Pharmacological properties of the drug Atacand
Angiotensin II is the primary vasoactive hormone of the renin-angiotensin-aldosterone system and is involved in the pathophysiology of hypertension (arterial hypertension), heart failure and other cardiovascular disorders. The major physiological effects of angiotensin II, such as vasoconstriction, stimulation of aldosterone secretion, regulation of salt and water homeostasis, and stimulation of cell growth, are mediated through the type 1 (AT1) receptor. Candesartan cilexetil is a prodrug suitable for oral administration. Candesartan is rapidly converted into the active substance by ester hydrolysis during absorption in the gastrointestinal tract. Candesartan is an angiotensin II receptor antagonist, selective for AT1 receptors, with strong binding to the receptor and slow dissociation from it. Candesartan does not inhibit ACE, which converts angiotensin I to angiotensin II and destroys bradykinin. There is no effect on ACE and potentiation of bradykinin or substance P. In controlled clinical trials in which candesartan was compared with ACE inhibitors, the incidence of cough was lower in patients receiving candesartan cilexetil. Candesartan does not bind to or block other hormone receptors or ion channels that play an important role in cardiovascular regulation. Antagonism of angiotensin II receptors (AT1) leads to a dose-dependent increase in the levels of plasma renin, angiotensin I and II, as well as a decrease in the concentration of aldosterone in the blood plasma. Arterial hypertension (AH) In hypertension (arterial hypertension), candesartan leads to a dose-dependent long-term decrease in blood pressure. Antihypertensive activity is due to a decrease in systemic peripheral resistance, which is not accompanied by a reflex increase in heart rate. There is nothing to indicate severe or increased hypotension after the first dose or a reactive effect after discontinuation of treatment. After taking a single dose of candesartan cilexetil, the onset of the antihypertensive effect occurs within 2 hours. With continuous therapy, the maximum reduction in blood pressure with any dose is achieved within 4 weeks and is maintained during long-term treatment. According to the meta-analysis, the average additional effect of increasing the dose from 16 to 32 mg once daily was insignificant. Given interindividual variability, greater than average effects may occur in some patients. When using candesartan cilexetil once a day, an effective and uniform reduction in blood pressure is ensured over 24 hours with a slight difference between the effects of the maximum and minimum doses. Candesartan increases renal blood flow and/or does not affect the glomerular filtration rate, or increases it, while vascular resistance and filtration fraction are reduced. In patients with hypertension (arterial hypertension) and type II diabetes mellitus, therapy with candesartan cilexetil 8–16 mg for 12 weeks did not cause side effects regarding blood glucose levels or lipid profile. Heart failure Treatment with candesartan cilexetil reduces mortality and hospitalization due to heart failure and improves symptoms in patients with impaired left ventricular systolic function. The beneficial effect of candesartan on reducing cardiovascular mortality or the incidence of first hospitalization due to chronic heart failure (CHF) was consistent regardless of age, sex and concomitant treatment. Candesartan was also effective in patients taking both beta-blockers and ACE inhibitors concomitantly, and the positive effect was achieved regardless of whether the patient was taking ACE inhibitors at the recommended dose. In patients with CHF and impaired left ventricular systolic function (left ventricular ejection fraction ≤40%), candesartan reduces systemic vascular resistance and pulmonary capillary pressure, increases renin activity and the concentration of angiotensin II in the blood plasma, and also reduces aldosterone levels. Absorption and distribution After oral administration, candesartan cilexetil is converted to the active substance candesartan. Absolute bioavailability - 40%. The average maximum concentration in the blood serum (Cmax) is reached 3–4 hours after taking the drug, increasing linearly with increasing doses within the therapeutic dose. No gender-related differences in pharmacokinetics were noted. Food intake does not have a significant effect on candesartan AUC. Candesartan is highly (99%) bound to plasma proteins. The apparent volume of distribution is 0.1 l/kg body weight. Metabolism and excretion Excreted unchanged in urine and bile and only in small amounts by hepatic metabolism. The terminal half-life is approximately 9 hours. No accumulation was noted after repeated doses. Total plasma clearance is approximately 0.37 ml/min/kg, and renal clearance is approximately 0.19 ml/min/kg. Candesartan is excreted by the kidneys both by glomerular filtration and active tubular secretion. Following an oral dose of 14C-labeled candesartan cilexetil, approximately 26% of the dose is excreted in the urine as candesartan and 7% as an inactive metabolite, although approximately 56% of the dose is excreted in the feces as candesartan and 10% as an inactive metabolite. In elderly patients (65 years), the Cmax and AUC of candesartan are increased by approximately 50 and 80%, respectively, compared to young patients. However, the blood pressure response and the incidence of side effects are the same after taking the drug at the prescribed dose in young and elderly patients. In patients with mild to moderate renal impairment, compared with patients with normal renal function, the Cmax and AUC of candesartan increased during multiple doses by approximately 50% and 70%, respectively, but the elimination half-life remained unchanged. The corresponding changes in patients with severe renal impairment were approximately 50 and 110%, respectively. The terminal half-life of candesartan was approximately doubled in patients with severe renal impairment. The AUC in hemodialysis patients was similar to that in patients with severe renal impairment. In patients with mild to moderate hepatic impairment, an increase in AUC of 23% was detected.
Atacand®
Angiotensin II is the main hormone of the renin-angiotensin-aldosterone system, which plays an important role in the pathogenesis of arterial hypertension, heart failure and other cardiovascular diseases.
The main physiological effects of angiotensin II are vasoconstriction, stimulation of aldosterone production, regulation of water-electrolyte homeostasis and stimulation of cell growth. All these effects are mediated by the interaction of angiotensin II with angiotensin type 1 receptors (AT1 receptors).
Candesartan is a selective antagonist of angiotensin II type 1 receptors (AT1 receptors). Candesartan does not inhibit angiotensin-converting enzyme (ACE), which converts angiotensin I to angiotensin II and destroys bradykinin; does not affect ACE and does not lead to the accumulation of bradykinin or substance P. When comparing candesartan with ACE inhibitors, the development of cough was less common in patients receiving candesartan cilexetil. Candesartan does not bind to the receptors of other hormones and does not block ion channels involved in the regulation of the functions of the cardiovascular system. As a result of blocking the AT1 receptors of angiotensin II, there is a dose-dependent increase in renin activity, the concentration of angiotensin I, angiotensin II and a decrease in the concentration of aldosterone in the blood plasma.
Arterial hypertension
In arterial hypertension, candesartan causes a dose-dependent, long-term decrease in blood pressure (BP). The antihypertensive effect of the drug is due to a decrease in total peripheral vascular resistance, without changing heart rate (HR). There were no cases of severe arterial hypotension after taking the first dose of the drug, as well as o) syndrome after cessation of therapy.
The onset of the hypotensive effect after taking the first dose of candesartan cilexetil usually develops within 2 hours. With continued therapy with the drug at a fixed dose, the maximum reduction in blood pressure is usually achieved within 4 weeks and is maintained throughout treatment. Candesartan cilexetil, prescribed once a day, provides an effective and smooth reduction in blood pressure over 24 hours with minor fluctuations in blood pressure in the intervals between doses of the drug. The use of candesartan cilexetil in combination with hydrochlorothiazide leads to an increased hypotensive effect. The combined use of candesartan cilexetil and hydrochlorothiazide (or amlodipine) is well tolerated.
The effectiveness of the drug does not depend on the age and gender of patients.
Candesartan cilexetil increases renal blood flow and does not change or increases glomerular filtration rate, while renal vascular resistance and filtration fraction are reduced. Taking candesartan cilexetil at a dose of 8-16 mg for 12 weeks does not have a negative effect on glucose concentrations and lipid profiles in patients with arterial hypertension and type 2 diabetes mellitus.
The clinical effects of candesartan cilexetil on cardiovascular morbidity and mortality when administered at a dose of 8-16 mg (mean dose 12 mg) once daily were investigated in a randomized clinical trial involving 4937 elderly patients (age range 70 to 89 years, 21 % of patients aged 80 years and older) with mild to moderate hypertension treated with candesartan cilexetil for an average of 3.7 years (SCOPE Study - Study of Cognitive Function and Prognosis in Elderly Patients). Patients received candesartan cilexetil or placebo, if necessary in combination with other antihypertensive agents. Both treatment regimens showed an effective reduction in systolic and diastolic blood pressure (from 166/90 to 145/80 mmHg in the group of patients receiving candesartan, and from 167/90 to 149/82 mmHg in the control group) by background of good tolerability. Cognitive function and quality of life remained at a good level in both groups of patients. There were no statistically significant differences in the incidence of cardiovascular events among the two groups of patients for the primary endpoint of cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. However, in the group of patients receiving candesartan, the risk of nonfatal stroke was 28% lower than in the control group (relative risk = 0.72, 95% confidence interval 0.53-0.99, p = 0.04).
Heart failure
According to the results of the CHARM (Candesartan in Heart Failure - Mortality and Morbidity Reduction Assessment) clinical trial program involving 7599 patients, the use of candesartan cilexetil (average dose was 24 mg/day) led to a reduction in the incidence of deaths and hospitalization for chronic heart failure, as well as improving left ventricular systolic function. The median follow-up duration was 37.7 months.
In the CHARM-Altemative study (n=2028), in patients with reduced left ventricular ejection fraction (LVEF) ≤ 40% who did not receive ACE inhibitors due to poor tolerability (mainly due to cough - 72%), a combined criterion that included Death from cardiovascular disease or first hospitalization for chronic heart failure was significantly lower in the group of patients receiving candesartan. compared with the placebo group (hazard ratio = 0.77, 95% confidence interval 0.67-0.89, p < 0.001). The relative risk reduction was 23%. At the same time, a positive effect of candesartan on each of the components of this combined criterion was noted. The use of candesartan cilexetil led to an improvement in the functional class of chronic heart failure according to the NYHA classification (p = 0.008).
In the CHARM-Added study (n=2548), in patients with reduced LVEF ≤ 40% receiving ACE inhibitors, the composite endpoint of cardiovascular death or first hospitalization for chronic heart failure was significantly lower in the group receiving candesartan compared with placebo (hazard ratio = 0.85, 95% confidence interval 0.75-0.96, p = 0.011), which corresponded to a 15% reduction in relative risk. The use of candesartan cilexetil led to an improvement in the functional class of chronic heart failure according to the NYHA classification (p = 0.020).
In the CHARM-Preserved study (n = 3023), in patients with LVEF > 40%, there were no statistically significant differences in the value of the combined effectiveness criterion, which included the frequency of deaths from cardiovascular diseases or the frequency of first hospitalization for chronic heart failure, between groups candesartan and placebo (hazard ratio = 0.89, 95% confidence interval 0.77-1.03, p = 0.118). At the same time, a positive effect of candesartan on one of the components of this combined criterion was noted - a decrease in the frequency of hospitalizations for chronic heart failure.
In a pooled analysis of all 3 CHARM studies, there was no significant difference in the incidence of deaths from all causes in the candesartan and placebo groups (hazard ratio = 0.91, 95% confidence interval 0.83-1.00, p = 0.055) .
The reduction in the incidence of death or hospitalization for chronic heart failure during therapy with candsartan did not depend on age, gender and concomitant therapy. Candesartan was also effective in patients taking beta-blockers in combination with ACE inhibitors, and the effectiveness of candesartan was independent of whether the patient was taking the optimal dose of the ACE inhibitor or not.
In patients with chronic heart failure and LVEF ≤ 40%, taking candesartan reduced total peripheral vascular resistance and capillary pressure in the lungs, increased renin activity and plasma angiotensin II concentrations, and decreased aldosterone levels.
Use of the drug Atacand
Arterial hypertension (AH) The recommended initial and usual maintenance dose is 8 mg 1 time per day. The dose can be increased to 16 mg 1 time per day. If sufficient blood pressure control is not achieved after 4 weeks of treatment with a dose of 16 mg once daily, it can be increased to a maximum dose of 32 mg once daily. If blood pressure control is not achieved using the drug at this dose, alternative treatment methods should be considered. Therapy must be adjusted based on blood pressure. The maximum antihypertensive effect is achieved within 4 weeks from the start of treatment. Elderly persons The initial dose does not require adjustment. Patients with reduced blood volume For patients at risk of developing arterial hypotension, for example for patients with a possible decrease in blood volume, an initial dose of 4 mg should be considered. Renal failure In patients with renal failure, including those on hemodialysis, the initial dose is 4 mg. The dose must be adjusted taking into account blood pressure. Experience in patients with severe renal failure or end-stage renal failure (creatinine clearance ≤15 ml/min) is limited. Liver failure For patients with mild to moderate liver failure, an initial dose of 2 mg once daily is recommended. The dose can be adjusted based on blood pressure. There is no experience with use in patients with severe liver failure. Concomitant therapy It has been established that the additional use of hydrochlorothiazide in combination with Atacand causes an additive antihypertensive effect. Patients of the Negroid race The antihypertensive effect of candesartan is less pronounced than in patients of the Caucasian race. Upward titration of Atacand and concomitant therapy to control blood pressure are more often necessary in black patients than in Caucasians. Heart failure The recommended starting dose of Atacand is 4 mg once daily. Titration upward to the target dose of 32 mg once daily or the maximum tolerated dose is carried out by doubling the dose over a period of at least 2 weeks. Special categories of patients For elderly patients or with a decrease in blood volume, mild to moderate renal or hepatic insufficiency, no adjustment of the initial dose is required. Concomitant therapy Atacand can be prescribed in combination with other drugs for the treatment of heart failure, including ACE inhibitors, beta-blockers, diuretics and digitalis drugs, or a combination of these drugs. Application. Atacand is taken once a day with or without food. Children and adolescents The safety and effectiveness of Atacanda in children and adolescents (under 18 years of age) have not been established.
Atacand, 8 mg, tablets, 28 pcs.
Angiotensin II is the main hormone of the RAAS, which plays an important role in the pathogenesis of arterial hypertension, heart failure and other cardiovascular diseases. The main physiological effects of angiotensin II are vasoconstriction, stimulation of aldosterone production, regulation of water-electrolyte homeostasis and stimulation of cell growth. All these effects are mediated by the interaction of angiotensin II with angiotensin type 1 receptors (AT1 receptors).
Candesartan is a selective angiotensin II type 1 receptor antagonist. Candesartan does not inhibit ACE, which converts angiotensin I to angiotensin II and destroys bradykinin; does not affect ACE and does not lead to the accumulation of bradykinin or substance P. When comparing candesartan with ACE inhibitors, the development of cough was less common in patients receiving candesartan cilexetil. Candesartan does not bind to the receptors of other hormones and does not block ion channels involved in the regulation of cardiovascular functions. As a result of blocking the AT1 receptors of angiotensin II, there is a dose-dependent increase in the levels of renin, angiotensin I, angiotensin II and a decrease in the concentration of aldosterone in the blood plasma.
Arterial hypertension
In arterial hypertension, candesartan causes a dose-dependent long-term decrease in blood pressure. The antihypertensive effect of the drug is due to a decrease in peripheral vascular resistance, without changing heart rate. There were no cases of severe arterial hypotension after taking the first dose of the drug, as well as o) syndrome after cessation of therapy.
The onset of the hypotensive effect after taking the first dose of candesartan cilexetil usually develops within 2 hours. With continued therapy with the drug at a fixed dose, the maximum reduction in blood pressure is usually achieved within 4 weeks and is maintained throughout treatment. Candesartan cilexetil, prescribed once a day, provides an effective and smooth decrease in blood pressure over 24 hours with minor fluctuations in blood pressure in the intervals between doses of the drug. The use of candesartan cilexetil in combination with hydrochlorothiazide leads to an increased hypotensive effect. The combined use of candesartan cilexetil and hydrochlorothiazide (or amlodipine) is well tolerated.
The effectiveness of the drug does not depend on the age and gender of patients.
Candesartan cilexetil increases renal blood flow and does not change or increases glomerular filtration rate, while renal vascular resistance and filtration fraction are reduced. Taking candesartan cilexetil at a dose of 8–16 mg for 12 weeks does not have a negative effect on glucose levels and lipid profiles in patients with arterial hypertension and type 2 diabetes mellitus.
The clinical effects of candesartan cilexetil on morbidity and mortality when administered at a dose of 8–16 mg (mean dose 12 mg) once daily were studied in a randomized clinical trial involving 4937 elderly patients (age 70 to 89 years, 21% of patients in aged 80 years and older) with mild to moderate hypertension treated with candesartan cilexetil for an average of 3.7 years ( COPE
- study of cognitive functions and prognosis in elderly patients). Patients received candesartan or placebo, if necessary, in combination with other antihypertensive agents. In the group of patients receiving candesartan, there was a decrease in blood pressure from 166/90 to 145/80 mm Hg. Art. and in the control group - from 167/90 to 149/82 mm Hg. Art. There were no statistically significant differences in the incidence of cardiovascular complications (cardiovascular mortality, myocardial infarction and non-fatal stroke) between the two groups of patients.
In the candesartan group, there were 26.7 incident cardiovascular events per 1000 patient-years compared with 30 per 1000 patient-years in the control group (hazard ratio = 0.89; 95% confidence interval 0. 75–1.06; p=0.19).
Chronic heart failure
According to the results of the CHARM
(Candesartan in Chronic Heart Failure—Evaluation of Mortality and Morbidity Reductions) use of candesartan cilexetil resulted in a reduction in the incidence of death and the need for hospitalization for chronic heart failure and an improvement in left ventricular systolic function.
Patients with chronic heart failure, in addition to the main therapy, received candesartan cilexetil at a dose of 4–8 mg/day with a dose increase to 32 mg/day or to the maximum tolerated therapeutic dose (the average dose of candesartan was 24 mg). The median follow-up duration was 37.7 months. After 6 months of therapy, 63% of patients who continued to take candesartan cilexetil (89%) received a therapeutic dose of 32 mg.
In another study, CHARM-Alternative
(n=2028) included patients with reduced (≤40%) left ventricular ejection fraction (LVEF) who did not receive an ACE inhibitor due to intolerance (mainly due to cough - 72%);
The rates of cardiovascular death and first hospitalization for chronic heart failure were significantly lower in the candesartan group compared with the placebo group (hazard ratio = 0.77; 95% confidence interval 0.67–0.89 ; p<0.001). The relative risk reduction was 23%. In this study, to prevent one cardiovascular death or hospitalization for chronic heart failure, it was necessary to treat 14 patients throughout the study period. The combined criterion, which included the incidence of deaths regardless of their cause and the rate of first hospitalization for chronic heart failure, was also significantly lower in the group of patients receiving candesartan (hazard ratio = 0.80; 95% confidence interval 0.7– 0.92; p=0.001). At the same time, a positive effect of candesartan was noted on each of the components of this combined criterion - the frequency of deaths and morbidity (an indicator of the frequency of hospitalizations for chronic heart failure). The use of candesartan cilexetil led to an improvement in the functional class of chronic heart failure according to the NYHA
(p = 0.008).
In the CHARM-Added
(n=2548) in patients with reduced LVEF ≤40% receiving ACE inhibitors, the composite criterion of cardiovascular mortality and first hospitalization for chronic heart failure was significantly lower in the group of patients receiving candesartan, according to compared with the placebo group (risk ratio = 0.85; 95% confidence interval 0.75–0.96; p = 0.011), which corresponded to a 15% reduction in relative risk.
In this study, to prevent one cardiovascular death or hospitalization for chronic heart failure, it was necessary to treat 23 patients throughout the study period. The value of the combined effectiveness criterion, which included an assessment of the incidence of deaths regardless of their cause or the frequency of the first hospitalization for chronic heart failure, was significantly lower in the group of patients receiving candesartan (hazard ratio = 0.87; 95% confidence interval 0. 78–0.98; p=0.021), which also indicated a positive effect when using candesartan. The use of candesartan cilexetil led to an improvement in the functional class of chronic heart failure according to the NYHA
(p = 0.02).
In the CHARM-Preserve
(n=3023) in patients with preserved systolic function (LVEF >40%), there were no statistically significant differences in the value of the combined effectiveness criterion, which included the incidence of deaths and the incidence of first hospitalization for chronic heart failure, in the candesartan and placebo groups (risk ratio =0.89; 95% confidence interval 0.77–1.03; p=0.118). The small numerical decrease in this criterion was due to a decrease in the frequency of hospitalizations for chronic heart failure. This study did not show the effect of candesartan on the incidence of deaths.
When separately analyzing the results of 3 studies of the CHARM
There were no significant differences in the incidence of deaths in the candesartan and placebo groups.
However, the incidence of death was estimated in the combined population of the CHARM-Alternative
and
CHARM-Added
and in all 3 studies (hazard ratio = 0.91; 95% confidence interval 0.83–1.0; p = 0.055). The reduction in the incidence of death and hospitalization for chronic heart failure during therapy with candesartan was independent of age, gender and concomitant therapy. Candesartan was also effective in patients taking beta-blockers in combination with ACE inhibitors, and the effectiveness of candesartan was independent of whether the patient was taking the optimal dose of the ACE inhibitor or not.
In patients with chronic heart failure and reduced left ventricular systolic function (LVEF ≤40%), taking candesartan contributed to a decrease in peripheral vascular resistance and capillary pressure in the lungs, an increase in renin activity and the concentration of angiotensin II in the blood plasma, as well as a decrease in aldosterone levels.
Side effects of the drug Atacand
For the treatment of arterial hypertension (HTN) During controlled clinical trials, side effects were mild, temporary and comparable to placebo. The overall incidence of side effects did not appear to be dose or age related. The rate of treatment discontinuation due to adverse reactions was similar for candesartan cilexetil (3.1%) and placebo (3.2%). The following common (1/100) adverse reactions were reported (the incidence of side effects that was at least 1% higher than the incidence of such effects when using placebo): from the nervous system: dizziness, headache. infections and infestations: respiratory tract infections. Results of laboratory studies No clinically significant effect of Atacand on laboratory parameters was noted. When using other inhibitors of the renin-angiotensin-aldosterone system, a slight decrease in hemoglobin was detected. Creatinine, urea, or potassium levels increased and sodium levels decreased. Increases in ALT, considered an adverse event, were not significantly more frequently reported with Atacand than with placebo (1.3 vs. 0.5%). For patients receiving Atacand, continuous monitoring of laboratory parameters is not necessary. However, periodic monitoring of serum potassium and creatinine levels is recommended in patients with renal impairment. For heart failure: the side effect profile of Atacanda in patients with heart failure is consistent with the pharmacological properties of this drug and the health status of the patients. Common adverse reactions (≥1/100, ≤1/10) identified during clinical trials included: From the cardiovascular system: arterial hypotension. Metabolic and nutritional disorders: hyperkalemia. From the urinary system: renal failure. Laboratory test indicators: increased levels of creatinine, urea and potassium. Periodic monitoring of serum creatinine and potassium levels is recommended. Post-marketing study: the following side effects were reported very rarely (≤1/10,000): from the blood system: leukopenia, neutropenia and agranulocytosis; metabolic and nutritional disorders: hyperkalemia, hyponatremia; from the nervous system: dizziness, headache; from the gastrointestinal tract: nausea; from the hepatobiliary system: increased levels of liver enzymes, abnormal liver function or hepatitis; from the skin and subcutaneous tissue: angioedema, rash, urticaria, itching; from the musculoskeletal system, connective tissue: back pain, arthralgia, myalgia; from the urinary system: impaired renal function, including renal failure in predisposed patients.
Special instructions for the use of the drug Atacand
Renal impairment As with other drugs that inhibit the renin-angiotensin-aldosterone system, changes in renal function can be expected in predisposed patients taking Atacand. When using Atacand in patients with hypertension (arterial hypertension) and renal failure, periodic monitoring of potassium and creatinine levels in the blood serum is recommended. Experience in patients with severe renal failure or end-stage renal failure (creatinine clearance ≤15 ml/min) is limited. In these patients, Atacand should be titrated in combination with blood pressure monitoring. Evaluation of patients with heart failure should include periodic assessment of renal function, especially in elderly patients over 75 years of age and in patients with renal insufficiency. Monitoring serum creatinine and potassium levels is recommended during Atacand dose titration. Clinical studies in patients with heart failure did not include subjects with a serum creatinine level of 265 mmol/L (3 mg/dL). Concomitant therapy with an ACE inhibitor in heart failure The risk of side effects, especially in renal failure and hyperkalemia, may be increased when candesartan is used in combination with an ACE inhibitor. These patients require regular and careful monitoring. Hemodialysis During dialysis, blood pressure may be particularly sensitive to AT1 receptor blockade due to a decrease in blood plasma volume and activation of the renin-angiotensin-aldosterone system. For patients on hemodialysis, Atacand should be carefully titrated and blood pressure monitored closely. Renal artery stenosis Other drugs that affect the renin-angiotensin-aldosterone system, such as ACE inhibitors, may increase blood urea and serum creatinine levels in patients with bilateral renal artery stenosis or stenosis of the artery leading to one kidney. A similar effect can be expected with the use of angiotensin II receptor antagonists. Kidney transplantation There is no experience with the use of Atacand in patients who have recently undergone kidney transplantation. Hypotension Hypotension may occur during use of Atacand in patients with heart failure. As described for other drugs that affect the renin-angiotensin-aldosterone system, hypotension can also occur in patients with hypertension (arterial hypertension) and reduced blood volume, such as those taking high doses of diuretics. When initiating therapy, caution should be exercised and attempts should be made to correct hypovolemia. Anesthesia and surgery In patients treated with angiotensin II receptor antagonists, hypotension may develop during anesthesia and surgery due to blockade of the renin-angiotensin-aldosterone system. In very rare cases, hypotension may be so severe that the use of IV fluids and/or vasopressors is required. Aortic and mitral valve stenosis (obstructive hypertrophic cardiomyopathy) As with other vasodilators, special caution should be used when treating patients with hemodynamically significant aortic or mitral valve stenosis, or obstructive hypertrophic cardiomyopathy. Primary hyperaldosteronism Patients with primary hyperaldosteronism usually do not respond to antihypertensive drugs that act by inhibiting the renin-angiotensin-aldosterone system. Therefore, the use of Atacand is not recommended. Hyperkalemia Experience with other drugs that affect the renin-angiotensin-aldosterone system suggests that concomitant use of Atacand with potassium-sparing diuretics, potassium supplements, potassium-containing salt substitutes, or other drugs that may increase potassium levels (eg, heparin) , may lead to increased serum potassium levels in patients with hypertension (arterial hypertension). Hyperkalemia may occur in patients with heart failure taking Atacand. During treatment with Atacand in patients with heart failure, it is recommended to periodically monitor serum potassium levels, especially if this drug is taken concomitantly with ACE inhibitors and potassium-sparing diuretics, such as spironolactone. General information: In patients whose vascular tone and renal function depend primarily on the activity of the renin-angiotensin-aldosterone system (for example, patients with severe congestive heart failure or kidney disease, including renal artery stenosis), treatment with other drugs that affect this system. has been associated with acute hypotension, azotemia, oliguria, or in rare cases, acute renal failure. The possibility of similar effects cannot be excluded when using angiotensin II receptor antagonists. As with any antihypertensive drug, excessive reduction of blood pressure in patients with ischemic cardiopathy or ischemic cerebrovascular disease can lead to myocardial infarction or stroke. Atacand should not be taken by patients with rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption. Pregnancy and lactation There is limited data regarding the use of Atacand during pregnancy, which is not sufficient to draw conclusions about the potential risk to the fetus when using the drug in the first trimester. Fetal renal perfusion, which develops in the second trimester, depends on the development of the renin-angiotensin-aldosterone system. The risk to the fetus increases if Atacand is taken during the second or third trimester of pregnancy. The use of drugs acting directly on the renin-angiotensin-aldosterone system during this period can cause harm to the fetus and newborn (hypotension, renal dysfunction, oliguria and/or anuria, oligohydramnios, cranial hypoplasia, intrauterine growth retardation) and lead to death. Cases of pulmonary hypoplasia, facial anomalies and contractures of the limbs have been described. An animal study using candesartan cilexetil showed renal damage in late pregnancy fetuses and newborns. This mechanism is considered to be pharmacologically mediated due to its effect on the renin-angiotensin-aldosterone system. Taking into account the above information, Atacand is not recommended for use during pregnancy. If pregnancy is detected during treatment, Atacand should be discontinued. It has not been established whether candesartan passes into breast milk, but due to potential adverse effects in breast-fed infants, Atacand should not be used during breastfeeding. The drug is unlikely to affect the ability to drive vehicles and operate machinery. When driving or operating machinery, dizziness and fatigue that may occur during treatment should be taken into account.
Atacand, 28 pcs., 16 mg, tablets
Angiotensin II is the main hormone of the RAAS, which plays an important role in the pathogenesis of arterial hypertension, heart failure and other cardiovascular diseases. The main physiological effects of angiotensin II are vasoconstriction, stimulation of aldosterone production, regulation of water-electrolyte homeostasis and stimulation of cell growth. All these effects are mediated by the interaction of angiotensin II with angiotensin type 1 receptors (AT1 receptors).
Candesartan is a selective angiotensin II type 1 receptor antagonist. Candesartan does not inhibit ACE, which converts angiotensin I to angiotensin II and destroys bradykinin; does not affect ACE and does not lead to the accumulation of bradykinin or substance P. When comparing candesartan with ACE inhibitors, the development of cough was less common in patients receiving candesartan cilexetil. Candesartan does not bind to the receptors of other hormones and does not block ion channels involved in the regulation of cardiovascular functions. As a result of blocking the AT1 receptors of angiotensin II, there is a dose-dependent increase in the levels of renin, angiotensin I, angiotensin II and a decrease in the concentration of aldosterone in the blood plasma.
Arterial hypertension
In arterial hypertension, candesartan causes a dose-dependent long-term decrease in blood pressure. The antihypertensive effect of the drug is due to a decrease in peripheral vascular resistance, without changing heart rate. There were no cases of severe arterial hypotension after taking the first dose of the drug, as well as o) syndrome after cessation of therapy.
The onset of the hypotensive effect after taking the first dose of candesartan cilexetil usually develops within 2 hours. With continued therapy with the drug at a fixed dose, the maximum reduction in blood pressure is usually achieved within 4 weeks and is maintained throughout treatment. Candesartan cilexetil, prescribed once a day, provides an effective and smooth decrease in blood pressure over 24 hours with minor fluctuations in blood pressure in the intervals between doses of the drug. The use of candesartan cilexetil in combination with hydrochlorothiazide leads to an increased hypotensive effect. The combined use of candesartan cilexetil and hydrochlorothiazide (or amlodipine) is well tolerated.
The effectiveness of the drug does not depend on the age and gender of patients.
Candesartan cilexetil increases renal blood flow and does not change or increases glomerular filtration rate, while renal vascular resistance and filtration fraction are reduced. Taking candesartan cilexetil at a dose of 8–16 mg for 12 weeks does not have a negative effect on glucose levels and lipid profiles in patients with arterial hypertension and type 2 diabetes mellitus.
The clinical effects of candesartan cilexetil on morbidity and mortality when administered at a dose of 8–16 mg (mean dose 12 mg) once daily were studied in a randomized clinical trial involving 4937 elderly patients (age 70 to 89 years, 21% of patients in aged 80 years and older) with mild to moderate hypertension treated with candesartan cilexetil for an average of 3.7 years ( COPE
- study of cognitive functions and prognosis in elderly patients). Patients received candesartan or placebo, if necessary, in combination with other antihypertensive agents. In the group of patients receiving candesartan, there was a decrease in blood pressure from 166/90 to 145/80 mm Hg. Art. and in the control group - from 167/90 to 149/82 mm Hg. Art. There were no statistically significant differences in the incidence of cardiovascular complications (cardiovascular mortality, myocardial infarction and non-fatal stroke) between the two groups of patients.
In the candesartan group, there were 26.7 incident cardiovascular events per 1000 patient-years compared with 30 per 1000 patient-years in the control group (hazard ratio = 0.89; 95% confidence interval 0. 75–1.06; p=0.19).
Chronic heart failure
According to the results of the CHARM
(Candesartan in Chronic Heart Failure—Evaluation of Mortality and Morbidity Reductions) use of candesartan cilexetil resulted in a reduction in the incidence of death and the need for hospitalization for chronic heart failure and an improvement in left ventricular systolic function.
Patients with chronic heart failure, in addition to the main therapy, received candesartan cilexetil at a dose of 4–8 mg/day with a dose increase to 32 mg/day or to the maximum tolerated therapeutic dose (the average dose of candesartan was 24 mg). The median follow-up duration was 37.7 months. After 6 months of therapy, 63% of patients who continued to take candesartan cilexetil (89%) received a therapeutic dose of 32 mg.
In another study, CHARM-Alternative
(n=2028) included patients with reduced (≤40%) left ventricular ejection fraction (LVEF) who did not receive an ACE inhibitor due to intolerance (mainly due to cough - 72%);
The rates of cardiovascular death and first hospitalization for chronic heart failure were significantly lower in the candesartan group compared with the placebo group (hazard ratio = 0.77; 95% confidence interval 0.67–0.89 ; p<0.001). The relative risk reduction was 23%. In this study, to prevent one cardiovascular death or hospitalization for chronic heart failure, it was necessary to treat 14 patients throughout the study period. The combined criterion, which included the incidence of deaths regardless of their cause and the rate of first hospitalization for chronic heart failure, was also significantly lower in the group of patients receiving candesartan (hazard ratio = 0.80; 95% confidence interval 0.7– 0.92; p=0.001). At the same time, a positive effect of candesartan was noted on each of the components of this combined criterion - the frequency of deaths and morbidity (an indicator of the frequency of hospitalizations for chronic heart failure). The use of candesartan cilexetil led to an improvement in the functional class of chronic heart failure according to the NYHA
(p = 0.008).
In the CHARM-Added
(n=2548) in patients with reduced LVEF ≤40% receiving ACE inhibitors, the composite criterion of cardiovascular mortality and first hospitalization for chronic heart failure was significantly lower in the group of patients receiving candesartan, according to compared with the placebo group (risk ratio = 0.85; 95% confidence interval 0.75–0.96; p = 0.011), which corresponded to a 15% reduction in relative risk.
In this study, to prevent one cardiovascular death or hospitalization for chronic heart failure, it was necessary to treat 23 patients throughout the study period. The value of the combined effectiveness criterion, which included an assessment of the incidence of deaths regardless of their cause or the frequency of the first hospitalization for chronic heart failure, was significantly lower in the group of patients receiving candesartan (hazard ratio = 0.87; 95% confidence interval 0. 78–0.98; p=0.021), which also indicated a positive effect when using candesartan. The use of candesartan cilexetil led to an improvement in the functional class of chronic heart failure according to the NYHA
(p = 0.02).
In the CHARM-Preserve
(n=3023) in patients with preserved systolic function (LVEF >40%), there were no statistically significant differences in the value of the combined effectiveness criterion, which included the incidence of deaths and the incidence of first hospitalization for chronic heart failure, in the candesartan and placebo groups (risk ratio =0.89; 95% confidence interval 0.77–1.03; p=0.118). The small numerical decrease in this criterion was due to a decrease in the frequency of hospitalizations for chronic heart failure. This study did not show the effect of candesartan on the incidence of deaths.
When separately analyzing the results of 3 studies of the CHARM
There were no significant differences in the incidence of deaths in the candesartan and placebo groups.
However, the incidence of death was estimated in the combined population of the CHARM-Alternative
and
CHARM-Added
and in all 3 studies (hazard ratio = 0.91; 95% confidence interval 0.83–1.0; p = 0.055). The reduction in the incidence of death and hospitalization for chronic heart failure during therapy with candesartan was independent of age, gender and concomitant therapy. Candesartan was also effective in patients taking beta-blockers in combination with ACE inhibitors, and the effectiveness of candesartan was independent of whether the patient was taking the optimal dose of the ACE inhibitor or not.
In patients with chronic heart failure and reduced left ventricular systolic function (LVEF ≤40%), taking candesartan contributed to a decrease in peripheral vascular resistance and capillary pressure in the lungs, an increase in renin activity and the concentration of angiotensin II in the blood plasma, as well as a decrease in aldosterone levels.
Drug interactions Atacand
No clinically significant interaction was identified. Compounds that were studied in clinical pharmacokinetic studies included hydrochlorothiazide, warfarin, digoxin, oral contraceptives (i.e., ethinyl estradiol/levonorgestrel), glibenclamide, nifedipine, and enalapril. Candesartan is excreted to a small extent by hepatic metabolism (CYP 2C9). Data from interaction studies indicate no effect on CYP 2C9 and CYP 3A4, however, the effect on other cytochrome P450 isoenzymes is not known. The antihypertensive effect of candesartan may be enhanced by other medicinal products that can lower blood pressure, whether prescribed as an antihypertensive agent or for other indications. Experience with other drugs that affect the renin-angiotensin-aldosterone system suggests that concomitant use of potassium-sparing diuretics, potassium supplements, potassium-containing salt substitutes, or other drugs that may increase potassium levels (eg, heparin) may result in increased potassium levels in the blood serum. There are reports of an inverse increase in serum lithium concentrations and toxicity during concomitant use of lithium with ACE inhibitors. A similar effect may occur with angiotensin II receptor antagonists. Therefore, careful monitoring of serum lithium levels is recommended during concurrent use. When combined with angiotensin II receptor antagonists and NSAIDs (for example, selective COX-2 inhibitors, acetylsalicylic acid (3 g/day) and non-selective NSAIDs), a weakening of the antihypertensive effect may occur. As with ACE inhibitors, concomitant use of angiotensin II receptor antagonists and NSAIDs may increase the risk of worsening renal function, including possible acute renal failure and increased serum potassium levels, especially in patients with impaired renal function. This combination is used with caution, especially in the elderly. Patients should receive sufficient fluids and consideration should be given to monitoring renal function at the initiation of concomitant therapy and periodically throughout the course of treatment. Food intake does not affect the bioavailability of candesartan.
Overdose of the drug Atacand, symptoms and treatment
Symptoms: hypotension and dizziness. Information on an individual case of overdose (up to 672 mg of candesartan cilexetil) reported that the patient recovered without consequences. Treatment: symptomatic, monitoring vital functions. The patient should be placed on his back with his lower limbs elevated. If this is not enough, it is necessary to increase the volume of blood plasma by infusion, for example, an isotonic saline solution. Candesartan is not eliminated by hemodialysis.
