Alkadil

Hypertension: The management of mild to moderate hypertension. In severe hypertension it should be used where standard therapy is ineffective or inappropriate.

Congestive heart failure: Alkadil is indicated for the treatment of congestive heart failure. The drug should be used together with diuretics and, when appropriate, digitalis and beta-blockers.

In patients on doses of over 100 mg daily plus or minus a diuretic, in those with severe renal impairment or those with severe congestive heart failure use of Alkadil should be under specialist supervision.

Myocardial Infarction:

- short-term (4 weeks) treatment: Alkadil is indicated in any clinically stable patient within the first 24 hours of an infarction.

- long-term prevention of symptomatic heart failure: Alkadil is indicated in clinically stable patients with asymptomatic left ventricular dysfunction (ejection fraction ≤ 40%) following myocardial infarction to improve survival, delay the onset of symptomatic heart failure, reduce hospitalisations for heart failure and reduce recurrent myocardial infarction and coronary revascularisation procedures.

Before starting therapy, cardiac function should be determined by radionuclide ventriculography or echocardiography.

Type I Diabetic nephropathy: Alkadil is indicated in insulin dependent diabetics for the treatment of macroproteinuric diabetic nephropathy (microalbuminuria greater than 30 mg/day). Alkadil may prevent the progression of the renal disease and reduce associated clinical events e.g. dialysis, renal transplantation and death.

Alkadil can be used alone or in combination with other antihypertensive agents .

For Oral Administration

Dose should be individualised according to patient's profile and blood pressure response. The recommended maximum daily dose is 150 mg.

Alkadil may be taken before, during and after meals.

Adults

Hypertension:Treatment with Alkadil should be at the lowest effective dose which should be titrated according to the needs of the patient.

The recommended starting dose is 25-50 mg daily in two divided doses. The dose may be increased incrementally, with intervals of at least 2 weeks, to 100-150 mg/day in two divided doses as needed to reach target blood pressure. Alkadil can be used alone or with other antihypertensive agents. A once-daily dosing regimen may be appropriate when concomitant antihypertensive medication such as thiazide diuretics is added.

In patients with a strongly active renin-angiotensin-aldosterone system (hypovolaemia, renovascular hypertension, cardiac decompensation) it is preferable to commence with a single dose of 6.25 mg or 12.5 mg. The inauguration of this treatment should preferably take place under close medical supervision. These doses will then be administered at a rate of two per day. The dosage can be gradually increased to 50 mg per day in one or two doses and if necessary to 100 mg per day in one or two doses.

Congestive heart failure: Alkadil therapy must be started under close medical supervision. The usual starting dose is 6.25 mg - 12.5 mg BID or TID.. Titration to the maintenance dose (75 - 150 mg per day) should be carried out based on patient's response, clinical status and tolerability, up to a maximum of 150 mg per day in divided doses. The dose should be increased incrementally, with intervals of at least 2 weeks to evaluate patient's response.

Myocardial infarction:

- short-term treatment: Alkadil treatment should begin in hospital as soon as possible following the appearance of the signs and/or symptoms in patients with stable haemodynamics. A 6.25 mg test dose should be administered, with a 12.5 mg dose being administered 2 hours afterwards and a 25 mg dose 12 hours later. From the following day, Alkadil should be administered in a 100 mg/day dose, in two daily administrations, for 4 weeks, if warranted by the absence of adverse haemodynamic reactions. At the end of the 4 weeks of treatment, the patient's state should be reassessed before a decision is taken concerning treatment for the post-myocardial infarction stage.

- chronic treatment: if Alkadil treatment has not begun during the first 24 hours of the acute myocardial infarction stage, it is suggested that treatment be instigated between the 3rd and 16th day post-infarction once the necessary treatment conditions have been attained (stable haemodynamics and management of any residual ischaemia). Treatment should be started in hospital under strict surveillance (particularly of blood pressure) until the 75 mg dose is reached. The initial dose must be low , particularly if the patient exhibits normal or low blood pressure at the initiation of therapy. Treatment should be initiated with a dose of 6.25 mg followed by 12.5 mg 3 times daily for 2 days and then 25 mg 3 times daily if warranted by the absence of adverse haemodynamic reactions. The recommended dose for effective cardioprotection during long-term treatment is 75 to 150 mg daily in two or three doses. In cases of symptomatic hypotension, as in heart failure, the dosage of diuretics and/or other concomitant vasodilators may be reduced in order to attain the steady state dose of Alkadil. Where necessary, the dose of Alkadil should be adjusted in accordance with the patient's clinical reactions. Alkadil may be used in combination with other treatments for myocardial infarction such as thrombolytic agents, beta-blockers and acetylsalicylic acid.

Type I Diabetic nephropathy: The recommended dose is 75-100 mg daily in divided doses. Alkadil may be used in combination with other antihypertensive agents, i.e. diuretics, beta blockers, centrally acting agents or vasodilators if the reduction in blood pressure is inadequate with Alkadil alone.

Patients with renal impairment

Since Alkadil is excreted primarily via the kidneys, dosage should be reduced or the dosage interval should be increased in patients with impaired renal function. When concomitant diuretic therapy is required, a loop diuretic (e.g. furosemide), rather than a thiazide diuretic, is preferred in patients with severe renal impairment.

In patients with impaired renal function, the following daily dose may be recommended to avoid accumulation of Alkadil.

Elderly

Dosage should be titrated against blood pressure response and kept as low as possible to achieve adequate control.

Children and adolescents

The efficacy and safety of Alkadil have not been fully established. The use of Alkadil in children and adolescents should be initiated under close medical supervision.

The initial starting dose should be 0.3 mg per kg body weight..For patients requiring special precautions (children with renal dysfunction, premature infants, new-borns and infants, because their renal function is not the same with older children and adults) the starting dose should be only 0.15 mg Alkadil/kg weight. Generally, Alkadil is administered to children 3 times a day, but dose and interval of dose should be adapted individually according to patient's response.

1. Hypersensitivity to Alkadil and other ACE inhibitors, or any of the excipients.

2. History of angioedema associated with previous ACE inhibitor therapy.

3. Hereditary or Idiopathic angioneurotic oedema.

4. Second and third trimesters of pregnancy.

5. The concomitant use of Alkadil tablets, hard with aliskiren-containing products is contraindicated in patients with diabetes mellitus or renal impairment (GFR < 60 ml/min/1.73 m2).”

Hypotension: rarely hypotension is observed in uncomplicated hypertensive patients. Symptomatic hypotension is more likely to occur in hypertensive patients who are volume and/or sodium depleted by vigorous diuretic therapy, dietary salt restriction, diarrhoea, vomiting or haemodialysis. Volume and/or sodium depletion should be corrected before the administration of an ACE inhibitor and a lower starting dose should be considered.

Patients with heart failure are at higher risk of hypotension and a lower starting dose is recommended when initiating therapy with an ACE inhibitor. The magnitude of the decrease is greatest early in the course of treatment; this effect stabilises within a week or two, and generally returns to pre-treatment levels, without a decrease in therapeutic efficacy, within two months. Caution should be used whenever the dose of Alkadil or diuretic is increased in patients with heart failure.

As with any antihypertensive agent, excessive blood pressure lowering in patients with ischaemic cardiovascular or cerebrovascular disease may increase the risk of myocardial infarction or stroke. If hypotension develops, the patient should be placed in a supine position. Volume repletion with intravenous normal saline may be required.

Infants, especially new-borns, may be more susceptible to the adverse haemodynamic effects of Alkadil. Excessive, prolonged and unpredictable decreases in blood pressure and associated complications, including oliguria and seizures have been reported.

Renovascular hypertension: there is an increased risk of hypotension and renal insufficiency when patients with bilateral renal artery stenosis or stenosis of the artery to a single functioning kidney are treated with ACE inhibitors. Loss of renal function may occur with only mild changes in serum creatinine. In these patients, therapy should be initiated under close medical supervision with low doses, careful titration and monitoring of renal function.

Renal impairment: The incidence of adverse reactions to Alkadil is principally associated with renal function since the drug is excreted primarily by the kidney. In cases of renal impairment (creatinine clearance ≤40 ml/min), the initial dosage of Alkadil must be adjusted according to the patient's creatinine clearance , and then as a function of the patient's response to treatment. The dose should not exceed that necessary for adequate control and should be reduced in patients with impaired renal function.

Evaluation of the patient should include assessment of renal function (monitoring of potassium and creatinine) prior to initiation of therapy and at appropriate intervals thereafter. Patients with renal impairment should not normally be treated with Alkadil.

Aortic and mitral valve stenosis/ Obstructive hypertropic cardiomyopathy: Alkadil should be used with caution in patients with left ventricular valvular and outflow tract obstruction. As limited experience has been obtained in the treatment of acute hypertensive crises, the use of Alkadil should be avoided in cases of cardiogenic shock and haemodynamically significant obstruction.

Angioedema: angioedema of the extremities, face, lips, mucous membranes, tongue, glottis or larynx may occur in patients treated with ACE inhibitors including Alkadil. This may occur anytime during treatment. However, in rare cases, severe angioedema may develop after long-term treatment with an ACE inhibitor. In such cases, Alkadil should be discontinued promptly and appropriate monitoring should be instituted to ensure complete resolution of symptoms prior to dismissing the patient. In those instances where swelling has been confined to the face and lips the condition generally resolved without treatment, although antihistamines have been useful in relieving symptoms. Angioedema involving the tongue, glottis or larynx may be fatal. Where there is involvement of the tongue, glottis or larynx, likely to cause airway obstruction, appropriate therapy, which may include subcutaneous epinephrine solution 1:1000 (0.3 ml to 0.5 ml) and/or measures to ensure a patent airway, should be administered promptly. 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.

Black patients receiving ACE inhibitors have been reported to have a higher incidence of angioedema compared to non-blacks.

Patients with a history of angioedema unrelated to ACE inhibitor therapy may be at increased risk of angioedema while receiving an ACE inhibitor.

Intestinal angioedema has also been reported rarely 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 facial angioedema and C-1 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.

Cough: cough has been reported with the use of ACE inhibitors. Characteristically, the cough is non-productive, persistent and resolves after discontinuation of therapy.

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.

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.”

Hepatic failure: rarely, ACE inhibitors have been associated with a syndrome that starts with cholestatic jaundice and progresses 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.

Hyperkalaemia: Elevations in serum potassium have been observed in some patients treated with ACE inhibitors, including Alkadil. 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 drugs 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.

Lithium: the combination of lithium and Alkadil is not recommended

Proteinuria: Proteinuria may occur particularly in patients with existing renal function impairment or on relatively high doses of ACE inhibitors.

Total urinary proteins greater than 1 g per day were seen in about 0.7% of patients receiving Alkadil. The majority of patients had evidence of prior renal disease or had received relatively high doses of Alkadil (in excess of 150 mg/day), or both. Nephrotic syndrome occurred in about one-fifth of proteinuric patients. In most cases, proteinuria subsided or cleared within six months whether or not Alkadil was continued. Parameters of renal function, such as BUN and creatinine, were seldom altered in the patients with proteinuria.

In patients with evidence of prior renal disease should have urinary protein estimations (dip stick on first morning urine) prior to treatment, and periodically thereafter.

Although membranous glomerulopathy was found in biopsies taken from some proteinuric patients, a causal relationship to Alkadil has not been established.

Anaphylactoid reactions during desensitisation: There have been rare reports of sustained life-threatening anaphylactoid reactions in patients undergoing desensitisation treatment with hymenoptera venom while receiving another ACE inhibitors. In the same patients, these reactions were avoided when the ACE inhibitor was temporarily withheld, but they reappeared upon inadvertent rechallenge. Therefore caution should be used in patients treated with ACE inhibitors undergoing such desensitisation procedures.

Anaphylactoid reactions during high-flux dialysis / lipoprotein apheresis membrane exposure: Recent clinical observations have shown a high incidence of anaphylactoid-like reactions during haemodialysis with high-flux dialysis membranes (e.g. AW 69) or undergoing low-density lipoprotein apheresis with dextran sulphate absorption in patients receiving ACE inhibitors. Therefore, this combination should be avoided. In these patients, consideration should be given to use a different type of dialysis, membrane or a different class of medication.

Diabetic patients: the glycaemia levels should be closely monitored in diabetic patients previously treated with oral antidiabetic drugs or insulin, namely during the first month of treatment with an ACE inhibitor.

Renal function in patients with Heart failure: Some patients may develop stable elevations of BUN and serum creatinine >20% above normal or baseline upon long-term treatment with Alkadil. A few patients, generally those with severe pre-existing renal disease, required discontinuation of treatment due to progressively increasing creatinine.

Neutropenia/Agranulocytosis: neutropenia/agranulocytosis, thrombocytopenia and anaemia have been reported in patients receiving ACE inhibitors, including Alkadil. In patients with normal renal function and no other complicating factors, neutropenia occurs rarely.

Alkadil should be used with extreme caution in patients with pre-existing impaired renal function, collagen vascular disease, immunosuppressant therapy, treatment with allopurinol or procainamide, or a combination of these complicating factors. Some of these patients developed serious infections which in a few instances did not respond to intensive antibiotic therapy.

If Alkadil is used in such patients, it is advised that white blood cell count and differential counts should be performed prior to therapy, every two weeks during the first three months of Alkadil therapy, and periodically thereafter.

During treatment all patients should be instructed to report any sign of infection (e.g. sore throat, fever), when a differential white blood cell count should be performed. Alkadil and other concomitant medication should be withdrawn if neutropenia (neutrophils less than 1000/mm³) is detected or suspected.

In most patients neutrophil counts rapidly returned to normal upon discontinuing Alkadil.

Surgery/Anaesthesia: In patients undergoing major surgery, or during anaesthesia with agents which produce hypotension, Alkadil will block angiotensin II formation secondary to compensatory renin release. This may lead to hypotension which can be corrected by volume expansion.

Lactose: Alkadil tablet contains lactose, therefore patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Ethnic differences: As with other angiotensin converting enzyme inhibitors, Alkadil 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.

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..

As with other antihypertensives, the ability to drive and use machines may be reduced, namely at the start of the treatment, or when posology is modified, and also when used in combination with alcohol, but these effects depend on the individual's susceptibility.

Frequency is defined using the following convention: common (> 1/100, < 1/10), uncommon (> 1/1,000, < 1/100), rare (> 1/10,000, < 1/1,000) and very rare (< 1/10,000). Undesirable effects reported for Alkadil and/or ACE inhibitor therapy include:

Blood and lymphatic disorders:

very rare: neutropenia/agranulocytosis , pancytopenia particularly in patients with renal dysfunction , anaemia (including aplastic and haemolytic), thrombocytopenia, lymphadenopathy, eosinophilia, auto-immune diseases and/or positive ANA-titres.

Metabolic and nutritional disorder:

Rare: Anorexia

Very rare: hyperkalaemia, hyponatremia and hypoglycaemia

Psychiatric disorders:

common: sleep disorders

very rare: confusion, depression.

Nervous system disorders:

Common: reversible and self limiting taste impairment and dizziness.

Uncommon: paraesthesia, headache.

Rare: Somnolence

Very rare: cerebrovascular incidents, including stroke and syncope.

Eye disorders:

very rare: blurred vision.

Cardiac disorders:

uncommon: tachycardia or tachyarrhythmia, angina pectoris, palpitations.

very rare: cardiac arrest, cardiogenic shock

Vascular disorders:

uncommon: hypotension , Raynaud syndrome, flush, pallor

Respiratory, thoracic and mediastinal disorders:

Common: dry, irritating (non-productive) cough and dyspnoea

Vary rare: bronchospasms, rhinitis, allergic alveolitis/ eosinophilic pneumonia.

Gastrointestinal disorders:

Common: nausea, vomiting, epigastric discomfort, abdominal pain, diarrhoea, constipation, dry mouth, peptic ulcer, dyspepsia.

Rare: stomatitis/aphthous stomatitis, small bowel angioedema

Very rare: glossitis, pancreatitis.

Hepato-biliary disorders:

Very rare: hepatic function abnormal, cholestasis, jaundice, hepatitis, hepatic necrosis, hepatic enzyme increased, blood bilirubin increased, transaminase increased, blood alkaline phosphatase increased.

Skin and subcutaneous tissue disorders:

Common: pruritus with or without a rash, rash, and alopecia.

Uncommon: angioedema (see 4.4)

very rare: urticaria, Stevens Johnson syndrome, erythema multiforme, photosensitivity, erythroderma, pemphigoid reactions and exfoliative dermatitis.

Musculoskeletal, connective tissue and bone disorders:

very rare: myalgia, arthralgia.

Renal and Urinary Disorders:

rare: renal impairment, renal failure, polyuria, oliguria, pollakiuria.

very rare: nephrotic syndrome.

Reproductive system and breast disorders:

very rare: erectile dysfunction, gynaecomastia.

General disorders and administration site conditions:

uncommon: chest pain, fatigue, malaise, asthenia

very rare: pyrexia

Investigations:

very rare: proteinuria, eosinophilia, blood potassium increased, blood sodium decreased, blood urea increased, blood creatinine increased, blood bilirubin increased, haemoglobin decreased, haematocrit decreased, white blood cell count decreased, platelet count decreased, antinuclear antibody positive, red blood cell sedimentation rate increased..

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 Yellow Card Scheme.

Website: www.mhra.gov.uk/yellowcard.

Symptoms of overdose are severe hypotension, shock, stupor, bradycardia, electrolyte disturbances and renal failure.

Measures to prevent absorption (e.g. gastric lavage, administration of adsorbents and sodium sulphate within 30 minutes after intake) and hasten elimination should be applied if ingestion is recent. If hypotension occurs, the patient should be placed in the shock position and salt and volume supplementations should be given rapidly. Treatment with angiotensin-II should be considered. Bradycardia or extensive vagal reactions should be treated by administering atropine. The use of a pacemaker may be considered.

Alkadil may be removed from adult circulation by haemodialysis. Alkadil is not adequately cleared by peritoneal dialysis.

Pharmacotherapeutic group: - Agents acting on the renin-angiotensin system, ACE Inhibitors, plain

ATC Code: C09A A01

Alkadil is a highly specific, competitive inhibitor of angiotensin-I converting enzyme (ACE inhibitors).

The beneficial effects of ACE inhibitors appear to result primarily from the suppression of the plasma renin-angiotensin-aldosterone system. Renin is an endogenous enzyme synthesised by the kidneys and released into the circulation where it converts angiotensinogen to angiotensin-I a relatively inactive decapeptide. Angiotensin-I is then converted by angiotensin converting enzyme, a peptidyldipeptidase, to angiotensin-II. Angiotensin-II is a potent vasoconstrictor responsible for arterial vasoconstriction and increased blood pressure, as well as for stimulation of the adrenal gland to secrete aldosterone. Inhibition of ACE results in decreased plasma angiotensin-II, which leads to decreased vasopressor activity and to reduced aldosterone secretion. Although the latter decrease is small, small increases in serum potassium concentrations may occur, along with sodium and fluid loss. The cessation of the negative feedback of angiotensin-II on the renin secretion results in an increase of the plasma renin activity.

Another function of the converting enzyme is to degrade the potent vasodepressive kinin peptide bradykinin to inactive metabolites. Therefore, inhibition of ACE results in an increased activity of circulating and local kallikrein-kinin-system which contributes to peripheral vasodilation by activating the prostaglandin system; it is possible that this mechanism is involved in the hypotensive effect of ACE inhibitors and is responsible for certain adverse reactions.

Reductions of blood pressure are usually maximal 60 to 90 minutes after oral administration of an individual dose of Alkadil. The duration of effect is dose related. The reduction in blood pressure may be progressive, so to achieve maximal therapeutic effects, several weeks of therapy may be required. The blood pressure lowering effects of Alkadil and thiazide-type diuretics are additive.

In patients with hypertension, Alkadil causes a reduction in supine and erect blood pressure, without inducing any compensatory increase in heart rate, nor water and sodium retention.

In haemodynamic investigations, Alkadil caused a marked reduction in peripheral arterial resistance. In general there were no clinically relevant changes in renal plasma flow or glomerular filtration rate. In most patients, the antihypertensive effect began about 15 to 30 minutes after oral administration of Alkadil; the peak effect was achieved after 60 to 90 minutes. The maximum reduction in blood pressure of a defined Alkadil dose was generally visible after three to four weeks.

In the recommended daily dose, the antihypertensive effect persists even during long-term treatment. Temporary withdrawal of Alkadil does not cause any rapid, excessive increase in blood pressure (rebound). The treatment of hypertension with Alkadil leads also to a decrease in left ventricular hypertrophy.

Haemodynamic investigations in patients with heart failure, showed that Alkadil caused a reduction in peripheral systemic resistance and a rise in venous capacity. This resulted in a reduction in pre-load and after-load of the heart (reduction in ventricular filling pressure). In addition, rises in cardiac output, work index and exercise capacity have been observed during treatment with Alkadil. In a large, placebo-controlled study in patients with left ventricular dysfunction (LVEF ≤40%) following myocardial infarction, it was shown that Alkadil (initiated between the 3rd to the 16th day after infarction) prolonged the survival time and reduced cardiovascular mortality. The latter was manifested as a delay in the development of symptomatic heart failure and a reduction in the necessity for hospitalisation due to heart failure compared to placebo. There was also a reduction in re-infarction and in cardiac revascularisation procedures and/or in the need for additional medication with diuretics and/or digitalis or an increase in their dosage compared to placebo.

A retrospective analysis showed that Alkadil reduced recurrent infarcts and cardiac revascularisation procedures (neither were target criteria of the study).

Another large, placebo-controlled study in patients with myocardial infarction showed that Alkadil (given within 24 hours of the event and for a duration of one month) significantly reduced overall mortality after 5 weeks compared to placebo. The favourable effect of Alkadil on total mortality was still detectable even after one year. No indication of a negative effect in relation to early mortality on the first day of treatment was found.

Alkadil cardioprotection effects are observed regardless of the patient's age or gender, location of the infarction and concomitant treatments with proven efficacy during the post-infarction period (thrombolytic agents, beta-blockers and acetylsalicylic acid).

Type I diabetic nephropathy

In a placebo-controlled, multicentre double blind clinical trial in insulin-dependent (Type I) diabetes with proteinuria, with or without hypertension (simultaneous administration of other antihypertensives to control blood pressure was allowed), Alkadil significantly reduced (by 51%) the time to doubling of the baseline creatinine concentration compared to placebo; the incidence of terminal renal failure (dialysis, transplantation) or death was also significantly less common under Alkadil than under placebo (51%). In patients with diabetes and microalbuminuria, treatment with Alkadil reduced albumin excretion within two years.

The effects of treatment with Alkadil on the preservation of renal function are in addition to any benefit that may have been derived from the reduction in blood pressure.

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.

Alkadil is an orally active agent that does not require biotransformation for activity. The average minimal absorption is approximately 75%. Peak plasma concentrations are reached within 60-90 minutes. The presence of food in the gastrointestinal tract reduces absorption by about 30-40%.Approximately 25 % to 30 % of the circulating drug is bound to plasma proteins.

The apparent elimination half-life of unchanged Alkadil in blood is about 2 hours. Greater than 95% of the absorbed dose is eliminated in the urine within 24 hours; 40-50% is unchanged drug and the remainder are inactive disulphide metabolites (Alkadil disulphide and Alkadil cysteine disulphide). Impaired renal function could result in drug accumulation. Therefore, in patients with impaired renal function the dose should be reduced and/or dosage interval prolonged (see 4.2).

Studies in animals indicate that Alkadil does not cross the blood-brain barrier to any significant extent.

Lactation:

In the report of twelve women taking oral Alkadil 100 mg 3 times daily, the average peak milk level was 4.7 µg/L and occurred 3.8 hours after the dose. Based on these data, the maximum daily dosage that a nursing infant would receive is less than 0.002% of the maternal daily dosage.

Animal studies performed during organogenesis with Alkadil have not shown any teratogenic effect but Alkadil has produced foetal toxicity in several species, including foetal mortality during late pregnancy, growth retardation and postnatal mortality in the rat. Preclinical data reveal no other specific hazard for humans based on conventional studies of safety pharmacology, repeated dose toxicology, genotoxicity and carcinogenicity.

Not applicable

No special instructions.