- moexipril hydrochloride
POM: Prescription only medicine
This information is intended for use by health professionals
General:Perdix should be administered orally in a single daily dose. As with all other medicinal products taken once daily, it should be taken at approximately the same time each day in the morning before having any food, best immediately upon waking. The absorption of Perdix is affected by food. Therefore it should be taken before food (see also section 5.2).
Initial therapy:In patients with uncomplicated essential hypertension not on diuretic therapy, the recommended initial dose is 7.5 mg once a day. Dosage should be adjusted according to blood pressure response. The maintenance dose is 7.5 to 15 mg moexipril daily, administered in a single dose. Some patients may benefit from a further increase to 30 mg per day. Doses over 30 mg have been used, but do not appear to give a greater effect.If blood pressure is not controlled with Perdix alone, a low dose of a diuretic may be added. Hydrochlorothiazide 12.5 mg has been shown to provide an additive effect. With concomitant diuretic therapy, it may be possible to reduce the dose of Perdix.
Diuretic treated patients:In hypertensive patients who are currently being treated with a diuretic, symptomatic hypotension may occur occasionally following the initial dose of Perdix. The diuretic should be discontinued, if possible, for two to three days before beginning therapy with Perdix to reduce the likelihood of hypotension (see section 4.4). The dosage of Perdix should be adjusted according to blood pressure response. If the patient's blood pressure is not controlled with Perdix alone, diuretic therapy may be resumed as described above.If the diuretic cannot be discontinued or the diuretic has recently been withdrawn, an initial dose of 3.75 mg (half 7.5 mg tablet) should be used under medical supervision for at least two hours and until blood pressure has stabilised for at least an additional hour (see section 4.4).
Patients on antihypertensive treatment:As add-on therapy, Perdix has been investigated in combination with nifedipine. If Perdix is used as add-on therapy to nifedipine or other antihypertensive agents, the starting dose of Perdix should be 3.75 mg (half 7.5 mg tablet). See sections 4.3, 4.4, 4.5 and 5.1.
Elderly patients:In elderly patients, an intial dosage of 3.75 mg (half 7.5 mg tablet) once daily is recommended followed by titration to the optimal response.
Renal failure:• Severe Renal Failure (creatinine clearance < 40 ml/min): An initial dose of 3.75 mg of Perdix (half 7.5 mg tablet) once daily must be given cautiously. Doses may be titrated upward to a maximum daily dose of 15 mg.• Moderate Renal Impairment (creatinine clearance > 40 ml/min: Based on the available studies with Perdix, no dose adaptation is necessary. However a decreased initial dose could be considered, e.g. 3.75 mg (half 7.5 mg tablet).
Patients with hepatic impairment:In patients with hepatic impairment, an initial dose of 3.75 mg of moexipril hydrochloride (half 7.5 mg tablet) is recommended.
Afro-Caribbean patients:Where Perdix is used as a single agent in hypertension, Afro-Caribbean patients may show a reduced therapeutic response.
Paediatric population:Not recommended. Safety and efficacy in children has not been established.
Diuretic treated patients:In hypertensive patients who are currently being treated with a diuretic, symptomatic hypotension may occur occasionally following the initial dose of Perdix. (See also section 4.2).
Renal vascular hypertension:Before ACE inhibitor therapy is started, renal function has to be controlled. There is an increased risk of severe hypotension and renal insufficiency when patients with renal vascular hypertension are treated with Perdix. Loss of renal function may occur with only mild changes in serum creatinine.
Impaired renal function:As a consequence of inhibiting the renin-angiotensin-aldosterone system, changes in renal function may be anticipated in susceptible individuals. In patients with severe congestive heart failure, whose renal function may depend on the activity of the renin-angiotensin-aldosterone system, treatment with ACE inhibitors, including Perdix, may be associated with oliguria and/or progressive azotemia and (rarely) with acute renal failure and/or death.In hypertensive patients with renal artery stenosis in a solitary kidney or bilateral renal artery stenosis, increases in blood urea nitrogen and serum creatinine may occur. Experience with other ACE inhibitors suggests that these increases are usually reversible upon discontinuation of ACE inhibitor and/or diuretic therapy. In such patients, renal function should be monitored during the first few weeks of therapy.Some hypertensive patients with no apparent pre-existing renal vascular disease have developed increases in blood urea nitrogen and serum creatinine, usually minor and transient, especially when Perdix has been given concomitantly with a diuretic. This is more likely to occur in patients with pre-existing renal impairment. A reduction in the dose of Perdix and/or discontinuation of the diuretic may be required.Evaluation of hypertensive patients should always include assessment of renal function.Impaired renal function decreases total clearance of moexiprilat and approximately doubles AUC.
Angioneurotic oedema:Angioneurotic oedema of the face, lips, mucous membranes, tongue, glottis or larynx and of the extremities has been reported in patients treated with ACE inhibitors, especially during the first weeks of treatment. However, in rare cases severe angioneurotic oedema may develop even after long-term treatment with an ACE inhibitor. Treatment must promptly be discontinued and replaced by another class of antihypertensive medicinal products.Angioneurotic oedema involving the tongue, glottis or larynx, may be fatal due to airway obstruction. Emergency therapy must include intravenous administration of corticosteroids, H1-receptor antagonists and H2-receptor antagonists. If the condition of the patient does not improve with the above mentioned therapy, epinephrine must be administered slowly intravenously monitored by ECG control.In case of hereditary angioneurotic oedema due to C1-inactivator deficiency associated with ACE inhibitor therapy, additionally a C1-inactivator must be administered. Furthermore, intubation or tracheotomy must be considered. (See section 4.8).
Intestinal angioneurotic oedema:Intestinal angioneurotic oedema has been reported in patients treated with ACE inhibitors. These patients presented with abdominal pain (with or without nausea and vomiting). In some cases there was no prior history of facial angioneurotic oedema and C1-esterase levels were normal. Intestinal angioneurotic oedema was diagnosed by procedures including abdominal CT scan or ultrasound, or at surgery. Symptoms resolved after stopping the ACE inhibitor. Intestinal angioneurotic oedema should be included in the differential diagnosis of patients on ACE inhibitors presenting with abdominal pain.
Pregnancy:ACE inhibitors should not be initiated during pregnancy. Unless continued ACE inhibitor therapy is considered essential, patients planning pregnancy should be changed to alternative antihypertensive treatments which have an established safety profile for use in pregnancy. When pregnancy is diagnosed, treatment with ACE inhibitors should be stopped immediately, and, if appropriate, alternative therapy should be started (see sections 4.3 and 4.6).
Cough:During treatment with an ACE inhibitor a dry and non-productive cough may occur which disappears after discontinuation.Hyperkalaemia:In clinical trials, persistent hyperkalaemia (serum potassium > 5.4 mEq/l) occurred in approximately 2.6% of hypertensive patients. In clinical trials, 0.1% of patients (two patients) were discontinued from therapy due to elevated serum potassium. Risk factors for the development of hyperkalaemia with ACE inhibitors include renal insufficiency and/or heart failure, diabetes mellitus and the concomitant use of potassium-sparing diuretics, potassium supplements and/or potassium-containing salt substitutes, which should be used cautiously, if at all, with Perdix.
Elderly:Some elderly patients may be more responsive to Perdix than younger patients. Control of renal function before start and during therapy is recommended. For dosage recommendations in elderly patients see 4.2.Surgery/anaesthesia:In patients undergoing surgery or during anaesthesia with agents that produce hypotension, Perdix will block the effect of compensatory renin release. Hypotension that occurs as a result of this mechanism can be corrected by volume expansion (see section 4.8)
Neutropenia/agranulocytosis:Other ACE inhibitors have been shown to cause agranulocytosis and bone marrow depression, rarely in uncomplicated patients, but more frequently in patients with renal impairment, especially if they also have a collagenosis such as systemic lupus erythematosus or dermatosclerosis. Available data from clinical trials of Perdix are insufficient to show that it does not cause agranulocytosis at similar rates. Monitoring of white blood cell counts should be considered for patients with collagenosis, especially if the disease is associated with impaired renal function.
Lactose:Patients with rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption must not take Perdix.
Dual blockade of the renin-angiotensin-aldosterone system (RAAS):There is evidence that the concomitant use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren increases the risk of hypotension, hyperkalaemia and decreased renal function (including acute renal failure). Dual blockade of RAAS through the combined use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is therefore not recommended (see sections 4.5 and 5.1).If dual blockade therapy is considered absolutely necessary, this should only occur under specialist supervision and subject to frequent close monitoring of renal function, electrolytes and blood pressure.ACE-inhibitors and angiotensin II receptor blockers should not be used concomitantly in patients with diabetic nephropathy.
Diuretics:Excessive reductions in blood pressure, especially in patients in whom diuretic therapy was recently instituted, have been reported with ACE inhibitors. The possibility of hypotensive effects with Perdix can be minimised by discontinuing diuretic therapy or increasing salt intake for several days before initiation of treatment with Perdix. If this is not possible, the starting dose should be reduced (see sections 4.2 and 4.4).
Antihypertensive agents:The co-administration of antihypertensive agents, including nifedipine, with Perdix gives rise to an enhanced antihypertensive effect.
Potassium supplements and potassium-sparing diuretics:Perdix can attenuate potassium loss caused by thiazide diuretics. Potassium-sparing diuretics (e.g. spironolactone, triamterene, amiloride) potassium supplements or potassium-containing salt substitutes have been shown to increase the risk of hyperkalaemia when used concomitantly with ACE inhibitors. Therefore, if concomitant use of such agents is indicated, because of demonstrated hypokalemia, they should be given with caution and with frequent monitoring of serum potassium.
Oral anticoagulants:Interaction studies with warfarin failed to identify any clinically important effects on the serum concentrations of the anticoagulants or on their anticoagulant effects.
Lithium:Increased serum lithium levels and symptoms of lithium toxicity have been reported in patients receiving ACE inhibitors during therapy with lithium. These drugs should be co-administered with caution, and frequent monitoring of serum lithium levels is recommended. If a diuretic is also used, the risk of lithium toxicity may be increased.
Anaesthetic medicinal products:Perdix may enhance the hypotensive effects of certain anaesthetic medicinal products.
Narcotic medicinal products/Antipsychotics:Postural hypotension may occur.
Allopurinol, cytostatic or immunosuppressive agents, systemic corticosteroids or procainamide:Concomitant administration with Perdix may lead to an increased risk of leucopenia.
Antacids:Decreased bioavailability of ACE inhibitiors may occur.Sympathomimetics:Sympathomimetics may reduce the antihypertensive effects of Perdix. Patients must be carefully monitored to confirm that the desired effect is being achieved.
Gold:Nitritoid reactions (symptoms include facial flushing, nausea, vomiting and hypotension leading to collapse) have been reported rarely in patients on therapy with injectable gold (sodium aurothiomalate) and concomitant ACE inhibitor.
Non-Steroidal anti-inflammatory drugs:The administration of NSAIDs may reduce the antihypertensive effect of Perdix. Furthermore, it has been reported that NSAIDs and ACE inhibitors exert an additive effect on increase in serum potassium, whereas renal function may decrease. These effects are in principle reversible, and occur especially in patients with compromised renal function.
Alcohol:Alcohol enhances the hypotensive effect of Perdix.Antidiabetic medicinal products:Antidiabetic medicinal products (insulins or sulphonylureas). A reduction in blood sugar may occur.
Dual Blockade of the Renin-Angiotensin-aldosterone- System (RAAS)Clinical trial data has shown that dual blockade of the renin-angiotensin- aldosterone-system (RAAS) through the combined use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is associated with a higher frequency of adverse events such as hypotension, hyperkalaemia and decreased renal function (including acute renal failure) compared to the use of a single RAAS-acting agent (see sections 4.3, 4.4 and 5.1).Other agents:No clinically important pharmacokinetic interactions occurred when Perdix was administered concomitantly with hydrochlorothiazide, digoxin, cimetidine, or nifedipine in healthy volunteers. However, in hypertensive patients, the antihypertensive effect of Perdix was enhanced when given in combination with diuretics, or calcium antagonists.
|The use of ACE inhibitors is not recommended during the first trimester of pregnancy (see section 4.4). The use of ACE inhibitors is contraindicated during the second and third trimester of pregnancy (see sections 4.3 and 4.4).|
LactationBecause no information is available regarding the use of Perdix during breast-feeding, Perdix is not recommended and alternative treatments with better established safety profiles during breast-feeding are preferable, especially while nursing a newborn or preterm infant.
Cardiovascular:Symptomatic hypotension, postural hypotension, or syncope was seen in ☐ 1% of patients; these reactions led to discontinuation of therapy in controlled trials in 2 patients (0.1%) who had received Perdix monotherapy and in 1 patient (0.05%) who had received Perdix with hydrochlorothiazide. Other reports included chest pain, angina/myocardial infarction, tachycardia, palpitations, rhythm disturbances, transient ischaemic attacks, cerebrovascular accident.
Renal:Of hypertensive patients with no apparent pre-existing renal disease, 0.8% of patients receiving Perdix alone and 1.5% of patients receiving Perdix with hydrochlorothiazide have experienced increases in serum creatinine to at least 140% of their baseline values. Acute renal failure has been reported for ACE inhibitors including Perdix (see section 4.4 Special Warnings and Precautions for use).
Gastrointestinal:Abdominal pain, dyspepsia, constipation, nausea, vomiting, diarrhoea, appetite/weight change, dry mouth, pancreatitis, hepatitis.
Intestinal Angioedema:Intestinal Angioedema has been reported in patients treated with ACE inhibitors (see section 4.4 Special Warnings and Precautions for use).
Respiratory:Upper respiratory infection, pharyngitis, sinusitis/rhinitis, bronchospasm, dyspnoea.
Dermatologic:Occasionally allergic and hypersensitivity reactions can occur like rash, pruritus, urticaria, erythema multiforme, Stevens-Johnson syndrome, toxic epidermic necrolysis, psoriasis-like efflorescence, pemphigus and alopecia. This can be accompanied by fever, myalgia, arthralgia, eosinophilia and/or increased ANA-titres. ACE inhibitors have been associated with the onset of angioneurotic oedema in a small subset of patients involving the face and oropharyngeal tissues.
Neurological and psychiatric:Headache or tiredness may occasionally occur; rarely there may be drowsiness, depression, sleep disturbances, impotence, tingling sensations, numbness or paraesthesia, disturbances of balance, confusion, tinnitus, blurred vision, and alterations of taste or a transient loss of taste.
OtherSweating, flu syndrome, malaise.Clinical Laboratory Test Findings: Decreases in haemoglobin, haematocrit, platelets and white cell count and individual cases of agranulocytosis or pancytopenia, as well as elevation of liver enzymes and serum bilirubin have been reported in a few patients. In patients with congenital deficiency concerning G-6-PDH individual cases of haemolytic anaemia have been reported.In rare cases, especially in patients with impaired kidney function or collagen disease, or those simultaneously receiving treatment with allopurinol, procainamide or certain drugs which suppress the defence reactions, there may be anaemia, thrombocytopenia, neutropenia, eosinophilia and in isolated cases, even agranulocytosis or pancytopenia.
Creatinine and blood urea nitrogen:As with other ACE inhibitors, minor increases in blood urea nitrogen or serum creatinine, reversible upon discontinuation of therapy, were observed in approximately 1% of patients with essential hypertension who were treated with Perdix. Increases are more likely to occur in patients receiving concomitant diuretics or in patients with compromised renal function.
Potassium:Since moexipril decreases aldosterone secretion, elevation of serum potassium can occur. Potassium supplements and potassium-sparing diuretics should be given with caution and the patient's serum potassium should be monitored frequently.Other:Clinically important changes in standard laboratory tests were rarely associated with Perdix administration. Elevations of liver enzymes and uric acid have been reported. In trials, less than 1% of moexipril-treated patients discontinued Perdix treatment because of laboratory abnormalities. Reporting of suspected adverse reactions Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme, website: www.mhra.gov.uk/yellowcard
Symptoms and treatment:To date, no case of overdosage has been reported. Symptoms of overdose would be severe hypotension, shock, stupor, bradycardia, electrolyte disturbances and renal failure. Treatment must be symptomatic and supportive.After ingestion of an overdose, the patients must be kept under close supervision, preferably in an intensive care unit. Serum electrolytes and creatinine must be monitored frequently. Therapeutic measures depend on the nature and severity of the symptoms. Measures to prevent absorption and to hasten elimination, such as administration of absorbents, must be applied if ingestion is recent, within 1 hour after intake. If hypotension occurs, the patient must be placed in a supine position and salt and volume supplementation must be given rapidly. Treatment with angiotensin II infusion and/or intravenous catecholamines must be considered. Bradycardia or extensive vagal reactions must be treated by administering atropine. The use of a pacemaker may be considered. It is not yet known whether Perdix is removed by haemodialysis.
ATC Code: C09AA13In animals as well as in humans, interactions between the renin-angiotensin-aldosterone system and the kallikrein-kinin system provide an important biochemical basis for blood pressure homeostasis. In hypertension the normal feedback mechanism formed by the renin-angiotensin system (RAS) may be dysfunctional, resulting in a self-perpetuating hypertensive condition. Angiotensin converting enzyme (ACE) inhibitors were developed to interrupt this system and thereby to lower blood pressure. Perdix potently inhibits ACE and by this the formation of angiotensin II, the active agent of the RAS, thus blocking its vasoconstrictor and sodium-retaining effects with a consequent reduction in blood pressure.Since ACE is identical to kininase II, an enzyme that degrades the potent vasodilator bradykinin, inhibition of ACE leads to an additional, non renin-mediated reduction in systemic blood pressure. The antihypertensive effects of ACE inhibitors are accompanied by a reduction in peripheral vascular resistance.Two large randomised, controlled trials (ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) and VA NEPHRON-D (The Veterans Affairs Nephropathy in Diabetes)) have examined the use of the combination of an ACE-inhibitor with an angiotensin II receptor blocker.ONTARGET was a study conducted in patients with a history of cardiovascular or cerebrovascular disease, or type 2 diabetes mellitus accompanied by evidence of end-organ damage. VA NEPHRON-D was a study in patients with type 2 diabetes mellitus and diabetic nephropathy.These studies have shown no significant beneficial effect on renal and/or cardiovascular outcomes and mortality, while an increased risk of hyperkalaemia, acute kidney injury and/or hypotension as compared to monotherapy was observed. Given their similar pharmacodynamic properties, these results are also relevant for other ACE-inhibitors and angiotensin II receptor blockers.ACE-inhibitors and angiotensin II receptor blockers should therefore not be used concomitantly in patients with diabetic nephropathy.ALTITUDE (Aliskiren Trial in Type 2 Diabetes Using Cardiovascular and Renal Disease Endpoints) was a study designed to test the benefit of adding aliskiren to a standard therapy of an ACE-inhibitor or an angiotensin II receptor blocker in patients with type 2 diabetes mellitus and chronic kidney disease, cardiovascular disease, or both. The study was terminated early because of an increased risk of adverse outcomes. Cardiovascular death and stroke were both numerically more frequent in the aliskiren group than in the placebo group and adverse events and serious adverse events of interest (hyperkalaemia, hypotension and renal dysfunction) were more frequently reported in the aliskiren group than in the placebo group.
Acute toxicity:Findings of the acute toxicity studies in animals do not raise questions as to the safety of moexipril HCl as well as the main metabolite moexiprilate under the conditions of proposed clinical usage.
Subacute/chronic toxicity:Subacute and chronic toxicity studies in rats and dogs with repeated oral administration of moexipril HCl up to 12 months, revealed mainly heart and kidney as target organs. The effects are completely comparable with those of other ACE inhibitors and can be interpreted as results of highly exaggerated pharmacological activity.First unspecific drug-related side-effects after long-term administration were seen at 75 mg/kg, i.e. a dose which corresponds 150 times the maximum recommended total daily dose in humans when compared on the basis of body weight.
Reproduction studies:Studies in rats and rabbits including all segments of reproduction revealed no direct effects of moexipril HCl on fertility, reproduction and abnormalities in F1 or F2 pups.Regarding precautions in women of child bearing potential and use during pregnancy and lactation see 4.3 and 4.6.
Mutagenicity:As conclusion of different 'in vitro' and one 'in vivo' mutagenicity studies, the mutagenic potential of moexipril HCl for human beings should be extremely low.
Carcinogenicity:Neither the long-term toxicity studies in rats and dogs nor special carcinogenicity studies in mice and rats over 78 and 104 weeks respectively, indicated neoplastigenic properties of moexipril HCl. Therefore, it can be concluded that the carcinogenic risk for human beings will be extremely low.
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