1. Name Of The Medicinal Product
Triapin mite 2.5mg/2.5mg prolonged release tablets
2. Qualitative And Quantitative Composition
Each tablet contains 2.5 mg of felodipine and 2.5 mg of ramipril.
Each tablet contains 52 mg lactose anhydrous.
For a full list of excipients, see section 6.1
3. Pharmaceutical Form
Triapin mite 2.5mg/2.5mg tablets are circular (diameter approx 9 mm), apricot coloured, biconvex and engraved on one side and marked 2.5 on the other side.
4. Clinical Particulars
4.1 Therapeutic Indications
Treatment of essential hypertension. Triapin mite fixed dose combination is indicated in patients whose blood pressure is not adequately controlled on felodipine or ramipril alone.
4.2 Posology And Method Of Administration
Posology
Use in adults, including elderly:
One tablet Triapin mite once daily. The maximum dose is two tablets Triapin mite once daily.
Special populations
Use in patients with impaired liver function:
See sections 4.3 and 4.4.
Use in patients with impaired renal function or patients already on diuretic treatment:
See sections 4.3 and 4.4.
Individual dose titration with the components can be recommended and when clinically appropriate, direct change from monotherapy to the fixed combination may be considered.
Paediatric population:
Triapin mite is not recommended for use in children due to a lack of data.
Method of administration
Triapin mite tablets should be swallowed whole with a sufficient amount of liquid. The tablets must not be divided, crushed or chewed. The tablet can be administered without food or following a light meal not rich in fat or carbohydrate.
4.3 Contraindications
Triapin Mite must not be used:
• in patients with hypersensitivity to felodipine (or other dihydropyridines), ramipril, other angiotensin converting enzyme (ACE) inhibitors or any of the excipients of Triapin mite.
• in patients with a history of angioedema.
• in unstable haemodynamic conditions: cardiovascular shock, untreated heart failure, acute myocardial infarction, unstable angina pectoris, stroke.
• in patients with AV block II or III.
• in patients with severely impaired hepatic function.
• in patients with severely impaired renal function (creatinine clearance less than 20 ml/min) and in patients on dialysis.
• during pregnancy.
• during lactation.
4.4 Special Warnings And Precautions For Use
Angioedema
Angioedema occurring during treatment with an ACE inhibitor necessitates immediate discontinuation of the medicinal product. Angioedema may involve the tongue, glottis or larynx and, if so, may necessitate emergency measures.
Angioedema of the face, extremities, lips, tongue, glottis or larynx has been reported in patients treated with ACE inhibitors. Emergency therapy should be given including, but not necessarily limited to, immediate subcutaneous adrenalin solution 1:1000 (0.3 to 0.5 ml) or slow intravenous adrenalin 1 mg/ml (observe dilution instructions) with control of ECG and blood pressure. The patient should be hospitalised and observed for at least 12 to 24 hours and should not be discharged until complete resolution of symptoms has occurred.
Intestinal angioedema has been reported in patients treated with ACE inhibitors. These patients presented with abdominal pain (with or without nausea or vomiting); in some cases there was no prior history of facial angioedema and C1-esterase levels were normal. The angioedema was diagnosed by procedures including abdominal CT scan or ultrasound, or at surgery, and symptoms resolved after stopping the ACE inhibitor. Intestinal angioedema should be included in the differential diagnosis of patients on ACE inhibitors presenting with abdominal pain.
Compared with non-black patients, a higher incidence of angioedema has been reported in black patients treated with ACE inhibitors.
Renal function
Renal function should be monitored, particularly in the initial weeks of treatment with ACE inhibitors. Caution should be observed in patients with an activated renin-angiotensin system.
Patients with mild to moderately impaired renal function (creatinine clearance 20-60 ml/min) and patients already on diuretic treatment: For dosage see the respective monoproducts.
Hyperkalaemia
Elevations in serum potassium have been observed in some patients treated with ACE inhibitors, including ramipril. Patients at risk for the development of hyperkalaemia include those with renal insufficiency, diabetes mellitus, or those using concomitant potassium-sparing diuretics, potassium supplements or potassium-containing salt substitutes; or those patients taking other medicinal products associated with increases in serum potassium (e.g. heparin). If concomitant use of the above mentioned agents is deemed appropriate, regular monitoring of serum potassium is recommended.
Proteinuria
It may occur particularly in patients with existing renal function impairment or on relatively high doses of ACE inhibitors.
Renovascular hypertension/renal artery stenosis
There is an increased risk of severe hypotension and renal insufficiency when patients with renovascular hypertension and pre-existing bilateral renal artery stenosis or stenosis of the artery to a solitary kidney are treated with ACE inhibitors. Loss of renal function may occur with only mild changes in serum creatinine even in patients with unilateral renal artery stenosis.
There is no experience regarding the administration of Triapin mite in patients with a recent kidney transplantation.
Hepatic failure
Rarely, ACE inhibitors have been associated with a syndrome that starts with cholestatic jaundice and progress to fulminant hepatic necrosis and (sometimes) death. The mechanism of this syndrome is not understood. Patients receiving ACE inhibitors who develop jaundice or marked elevations of hepatic enzymes should discontinue the ACE inhibitor and receive appropriate medical follow-up.
Patients with mild to moderately impaired liver function
For dosage see respective monoproducts.
Surgery/Anaesthesia
Hypotension may occur in patients undergoing major surgery or during treatment with anaesthetic agents that are known to lower blood pressure. If hypotension occurs, it may be corrected by volume expansion.
Aortic stenosis/Hypertrophic cardiomyopathy
ACE inhibitors should be used with caution in patients with haemodynamically relevant left-ventricular inflow or outflow impediment (e.g. stenosis of the aortic or mitral valve, obstructive cardiomyopathy). The initial phase of treatment requires special medical supervision.
Symptomatic hypotension
In some patients, symptomatic hypotension may be observed after the initial dose, mainly in patients with heart failure (with or without renal insufficiency) treated with high doses of loop diuretics, in hyponatraemia or in reduced renal function. Therefore, Triapin mite should only be given to such patients after special considerations and after the doses of the individual components have been carefully titrated. Triapin mite should only be given if the patient is in a stable circulatory condition (see section 4.3). In hypertensive patients without cardiac and renal insufficiency, hypotension may occur especially in patients with decreased blood volume due to diuretic therapy, salt restriction, diarrhoea or vomiting.
Patients who would be at particular risk from an undesirably pronounced reduction in blood pressure (e.g. patients with coronary or cerebrovascular insufficiency) should be treated with ramipril and felodipine in a free combination. If satisfactory and stable blood pressure control is achieved with the doses of ramipril and felodipine included in Triapin mite, the patient can be switched to this combination. In some cases, felodipine may cause hypotension with tachycardia, which may aggravate angina pectoris.
Neutropenia/Agranulocytosis
Triapin mite may cause agranulocytosis and neutropenia. These undesirable effects have also been shown with other ACE inhibitors, rarely in uncomplicated patients but more frequently in patients with some degree of renal impairment, especially when it is associated with collagen vascular disease (e.g. systemic lupus erythematodes, scleroderma) and therapy with immunosuppressive agents. Monitoring of white blood cell counts should be considered for patients who have collagen vascular disease, especially if the disease is associated with impaired renal function. Neutropenia and agranulocytosis are reversible after discontinuation of the ACE inhibitor. Should symptoms such as fever, swelling of the lymph nodes, and/or inflammation of the throat occur in the course of therapy with Triapin mite, the treating physician must be consulted and the white blood picture investigated immediately.
Cough
During treatment with an ACE inhibitor a dry cough may occur which disappears after discontinuation.
Concomitant treatment with ACER inhibitors and antidiabetics
Concomitant treatment with ACE inhibitors and antidiabetics (insulin and oral antidiabetics) may lead to an enhanced hypoglycaemic effect with the risk of hypoglycaemia. This effect may be most pronounced at the beginning of treatment and in patients with impaired renal function.
Felodipine is metabolised by CYP3A4. Therefore, combination with medicinal products which are potent CYP3A4 inhibitors or inducers should be avoided. For the same reason, the concomitant intake of grapefruit juice should be avoided (see section 4.5).
Lithium
The combination of lithium and ACE inhibitors is not recommended. (see section 4.5).
LDL-apheresis
Concomitant use of ACE inhibitors and extracorporeal treatments leading to contact of blood with negatively charged surfaces should be avoided since it may lead to severe anaphylactoid reactions. Such extracorporeal treatments include dialysis or haemofiltration with certain high-flux (e.g. polyacrylonitrile) membranes and low-density lipoprotein apheresis with dextran sulphate.
Desensitisation therapy
Increased likelihood and greater severity of anaphylactic and anaphylactoid reactions to insect venom (e.g. bee and wasp) as for other ACE inhibitors.
Ethnic differences
As with other angiotensin converting enzyme inhibitors, ramipril is apparently less effective in lowering blood pressure in black people than in non-blacks, possibly because of a higher prevalence of low-renin states in the black hypertensive population.
Children, patients with creatinine clearance under 20 ml/min and dialysis-treated patients
No experience is available. Triapin mite should not be given to these patient groups.
Lactose
This product contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
Not recommended associations
Potassium salts, potassium-retaining diuretics: Rise in serum potassium concentration is to be anticipated. Concomitant treatment with potassium-retaining diuretics (e.g. spironolactone, triamterene, or amiloride) or with potassium salts requires close monitoring of serum potassium.
Felodipine is a CYP3A4 substrate. Medicinal products that induce or inhibit CYP3A4 will have large influence on felodipine plasma concentrations.
Medicinal products that increase the metabolism of felodipine through induction of cytochrome P450 3A4 include carbamazepine, phenytoin, phenobarbital and rifampin as well as St John's wort (Hypericum perforatum). During concomitant administration of felodipine with carbamazepine, phenytoin, phenobarbital, AUC decreased by 93% and Cmax by 82%. A similar effect is expected with St John's wort. Combination with CYP3A4 inducers should be avoided.
Potent inhibitors of cytochrome P450 3A4 include azole antifungals, macrolide antibiotics, telithomycin and HIV protease inhibitors. During concomitant administration of felodipine with itraconazole, Cmax increased 8-fold and AUC 6-fold. During concomitant administration of felodipine with erythromycin, Cmax and AUC increased approximately 2.5-fold. Combination with potent CYP3A4 inhibitors should be avoided.
Grapefruit juice inhibits cytochrome P450 3A4. Concomitant administration of felodipine with grapefruit juice increased felodipine Cmax and AUC approximately 2-fold. The combination should be avoided.
Caution is recommended with concomitant use
Lithium
Excretion of lithium may be reduced by ACE inhibitors, leading to lithium toxicity. Lithium levels must, therefore, be monitored.
Antihypertensive agents and other substances with blood pressure lowering potential (e.g. nitrates, antipsychotics, narcotics, anaesthetics)
Potentiation of the antihypertensive effect of Triapin mite is to be anticipated.
Allopurinol, immunosuppressants, corticosteroids, procainamide, cytostatics and other substances that may change the blood picture
Increased likelihood of haematological reactions.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Attenuation of the effect of ramipril is to be expected. Furthermore, concomitant treatment with ACE inhibitors and such medicinal products may lead to an increased risk of worsening of the renal function and an increase in serum potassium.
Vasopressor sympathomimetics
These may reduce the antihypertensive effect of Triapin mite. Particularly close blood pressure monitoring is recommended.
Insulins, metformin, sulphonylureas
Concomitant treatment with ACE inhibitors and antidiabetic agents may cause a pronounced hypoglycaemic effect with the risk of hypoglycaemia. This effect is most pronounced at the beginning of treatment.
Theophylline
Concomitant administration of felodipine and oral theophylline reduces theophylline absorption by approximately 20%. This is probably of minor clinical importance.
Tacrolimus
Felodipine may increase the concentration of tacrolimus. When used together, the tacrolimus serum concentration should be followed and the tacrolimus dose may need to be adjusted.
Heparin
Rise in serum potassium concentration possible.
Salt
Increased dietary salt intake may attenuate the antihypertensive effect of Triapin mite.
Alcohol
Increased vasodilatation. The antihypertensive effect of Triapin mite may increase.
4.6 Pregnancy And Lactation
Pregnancy
Triapin mite is contra-indicated (see section, 4.3.) in pregnancy.
Calcium antagonists may inhibit contractions of the uterus during labour. Definite evidence that labour is prolonged in full-term pregnancy is lacking. Risk of foetal hypoxia may occur if the mother is hypotensive and perfusion of the uterus is reduced due to redistribution of the blood-flow through peripheral vasodilatation. In animal experiments, calcium antagonists have caused embryotoxic and/or teratogenic effects, especially in the form of distal skeletal malformations in several species.
Appropriate and well-controlled studies with ramipril have not been done in humans. ACE inhibitors cross the placenta and can cause foetal and neonatal morbidity and mortality when administered to pregnant women.
Fetal exposure to ACE inhibitors during the second and third trimesters has been associated with neonatal hypotension, renal failure, face or skull deformities and/or death. Maternal oligohydramnios have also been reported reflecting decreasing renal function in the fetus. Limb contractures, craniofacial deformities, hypoplastic lung development and intrauterine growth retardation have been reported in association with oligohydramnios. Intrauterine growth retardation, prematurity, persistent ductus arteriosus and fetal death have also been reported, but it is not clear whether they are related to the ACE inhibitor or to the underlying maternal disease. Whether exposure limited to the first trimester can adversely effect fetal outcome is not known.
Breastfeeding
In animals, ramipril is excreted in milk. No information is available on whether or not ramipril is excreted in human breast-milk. Felodipine is excreted in human breast-milk.
Women must not breast-feed during treatment with Triapin mite (see section 4.3).
4.7 Effects On Ability To Drive And Use Machines
Some undesirable effects (e.g. some symptoms of reduction in blood pressure such as dizziness) may be accompanied by an impairment of the ability to concentrate and react. This may constitute a risk in situations where these abilities are of special importance, e.g., when driving a car or operating machinery.
4.8 Undesirable Effects
The frequencies used in the tables throughout this section are:
very common (
The following undesirable effects may occur in connection with felodipine treatment
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The following undesirable effects may occur in connection with ramipril treatment
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4.9 Overdose
Symptoms
Overdosage may cause excessive peripheral vasodilatation with marked hypotension, bradycardia, shock, electrolyte disturbances and renal failure.
Management
Primary detoxification by, for example, gastric lavage, administration of adsorbents and/or sodium sulphate (if possible during the first 30 minutes). In case of hypotension, administration of α1-adrenergic sympathomimetics and angiotensin II must be considered in addition to volume and salt substitution. Bradycardia or extensive vagal reactions should be treated by administering atropine.
No experience is available concerning the efficacy of forced diuresis, alteration in urine pH, haemofiltration, or dialysis in speeding up the elimination of ramipril or ramiprilat. If dialysis or haemofiltration is nevertheless considered, see also under 4.4 Special Warnings and Special Precautions for use.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Pharmacotherapeutic group: Antihypertensive drugs. ATC code: C09B B05
Both the calcium antagonist felodipine and the ACE inhibitor ramipril reduce blood pressure by dilation of the peripheral blood vessels. Calcium antagonists dilate the arterial beds while ACE inhibitors dilate both arterial and venous beds. Vasodilatation and thereby reduction of blood pressure may lead to activation of the sympathetic nervous system and the renin-angiotensin system. Inhibition of ACE results in decreased plasma angiotensin II.
The onset of the antihypertensive effect of a single dose of Triapin mite is 1 to 2 hours. The maximum antihypertensive effect is achieved within 2 to 4 weeks and is maintained during long-term therapy. The blood pressure reduction is maintained throughout the 24-hour dosage interval. Morbidity and mortality data are not available.
Felodipine is a vascular selective calcium antagonist, which lowers arterial blood pressure by decreasing peripheral vascular resistance via a direct relaxant action on vascular smooth muscles. Due to its selectivity for smooth muscle in the arterioles, felodipine, in therapeutic doses, has no direct effect on cardiac contractility or conduction. The renal vascular resistance is decreased by felodipine. The normal glomerular filtration rate is not influenced. In patients with impaired renal function, the glomerular filtration rate may increase. Felodipine possesses a mild natriuretic/diuretic effect and fluid retention does not occur.
Ramipril is a prodrug which hydrolyses to the active metabolite ramiprilat, a potent and long-acting ACE (angiotensin converting enzyme) inhibitor. In plasma and tissue, ACE catalyses the conversion of angiotensin I to the vasoconstrictor angiotensin II and also the breakdown of the vasodilator bradykinin. The vasodilatation induced by the ACE inhibitor reduces blood pressure pre-load and after-load. Since angiotensin II also stimulates the release of aldosterone, ramiprilat reduces secretion of aldosterone. Ramipril reduces peripheral arterial resistance without major changes in renal plasma flow or glomerular filtration rate. In hypertensive patients, ramipril leads to a reduction in supine and standing blood pressure without a compensatory rise in heart rate.
5.2 Pharmacokinetic Properties
General characteristics of the active substances
Felodipine ER (extended-release formulation): The bioavailability is approximately 15% and is not influenced by concomitant intake of food. The peak plasma concentration is reached after 3 to 5 hours. Binding to plasma proteins is more than 99%. The distribution volume at steady state is 10 l/kg. The half-life for felodipine in the elimination phase is approximately 25 hours and steady state is reached after 5 days. There is no risk of accumulation during long-term treatment. Mean clearance is 1200 ml/min. Decreased clearance in elderly patients leads to higher plasma concentrations of felodipine. Age only partly explains the inter-individual variation in plasma concentration, however. Felodipine is metabolised in the liver and all identified metabolites are devoid of vasodilating properties. Approximately 70% of a given dose is excreted as metabolites in the urine and about 10% with the faeces. Less than 0.5% of the dose is excreted unchanged in the urine. Impaired renal function does not influence the plasma concentration of felodipine.
Ramipril: The pharmacokinetic parameters of ramiprilat are calculated after intravenous administration of ramipril. Ramipril is metabolised in the liver, and aside from the active metabolite ramiprilat, pharmacologically inactive metabolites have been identified. The formation of active ramiprilat may be decreased in patients with impaired liver function. The metabolites are excreted mainly via the kidneys. The bioavailability of ramiprilat is approximately 28% after oral administration of ramipril. After intravenous administration of 2.5 mg ramipril, approximately 53% of the dose is converted to ramiprilat. A maximum serum concentration of ramiprilat is achieved after 2 to 4 hours. Absorption and bioavailability are not influenced by concomitant intake of food. The protein binding of ramiprilat is approximately 55%. The distribution volume is approximately 500 litres. The effective half-life, after repeated daily dosage of 5 to 10 mg, is 13 to 17 hours. Steady-state is achieved after approximately 4 days. Renal clearance is 70 to 100 ml/min and total clearance is approximately 380 ml/min. Impaired renal function delays the elimination of ramiprilat and excretion in the urine is reduced.
Characteristics of the combination product
In Triapin mite the pharmacokinetics of ramipril, ramiprilat and felodipine are essentially unaltered compared to the monoproducts, felodipine ER tablets and ramipril tablets. Felodipine does not influence the ACE inhibition caused by ramiprilat. The fixed combination tablets are thus regarded as bioequivalent to the free combination.
5.3 Preclinical Safety Data
Repeated-dose toxicity studies performed with the combination in rats and monkeys did not demonstrate any synergistic effects.
Non-clinical data for felodipine and ramipril reveal no special hazard for humans based on conventional studies of genotoxicity and carcinogenic potential.
Reproduction toxicity
Felodipine: In investigations on fertility and general reproductive performance in rats, a prolongation of parturition resulting in difficult labour/increased foetal deaths and early postnatal deaths was observed. Reproduction toxicity studies in rabbits have shown a dose-related reversible enlargement of the mammary glands of the parent animals and dose-related digital anomalies in the foetuses.
Ramipril: Studies in rats, rabbits and monkeys did not disclose any teratogenic properties. Daily doses during pregnancy and lactation in rats produced irreversible renal pelvis dilatation in the offspring.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Cellulose microcrystalline
Hyprolose
Hypromellose
Iron oxides E172
Lactose anhydrous
Macrogol 6000
Macrogolglycerol hydroxystearate
Maize starch
Paraffin
Propyl gallate
Sodium aluminium silicate
Sodium stearyl fumarate
Titanium dioxide E 171
6.2 Incompatibilities
Not applicable.
6.3 Shelf Life
Triapin mite: 2 years
6.4 Special Precautions For Storage
Do not store above 30°C.
6.5 Nature And Contents Of Container
PVC/PVDC blisters: 28 tablets
6.6 Special Precautions For Disposal And Other Handling
No special requirements.
7. Marketing Authorisation Holder
Sanofi-aventis
One Onslow Street
Guildford
Surrey
GU1 4YS
UK
8. Marketing Authorisation Number(S)
PL 04425/0321
9. Date Of First Authorisation/Renewal Of The Authorisation
15th April 2002
15th January 2008
10. Date Of Revision Of The Text
31 August 2011
LEGAL STATUS
POM
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