-Coated Tablet contains the following excipients:
microcrystalline cellulose (E460) sodium stearyl fumarate croscarmellose sodium colloidal anhydrous silica hypromellose (E464) polyoxyethylene stearate titanium dioxide (E171)
6.2 Incompatibilities
Not applicable
6.3 Shelf life
Three years.
6.4 Special precautions for storage
This medicinal product does not require any special storage conditions.
6.5 Nature and contents of container
Losartan Potassium 12.5 mg Tablet is supplied in PVC/PE/PVDC aluminium blisters. Pack of 28 tablets.
6.6 Special precautions for disposal
No special requirements.
Any unused product or waste material should be disposed of in accordance with local requirements.
7 MARKETING AUTHORISATION HOLDER
Chanelle Medical U.K. Limited
Stanford Bridge Farm
Station Road
Pluckley
Ashford
Kent
TN27 0RU
8 MARKETING AUTHORISATION NUMBER(S)
PL 18110/0019
9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION
26/11/2009
10 DATE OF REVISION OF THE TEXT
16/07/2015