Telmisartan and Hydrochlorothiazide Tablets USP 80mg/12.5mg Taj Pharma

1. Name of the medicinal product

Telmisartan and Hydrochlorothiazide Tablets USP 40mg/12.5mg Taj Pharma
Telmisartan and Hydrochlorothiazide Tablets USP 80mg/12.5mg Taj Pharma

2. Qualitative and quantitative composition

a) Each film-coated tablet contains:
Telmisartan USP? ? ? ? ? ? ? ? ? ? 40mg
Hydrochlorothiazide USP? ? ?12.5mg
Excipients? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?q.s
Colours: Yellow Oxide of Iron & Titanium Dioxide USP

b) Each film-coated tablet contains:
Telmisartan USP? ? ? ? ? ? ? ? ? ? 80mg
Hydrochlorothiazide USP? ? ?12.5mg
Excipients? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? q.s
Colours: Yellow Oxide of Iron & Titanium Dioxide USP

For the full list of excipients, see section 6.1.

3. Pharmaceutical form

Film-coated tablets.

4. Clinical particulars

4.1 Therapeutic indications

Treatment of essential hypertension.

Telmisartan/Hydrochlorothiazide fixed-dose combination (80 mg telmisartan/12.5 mg hydrochlorothiazide) is indicated in patients whose blood pressure is not adequately controlled on telmisartan alone.

4.2 Posology and method of administration

Posology

Telmisartan/Hydrochlorothiazide should be taken in patients whose blood pressure is not adequately controlled by telmisartan alone. Individual dose titration with each of the two components is recommended before changing to the fixed dose combination. When clinically appropriate, direct change from monotherapy to the fixed combination may be considered

• Telmisartan/Hydrochlorothiazide 40 mg/12.5 mg may be administered once daily in patients whose blood pressure is not adequately controlled by Micardis 40 mg
• Telmisartan/Hydrochlorothiazide 80 mg/12.5 mg may be administered once daily in patients whose blood pressure is not adequately controlled by Micardis 80 mg

Special populations:

Renal impairment

Periodic monitoring of renal function is advised (see section 4.4).

Hepatic impairment

In patients with mild to moderate hepatic impairment the posology should not exceed Telmisartan/Hydrochlorothiazide 40 mg/12.5 mg once daily. Telmisartan/Hydrochlorothiazide is not indicated in patients with severe hepatic impairment. Thiazides should be used with caution in patients with impaired hepatic function (see section 4.4).

Elderly

No dosage adjustment is necessary.

Paediatric population

The safety and efficacy of Telmisartan/Hydrochlorothiazide in children and adolescents aged below 18 have not been established. No data are available.

Method of administration

Telmisartan/Hydrochlorothiazide tablets are for once-daily oral administration and should be taken with liquid, with or without food.

Precautions to be taken before handling or administering the medicinal product

Telmisartan/Hydrochlorothiazide should be kept in the sealed blister due to the hygroscopic property of the tablets. Tablets should be taken out of the blister shortly before administration (see section 6.6).

4.3 Contraindications

• Hypersensitivity to any of the active substances or to any of the excipients (see section 6.1).
• Hypersensitivity to other sulphonamide-derived substances (since hydrochlorothiazide is a sulphonamide-derived medicinal product).
• Second and third trimesters of pregnancy (see sections 4.4 and 4.6).
• Cholestasis and biliary obstructive disorders.
• Severe hepatic impairment.
• Severe renal impairment (creatinine clearance <30 ml/min).
• Refractory hypokalaemia, hypercalcaemia.
• The concomitant use of telmisartan with aliskiren-containing products is contraindicated in patients with diabetes mellitus or renal impairment (GFR < 60 ml/min/1.73 m²) (see sections 4.5 and 5.1).

4.4 Special warnings and precautions for use

Pregnancy

Angiotensin II receptor antagonists should not be initiated during pregnancy. Unless continued angiotensin II receptor antagonist 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 angiotensin II receptor antagonists should be stopped immediately, and, if appropriate, alternative therapy should be started (see sections 4.3 and 4.6).

Hepatic impairment

Telmisartan/Hydrochlorothiazide should not be given to patients with cholestasis, biliary obstructive disorders or severe hepatic insufficiency (see section 4.3) since telmisartan is mostly eliminated with the bile. These patients can be expected to have reduced hepatic clearance for telmisartan.

In addition, Telmisartan/Hydrochlorothiazide should be used with caution in patients with impaired hepatic function or progressive liver disease, since minor alterations of fluid and electrolyte balance may precipitate hepatic coma. There is no clinical experience with Telmisartan/Hydrochlorothiazide in patients with hepatic impairment.

Renovascular hypertension

There is an increased risk of severe hypotension and renal insufficiency when patients with bilateral renal artery stenosis or stenosis of the artery to a single functioning kidney are treated with medicinal products that affect the renin-angiotensin-aldosterone system.

Renal impairment and kidney transplantation

Telmisartan/Hydrochlorothiazide should not be used in patients with severe renal impairment (creatinine clearance <30 ml/min) (see section 4.3). There is no experience regarding the administration of Telmisartan/Hydrochlorothiazide in patients with recent kidney transplantation. Experience with Telmisartan/Hydrochlorothiazide is modest in the patients with mild to moderate renal impairment, therefore periodic monitoring of potassium, creatinine and uric acid serum levels is recommended. Thiazide diuretic-associated azotaemia may occur in patients with impaired renal function.

Intravascular hypovolaemia

Symptomatic hypotension, especially after the first dose, may occur in patients who are volume and/or sodium depleted by vigorous diuretic therapy, dietary salt restriction, diarrhoea or vomiting. Such conditions should be corrected before the administration of Telmisartan/Hydrochlorothiazide.

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.

Other conditions with stimulation of the renin-angiotensin-aldosterone system

In patients whose vascular tone and renal function depend predominantly on the activity of the renin-angiotensin-aldosterone system (e.g. patients with severe congestive heart failure or underlying renal disease, including renal artery stenosis), treatment with medicinal products that affect this system has been associated with acute hypotension, hyperazotaemia, oliguria, or rarely acute renal failure (see section 4.8).

Primary aldosteronism

Patients with primary aldosteronism generally will not respond to antihypertensive medicinal products acting through inhibition of the renin-angiotensin system. Therefore, the use of Telmisartan/Hydrochlorothiazide is not recommended.

Aortic and mitral valve stenosis, obstructive hypertrophic cardiomyopathy

As with other vasodilators, special caution is indicated in patients suffering from aortic or mitral stenosis, or obstructivehypertrophic cardiomyopathy.

Metabolic and endocrine effects

Thiazide therapy may impair glucose tolerance, whereas hypoglycaemia may occur in diabetic patients under insulin or antidiabetic therapy and telmisartan treatment. Therefore, in these patients blood glucose monitoring should be considered; a dose adjustment of insulin or antidiabetics may be required, when indicated. Latent diabetes mellitus may become manifest during thiazide therapy.

An increase in cholesterol and triglyceride levels has been associated with thiazide diuretic therapy; however, at the 12.5 mg dose contained in Telmisartan/Hydrochlorothiazide, minimal or no effects were reported. Hyperuricaemia may occur or frank gout may be precipitated in some patients receiving thiazide therapy.

Electrolyte imbalance

As for any patient receiving diuretic therapy, periodic determination of serum electrolytes should be performed at appropriate intervals.

Thiazides, including hydrochlorothiazide, can cause fluid or electrolyte imbalance (including hypokalaemia, hyponatraemia, and hypochloraemic alkalosis). Warning signs of fluid or electrolyte imbalance are dryness of mouth, thirst, asthenia, lethargy, drowsiness, restlessness, muscle pain or cramps, muscular fatigue, hypotension, oliguria, tachycardia, and gastrointestinal disturbances such as nausea or vomiting (see section 4.8).

– Hypokalaemia

Although hypokalaemia may develop with the use of thiazide diuretics, concurrent therapy with telmisartan may reduce diuretic-induced hypokalaemia. The risk of hypokalaemia is greater in patients with cirrhosis of liver, in patients experiencing brisk diuresis, in patients who are receiving inadequate oral intake of electrolytes and in patients receiving concomitant therapy with corticosteroids or Adrenocorticotropic hormone (ACTH) (see section 4.5).

– Hyperkalaemia

Conversely, due to the antagonism of the angiotensin II (AT₁) receptors by the telmisartan component of Telmisartan/Hydrochlorothiazide, hyperkalaemia might occur. Although clinically significant hyperkalaemia has not been documented with Telmisartan/Hydrochlorothiazide, risk factors for the development of hyperkalaemia include renal insufficiency and/or heart failure, and diabetes mellitus. Potassium-sparing diuretics, potassium supplements or potassium-containing salt substitutes should be co-administered cautiously with Telmisartan/Hydrochlorothiazide (see section 4.5).

– Hyponatraemia and hypochloraemic alkalosis

There is no evidence that Telmisartan/Hydrochlorothiazide would reduce or prevent diuretic-induced hyponatraemia. Chloride deficit is generally mild and usually does not require treatment.

– Hypercalcaemia

Thiazides may decrease urinary calcium excretion and cause an intermittent and slight elevation of serum calcium in the absence of known disorders of calcium metabolism. Marked hypercalcaemia may be evidence of hidden hyperparathyroidism. Thiazides should be discontinued before carrying out tests for parathyroid function.

– Hypomagnesaemia

Thiazides have been shown to increase the urinary excretion of magnesium, which may result in hypomagnesaemia (see section 4.5).

Lactose Monohydrate

This medicinal product contains lactose monohydrate. Patients with rare hereditary problems of fructose intolerance and/or with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Ethnic differences

As with all other angiotensin II receptor antagonists telmisartan is apparently less effective in lowering blood pressure in black patients than in non blacks, possibly because of higher prevalence of low renin states in the black hypertensive population.

Other

As with any antihypertensive agent, excessive reduction of blood pressure in patients with ischaemiccardiopathy or ischaemic cardiovascular disease could result in a myocardial infarction or stroke.

General

Hypersensitivity reactions to hydrochlorothiazide may occur in patients with or without a history of allergy or bronchial asthma, but are more likely in patients with such a history. Exacerbation or activation of systemic lupus erythematosus has been reported with the use of thiazide diuretics, including hydrochlorothiazide.

Cases of photosensitivity reactions have been reported with thiazide diuretics (see section 4.8). If a photosensitivity reaction occurs during treatment, it is recommended to stop the treatment. If a readministration of the diuretic is deemed necessary, it is recommended to protect exposed areas to the sun or to artificial UVA.

Acute Myopia and Angle-Closure Glaucoma

Hydrochlorothiazide, a sulfonamide, can cause an idiosyncratic reaction, resulting in acute transient myopia and acute angle-closure glaucoma. Symptoms include acute onset of decreased visual acuity or ocular pain and typically occur within hours to weeks of drug initiation. Untreated acute angle-closure glaucoma can lead to permanent vision loss. The primary treatment is to discontinue hydrochlorothiazide as rapidly as possible. Prompt medical or surgical treatments may need to be considered if the intraocular pressure remains uncontrolled. Risk factors for developing acute angle- closure glaucoma may include a history of sulfonamide or penicillin allergy.

Non-melanoma skin cancer

An increased risk of non-melanoma skin cancer (NMSC) [basal cell carcinoma (BCC) and squamous cell carcinoma (SCC)] with increasing cumulative dose of hydrochlorothiazide (HCTZ) exposure has been observed in two epidemiological studies based on the Danish National Cancer Registry. Photosensitizing actions of HCTZ could act as a possible mechanism for NMSC.

Patients taking HCTZ should be informed of the risk of NMSC and advised to regularly check their skin for any new lesions and promptly report any suspicious skin lesions. Possible preventive measures such as limited exposure to sunlight and UV rays and, in case of exposure, adequate protection should be advised to the patients in order to minimize the risk of skin cancer. Suspicious skin lesions should be promptly examined potentially including histological examinations of biopsies. The use of HCTZ may also need to be reconsidered in patients who have experienced previous NMSC (see also section 4.8).

4.5 Interaction with other medicinal products and other forms of interaction

Lithium

Reversible increases in serum lithium concentrations and toxicity have been reported during concomitant administration of lithium with angiotensin converting enzyme inhibitors. Rare cases have also been reported with angiotensin II receptor antagonists (including Telmisartan/Hydrochlorothiazide). Co-administration of lithium and Telmisartan/Hydrochlorothiazide is not recommended (see section 4.4). If this combination proves essential, careful monitoring of serum lithium level is recommended during concomitant use.

Medicinal products associated with potassium loss and hypokalaemia?(e.g. other kaliuretic diuretics, laxatives, corticosteroids, ACTH, amphotericin, carbenoxolone, penicillin G sodium, salicylic acid and derivatives)

If these substances are to be prescribed with the hydrochlorothiazide-telmisartan combination, monitoring of potassium plasma levels is advised. These medicinal products may potentiate the effect of hydrochlorothiazide on serum potassium (see section 4.4).

Medicinal products that may increase potassium levels or induce hyperkalaemia?(e.g. ACE inhibitors, potassium-sparing diuretics, potassium supplements, salt substitutes containing potassium, cyclosporine or other medicinal products such as heparin sodium)

If these medicinal products are to be prescribed with the hydrochlorothiazide-telmisartan combination, monitoring of potassium plasma levels is advised. Based on the experience with the use of other medicinal products that blunt the rennin-angiotensin system, concomitant use of the above medicinal products may lead to increases in serum potassium and is, therefore, not recommended (see section 4.4).

Medicinal products affected by serum potassium disturbances

Periodic monitoring of serum potassium and ECG is recommended when Telmisartan/Hydrochlorothiazide is administered with medicinal products affected by serum potassium disturbances (e.g. digitalis glycosides, antiarrhythmics) and the following torsades de pointes inducing medicinal products (which include some antiarrhythmics), hypokalaemia being a predisposing factor to torsades de pointes.

– class Iaantiarrythmics (e.g. quinidine, hydroquinidine, disopyramide)

– class III antiarrythmics (e.g. amiodarone, sotalol, dofetilide, ibutilide)

– some antipsychotics (e.g. thioridazine, chlorpromazine, levomepromazine, trifluoperazine, cyamemazine, sulpiride, sultopride, amisulpride, tiapride, pimozide, haloperidol, droperidol)

– others (e.g. bepridil, cisapride, diphemanil, erythromycin IV, halofantrin, mizolastin, pentamidine, sparfloxacine, terfenadine, vincamine IV.)

Digitalis glycosides

Thiazide-induced hypokalaemia or hypomagnesaemia favours the onset of digitalis-induced arrhythmia (see section 4.4).

Digoxin

When telmisartan was co-administered with digoxin, median increases in digoxin peak plasma concentration (49%) and in trough concentration (20%) were observed. When initiating, adjusting, and discontinuing telmisartan, monitor digoxin levels in order to maintain levels within the therapeutic range.

Other antihypertensive agents

Telmisartan may increase the hypotensive effect of other antihypertensive agents.

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).

Antidiabetic medicinal products?(oral agents and insulin)

Dosage adjustment of the antidiabetic medicinal products may be required (see section 4.4).

Metformin

Metformin should be used with precaution: risk of lactic acidosis induced by a possible functional renal failure linked to hydrochlorothiazide.

Cholestyramine and colestipol resins

Absorption of hydrochlorothiazide is impaired in the presence of anionic exchange resins.

Non-steroidal anti-inflammatory medicinal products

NSAIDs (i.e. acetylsalicylic acid at anti-inflammatory dosage regimens, COX-2 inhibitors and non-selective NSAIDs) may reduce the diuretic, natriuretic and antihypertensive effects of thiazide diuretics and the antihypertensive effects of angiotensin II receptor antagonists.

In some patients with compromised renal function (eg dehydrated patients or elderly patients with compromised renal function) the co-administration of angiotensin II receptor antagonists and agents that inhibit cyclo-oxygenase may result in further deterioration of renal function, including possible acute renal failure, which is usually reversible. Therefore the combination should be administered with caution, especially in the elderly. Patients should be adequately hydrated and consideration should be given to monitoring of renal function after initiation of concomitant therapy and periodically thereafter.

In one study the co-administration of telmisartan and ramipril led to an increase of up to 2.5 fold in the AUC_0-24?and C_max?of ramipril and ramiprilat. The clinical relevance of this observation is not known.

Pressor amines?(e.g. noradrenaline)

The effect of pressor amines may be decreased.

Nondepolarizing skeletal muscle relaxants?(e.g. tubocurarine)

The effect of nondepolarizing skeletal muscle relaxants may be potentiated by hydrochlorothiazide.

Medicinal products used in the treatment for gout?(e.g. probenecid, sulfinpyrazone and allopurinol)

Dosage adjustment of uricosuric medications may be necessary as hydrochlorothiazide may raise the level of serum uric acid. Increase in dosage of probenecid or sulfinpyrazone may be necessary. Co-administration of thiazide may increase the incidence of hypersensitivity reactions of allopurinol.

Calcium salts

Thiazide diuretics may increase serum calcium levels due to the decreased excretion. If calcium supplements or calcium sparing medicinal products (e.g. vitamin D therapy) must be prescribed, serum calcium levels should be monitored and calcium dosage adjusted accordingly.

Beta-blockers and diazoxide

The hyperglycaemic effect of beta-blockers and diazoxide may be enhanced by thiazides.

Anticholinergic agents?(e.g. atropine, biperiden) may increase the bioavailability of thiazide-type diuretics by decreasing gastrointestinal motility and stomach emptying rate.

Amantadine

Thiazides may increase the risk of adverse effects caused by amantadine.

Cytotoxic agents?(e.g. cyclophosphamide, methotrexate)

Thiazides may reduce the renal excretion of cytotoxic medicinal products and potentiate their myelosuppressive effects.

Based on their pharmacological properties it can be expected that the following medicinal products may potentiate the hypotensive effects of all antihypertensives including telmisartan: Baclofen, amifostine.

Furthermore, orthostatic hypotension may be aggravated by alcohol, barbiturates, narcotics or antidepressants.

4.6 Fertility, pregnancy and lactation

Pregnancy

The use of angiotensin II receptor antagonists is not recommended during the first trimester of pregnancy (see section 4.4). The use of angiotensin II receptor antagonists is contraindicated during the second and third trimesters of pregnancy (see sections 4.3 and 4.4).

There are no adequate data from the use of Telmisartan/Hydrochlorothiazide in pregnant women. Studies in animals have shown reproductive toxicity (see section 5.3).

Epidemiological evidence regarding the risk of teratogenicity following exposure to ACE inhibitors during the first trimester of pregnancy has not been conclusive; however a small increase in risk cannot be excluded. Whilst there is no controlled epidemiological data on the risk with angiotensin II receptor antagonists, similar risks may exist for this class of drugs. Unless continued angiotensin II receptor antagonist 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 angiotensin II receptor antagonists should be stopped immediately, and, if appropriate, alternative therapy should be started.

Exposure to angiotensin II receptor antagonist therapy during the second and third trimesters is known to induce human fetotoxicity (decreased renal function, oligohydramnios, skull ossification retardation) and neonatal toxicity (renal failure, hypotension, hyperkalaemia). (See section 5.3). Should exposure to angiotensin II receptor antagonists have occurred from the second trimester of pregnancy, ultrasound check of renal function and skull is recommended. Infants whose mothers have taken angiotensin II receptor antagonists should be closely observed for hypotension (see sections 4.3 and 4.4).

There is limited experience with hydrochlorothiazide during pregnancy, especially during the first trimester. Animal studies are insufficient. Hydrochlorothiazide crosses the placenta. Based on the pharmacological mechanism of action of hydrochlorothiazide its use during the second and third trimester may compromise foeto-placental perfusion and may cause foetal and neonatal effects like icterus, disturbance of electrolyte balance and thrombocytopenia.

Hydrochlorothiazide should not be used for gestational oedema, gestational hypertension or preeclampsia due to the risk of decreased plasma volume and placental hypoperfusion, without a beneficial effect on the course of the disease.

Hydrochlorothiazide should not be used for essential hypertension in pregnant women except in rare situations where no other treatment could be used.

Breast-feeding

Because no information is available regarding the use of Telmisartan/Hydrochlorothiazide during breast-feeding, Telmisartan/Hydrochlorothiazide is not recommended and alternative treatments with better established safety profiles during breast-feeding are preferable, especially while nursing a newborn or preterm infant.

Hydrochlorothiazide is excreted in human milk in small amounts. Thiazides in high doses causing intense diuresis can inhibit the milk production. The use of Telmisartan/Hydrochlorothiazide during breast feeding is not recommended. If Telmisartan/Hydrochlorothiazide is used during breast-feeding, doses should be kept as low as possible.

Fertility

In preclinical studies, no effects of telmisartan and hydrochlorothiazide on male and female fertility were observed.

4.7 Effects on ability to drive and use machines

Telmisartan/Hydrochlorothiazide can have influence on the ability to drive and use machines. Dizziness or drowsiness may occasionally occur when taking Telmisartan/Hydrochlorothiazide.

4.8 Undesirable effects

Summary of the safety profile

The most commonly reported adverse reaction is dizziness. Serious angioedema may occur rarely (?1/10,000 to <1/1,000).

The overall incidence of adverse reactions reported with Telmisartan/Hydrochlorothiazide was comparable to those reported with telmisartan alone in randomised controlled trials involving 1471 patients randomised to receive telmisartan plus hydrochlorothiazide (835) or telmisartan alone (636). Dose-relationship of adverse reactions was not established and they showed no correlation with gender, age or race of the patients.

Tabulated list of adverse reactions

Adverse reactions reported in all clinical trials and occurring more frequently (p ?0.05) with telmisartan plus hydrochlorothiazide than with placebo are shown below according to system organ class. Adverse reactions known to occur with each component given singly but which have not been seen in clinical trials may occur during treatment with Telmisartan/Hydrochlorothiazide.

Adverse reactions have been ranked under headings of frequency using the following convention: very common (?1/10); common (?1/100 to <1/10); uncommon (?1/1,000 to <1/100); rare (?1/10,000 to <1/1,000); very rare (<1/10,000), not known (cannot be estimated from the available data).

Within each frequency grouping, adverse reactions are presented in order of decreasing seriousness.

Infections and infestations
Rare:	Bronchitis, pharyngitis, sinusitis
Immune system disorders
Rare:	Exacerbation or activation of systemic lupus erythematosus1
Metabolism and nutrition disorders
Uncommon: Rare:	Hypokalaemia Hyperuricaemia, hyponatraemia
Psychiatric disorders
Uncommon: Rare:	Anxiety Depression
Nervous system disorders
Common: Uncommon: Rare:	Dizziness Syncope, paraesthesia Insomnia, sleep disorders
Eye disorders
Rare:	Visual disturbance, vision blurred
Ear and labyrinth disorders
Uncommon:	Vertigo
Cardiac disorders
Uncommon:	Tachycardia, arrhythmias
Vascular disorders
Uncommon:	Hypotension, orthostatic hypotension
Respiratory, thoracic and mediastinal disorders
Uncommon: Rare:	Dyspnoea Respiratory distress (including pneumonitis and pulmonary oedema)
Gastrointestinal disorders
Uncommon: Rare:	Diarrhoea, dry mouth, flatulence Abdominal pain, constipation, dyspepsia, vomiting, gastritis
Hepatobiliary disorders
Rare:	Abnormal hepatic function/liver disorder2
Skin and subcutaneous tissue disorders
Rare:	Angioedema (also with fatal outcome), erythema, pruritus, rash, hyperhidrosis, urticaria
Muscoloskeletal, connective tissue and bone disorders
Uncommon: Rare:	Back pain, muscle spasms, myalgia Arthralgia, muscle cramps, pain in limb
Reproductive system and breast disorders
Uncommon:	Erectile dysfunction
General disorders and administration site conditions
Uncommon: Rare:	Chest pain Influenza-like illness, pain
Investigations
Uncommon: Rare:	Blood uric acid increased Blood creatinine increased, blood creatine phosphokinase increased, hepatic enzyme increased

1: Based on post-marketing experience

2: For further description, please see sub-section??Description of selected adverse reactions?

Additional information on individual components

Adverse reactions previously reported with one of the individual components may be potential adverse reactions with Telmisartan/Hydrochlorothiazide, even if not observed in clinical trials with this product.

Telmisartan:

Adverse reactions occurred with similar frequency in placebo and telmisartan treated patients.

The overall incidence of adverse reactions reported with telmisartan (41.4 %) was usually comparable to placebo (43.9 %) in placebo controlled trials. The following adverse reactions listed below have been accumulated from all clinical trials in patients treated with telmisartan for hypertension or in patients 50 years or older at high risk of cardiovascular events.

Infections and infestations
Uncommon: Rare:	Upper respiratory tract infection, urinary tract infection including cystitis Sepsis including fatal outcome3
Blood and lymphatic system disorders
Uncommon: Rare:	Anaemia Eosinophilia, thrombocytopenia
Immune system disorders
Rare:	Hypersensitivity, anaphylactic reactions
Metabolism and nutrition disorders
Uncommon: Rare:	Hyperkalaemia Hypoglycaemia (in diabetic patients)
Cardiac disorders
Uncommon:	Bradycardia
Nervous system disorders
Rare:	Somnolence
Respiratory, thoracic and mediastinal disorders
Uncommon: Very rare:	Cough Interstitial lung disease3
Gastrointestinal disorders
Rare:	Stomach discomfort
Skin and subcutaneous tissue disorders
Rare:	Eczema, drug eruption, toxic skin eruption
Musculoskeletal, connective tissue and bone disorders
Rare:	Arthrosis, tendon pain
Renal and urinary disorders
Uncommon:	Renal impairment (including acute renal failure)
General disorders and administration site conditions
Uncommon:	Asthenia
Investigations
Rare:	Haemoglobin decreased

3: For further description, please see sub-section??Description of selected adverse reactions?

Hydrochlorothiazide:

Hydrochlorothiazide may cause or exacerbate hypovolaemia which could lead to electrolyte imbalance (see section 4.4).

Adverse reactions reported with the use of hydrochlorothiazide alone include:

Infections and infestations
Not known:	Sialadenitis
Neoplasms benign, malignant and unspecified (incl cysts and polyps)
Not known:	Non-melanoma skin cancer (Basal cell carcinoma and Squamous cell carcinoma)
Blood and lymphatic system disorders
Rare:	Thrombocytopenia (sometimes with purpura)
Not known:	Aplastic anaemia, haemolyticanaemia, bone marrow failure, leukopenia, neutropenia, agranulocytosis,
Immune system disorders
Not known:	Anaphylactic reactions, hypersensitivity
Endocrine disorders
Not known:	Diabetes mellitus inadequate control
Metabolism and nutrition disorders
Common:	Hypomagnesaemia
Rare:	Hypercalcaemia
Very rare:	Hypochloraemic alkalosis
Not known:	Anorexia, appetite decreased, electrolyte imbalance, hypercholesterolaemia, hyperglycaemia, hypovolaemia
Psychiatric disorders
Not known:	Restlessness
Nervous system disorders
Rare:	Headache
Not known:	Light-headedness
Eye disorders
Not known	Xanthopsia, acute myopia, acute angle-closure glaucoma
Vascular disorders
Not known:	Vasculitis necrotizing
Gastrointestinal disorders
Common:	Nausea
Not known:	Pancreatitis, stomach discomfort
Hepatobiliary disorders
Not known:	Jaundice hepatocellular, jaundice cholestatic
Skin and subcutaneous tissue disorders
Not known:	Lupus-like syndrome, photosensitivity reactions, skin vasculitis, toxic epidermal necrolysis, erythema multiforme
Musculoskeletal, connective tissue and bone disorders
Not known:	Weakness
Renal and urinary disorders
Not known:	Nephritis interstitial, renal dysfunction, glycosuria
General disorders and administration site conditions
Not known:	Pyrexia
Investigations
Not known:	Triglycerides increased

Description of selected adverse reactions

Hepatic function abnormal / liver disorder

Most cases of hepatic function abnormal / liver disorder from post-marketing experience with telmisartan occurred in Japanese patients. Japanese patients are more likely to experience these adverse reactions.

Sepsis

In the PRoFESS trial, an increased incidence of sepsis was observed with telmisartan compared with placebo. The event may be a chance finding or related to a mechanism currently not known (see section 5.1).

Interstitial lung disease

Cases of interstitial lung disease have been reported from post-marketing experience in temporal association with the intake of telmisartan. However, a causal relationship has not been established.

Non-melanoma skin cancer

Based on available data from epidemiological studies, cumulative dose-dependent association between HCTZ and NMSC has been observed (see also sections 4.4 and 5.1)

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.

4.9 Overdose

There is limited information available for telmisartan with regard to overdose in humans. The degree to which hydrochlorothiazide is removed by haemodialysis has not been established.

Symptoms

The most prominent manifestations of telmisartan overdose were hypotension and tachycardia; bradycardia dizziness, vomiting, increase in serum creatinine, and acute renal failure have also been reported. Overdose with hydrochlorothiazide is associated with electrolyte depletion (hypokalaemia, hypochloraemia) and hypovolaemia resulting from excessive diuresis. The most common signs and symptoms of overdose are nausea and somnolence. Hypokalaemia may result in muscle spasms and/or accentuate arrhythmia associated with the concomitant use of digitalis glycosides or certain anti-arrhythmic medicinal products.

Treatment

Telmisartan is not removed by haemodialysis. The patient should be closely monitored, and the treatment should be symptomatic and supportive. Management depends on the time since ingestion and the severity of the symptoms. Suggested measures include induction of emesis and/or gastric lavage. Activated charcoal may be useful in the treatment of overdose. Serum electrolytes and creatinine should be monitored frequently. If hypotension occurs, the patient should be placed in a supine position, with salt and volume replacements given quickly.

5. Pharmacological properties

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Angiotensin II antagonists and diuretics.

Telmisartan/Hydrochlorothiazide is a combination of an angiotensin II receptor antagonist, telmisartan, and a thiazide diuretic, hydrochlorothiazide. The combination of these ingredients has an additive antihypertensive effect, reducing blood pressure to a greater degree than either component alone. Telmisartan/Hydrochlorothiazide once daily produces effective and smooth reductions in blood pressure across the therapeutic dose range.

Mechanism of action

Telmisartan is an orally effective and specific angiotensin II receptor subtype 1 (AT₁) antagonist. Telmisartan displaces angiotensin II with very high affinity from its binding site at the AT₁?receptor subtype, which is responsible for the known actions of angiotensin II. Telmisartan does not exhibit any partial agonist activity at the AT₁?receptor. Telmisartan selectively binds the AT₁?receptor. The binding is long-lasting. Telmisartan does not show affinity for other receptors, including AT₂?and other less characterised AT receptors. The functional role of these receptors is not known, nor is the effect of their possible overstimulation by angiotensin II, whose levels are increased by telmisartan. Plasma aldosterone levels are decreased by telmisartan. Telmisartan does not inhibit human plasma renin or block ion channels. Telmisartan does not inhibit angiotensin converting enzyme (kininase II), the enzyme which also degrades bradykinin. Therefore, it is not expected to potentiate bradykinin-mediated adverse effects.

An 80 mg dose of telmisartan administered to healthy volunteers almost completely inhibits the angiotensin II evoked blood pressure increase. The inhibitory effect is maintained over 24 hours and still measurable up to 48 hours.

Hydrochlorothiazide is a thiazide diuretic. The mechanism of the antihypertensive effect of thiazide diuretics is not fully known. Thiazides have an effect on the renal tubular mechanisms of electrolyte reabsorption, directly increasing excretion of sodium and chloride in approximately equivalent amounts. The diuretic action of hydrochlorothiazide reduces plasma volume, increases plasma rennin activity, increases aldosterone secretion, with consequent increases in urinary potassium and bicarbonate loss, and decreases in serum potassium. Presumably through blockade of the rennin-angiotensin- aldosterone system, co-administration of telmisartan tends to reverse the potassium loss associated with these diuretics. With hydrochlorothiazide, onset of diuresis occurs in 2 hours, and peak effect occurs at about 4 hours, while the action persists for approximately 6-12 hours.

Clinical efficacy and safety

Treatment of essential hypertension:

After the first dose of telmisartan, the antihypertensive activity gradually becomes evident within 3 hours. The maximum reduction in blood pressure is generally attained 4-8 weeks after the start of treatment and is sustained during long-term therapy. The antihypertensive effect persists constantly over 24 hours after dosing and includes the last 4 hours before the next dose as shown by ambulatory blood pressure measurements. This is confirmed by measurements made at the point of maximum effect and immediately prior to the next dose (through to peak ratios consistently above 80 % after doses of 40 and 80 mg of telmisartan in placebo controlled clinical studies).

In patients with hypertension telmisartan reduces both systolic and diastolic blood pressure without affecting pulse rate. The antihypertensive efficacy of telmisartan is comparable to that of agents representative of other classes of antihypertensive medicinal products (demonstrated in clinical trials comparing telmisartan to amlodipine, atenolol, enalapril, hydrochlorothiazide, and lisinopril).

Upon abrupt cessation of treatment with telmisartan, blood pressure gradually returns to pre-treatment values over a period of several days without evidence of rebound hypertension. The incidence of dry cough was significantly lower in patients treated with telmisartan than in those given angiotensin converting enzyme inhibitors in clinical trials directly comparing the two antihypertensive treatments.

Cardiovascular prevention

ONTARGET (ONgoingTelmisartan Alone and in Combination with Ramipril Global Endpoint Trial) compared the effects of telmisartan, ramipril and the combination of telmisartan and ramipril on cardiovascular outcomes in 25620 patients aged 55 years or older with a history of coronary artery disease, stroke, TIA, peripheral arterial disease, or type 2 diabetes mellitus accompanied by evidence of end-organ damage (e.g. retinopathy, left ventricular hypertrophy, macro- or microalbuminuria), which is a population at risk for cardiovascular events.

Patients were randomized to one of the three following treatment groups: telmisartan 80 mg (n = 8542), ramipril 10 mg (n = 8576), or the combination of telmisartan 80 mg plus ramipril 10 mg (n = 8502), and followed for a mean observation time of 4.5 years.

Telmisartan showed a similar effect to ramipril in reducing the primary composite endpoint of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or hospitalization for congestive heart failure. The incidence of the primary endpoint was similar in the telmisartan (16.7 %) and ramipril (16.5 %) groups. The hazard ratio for telmisartan vs. ramipril was 1.01 (97.5 % CI 0.93 – 1.10, p (non-inferiority) = 0.0019 at a margin of 1.13). The all-cause mortality rate was 11.6 % and 11.8 % among telmisartan and ramipril treated patients, respectively.

Telmisartan was found to be similarly effective to ramipril in the pre-specified secondary endpoint of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke [0.99 (97.5 % CI 0.90 – 1.08), p (non-inferiority) = 0.0004], the primary endpoint in the reference study HOPE (The Heart Outcomes Prevention Evaluation Study), which had investigated the effect of ramipril vs. placebo.

TRANSCEND randomized ACE-I intolerant patients with otherwise similar inclusion criteria as ONTARGET to telmisartan 80 mg (n=2954) or placebo (n=2972), both given on top of standard care. The mean duration of follow up was 4 years and 8 months. No statistically significant difference in the incidence of the primary composite endpoint (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, or hospitalization for congestive heart failure) was found [15.7 % in the telmisartan and 17.0 % in the placebo groups with a hazard ratio of 0.92 (95 % CI 0.81 – 1.05, p = 0.22)]. There was evidence for a benefit of telmisartan compared to placebo in the pre-specified secondary composite endpoint of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke [0.87 (95 % CI 0.76 – 1.00, p = 0.048)]. There was no evidence for benefit on cardiovascular mortality (hazard ratio 1.03, 95 % CI 0.85 – 1.24).

Cough and angioedema were less frequently reported in patients treated with telmisartan than in patients treated with ramipril, whereas hypotension was more frequently reported with telmisartan.

Combining telmisartan with ramipril did not add further benefit over ramipril or telmisartan alone. CV mortality and all cause mortality were numerically higher with the combination. In addition, there was a significantly higher incidence of hyperkalaemia, renal failure, hypotension and syncope in the combination arm. Therefore the use of a combination of telmisartan and ramipril is not recommended in this population.

In the “Prevention Regimen For Effectively avoiding Second Strokes” (PRoFESS) trial in patients 50 years and older, who recently experienced stroke, an increased incidence of sepsis was noted for telmisartan compared with placebo, 0.70 % vs. 0.49 % [RR 1.43 (95 % confidence interval 1.00 – 2.06)]; the incidence of fatal sepsis cases was increased for patients taking telmisartan (0.33 %) vs. patients taking placebo (0.16 %) [RR 2.07 (95 % confidence interval 1.14 – 3.76)]. The observed increased occurrence rate of sepsis associated with the use of telmisartan may be either a chance finding or related to a mechanism not currently known.

Two large randomised, controlled trials (ONTARGET (ONgoingTelmisartan 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. For more detailed information see above under the heading ?Cardiovascular prevention?.

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.

Epidemiological studies have shown that long-term treatment with hydrochlorothiazide reduces the risk of cardiovascular mortality and morbidity.

The effects of Fixed Dose Combination of telmisartan/HCTZ on mortality and cardiovascular morbidity are currently unknown.

Non-melanoma skin cancer: Based on available data from epidemiological studies, cumulative dose-dependent association between HCTZ and NMSC has been observed. One study included a population comprised of 71,533 cases of BCC and of 8,629 cases of SCC matched to 1,430,833 and 172,462 population controls, respectively. High HCTZ use (?50,000 mg cumulative) was associated with an adjusted OR of 1.29 (95% CI: 1.23-1.35) for BCC and 3.98 (95% CI: 3.68-4.31) for SCC. A clear cumulative dose response relationship was observed for both BCC and SCC. Another study showed a possible association between lip cancer (SCC) and exposure to HCTZ: 633 cases of lip-cancer were matched with 63,067 population controls, using a risk-set sampling strategy. A cumulative dose-response relationship was demonstrated with an adjusted OR 2.1 (95% CI: 1.7-2.6) increasing to OR 3.9 (3.0-4.9) for high use (~25,000 mg) and OR 7.7 (5.7-10.5) for the highest cumulative dose (~100,000 mg) (see also section 4.4).

Paediatric population

The European Medicines Agency has waived the obligation to submit the results of studies with Fixed Dose Combination of telmisartan/HCTZ in all subsets of the paediatric population in hypertension (see section 4.2 for information on paediatric use).

5.2 Pharmacokinetic properties

Concomitant administration of hydrochlorothiazide and telmisartan does not appear to affect the pharmacokinetics of either substance in healthy subjects.

Absorption

Telmisartan: Following oral administration peak concentrations of telmisartan are reached in 0.5 ? 1.5 h after dosing. The absolute bioavailability of telmisartan at 40 mg and 160 mg was 42 % and 58 %, respectively. Food slightly reduces the bioavailability of telmisartan with a reduction in the area under the plasma concentration time curve (AUC) of about 6 % with the 40 mg tablet and about 19 % after a 160 mg dose. By 3 hours after administration plasma concentrations are similar whether telmisartan is taken fasting or with food. The small reduction in AUC is not expected to cause a reduction in the therapeutic efficacy. Telmisartan does not accumulate significantly in plasma on repeated administration.

Hydrochlorothiazide: Following oral administration of Telmisartan/Hydrochlorothiazide peak concentrations of hydrochlorothiazide are reached in approximately 1.0 ? 3.0 hours after dosing. Based on cumulative renal excretion of hydrochlorothiazide the absolute bioavailability was about 60 %.

Distribution

Telmisartan is highly bound to plasma proteins (>99.5 %) mainly albumin and alpha lacid glycoprotein. The apparent volume of distribution for telmisartan is approximately 500 litres indicating additional tissue binding.

Hydrochlorothiazide is 68 % protein bound in the plasma and its apparent volume of distribution is 0.83 ? 1.14 1/kg.

Biotransformation

Telmisartan is metabolised by conjugation to form a pharmacologically inactive acylglucuronide. The glucuronide of the parent compound is the only metabolite that has been identified in humans. After a single dose of?₁₄C-labelled telmisartan the glucuronide represents approximately 11 % of the measured radioactivity in plasma. The cytochrome P450 isoenzymes are not involved in the metabolism of telmisartan.

Hydrochlorothiazide is not metabolised in man.

Elimination

Telmisartan: Following either intravenous or oral administration of?₁₄C-labelled telmisartan most of the administered dose (>97 %) was eliminated in faeces via biliary excretion. Only minute amounts were found in urine. Total plasma clearance of telmisartan after oral administration is >1500 ml/min.

Terminal elimination half-life was >20 hours.

Hydrochlorothiazide is excreted almost entirely as unchanged substance in urine. About 60 % of the oral dose is eliminated within 48 hours. Renal clearance is about 250 ? 300 ml/min. The terminal elimination half-life of hydrochlorothiazide is 10 ? 15 hours.

Linearity/non-linearity

Telmisartan: The pharmacokinetics of orally administered telmisartanare non-linear over doses from 20 ? 160 mg with greater than proportional increases of plasma concentrations (C_max?and AUC) with increasing doses.

Hydrochlorothiazide exhibits linear pharmacokinetics.

Special populations

Elderly

Pharmacokinetics of telmisartando not differ between the elderly and those younger than 65 years.

Gender

Plasma concentrations of telmisartan are generally 2 ? 3 times higher in females than in males. In clinical trials however, no significant increases in blood pressure response or in the incidence of orthostatic hypotension were found in women. No dosage adjustment is necessary. There was a trend towards higher plasma concentrations of hydrochlorothiazide in female than in male subjects. This is not considered to be of clinical relevance.

Renal impairment:

Renal excretion does not contribute to the clearance of telmisartan. Based on modest experience in patients with mild to moderate renal impairment (creatinine clearance of 30 ? 60 ml/min, mean about 50 ml/min) no dosage adjustment is necessary in patients with decreased renal function. Telmisartan is not removed from blood by haemodialysis. In patients with impaired renal function the rate of hydrochlorothiazide elimination is reduced. In a typical study in patients with a mean creatinine clearance of 90 ml/min the elimination half-life of hydrochlorothiazide was increased. In functionally anephric patients the elimination half-life is about 34 hours.

Hepatic impairment:

Pharmacokinetic studies in patients with hepatic impairment showed an increase in absolute bioavailability up to nearly 100 %. The elimination half-life is not changed in patients with hepatic impairment.

5.3 Preclinical safety data

In preclinical safety studies performed with co-administration of telmisartan and hydrochlorothiazide in normotensive rats and dogs, doses producing exposure comparable to that in the clinical therapeutic range caused no additional findings not already observed with administration of either substance alone. The toxicological findings observed appear to have no relevance to human therapeutic use.

Toxicological findings also well known from preclinical studies with angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists were: a reduction of red cell parameters (erythrocytes, haemoglobin, haematocrit), changes of renal haemodynamics (increased blood urea nitrogen and creatinine), increased plasma renin activity, hypertrophy/hyperplasia of the juxtaglomerular cells and gastric mucosal injury. Gastric lesions could be prevented/ameliorated by oral saline supplementation and group housing of animals. In dogs renal tubular dilation and atrophy were observed. These findings are considered to be due to the pharmacological activity of telmisartan.

No clear evidence of a teratogenic effect was observed, however at toxic dose levels of telmisartan an effect on the postnatal development of the offsprings such as lower body weight and delayed eye opening was observed.

Telmisartan showed no evidence of mutagenicity and relevant clastogenic activity in?in vitro?studies and no evidence of carcinogenicity in rats and mice. Studies with hydrochlorothiazide have shown equivocal evidence for a genotoxic or carcinogenic effect in some experimental models. However, the extensive human experience with hydrochlorothiazide has failed to show an association between its use and an increase in neoplasms.

For the foetotoxic potential of the telmisartan/hydrochlorothiazide combination see section 4.6.

6. Pharmaceutical particulars

6.1 List of excipients

Crospovidone, Hypromellose, Lactose monohydrate, Magnesium stearate, Mannitol, Meglumine, Povidone

Silica colloidal anhydrous, Sodium hydroxide, Sodium stearylfumarate, Talc, Yellow Iron oxide.

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

3 years

6.4 Special precautions for storage

Store in the original package in order to protect from moisture.

6.5 Nature and contents of container

Aluminium-Aluminium foil blisters packed in cartons containing 7, 14, 28, 30, 56, 90, 100 or 500 tablets.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal and other handling

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.

7. Manufactured In India By:
TAJ PHARMACEUTICALS LTD.
Mumbai, India
Unit No. 214.Old Bake House,
Maharashtra chambers of ?Commerce Lane,
Fort, Mumbai – 400001
at:Gujarat, INDIA.
Customer Service and Product Inquiries:
1-800-TRY-FIRST (1-800-222-434 & 1-800-222-825)
Monday through Saturday 9:00 a.m. to 7:00 p.m. EST
E-mail:?tajgroup@tajpharma.com

Telmisartan and Hydrochlorothiazide Tablets USP 40mg/12.5mg, 80mg/12.5mg
(Telmisartan and Hydrochlorothiazide)

Package leaflet: Information for the patient

Read all of this leaflet carefully before you start taking this medicine because it contains important information for you.

• Keep this leaflet. You may need to read it again.
• If you have any further questions, ask your doctor or pharmacist.
• This medicine has been prescribed for you only. Do not pass it on to others. It may harm them, even if their signs of illness are the same as yours.
• If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet. See section 4.

What is in this leaflet

1. What Telmisartan/Hydrochlorothiazide is and what it is used for
2. What you need to know before you take Telmisartan/Hydrochlorothiazide
3. How to take Telmisartan/Hydrochlorothiazide
4. Possible side effects
5. How to store Telmisartan/Hydrochlorothiazide
6. Contents of the pack and other information

 

1. What Telmisartan/Hydrochlorothiazide is and what it is used for

Telmisartan/Hydrochlorothiazide is a combination of two active substances, telmisartan and hydrochlorothiazide in one tablet. Both of these substances help to control high blood pressure.

• Telmisartan belongs to a group of medicines called angiotensin II receptor antagonists. Angiotensin-II is a substance produced in your body which causes your blood vessels to narrow thus increasing your blood pressure. Telmisartan blocks the effect of angiotensin II so that the blood vessels relax, and your blood pressure is lowered.
• Hydrochlorothiazide belongs to a group of medicines called thiazide diuretics, which cause your urine output to increase, leading to a lowering of your blood pressure.

High blood pressure, if not treated, can damage blood vessels in several organs, which could lead sometimes to heart attack, heart or kidney failure, stroke, or blindness. There are usually no symptoms of high blood pressure before damage occurs. Thus it is important to regularly measure blood pressure to verify if it is within the normal range.

Telmisartan/Hydrochlorothiazide is used to treat high blood pressure (essential hypertension) in adults whose blood pressure is not controlled enough when telmisartan is used alone.

2. What you need to know before you take Telmisartan/Hydrochlorothiazide

Do not take Telmisartan/Hydrochlorothiazide:

• if you are allergic to telmisartan or any of the other ingredients of this medicine (listed in section 6).
• if you are allergic to hydrochlorothiazide or to any other sulfonamide-derived medicines.
• if you are more than 3 months pregnant. (It is also better to avoid this medicine in early pregnancy ? see pregnancy section.)
• if you have severe liver problems such as cholestasis or biliary obstruction (problems with drainage of the bile from the liver and gall bladder) or any other severe liver disease.
• if you have severe kidney disease.
• if your doctor determines that you have low potassium levels or high calcium levels in your blood that do not get better with treatment.
• if you have diabetes or impaired kidney function and you are treated with a blood pressure lowering medicine containing aliskiren.

If any of the above applies to you, do not take the tablets and tell your doctor or pharmacist before taking this medicine.

Warnings and precautions

Talk to your doctor before taking this medicine if you are suffering or have ever suffered from any of the

following conditions

or illnesses:

• Low blood pressure (hypotension), likely to occur if you are dehydrated (excessive loss of body water) or have salt deficiency due to diuretic therapy (water tablets), low-salt diet, diarrhoea, vomiting, or haemodialysis.
• Kidney disease or kidney transplant.
• Renal artery stenosis (narrowing of the blood vessels to one or both kidneys).
• Liver disease.
• Heart trouble.
• Raised aldosterone levels (water and salt retention in the body along with imbalance of various blood minerals).
• Systemic lupus erythematosus (also called ?lupus? or ?SLE?) a disease where the body?s immune system attacks the body.
• The active ingredient hydrochlorothiazide can cause an unusual reaction, resulting in a decrease in vision and eye pain. These could be symptoms of an increase of pressure in your eye and can happen within hours to weeks of taking Telmisartan/Hydrochlorothiazide. This can lead to permanent vision impairment, if not treated.

Talk to your doctor before taking Telmisartan/Hydrochlorothiazide:

• if you are taking any of the following medicines used to treat high blood pressure:
• an ACE-inhibitor (for example enalapril, lisinopril, ramipril), in particular if you have diabetes-related kidney problems.

Your doctor may check your kidney function, blood pressure, and the amount of electrolytes (e.g. potassium) in your blood at regular intervals. See also information under the heading ?Do not take Telmisartan/Hydrochlorothiazide?

• if you are taking digoxin.
• if you have had skin cancer or if you develop an unexpected skin lesion during the treatment. Treatment with hydrochlorothiazide, particularly long term use with high doses, may increase the risk of some types of skin and lip cancer (non-melanoma skin cancer). Protect your skin from sun exposure and UV rays while taking Telmisartan/Hydrochlorothiazide.

You must tell your doctor if you think you are (or might become) pregnant. Telmisartan/Hydrochlorothiazide is not recommended in early pregnancy, and must not be taken if you are more than 3 months pregnant, as it may cause serious harm to your baby if used at that stage (see pregnancy section).

Treatment with hydrochlorothiazide may cause electrolyte imbalance in your body. Typical symptoms of fluid or electrolyte imbalance include dry mouth, weakness, lethargy, drowsiness, restlessness, muscle pain

or cramps, nausea (feeling sick), vomiting, tired muscles, and an abnormally fast heart rate (faster than 100 beats per minute). If you experience any of these you should tell your doctor.

You should also tell your doctor, if you experience an increased sensitivity of the skin to the sun with symptoms of sunburn (such as redness, itching, swelling, blistering) occurring more quickly than normal.

In case of surgery or anaesthetics,you should tell your doctor that you are taking this medicine.

These tablets may be less effective in lowering the blood pressure in black patients.

Children and adolescents

This medicine is not recommended in children and adolescents up to the age of 18 years.

Other medicines and Telmisartan/Hydrochlorothiazide:

Tell your doctor or pharmacist if you are taking, have recently taken or might take any other medicines. Your doctor may need to change the dose of these other medications or take other precautions. In some cases you may have to stop taking one of the medicines. This applies especially to the medicines listed below taken at the same time with Telmisartan/Hydrochlorothiazide:

• Lithium containing medicines to treat some types of depression.
• Medicines associated with low blood potassium (hypokalaemia) such as other diuretics, (‘water tablets’), laxatives (e.g. castor oil), corticosteroids (e.g. prednisone), ACTH (a hormone), amphotericin (an antifungal medicine), carbenoxolone (used to treat mouth ulcers), penicillin G sodium (an antibiotic), and salicylic acid and derivatives.
• Medicines that may increase blood potassium levels such as potassium-sparing diuretics, potassium supplements, salt substitutes containing potassium, ACE inhibitors, ciclosporin (an immunosuppressant drug) and other medicinal products such as heparin sodium (an anticoagulant)
• Medicines that are affected by changes of the blood potassium level such as heart medicines (e.g. digoxin) or medicines to control the rhythm of your heart (e.g. quinidine, disopyramide, amiodarone, sotalol) medicines used for mental disorders (e.g. thioridazine, chlorpromazine, levomepromazine) and other medicines such as certain antibiotics (e.g. sparfloxacine, pentamidine) or certain medicines to treat allergic reactions (e.g. terfenadine).
• Medicines for the treatment of diabetes (insulins or oral agents such as metformin).
• Cholestyramine and colestipol, medicines for lowering blood fat levels.
• Medicines to increase blood pressure, such as noradrenaline.
• Muscle relaxing medicines, such as tubocurarine. – Calcium supplements and/or vitamin D supplements.
• Anti-cholinergic medicines (medicines used to treat a variety of disorders such as gastrointestinal cramps, urinary bladder spasm, asthma, motion sickness, muscular spasms, Parkinson?s disease and as an aid to anaesthesia) such as atropine and biperiden.
• Amantadine (medicine used to treat Parkinson?s disease and also used to treat or prevent certain illnesses caused by viruses).
• Other medicines used to treat high blood pressure, corticosteroids, painkillers (such as non-steroidal anti-inflammatory drugs [NSAIDs]), medicines to treat cancer, gout, or arthritis
• If you are taking an ACE-inhibitor or aliskiren (see also information under the headings ?Do not take Telmisartan/Hydrochlorothiazide? and ?Warnings and precautions?).

Telmisartan/Hydrochlorothiazide may increase the blood pressure lowering effect of other medicines used to treat high blood pressure or of medicines with blood pressure lowering potential (e.g. baclofen, amifostine). Furthermore, low blood pressure may be aggravated by alcohol, barbiturates, narcotics or antidepressants.

You may notice this as dizziness when standing up. You should consult with your doctor if you need to adjust the dose of your other medicine while taking Telmisartan/Hydrochlorothiazide.

The effect of Telmisartan/Hydrochlorothiazide may be reduced when you take NSAIDs (non steroidal anti-inflammatory medicines, e.g. aspirin or ibuprofen).

Telmisartan/Hydrochlorothiazide with food and alcohol

You can take Telmisartan/Hydrochlorothiazide with or without food. Avoid taking alcohol until you have talked to your doctor. Alcohol may make your blood pressure fall more and/or increase the risk of you becoming dizzy or feeling faint.

Pregnancy and breast-feeding

Pregnancy

You must tell your doctor if you think you are (or might become) pregnant. Your doctor will normally advise you to stop taking this medicine before you become pregnant or as soon as you know you are pregnant and will advise you to take another medicine instead Telmisartan/Hydrochlorothiazide. These tablets are not recommended during pregnancy, and must not be taken when more than 3 months pregnant, as it may cause serious harm to your baby if used after the third month of pregnancy.

Breast-feeding

Tell your doctor if you are breast-feeding or about to start breast-feeding. These tablets are not recommended for mothers who are breast-feeding, and your doctor may choose another treatment for you if you wish to breast-feed.

Driving and using machines

Some people feel dizzy or tired when taking Telmisartan/Hydrochlorothiazide. If you feel dizzy or tired, do not drive or operate machinery.

Telmisartan/Hydrochlorothiazide contains milk sugar (lactose)

If you are intolerant to some sugars, consult your doctor before taking this medicine.

3. How to take Telmisartan/Hydrochlorothiazide

Always take this medicine exactly as your doctor has told you. Check with your doctor or pharmacist if you are not sure.

The recommended dose is one tablet a day.

Try to take a tablet at the same time each day.

You can take the tablets with or without food. They should be swallowed with some water or other non-alcoholic drink.

It is important that you take the tablets every day until your doctor tells you otherwise.

If your liver is not working properly, the usual dose should not exceed 40 mg/12.5 mg once a day.

If you take more Telmisartan/Hydrochlorothiazide than you should

If you accidentally take too many tablets you may experience symptoms such as low blood pressure and rapid heartbeat. Slow heartbeat, dizziness, vomiting, reduced kidney function including kidney failure, have also been reported. Due to the hydrochlorothiazide component, markedly low blood pressure and low blood levels of potassium can also happen, which may result in nausea, sleepiness and muscle cramps and/or irregular heartbeat associated with the concomitant use of drugs such as digitalis or certain anti-arrhythmic treatments. Contact your doctor, pharmacist, or your nearest hospital emergency department immediately.

If you forget to take Telmisartan/Hydrochlorothiazide

If you forget to take a dose, do not worry. Take it as soon as you remember then carry on as before. If you do not take your tablet on one day, take your normal dose on the next day. Do not take a double dose to make up for forgotten individual doses.

If you have further questions on the use of this medicine, ask your doctor or pharmacist.

4. Possible side effects

Like all medicines, this medicine can cause side effects, although not everybody gets them.

Some side effects can be serious and need immediate medical attention:

You should see your doctor immediately if you experience any of the following symptoms:

Sepsis* (often called ?blood poisoning)

is a severe infection with whole-body inflammatory response, rapid swelling of the skin and mucosa (angioedema, blistering and peeling of the top layer of skin (toxic epidermal necrolysis); these side effects are rare (may affect up to 1 in 1,000 people) or of unknown frequency (toxic epidermal necrolysis) but are extremely serious and patients should stop taking the medicine and see their doctor immediately.

If these effects are not treated they could be fatal. Increased incidence of sepsis has been observed with telmisartan only, however cannot be ruled out for Telmisartan/Hydrochlorothiazide.

Possible side effects of Telmisartan/Hydrochlorothiazide:

Common side effects (may affect up to 1 in 10 people):

• Dizziness

Uncommon side effects (may affect up to 1 in 100 people):

• Decreased blood potassium levels
• Anxiety, fainting (syncope)
• Sensation of tingling, pins and needles (paraesthesia)
• Feeling of spinning (vertigo)
• Fast heart beat (tachycardia), heart rhythm disorders
• Low blood pressure, a sudden fall in blood pressure when you stand up
• Shortness of breath (dyspnoea)
• Diarrhoea
• Flatulence
• Dry mouth
• Back pain, muscle spasm, muscle pain, chest pain
• Erectile dysfunction (inability to get or keep an erection)
• Increased blood uric acid levels.

Rare side effects (may affect up to 1 in 1,000 people):

• Inflammation of the lung (bronchitis)
• Activation or worsening of systemic lupus erythematosus (a disease where the body?s immune system attacks the body, which causes joint pain, skin rashes and fever)
• Sore throat, inflamed sinuses
• Feeling sad (depression)
• Difficulty falling asleep (insomnia)
• Impaired vision
• Difficulty breathing
• Abdominal pain, constipation, bloating (dyspepsia), feeling sick (vomiting)
• Inflammation of the stomach (gastritis)
• Abnormal liver function (Japanese patients are more likely to experience this side effect)
• Redness of the skin (erythema)
• Allergic reactions such as itching or rash
• Increased sweating
• Hives (urticaria)
• Joint pain (arthralgia) and pain in extremities
• Muscle cramps
• Flu-like-illness
• Pain
• Low levels of sodium
• Increased levels of creatinine, liver enzymes or creatine phosphokinase in the blood.

Adverse reactions reported with one of the individual components of this medicine may be potential adverse reactions with Telmisartan/Hydrochlorothiazide, even if not observed in clinical trials with this product.

Possible side effects of Telmisartan alone:

In patients taking telmisartan alone the following additional side effects have been reported:

Uncommon side effects (may affect up to 1 in 100 people):

• Upper respiratory tract infection (e.g. sore throat, inflamed sinuses, common cold)
• Urinary tract infections
• Deficiency in red blood cells (anaemia), high potassium levels in blood
• Slow heart rate (bradycardia)
• Kidney impairment including acute kidney failure
• Weakness

Rare side effects (may affect up to 1 in 1,000 people):

• Low blood platelet count (thrombocytopenia), increase in certain white blood cells (eosinophilia)
• Serious allergic reaction (e.g. hypersensitivity, anaphylactic reaction, drug rash)
• Low blood sugar levels (in diabetic patients), upset stomach, eczema (a skin disorder)
• Joint pain (arthrosis)
• Inflammation of the tendons
• Decreased haemoglobin (a blood protein

Very rare side effects (may affect up to 1 in 10,000 people):

• Progressive scarring of lung tissue (interstitial lung disease)**
• The event may have happened by chance or could be related to a mechanism currently not known.

**Cases of progressive scarring of lung tissue have been reported during intake of telmisartan.

However, it is not known whether telmisartan was the cause.

Possible side effects of Hydrochlorothiazide alone:

In patients taking hydrochlorothiazide alone the following additional side effects have been reported:

Common side effects (may affect up to 1 in 10 people):

• Feeling sick (nausea)
• Low blood magnesium level.

Rare side effects (may affect up to 1 in 1,000 people):

• Reduction in blood platelets, which increases risk of bleeding or bruising (small purple-red marks in skin or other tissue caused by bleeding)
• High blood calcium level

Very rare side effects (may affect up to 1 in 10,000 people):

Increased pH (disturbed acid-base balance) due to low blood chloride level.

Side effects of unknown frequency (frequency cannot be estimated from the available data):

• Inflammation of the salivary gland
• Decreases in the number (or even lack) of cells in the blood, including low red and white blood cell count Serious allergic reactions (e.g. hypersensitivity, anaphylactic reaction)
• Decreased or loss of appetite
• Restlessness, light-headedness
• Blurred or yellowing of vision, decrease in vision and eye pain (possible signs of myopia or acute-angle closure glaucoma)
• Inflammation of blood vessels (vasculitis necrotising), inflamed pancreas, upset stomach
• Yellowing of the skin or eyes (jaundice)
• Lupus-like syndrome (a condition mimicking a disease called systemic lupus erythematosus where the body?s immune system attacks the body)
• Skin disorders such as inflamed blood vessels in the skin, increased sensitivity to sunlight, rash, redness of the skin, blistering of the lips, eyes or mouth, skin peeling
• Fever (possible signs of erythema multiforme)
• Weakness
• Kidney inflammation or impaired kidney function
• Glucose in the urine (glycosuria)
• Fever
• Impaired electrolyte balance
• High blood cholesterol levels
• Decreased blood volume
• Increased blood levels of glucose, difficulties in controlling blood/urine levels of glucose in patients with a diagnosis of diabetes mellitus, or fat in the blood.
• Skin and lip cancer (Non-melanoma skin cancer)

Reporting of side effects

If you get any side effects, talk to your doctor or pharmacist. This includes any possible side effects not listed in this leaflet

5. How to store Telmisartan/Hydrochlorothiazide

Keep this medicine out of the sight and reach of children.

Do not use this medicine after the expiry date which is stated on the carton after EXP. The expiry date refers to the last day of that month.

You should store your medicine in the original package in order to protect the tablets from moisture.

Do not use this medicine if you notice that the tablets are discoloured.

Do not throw away any medicines via wastewater or household waste. Ask your pharmacist how to throw away medicines you no longer use. These measures will help protect the environment.

6. Contents of the pack and other information

What Telmisartan/Hydrochlorothiazide contains

The active substances are telmisartan and hydrochlorothiazide.

a) Each film-coated tablet contains:
Telmisartan USP? ? ? ? ? ? ? ? ? ? 40mg
Hydrochlorothiazide USP? ? ?12.5mg
Excipients? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?q.s
Colours: Yellow Oxide of Iron & Titanium Dioxide USP

b) Each film-coated tablet contains:
Telmisartan USP? ? ? ? ? ? ? ? ? ? 80mg
Hydrochlorothiazide USP? ? ?12.5mg
Excipients? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? q.s
Colours: Yellow Oxide of Iron & Titanium Dioxide USP

The other ingredients are: Crospovidone, Hypromellose, Lactose monohydrate, Magnesium stearate, Mannitol, Meglumine, Povidone

Silica colloidal anhydrous, Sodium hydroxide, Sodium stearyl fumarate, Talc, Yellow Iron oxide.

Contents of the pack:

Aluminium-Aluminium foil blisters packed in cartons containing 7, 14, 28, 30, 56, 90, 100 or 500 tablets.

Not all pack sizes may be marketed.

7. Manufactured In India By:
TAJ PHARMACEUTICALS LTD.
Mumbai, India
Unit No. 214.Old Bake House,
Maharashtra chambers of ?Commerce Lane,
Fort, Mumbai – 400001
at:Gujarat, INDIA.
Customer Service and Product Inquiries:
1-800-TRY-FIRST (1-800-222-434 & 1-800-222-825)
Monday through Saturday 9:00 a.m. to 7:00 p.m. EST
E-mail:?tajgroup@tajpharma.com