Amlodipine, Valsartan and Hydrochlorothiazide: Package Insert and Label Information
AMLODIPINE, VALSARTAN AND HYDROCHLOROTHIAZIDE — amlodipine besylate, valsartan and hydrochlorothiazide tablet, film coated
Lupin Pharmaceuticals, Inc.
WARNING: FETAL TOXICITY
1 INDICATIONS AND USAGE
Amlodipine, valsartan and hydrochlorothiazide tablets are indicated for the treatment of hypertension, to lower blood pressure. Lowering blood pressure reduces the risk of fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions. These benefits have been seen in controlled trials of antihypertensive drugs from a wide variety of pharmacologic classes, including amlodipine, hydrochlorothiazide, and the ARB class to which valsartan principally belongs. There are no controlled trials demonstrating risk reduction with amlodipine, valsartan and hydrochlorothiazide tablets.
Control of high blood pressure should be part of comprehensive cardiovascular risk management, including, as appropriate, lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake. Many patients will require more than 1 drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC).
Numerous antihypertensive drugs, from a variety of pharmacologic classes and with different mechanisms of action, have been shown in randomized controlled trials to reduce cardiovascular morbidity and mortality, and it can be concluded that it is blood pressure reduction, and not some other pharmacologic property of the drugs, that is largely responsible for those benefits. The largest and most consistent cardiovascular outcome benefit has been a reduction in the risk of stroke, but reductions in myocardial infarction and cardiovascular mortality also have been seen regularly.
Elevated systolic or diastolic pressure causes increased cardiovascular risk, and the absolute risk increase per mmHg is greater at higher blood pressures, so that even modest reductions of severe hypertension can provide substantial benefit. Relative risk reduction from blood pressure reduction is similar across populations with varying absolute risk, so the absolute benefit is greater in patients who are at higher risk independent of their hypertension (e.g., patients with diabetes or hyperlipidemia), and such patients would be expected to benefit from more aggressive treatment to a lower blood pressure goal.
Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (e.g., on angina, heart failure, or diabetic kidney disease). These considerations may guide selection of therapy.
Limitation of Use
Amlodipine, valsartan and hydrochlorothiazide tablets are not indicated for the initial therapy of hypertension [see Dosage and Administration (2) ].
2 DOSAGE AND ADMINISTRATION
2.1 General Considerations
Dose once-daily. The dosage may be increased after 2 weeks of therapy. The full blood pressure lowering effect was achieved 2 weeks after being on the maximal dose of amlodipine, valsartan and hydrochlorothiazide tablets. The maximum recommended dose of amlodipine, valsartan and hydrochlorothiazide tablets is 10/320/25 mg.
2.2 Add-on / Switch Therapy
Amlodipine, valsartan and hydrochlorothiazide tablets may be used for patients not adequately controlled on any 2 of the following antihypertensive classes: calcium channel blockers, angiotensin receptor blockers, and diuretics.
A patient who experiences dose-limiting adverse reactions to an individual component while on any dual combination of the components of amlodipine, valsartan and hydrochlorothiazide tablets may be switched to amlodipine, valsartan and hydrochlorothiazide tablets containing a lower dose of that component to achieve similar blood pressure reductions.
2.3 Replacement Therapy
Amlodipine, valsartan and hydrochlorothiazide tablets may be substituted for the individually titrated components.
2.4 Use with Other Antihypertensive Drugs
Amlodipine, valsartan and hydrochlorothiazide tablets may be administered with other antihypertensive agents.
3 DOSAGE FORMS AND STRENGTHS
- Amlodipine, valsartan and hydrochlorothiazide tablets USP, 5 mg/160 mg/12.5 mg are white to off-white, capsule shaped, film coated, biconvex tablets, debossed with ‘LU’ on one side and ‘W41’ on the other side.
- Amlodipine, valsartan and hydrochlorothiazide tablets USP, 10 mg/160 mg/12.5 mg are mustard colored, capsule shaped, film coated, biconvex tablets, debossed with ‘LU’ on one side and ‘W43’ on the other side.
- Amlodipine, valsartan and hydrochlorothiazide tablets USP, 5 mg/160 mg/25 mg are yellow colored, capsule shaped, film coated, biconvex tablets, debossed with ‘LU’ on one side and ‘W42’ on the other side.
- Amlodipine, valsartan and hydrochlorothiazide tablets USP, 10 mg/160 mg/25 mg are beige colored, capsule shaped, film coated, biconvex tablets, debossed with ‘LU’ on one side and ‘W44’ on the other side.
- Amlodipine, valsartan and hydrochlorothiazide tablets USP, 10 mg/320 mg/25 mg are light brick red colored, capsule shaped, film coated, biconvex tablets, debossed with ‘LU’ on one side and ‘W45’ on the other side.
Do not use in patients with anuria, hypersensitivity to other sulfonamide-derived drugs, or hypersensitivity to any component of this product.
Do not coadminister aliskiren with amlodipine, valsartan and hydrochlorothiazide in patients with diabetes [see Drug Interactions (7) ].
5 WARNINGS AND PRECAUTIONS
5.1 Fetal Toxicity
Amlodipine, valsartan and hydrochlorothiazide can cause fetal harm when administered to a pregnant woman. Use of drugs that act on the renin-angiotensin system during the second and third trimesters of pregnancy reduces fetal renal function and increases fetal and neonatal morbidity and death. Resulting oligohydramnios can be associated with fetal lung hypoplasia and skeletal deformations. Potential neonatal adverse effects include skull hypoplasia, anuria, hypotension, renal failure, and death. When pregnancy is detected, discontinue amlodipine, valsartan and hydrochlorothiazide as soon as possible [see Use in Specific Populations (8.1) ].
Thiazides cross the placenta, and use of thiazides during pregnancy is associated with fetal or neonatal jaundice, thrombocytopenia, and possibly other adverse reactions that have occurred in adults.
5.2 Hypotension in Volume- or Salt-Depleted Patients
Excessive hypotension, including orthostatic hypotension, was seen in 1.7% of patients treated with the maximum dose of amlodipine, valsartan and hydrochlorothiazide (10/320/25 mg) compared to 1.8% of valsartan/HCTZ (320/25 mg) patients, 0.4% of amlodipine/valsartan (10/320 mg) patients, and 0.2% of HCTZ/amlodipine (25/10 mg) patients in a controlled trial in patients with moderate to severe uncomplicated hypertension. In patients with an activated renin-angiotensin system, such as volume- or salt-depleted patients receiving high doses of diuretics, symptomatic hypotension may occur in patients receiving angiotensin receptor blockers. Correct this condition prior to administration of amlodipine, valsartan and hydrochlorothiazide.
Amlodipine, valsartan and hydrochlorothiazide have not been studied in patients with heart failure, recent myocardial infarction, or in patients undergoing surgery or dialysis. Patients with heart failure or post-myocardial infarction patients given valsartan commonly have some reduction in blood pressure, but discontinuation of therapy because of continuing symptomatic hypotension usually is not necessary when dosing instructions are followed. In controlled trials in heart failure patients, the incidence of hypotension in valsartan-treated patients was 5.5% compared to 1.8% in placebo-treated patients. In the Valsartan in Acute Myocardial Infarction Trial (VALIANT), hypotension in post-myocardial infarction patients led to permanent discontinuation of therapy in 1.4% of valsartan-treated patients and 0.8% of captopril-treated patients.
Since the vasodilation induced by amlodipine is gradual in onset, acute hypotension has rarely been reported after oral administration. Do not initiate treatment with amlodipine, valsartan and hydrochlorothiazide in patients with aortic or mitral stenosis or obstructive hypertrophic cardiomyopathy.
If excessive hypotension occurs with amlodipine, valsartan and hydrochlorothiazide, place the patient in a supine position and, if necessary, give intravenous normal saline. A transient hypotensive response is not a contraindication to further treatment, which usually can be continued without difficulty once the blood pressure has stabilized.
5.3 Increased Angina and/or Myocardial Infarction
Worsening angina and acute myocardial infarction can develop after starting or increasing the dose of amlodipine, particularly in patients with severe obstructive coronary artery disease.
5.4 Impaired Renal Function
Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system and by diuretics. Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, or volume depletion) may be at particular risk of developing acute renal failure on amlodipine, valsartan and hydrochlorothiazide. Monitor renal function periodically in these patients. Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on amlodipine, valsartan and hydrochlorothiazide [see Drug Interactions (7) ].
5.5 Potassium Abnormalities
In the controlled trial of amlodipine, valsartan and hydrochlorothiazide in moderate to severe hypertensive patients, the incidence of hypokalemia (serum potassium <3.5 mEq/L) at any time post-baseline with the maximum dose of amlodipine, valsartan and hydrochlorothiazide (10/320/25 mg) was 10% compared to 25% with HCTZ/amlodipine (25/10 mg), 7% with valsartan/HCTZ (320/25 mg), and 3% with amlodipine/valsartan (10/320 mg). One patient (0.2%) discontinued therapy due to an adverse event of hypokalemia in each of the amlodipine, valsartan and hydrochlorothiazide and HCTZ/amlodipine groups. The incidence of hyperkalemia (serum potassium >5.7 mEq/L) was 0.4% with amlodipine, valsartan and hydrochlorothiazide compared to 0.2% to 0.7% with the dual therapies.
Some patients with heart failure have developed increases in potassium on valsartan. These effects are usually minor and transient, and they are more likely to occur in patients with pre-existing renal impairment. Dosage reduction and/or discontinuation of the diuretic and/or valsartan may be required.
Hydrochlorothiazide can cause hypokalemia and hyponatremia. Hypomagnesemia can result in hypokalemia which appears difficult to treat despite potassium repletion. Drugs that inhibit the renin-angiotensin system can cause hyperkalemia. Monitor serum electrolytes periodically.
If hypokalemia is accompanied by clinical signs (e.g., muscular weakness, paresis, or ECG alterations), amlodipine, valsartan and hydrochlorothiazide should be discontinued. Correction of hypokalemia and any coexisting hypomagnesemia is recommended prior to the initiation of thiazides.
5.6 Hypersensitivity Reaction
Hypersensitivity reactions to hydrochlorothiazide may occur in patients with or without a history of allergy or bronchial asthma, but are more likely in patients with such a history.
5.7 Systemic Lupus Erythematosus
Thiazide diuretics have been reported to cause exacerbation or activation of systemic lupus erythematosus.
5.8 Lithium Interaction
Increases in serum lithium concentrations and lithium toxicity have been reported with concomitant use of valsartan or thiazide diuretics. Monitor lithium levels in patients receiving amlodipine, valsartan and hydrochlorothiazide and lithium [see Drug Interactions (7) ].
5.9 Metabolic Imbalances
Hydrochlorothiazide may alter glucose tolerance and raise serum levels of cholesterol and triglycerides.
Hydrochlorothiazide may raise the serum uric acid level due to reduced clearance of uric acid and may cause or exacerbate hyperuricemia and precipitate gout in susceptible patients.
Hydrochlorothiazide decreases urinary calcium excretion and may cause elevations of serum calcium. Monitor calcium levels in patients with hypercalcemia receiving amlodipine, valsartan and hydrochlorothiazide.
5.10 Acute Myopia and Secondary Angle-Closure Glaucoma
Hydrochlorothiazide, a sulfonamide, can cause an idiosyncratic reaction, resulting in acute transient myopia and acute angle-closure glaucoma. Symptoms include acute onset of decreased visual acuity or ocular pain and typically occur within hours to weeks of drug initiation. Untreated acute angle-closure glaucoma can lead to permanent vision loss. The primary treatment is to discontinue hydrochlorothiazide as rapidly as possible. Prompt medical or surgical treatments may need to be considered if the intraocular pressure remains uncontrolled. Risk factors for developing acute angle-closure glaucoma may include a history of sulfonamide or penicillin allergy.
6 ADVERSE REACTIONS
6.1 Clinical Trials Experience
Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in clinical practice.
In the controlled trial of amlodipine, valsartan and hydrochlorothiazide, where only the maximum dose (10/320/25 mg) was evaluated, safety data were obtained in 582 patients with hypertension. Adverse reactions have generally been mild and transient in nature and have only infrequently required discontinuation of therapy.
The overall frequency of adverse reactions was similar between men and women, younger (<65 years) and older (>65 years) patients, and black and white patients. In the active controlled clinical trial, discontinuation because of adverse events occurred in 4.0% of patients treated with amlodipine, valsartan and hydrochlorothiazide 10/320/25 mg compared to 2.9% of patients treated with valsartan/HCTZ 320/25 mg, 1.6% of patients treated with amlodipine/valsartan 10/320 mg, and 3.4% of patients treated with HCTZ/amlodipine 25/10 mg. The most common reasons for discontinuation of therapy with amlodipine, valsartan and hydrochlorothiazide were dizziness (1.0%) and hypotension (0.7%).
The most frequent adverse events that occurred in the active controlled clinical trial in at least 2% of patients treated with amlodipine, valsartan and hydrochlorothiazide are presented in the following table.
|Preferred Term||Aml/Val/HCTZ 10/320/25 mg N=582 n (%)||Val/HCTZ 320/25 mg N=559 n (%)||Aml/Val 10/320 mg N=566 n (%)||HCTZ/Aml 25/10 mg N=561 n (%)|
|Dizziness||48 (8.2)||40 (7.2)||14 (2.5)||23 (4.1)|
|Edema||38 (6.5)||8 (1.4)||65 (11.5)||63 (11.2)|
|Headache||30 (5.2)||31 (5.5)||30 (5.3)||40 (7.1)|
|Dyspepsia||13 (2.2)||5 (0.9)||6 (1.1)||2 (0.4)|
|Fatigue||13 (2.2)||15 (2.7)||12 (2.1)||8 (1.4)|
|Muscle spasms||13 (2.2)||7 (1.3)||7 (1.2)||5 (0.9)|
|Back pain||12 (2.1)||13 (2.3)||5 (0.9)||12 (2.1)|
|Nausea||12 (2.1)||7 (1.3)||10 (1.8)||12 (2.1)|
|Nasopharyngitis||12 (2.1)||13 (2.3)||13 (2.3)||12 (2.1)|
Orthostatic events (orthostatic hypotension and postural dizziness) were seen in 0.5% of patients.
Valsartan has been evaluated for safety in more than 4000 hypertensive patients in clinical trials. In trials in which valsartan was compared to an ACE inhibitor with or without placebo, the incidence of dry cough was significantly greater in the ACE inhibitor group (7.9%) than in the groups who received valsartan (2.6%) or placebo (1.5%). In a 129-patient trial limited to patients who had dry cough when they had previously received ACE inhibitors, the incidences of cough in patients who received valsartan, HCTZ, or lisinopril were 20%, 19%, and 69% respectively (p<0.001).
Clinical Laboratory Test Findings
Clinical laboratory test findings for amlodipine, valsartan and hydrochlorothiazide were obtained in a controlled trial of amlodipine, valsartan and hydrochlorothiazide administered at the maximal dose of 10/320/25 mg compared to maximal doses of dual therapies, i.e., valsartan/HCTZ 320/25 mg, amlodipine/valsartan 10/320 mg, and HCTZ/amlodipine
25/10 mg. Findings for the components of amlodipine, valsartan and hydrochlorothiazide tablets were obtained from other trials.
In heart failure patients, greater than 50% increases in creatinine were observed in 3.9% of valsartan-treated patients compared to 0.9% of placebo-treated patients. In post-myocardial infarction patients, doubling of serum creatinine was observed in 4.2% of valsartan-treated patients and 3.4% of captopril-treated patients.
Blood Urea Nitrogen (BUN):
In hypertensive patients, greater than 50% increases in BUN were observed in 30% of amlodipine, valsartan and hydrochlorothiazide-treated patients compared to 29% of valsartan/HCTZ patients, 15.8% of amlodipine/valsartan patients, and 18.5% of HCTZ/amlodipine patients. In heart failure patients, greater than 50% increases in BUN were observed in 17% of valsartan-treated patients compared to 6% of placebo-treated patients [see Warnings and Precautions (5.4)].
Neutropenia (<1500/L) was observed in 1.9% of patients treated with valsartan and 0.8% of patients treated with placebo.
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