Losartan Potassium 25mg Film-Coated Tablets
SUMMARY OF PRODUCT CHARACTERISTICS
1 NAME OF THE MEDICINAL PRODUCT
Losartan potassium 25 mg film-coated tablets
2 QUALITATIVE AND QUANTITATIVE COMPOSITION
Each film-coated tablet contains 25 mg losartan potassium Excipients:
Each Losartan potassium 25 mg film-coated tablet contains 12.5 mg lactose. For a full list of excipients, see section 6.1.
3 PHARMACEUTICAL FORM
Film-coated tablet
Losartan potassium 25 mg film-coated tablets are white to off-white, oval shaped, film-coated tablets, debossed with “J” on one side and “25” on the other side
4
CLINICAL PARTICULARS
4.1 Therapeutic indications
• Treatment of essential hypertension in adults and in children and adolescents 6-18 years of age.
• Treatment of renal disease in adult patients with hypertension and type 2 diabetes mellitus with proteinuria > 0.5 g/day as part of an antihypertensive treatment.
4.2 Posology and method of administration
Hypertension
The usual initial and maintenance dose is 50 mg 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 100 mg losartan once daily (in the morning). Losartan potassium may be administered with other antihypertensive agents, especially with diuretics (e.g. hydrochlorothiazide).
Hypertensive type II diabetic patients with proteinuria > 0.5 g/day
The usual starting dose is 50 mg once daily. The dose may be increased to 100 mg once daily based on blood pressure response from one month onwards after initiation of therapy. Losartan 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).
Special populations
Pediatric hypertension
There are limited data on the efficacy and safety of losartan in children and adolescents aged 6-18 years old 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 can swallow tablets, the recommended dose is 25 mg once daily in patients >20 to <50 kg. In exceptional cases the dose can be increased to a maximum of 50 mg once daily. Dosage should be adjusted according to blood pressure response.
In patients >50 kg, the usual dose is 50 mg once daily. In exceptional cases the dose can be adjusted to a maximum of 100 mg once daily. Doses above 1.4 mg/ kg (or in excess of 100 mg) daily have not been studied in pediatric patients.
Losartan is not recommended for use in children under 6 years old, as limited data are available in these patient groups.
It is not recommended in children with glomerular filtration rate < 30 ml/ min / 1.73 m2, as no data are available (see also section 4.4).
Losartan is also not recommended in children with hepatic impairment (see also section 4.4).
Use in patients with intravascular volume depletion:
For patients with intravascular volume depletion (e.g. those treated with high-dose diuretics), a starting dose of 25 mg once daily is recommended (see section 4.4).
Use in patients with renal impairment and haemodialysis patients:
No initial dosage 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 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 25 mg in patients over 75 years of age, dosage adjustment is not usually necessary for the elderly.
Method of administration
Losartan Potassium should be swallowed with a glass of water.
Losartan Potassium may be administered with or without food.
4.3 Contraindications
Hypersensitivity to the active substance or to any of the excipients (see section
4.4 and 6.1)
Second and third trimesters of pregnancy (see section 4.4 and 4.6).
Severe hepatic impairment.
4.4 Special warnings and precautions for use
Hypersensitivity
Angio-oedema:
Patients with a history of angio-oedema (swelling of the face, lips, throat, and/or tongue) should be closely monitored (see section 4.8).
Hypotension and Electrolyte/Fluid imbalance
Symptomatic hypotension, especially after the first dose and after increasing of the dose, may occur in patients who are volume- and/or sodium-depleted by vigorous diuretic therapy, dietary salt restriction, diarrhoea or vomiting. These conditions should be corrected prior to the administration of Losartan tablets, or a lower starting dose should be used (see section 4.2). 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 as compared to the placebo group (see section 4.8, '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 patients with heart failure and a Creatinine Clearance between 30-50 ml/ min should be closely monitored.
The concomitant use of potassium sparing diuretics, potassium supplements and potassium containing salt substitutes with losartan 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 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 glomerular filtration rate < 30ml/ min/ 1.73 m2 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 shown to impair renal function. Therefore, concomitant use is not recommended.
Renal transplantation
There is no experience in patients with recent kidney transplantation.
Primary hyperaldosteronism
Patients with primary aldosteronism generally will not respond to antihypertensive drugs acting through inhibition of the renin-angiotensin system. Therefore, the use of Losartan tablets is not recommended.
Coronary heart disease and cerebrovascular disease
As with any antihypertensive agents, 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 no sufficient 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 or mitral stenosis, or obstructive hypertrophic cardiomyopathy.
Galactose intolerance, Lapp lactase deficiency, glucose-galactose malabsorption Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
Pregnancy
AIIRA’s should not be initiated during pregnancy. 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 sections 4.3 and 4.6).
Other warnings and precautions
As observed for angiotensin converting enzyme inhibitors, losartan and the other angiotensin antagonists are apparently less effective in lowering blood pressure in black people than in non-blacks, possibly because of higher prevalence of low-renin states in the black hypertensive population.
4.5 Interaction with other medicinal products and other forms of interaction
Other antihypertensive agents may increase the hypotensive effects of losartan. Other substances inducing hypotension like tricyclic antidepressants, antipsychotics, baclofen, amifostine. Concomitant use with these drugs that lower blood pressure, as main or side-effect, may increase the risk of hypotension.
Losartan is predominantly metabolised by cytochroom 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 rifampicine (inducer of metabolism enzymes) gave a 40% reduction in plasma concentration of the active metabolite. The clinical relevance of this effect is unknown. No difference in exposure was found with concomitantly treatment of 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: 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 should be undertaken with caution. If this combination proves essential, serum lithium level monitoring is recommended during concomitant use.
When angiotensin II antagonists are administered simultaneously with NSAIDs (i.e. selective COX-2 inhibitors, acetylsalicylic acid at anti-inflammatory doses and nonselective NSAIDs), attenuation of the antihypertensive 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 preexisting 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.
Dual blockade (e.g., by adding an ACE-inhibitor to an angiotensin II receptor antagonist [AIIRA]) should be limited to individually- defined cases with close monitoring of renal function. Some studies have shown that in patients with established atherosclerotic disease, heart failure, or with diabetes with end organ damage, dual blockade of the renin-angiotensin-aldosterone system is associated with a higher frequency of hypotension, syncope, hyperkalaemia, and changes in renal function (including acute renal failure) as compared with use of a single renin-angiotensin-aldosterone system agent.
4.6 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 trimester of pregnancy (see section 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 is 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 antihypertensive 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.
Exposure to AIIRA 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 5.3 'Preclinical safety data').
Should exposure to AIIRAs have occurred from the second trimester of pregnancy, ultrasound check of renal function and skull is recommended.
Infants whose mothers have taken AIIRAs should be closely observed for hypotension (see also section 4.3 and 4.4).
Lactation
Because no information is available regarding the use of Losartan potassium during breastfeeding, Losartan potassium is not recommended and alternative treatments with better established safety profiles during breast-feeding 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 the dose is increased.
4.8 Undesirable effects
Losartan has been evaluated in clinical studies as follows:
• In a controlled clinical trial in > 3,000 adult patients aged 18 years of age and older for essential hypertension;
• In a controlled clinical trial in 177 hypertensive paediatric patients aged 6 to 16 years; of age
• In a controlled clinical trial in > 9,000 hypertensive patients aged 55 to 80 years of age with left ventricular hypertrophy; 1
In these clinical trials, the most common adverse event was dizziness.
The frequency of adverse reactions listed below is defined using the following convention:
very common (> 1/10); common (> 1/100, to < 1/10); uncommon (> 1/1,000, to < 1/100); rare (> 1/10,000 to < 1/1,000); very rare (< 1/10,000), not known (cannot be estimated from the available data).
Hypertension
|
System Organ Class |
Adverse reaction |
Frequency |
|
Nervous system disorders |
dizziness, vertigo |
common |
|
somnolence, headache, sleep disorders |
uncommon | |
|
Cardiac disorders |
palpitations, angina pectoris |
uncommon |
|
Vascular disorders |
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 |
uncommon |
|
Gastrointestinal disorders |
abdominal pain, constipation |
uncommon |
|
General disorders and administration site conditions |
asthenia, fatigue, oedema |
uncommon |
|
Investigations |
hyperkalaemia |
common |
|
increased alanine aminotransferase (ALT)1 |
rare |
*usually resolved upon discontinuation Hypertensive patients with left ventricular hypertrophy
In a controlled clinical trial in 9,193 hypertensive patients aged 55 to 80 years of age with left ventricular hypertrophy the following adverse events were reported:
|
System Organ Class |
Adverse reaction |
Frequency |
|
Nervous system disorders |
dizziness |
common |
|
Ear and labyrinth disorders |
vertigo |
common |
|
General disorders and administration site conditions |
asthenia/fatigue |
common |
Chronic heart failure
In controlled clinical trials in patients with chronic heart failure (see ELITE I, ELITE II and HEAAL study, section 5.1), the following adverse reactions were reported:
|
System Organ Class |
Adverse reaction |
Frequency |
|
Nervous system disorders |
dizziness |
common |
|
headache |
uncommon | |
|
paraesthesia |
rare | |
|
Cardiac disorders |
syncope, atrial fibrillation, cerebrovascular accident |
rare |
|
Vascular disorders |
hypotension, including orthostatic hypotension |
common |
|
Blood and lymphatic system disorders |
anaemia |
common |
|
Respiratory, thoracic and mediastinal disorders |
dyspnoea, cough |
uncommon |
|
Gastrointestinal disorders |
diarrhoea, nausea, vomiting |
uncommon |
|
Skin and subcutaneous tissue disorders |
urticaria, pruritus, rash |
uncommon |
|
General disorders and administration site conditions |
asthenia/fatigue |
uncommon |
|
Investigations |
increase in blood urea, serum creatinine and serum potassium |
common |
|
Metabolism and nutrition disorders |
hyperkalaemia |
uncommon* |
|
Renal and urinary disorders |
renal impairment, renal failure |
common |
* common in patients who received 150 mg losartan instead of 50 mg losartan
Hypertension and type 2 diabetes with renal disease
In a controlled clinical trial in 1,513 type 2 diabetic patients aged 31 years of age and older with proteinuria (RENAAL study, see section 5.1) the most common drug-related adverse reactions which were reported for losartan are as follows:
|
System Organ Class |
Adverse reaction |
Frequency |
|
Nervous system disorders |
dizziness |
common |
|
Vascular disorders |
hypotension |
common |
|
General disorders and administration site conditions |
asthenia/fatigue |
common |
|
Investigations |
hypoglycaemia, hyperkalaemia* |
common |
* In a clinical study conducted in type 2 diabetic patients with nephropathy, 9.9% of patients treated with losartan tablets developed hyperkalaemia >5.5 mmol/l and 3.4% of patients treated with placebo.
The following adverse reactions occurred more often in patients receiving losartan than placebo:
|
System Organ Class |
Adverse reaction |
Frequency |
|
Blood and lymphatic system disorders |
anaemia |
not known |
|
Cardiac disorders |
syncope, palpitations |
not known |
|
Vascular disorders |
orthostatic hypotension |
not known |
|
Gastrointestinal disorders |
diarrhoea |
not known |
|
Musculoskeletal and connective tissue disorders |
back pain |
not known |
|
Renal and urinary disorders |
urinary tract infections |
not known |
|
General disorders and administration site conditions |
flu-like symptoms |
not known |
Post-marketing experience
The following adverse reactions have been reported in post-marketing experience:
|
System Organ Class |
Adverse reaction |
Frequency |
|
Blood and lymphatic system disorders |
anaemia, thrombocytopenia |
not known |
|
Ear and labyrinth disorders |
tinnitus |
not known |
|
Immune system disorders |
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 |
rare |
|
these patients angioedema had been reported in the past in connection with the administration of other medicines, including ACE inhibitors; vasculitis, including Henoch-Schonlein purpura | ||
|
Nervous system disorders |
migraine |
not known |
|
Respiratory, thoracic and mediastinal disorders |
cough |
not known |
|
Gastrointestinal disorders |
diarrhoea, pancreatitis |
not known |
|
General disorders and administration site conditions |
malaise |
not known |
|
Hepatobiliary disorders |
hepatitis |
rare |
|
liver function abnormalities |
not known | |
|
Skin and subcutaneous tissue disorders |
urticaria, pruritus, rash, photosensitivity |
not known |
|
Musculoskeletal and connective tissue disorders |
myalgia, arthralgia, rhabdomyolysis |
not known |
|
Reproductive system and breast disorders |
erectile dysfunction/impotence |
not known |
|
Psychiatric disorders |
depression |
not known |
|
Investigations |
hyponatraemia |
not known |
Renal and urinary 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).
Paediatric population
The adverse reaction profile for paediatric patients appears to be similar to that seen in adult patients. Data in the paediatric population are limited.
4.9 Overdose
Symptoms of intoxication
No experience with overdose in man is available so far. The most likely symptoms, depending on the extent of overdose, are hypotension and tachycardia. Bradycardia could occur from parasympathetic (vagal) stimulation.
Treatment of intoxication
Measures are depending 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. Afterwards, close monitoring of the vital parameters should be performed. Vital parameters should be corrected if necessary.
Neither losartan nor the active metabolite can by removed by haemodialysis.
5 PHARMACOLOGICAL PROPERTIES
5.1 Pharmacodynamic properties
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 AT1 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 vivo, both losartan and its pharmacologically active carboxylic acid metabolite E-3174 block all physiologically relevant actions of angiotensin II, regardless of its source or route of its 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 (kininase II), the enzyme that degrades bradykinin. Consequently, there is no potentiation of undesirable bradykinin-mediated effects.
During administration of losartan, removal of angiotensin II negative feedback on renin secretion leads to increased plasma-renin activity (PRA). Increase in PRA leads to an increase in angiotensin II in plasma. Despite 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. Measurements 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 marked decrease in blood pressure, losartan had no clinically significant effect on heart rate.
Losartan is equally effective in males and females, and in younger (below the age of 65 years) 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 50 mg or once daily atenolol 50 mg. If goal blood pressure (<140/90 mmHg) was not reached, hydrochlorothiazide (12.5 mg) was added first and, if needed, the dose of losartan or atenolol was then increased to 100 mg once daily. Other antihypertensives, with the exception of ACE inhibitors, angiotensin II antagonists or beta-blockers were added if necessary to reach the goal blood pressure.
The mean length of follow up was 4.8 years.
The primary endpoint 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 endpoint. 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 the 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 with losartan in comparison with atenolol in the LIFE study with regard to 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 clinical study conducted worldwide in 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 the nephroprotective effect of losartan potassium over and above the benefit of a blood lowering pressure.
Patients with proteinuria and a serum creatinine of 1.3-3.0 mg/dl were randomised to receive losartan 50 mg once daily, titrated if necessary, to achieve blood pressure response, or to placebo, on a background of conventional antihypertensive therapy excluding ACE inhibitors and angiotensin II antagonists.
Investigators were instructed to titrate the study medication to 100 mg once daily as appropriate; 72% of patients were taking the 100 mg daily dose for the majority of the time. Other antihypertensives (diuretic agents, calcium antagonists, alpha and beta receptor blockers and also centrally acting antihypertensives) were permitted as supplementary treatment depending on the requirement in both groups. Patients were followed 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 endpoint, the results also showed a 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 failure (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.
HEAAL Study
The Heart Failure Endpoint Evaluation of Angiotensin II Antagonist Losartan (HEAAL) study was a controlled clinical study conducted worldwide in 3,834 patients aged 18 to 98 years with heart failure (NYHA Class II-IV) who were intolerant of ACE inhibitor treatment. Patients were randomised to receive losartan 50 mg once a day or losartan 150 mg, on a background of conventional therapy excluding ACE-inhibitors.
Patients were followed for over four years (median 4.7 years). The primary endpoint of the study was a composite endpoint of all- cause death or hospitalisation for heart failure.
The results showed that treatment with 150 mg losartan (828 events) as compared with 50 mg losartan (889 events) resulted in a 10.1% risk reduction (p=0.027 95% confidence interval 0.82-0.99) in the number of patients reaching the primary composite endpoint. This was mainly attributable to a reduction of the incidence of hospitalisation for heart failure. Treatment with 150 mg losartan reduced the risk of hospitalisation for heart failure by 13.5% relative to 50 mg losartan (p=0.025 95% confidence interval 0.76-0.98). The rate of all- cause death was not significantly different between the treatment groups. Renal impairment, hypotension, and hyperkalaemia were more common in the 150 mg group than in the 50 mg group, but these adverse events did not lead to significantly more treatment discontinuations in the 150 mg 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 between the patients treated with losartan and those treated with captopril was observed with regard to the primary endpoint of a longterm 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 50 mg once daily (starting dose 12.5 mg, increased to 25 mg, then 50 mg once daily) was compared with captopril 50 mg three times daily (starting dose 12.5 mg, increased to 25 mg, then to 50 mg 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 all-cause mortality. The primary endpoint did not show any statistically significant difference between losartan and captopril in reducing all-cause 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.
Pediatric Hypertension
The antihypertensive effect of losartan was established in a clinical study involving 177 hypertensive pediatric patients 6 to 16 years of age with a body weight > 20 kg and a glomerular filration rate > 30 ml/min/1.73 m2. Patients who weighted >20 kg to <50 kg received either 2.5, 25 or 50 mg of losartan daily and patients who weighted > 50 kg received either 5, 50 or 100 mg 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: -6.2 mmHg vs. -11.65 mmHg), but was attenuated when comparing the middle dose group with the high dose group (period I: -11.65 mmHg vs. -12.21 mmHg). The lowest doses studied, 2.5 mg and 5 mg, corresponding to an average daily dose of 0.07 mg/ kg, did not appear to offer consistent antihypertensive efficacy.
These results were confirmed during period II of the study where patients were randomized 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 dose group (6.70 mm Hg middle dose vs. 5.38 mmHg 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.
In hypertensive (N=60) and normotensive (N=246) children with proteinuria, the effect of losartan on proteinuria was evaluated in a 12-week placebo- and active-controlled (amlodipine) clinical study. Proteinuria was defined as urinary protein/creatinine ratio of ^0.3. The hypertensive patients (ageds 6 tothrough 18 years) were randomised to receive either losartan (n=30) or amlodipine (n=30). The normotensive patients (ageds 1 tothrough 18 years) were randomised to receive either losartan (n=122) or placebo (n=124). Losartan was given at doses of 0.7 mg/kg to 1.4 mg/kg (up to maximum dose of 100 mg per day). Amlodipine was given at doses of 0.05 mg/kg to 0.2 mg/kg (up to a maximum dose of 5 mg per day).
Overall, after 12 weeks of treatment, patients receiving losartan experienced a statistically significant reduction from baseline in proteinuria of 36% versus 1% increase in the placebo/amlodipine group (p < 0.001). Hypertensive patients receiving losartan experienced a reduction from baseline proteinuria of -41.5% (95% CI -29.9;-51.1) versus +2.4% (95% CI -22.2;14.1) in the amlodipine group. The decline in both systolic blood pressure and diastolic blood pressure was greater in the losartan group (-5.5/-3.8 mmHg) than inversus the amlodipine group (-0.1/+0.8 mm Hg). In normotensive children a small decrease in blood pressure was observed in the losartan group (-3.7/-3.4 mm Hg) compared with theto placebo group. No significant correlation between the decline in proteinuria and blood pressure was noted;, however, it is possible that the decline in blood pressure was responsible, in part, for the decline in proteinuria in the llosartanosartan- treated group.
Long-term effects of losartan in children with proteinuria were studied for up to 33 years in the open-label safety extension phase of the same study, in which all patients completing the 12-week base study were invited to participate. A total of 268 patients entered the open-label extension phase and were re-randomized to losartan (N=134) or enalapril (N=134) and 109 patients had > 3 years of follow-up (pre-specified termination point of > 100 patients completing 3 years of follow-up in the extension period). The dose ranges of losartan and enalapril, given according to investigator discretion, were 0.30 to 4.42 mg/kg/day and 0.02 to 1.13 mg/kg/day, respectively.
The maximum daily doses of 50 mg for <50 kg body weight and 100 mg for >50 kg were not exceeded for most patients during the extension phase of the study. For normotensive patients (n=205), enalapril had a numerically greater effect compared to losartan on proteinuria (-33.0% (95%CI -47.2;-15.0) vs -16.6% (95%CI -34.9; 6.8)) and on GFR ( 9.4(95%CI 0.4; 18.4) vs -4.0(95%CI -13.1; 5.0) ml/min/1.73m2)). For hypertensive patients (n=49), losartan had a numerically greater effect on proteinuria (-44.5% (95%CI -64.8; -12.4) vs -39.5% (95%CI -62.5; -2.2)) and GFR (18.9(95%CI 5.2; 32.5) vs -13.4(95%CI -27.3; 0.6)) ml/min/1.73m2.
In summary, the results of the safety extension show that losartan was well-tolerated and led to sustained decreases in proteinuria with no appreciable change in glomerular filtration rate (GFR) over 3 years.
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 is approx. 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
About 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 primarily is attributed to losartan and its active metabolite. Minimal conversion of losartan to its active metabolite was seen in about one percent of individuals studied.
In addition to the active metabolite, inactive metabolites are formed. Elimination
Plasma clearance of losartan and its active metabolite is approximately 600 ml/minute and 50 ml/minute, respectively. Renal clearance of losartan and its active metabolite is approximately 74 ml/minute and 26 ml/minute, respectively. When losartan is administered orally, approximately 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 doses up to 200 mg.
Following oral administration, plasma concentrations of losartan potassium and its active metabolite decline polyexponentially with a terminal half-life of approximately 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 potassium and its metabolites. Following an oral dose of 14C-labelled losartan potassium in man, approximately 35% of radioactivity is recovered in the urine and 58% in the faeces.
Following intravenous administration of 14C-labelled losartan potassium, approximately 43% of the radioactivity is recovered in the urine and 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 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/minute. Compared to patients with normal renal function, the AUC for losartan is about two times higher 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 of losartan (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 preschool 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 repeated dose toxicity studies, the administration of losartan induced a decrease in the 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 a 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 the late foetal development, resulting in foetal death and malformations.
6 PHARMACEUTICAL PARTICULARS
6.1 List of excipients
Core tablet:
Lactose monohydrate
Microcrystalline cellulose (E460) Pregelatinised starch Magnesium stearate (E572)
Film-coating:
Hypromellose (E464) Hydroxypropylcellulose (E463) Titanium dioxide (E171)
6.2 Incompatibilities
Not applicable
6.3 Shelf life
2 years.
6.4 Special precautions for storage
No special storage conditions.
6.5 Nature and contents of container
Blisters (Al/PVC/PVDC)
Pack sizes:
10, 28, 30, 50, 56, 90, 98 and 100 tablets Not all pack sizes may be marketed.
6.6 Special precautions for disposal
No special requirements.
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Waymade Healthcare Plc trading as Sovereign Medical
Sovereign House
Miles Gray Road, Basildon
Essex SS14 3FR
United Kingdom
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03/04/2014
In a controlled clinical trial in > 1,500 type 2 diabetic patients aged 31 years of age and older with proteinuria;