One film-coated tablet contains 10 mg lercanidipine hydrochloride, equivalent to 9.4 mg lercanidipine. Excipient: Lercanidipine Hydrochloride 10 mg film-coated tablets: Lactose monohydrate 30 mg

Film-coated tablets Lercanidipine Hydrochloride 10 mg film-coated tablets: Yellow, round, biconvex 6.5 mm film-coated tablets, scored on one side, marked 'L' on the other side. The score line is only to facilitate breaking for ease of swallowing and not to divide into equal doses.

Lercanidipine is indicated for the treatment of mild to moderate essential hypertension.

The recommended dosage is 10 mg orally once a day at least 15 minutes before meals; the dose may be increased to 20 mg depending on the individual patient's response.

Dose titration should be gradual, because it may take about 2 weeks before the maximal antihypertensive effect is apparent.

Some individuals, not adequately controlled on a single antihypertensive agent, may benefit from the addition of lercandipine to therapy with a beta-adrenoreceptor blocking drug, a diuretic (hydrochlorothiazide) or an angiotensin converting enzyme inhibitor.

Since the dose-response curve is steep with a plateau at doses between 20-30 mg, it is unlikely that efficacy will be improved by higher doses; whereas side effects may increase.

Elderly

Although the pharmacokinetic data and clinical experience suggest that no adjustment of the daily dosage is required, special care should be exercised when initiating treatment in the elderly.

Children and adolescents

Lercanidipine is not recommended for use in children and adolescents below the age of 18 years as there is no clinical experience.

Renal insufficiency

Special care should be exercised when treatment is commenced in patients with mild to moderate renal impairment. Although the usually recommended dose schedule may be tolerated, an increase in dose to 20mg daily must be approached with caution.

Lercanidipine is not recommended for use in patients with severe renal impairment (GFR < 30 ml/min).

Hepatic insufficiency

Special care should be exercised when treatment is commenced in patients with mild to moderate hepatic dysfunction. Although the usually recommended dose schedule may be tolerated, an increase in dose to 20 mg daily must be approached with caution. The antihypertensive effect may be enhanced in patients with hepatic impairment and consequently an adjustment of the dosage should be considered.

Administration

The tablets should be taken with some water before a meal.

- Hypersensitivity to lercanidipine, to any dihydropyridine or to any of the excipients.

- Left ventricular outflow tract obstruction.

- Untreated congestive cardiac failure.

- Unstable angina pectoris.

- Within 1 month of a myocardial infarction.

- Severe renal or hepatic impairment.

- Pregnancy and lactation

- Women of child-bearing potential unless effective contraception is used.

- Strong inhibitors of CYP3A4 

- Cyclosporin

- Grapefruit juice

Sick sinus syndrome

Special care should be exercised when lercanidipine is used in patients with sick sinus syndrome (if a pacemaker is not in situ). Although hemodynamic controlled studies revealed no impairment of ventricular function, care is also required in patients with LV dysfunction. It has been suggested that some short-acting dihydropyridines may be associated with increased cardiovascular risk in patients with ischaemic heart disease. Although lercanidipine is long-acting caution is required in such patients.

Angina pectoris

Some dihydropyridines may rarely lead to precordial pain or angina pectoris. Very rarely patients with pre-existing angina pectoris may experience increased frequency, duration or severity of these attacks.

Isolated cases of myocardial infarction may be observed.

Use in renal or hepatic dysfunction:

Special care should be exercised when treatment is commenced in patients with mild to moderate renal or hepatic dysfunction. Although the usually recommended dose schedule may be tolerated by these subgroups, an increase in dose to 20 mg daily must be approached with caution. The antihypertensive effect may be enhanced in patients with hepatic impairment and consequently an adjustment of the dosage should be considered.

Lercanidipine is not recommended for use in patients with severe hepatic impairment or in patients with severe renal impairment (GFR < 30 ml/min).

Alcohol should be avoided since it may potentiate the effect of vasodilating antihypertensive drugs.

CYP3A4 inducers

Inducers of CYP3A4 like anticonvulsants (e.g. phenytoin, carbamazepine) and rifampicin may reduce lercanidipine's plasma levels and therefore the efficacy of lercanidipine may be less than expected.

This medicinal product contains lactose monohydrate and therefore should not be administered to patients with Lapp lactase insufficiency, galactosaemia or glucose/galactose malabsorption syndrome.

Metabolic interactions

Lercanidipine is known to be metabolised by the CYP3A4 enzyme and, therefore, inhibitors and inducers of CYP3A4 administered concurrently may interact with the metabolism and elimination of lercanidipine.

CYP3A4 inhibitors

Co-administration of lercanidipine with inhibitors of CYP3A4 (e.g. ketoconazole, itraconazole, ritonavir, erythromycin, troleandomycin) should be avoided.

An interaction study with a strong CYP3A4 inhibitor, ketoconazole, has shown a considerable increase in plasma levels of lercanidipine (a 15-fold increase of the AUC and an 8-fold increase of the Cmax for the eutomer S-lercanidipine).

Increased plasma levels of both lercanidipine and ciclosporin have been observed following concomitant administration. A study in young healthy volunteers has shown that when ciclosporin was administered 3 hours after the lercanidipine intake, the plasma levels of lercanidipine did not change, while the AUC of ciclosporin increased by 27%. However, the co-administration of lercanidipine with ciclosporin has caused a 3-fold increase of the plasma levels of lercanidipine and a 21% increase of the ciclosporin AUC. Ciclosporin and lercanidipine should not be administered together.

As for other dihydropyridines, lercanidipine is sensitive to inhibition of metabolism by grapefruit juice, with a consequent rise in its systemic availability and increased hypotensive effect. Lercanidipine should not be taken with grapefruit juice.

When concomitantly administered at a dose of 20 mg with midazolam p.o. to elderly volunteers, lercanidipine's absorption was increased (by approximately 40%) and the rate of absorption was decreased (tmax was delayed from 1.75 to 3 hours). Midazolam concentrations were not modified.

CYP3A4 inducers

Co-administration of lercanidipine with CYP3A4 inducers like anticonvulsants (e.g. phenytoin, carbamazepine), rifampicin should be approached with caution since the antihypertensive effect may be reduced and blood pressure should be monitored more frequently than usual.

CYP3A4 substrates

Healthy volunteers treated with digoxin following dosing with 20 mg lercanidipine given fasted showed a mean increase of 33% in digoxin Cmax , while AUC and renal clearance were not significantly modified. Patients on concomitant digoxin treatment should be closely monitored clinically for signs of digoxin toxicity.

Co-administration of 20 mg lercanidipine in patients chronically treated with b-methyldigoxin showed no evidence of pharmacokinetic interaction.

Concomitant administration of cimetidine 800 mg daily does not cause significant modifications in plasma levels of lercanidipine, but at higher doses caution is required since the bioavailability and the hypotensive effect of lercanidipine may be increased.

An interaction study with fluoxetine (an inhibitor of CYP2D6 and CYP3A4), conducted in volunteers of an age of 65 ± 7 years (mean ± s.d.), has shown no clinically relevant modification of the pharmacokinetics of lercanidipine.

The co-administration of 20 mg lercanidipine to healthy volunteers given fasted did not alter the pharmacokinetics of warfarin.

Caution should be exercised when lercanidipine is co-prescribed with other substrates of CYP3A4, like terfenadine, astemizole, class III antiarrhythmic drugs such as amiodarone, quinidine.

Alcohol

Alcohol should be avoided since it may potentiate the effect of vasodilating antihypertensive drugs.

Other interactions

When lercanidipine was co-administered with metoprolol, β-blocker eliminated mainly by the liver, the bioavailability of metoprolol was not changed while that of lercanidipine was reduced by 50%. This effect may be due to the reduction in the hepatic blood flow caused by β-blockers and may therefore occur with other drugs of this class. Consequently, lercanidipine may be safely administered with beta-adrenoceptor blocking drugs, but dose adjustment may be required.

When a dose of 20 mg of lercanidipine was repeatedly co-administered with 40 mg of simvastatin, the AUC of lercanidipine was not significantly modified, while simvastatin's AUC increased by 56% and that of its active metabolite β-hydroxyacid by 28%. It is unlikely that such changes are of clinical relevance. No interaction is expected when lercanidipine is administered in the morning and simvastatin in the evening, as indicated for such drug.

Lercanidipine has been safely administered with diuretics and ACE inhibitors.

The following undesirable effects have been reported in clinical studies and in the post-marketing phase:

Assessment of frequencies:

Investigations

Very rare: reversible increases in serum levels of hepatic transaminases

Cardiac disorders

Uncommon: tachycardia; palpitations, peripheral oedema

Rare: angina pectoris

Very rare: chest pain, myocardial infarction, hypotension

Some dihydropyridines may rarely lead to precordial pain or angina pectoris. Very rarely patients with pre-existing angina pectoris may experience increased frequency, duration or severity of these attacks.

Nervous system disorders

Uncommon: headache; dizziness

Gastrointestinal disorders

Rare: nausea; dyspepsia; diarrhoea; abdominal pain; vomiting

Very rare: gingival hypertrophy

Renal and urinary disorders

Rare: polyuria

Very rare: urinary frequency

Skin and subcutaneous tissue disorders

Rare: rash

Musculoskeletal and connective tissue disorders

Rare: myalgia

Vascular disorders

Uncommon: flushing

General disorders and administration site conditions

Rare: asthenia; fatigue

Immune system disorders

Very rare: hypersensitivity

Psychiatric disorders

Rare: somnolence

Lercanidipine does not appear to influence adversely blood sugar or serum lipid levels.

Winthrop Pharmaceuticals UK Ltd

POM – Prescription Only Medicine

18 August 2010