13 Apr 2012

Equasym XL (methylphenidate hydrochloride) - United Kingdom

Updated: 13 Apr 2012

Equasym XL 10 mg, 20 mg or 30 mg Capsules

Methylphenidate is indicated as part of a comprehensive treatment programme for attention-deficit/hyperactivity disorder (ADHD) in children aged 6 years of age and over when remedial measures alone prove insufficient. Treatment must be under the supervision of a specialist in childhood behavioural disorders. Diagnosis should be made according to DSM-IV criteria or the guidelines in ICD-10 and should be based on a complete history or evaluation of the patient. Diagnosis cannot be made solely on the presence of one or more symptom.

The specific aetiology of this syndrome is unknown, and there is no single diagnostic test. Adequate diagnosis requires the use of medical and specialised psychological, educational, and social resources.

A comprehensive treatment programme typically includes psychological, educational and social measures as well as pharmacotherapy and is aimed at stabilising children with a behavioural syndrome characterised by symptoms which may include chronic history of short attention span, distractibility, emotional lability, impulsivity, moderate to severe hyperactivity, minor neurological signs and abnormal EEG. Learning may or may not be impaired.

Methylphenidate treatment is not indicated in all children with this syndrome and the decision to use the drug must be based on a very thorough assessment of the severity and chronicity of the child's symptoms in relation to the child's age.

Appropriate educational placement is essential, and psychosocial intervention is generally necessary. Where remedial measures alone prove insufficient, the decision to prescribe a stimulant must be based on rigorous assessment of the severity of the child's symptoms. The use of methylphenidate should always be used in this way according to the licensed indication and according to prescribing / diagnostic guidelines.

Equasym XL Description, Presentation and Dosage

Equasym XL Description

Equasym XL Drug Class Description

Psychoanaleptics, Psychostimulants and agents used for ADHD and nootropics, Centrally acting Sympathomimetics - ATC code: N06BA04

Equasym XL Drug Description

Each capsule contains 10 mg methylphenidate hydrochloride corresponding to 8.65 mg methylphenidate. Excipient: 45 mg sucrose/capsule for Equasym XL 10 mg Each capsule contains 20 mg methylphenidate hydrochloride corresponding to 17.30 mg methylphenidate. Excipient: 90 mg sucrose/capsule for Equasym XL 20 mg Each capsule contains 30 mg methylphenidate hydrochloride corresponding to 25.94 mg methylphenidate. Excipient: 135 mg sucrose/capsule for Equasym XL 30 mg Modified release capsule, hard. The capsule has a dark green opaque cap imprinted with “Celltech 574” in white and a white opaque body imprinted with “10mg” in black. The capsule has a blue opaque cap imprinted with “Celltech 575” in white and a white opaque body imprinted with “20mg” in black. The capsule has a reddish-brown opaque cap imprinted with “Celltech 576” in white and a white opaque body imprinted with “30mg” in black.

Equasym XL Generic Name

methylphenidate hydrochloride

Equasym XL Presentation

Equasym XL Presentation

Modified release capsule, hard. Equasym XL 10 mg capsule: The capsule has a dark green opaque cap imprinted with “S544” in white and a white opaque body imprinted with “10 mg” in black. Equasym XL 20 mg capsule: The capsule has a blue opaque cap imprinted with “S544” in white and a white opaque body imprinted with “20 mg” in black. Equasym XL 30 mg capsule: The capsule has a reddish-brown opaque cap imprinted with “S544” in white and a white opaque body imprinted with “30 mg” in black. The capsule has a blue opaque cap imprinted with “UCB 580” in white and a white opaque body imprinted with “20mg” in black. The capsule has a reddish-brown opaque cap imprinted with “UCB 581” in white and a white opaque body imprinted with “30mg” in black.

Equasym XL Manufacturer

Shire Pharmaceuticals Limited

Free Medical Education Resources

Equasym XL Dosage

Equasym XL Adult Dosage

Equasym XL consists of an immediate release component (30% of the dose) and a modified release component (70% of the dose). Hence Equasym XL 10 mg yields an immediate-release dose of 3 mg and an extended release dose of 7 mg methylphenidate hydrochloride. The extended-release portion of each dose is designed to maintain a treatment response through the afternoon without the need for a midday dose. It is designed to deliver therapeutic plasma levels for a period of approximately 8 hours, which is consistent with the school day rather than the whole day (see section 5.2 “Pharmacokinetic properties”). For example, 20 mg of Equasym XL is intended to take the place of 10 mg at breakfast and 10 mg at lunchtime of immediate release methylphenidate hydrochloride.

Methylphenidate is not licensed for use in adults in ADHD. Safety and efficacy have not been established in this age group.

Equasym XL Child Dosage

Children (aged 6 years and over) and adolescents:

Treatment must be initiated under the supervision of a specialist in childhood and/or adolescent behavioural disorders.

Pre-treatment screening:

Prior to prescribing, it is necessary to conduct a baseline evaluation of a patient's cardiovascular status including blood pressure and heart rate. A comprehensive history should document concomitant medications, past and present co-morbid medical and psychiatric disorders or symptoms, family history of sudden cardiac/unexplained death and accurate recording of pre-treatment height and weight on a growth chart.

Ongoing monitoring:

Growth, psychiatric and cardiovascular status should be continuously monitored.

• Blood pressure and pulse should be recorded on a centile chart at each adjustment of dose and then at least every 6 months;

• height, weight and appetite should be recorded at least 6 monthly with maintenance of a growth chart;

• development of de novo or worsening of pre-existing psychiatric disorders should be monitored at every adjustment of dose and then least every 6 months and at every visit.

Patients should be monitored for the risk of diversion, misuse and abuse of methylphenidate.

Dose titration:

Careful dose titration is necessary at the start of treatment with methylphenidate. Dose titration should be started at the lowest possible dose. This is normally achieved using an immediate release formulation taken in divided doses. The recommended starting daily dose is 5 mg once daily or twice daily (e.g. at breakfast and lunch), increasing if necessary by weekly increments of 5-10 mg in the daily dose according to tolerability and degree of efficacy observed. Equasym XL 10 mg once daily may be used in place of immediate release methylphenidate hydrochloride 5 mg twice daily from the beginning of treatment where the treating physician considers that twice daily dosing is appropriate from the outset and twice daily treatment administration is impracticable.

The maximum daily dose of methylphenidate hydrochloride is 60 mg.

For doses not realisable/practicable with this strength, other strengths of this medicinal product and other methylphenidate containing products are available.

Patients Currently Using Methylphenidate: Patients established on an immediate release methylphenidate hydrochloride formulation may be switched to the milligram equivalent daily dose of Equasym XL.

Equasym XL should not be taken too late in the morning as it may cause disturbances in sleep. If the effect of the medicinal product wears off too early in the late afternoon or evening, disturbed behaviour and/or inability to go to sleep may recur. A small dose of an immediate-release methylphenidate hydrochloride tablet late in the day may help to solve this problem. In that case, it could be considered that adequate symptom control might be achieved with a twice daily immediate release methylphenidate regimen. The pros and cons of a small evening dose of immediate-release methylphenidate versus disturbances in falling asleep should be considered. Treatment should not continue with Equasym XL if an additional late dose of immediate-release methylphenidate is required, unless it is known that the same extra dose was also required for a conventional immediate-release regimen at equivalent breakfast/lunchtime dose. The regimen that achieves satisfactory symptom control with the lowest total daily dose should be employed.

Equasym XL should be given in the morning before breakfast.

The capsules may be swallowed whole with the aid of liquids, or alternatively, the capsule may be opened and the capsule contents sprinkled onto a small amount (tablespoon) of applesauce and given immediately, and not stored for future use. Drinking some fluids, e.g. water, should follow the intake of the sprinkles with applesauce. The capsules and the capsule contents must not be crushed or chewed.

Long-term (more than 12 months) use in children and adolescents:

The safety and efficacy of long term use of methylphenidate has not been systematically evaluated in controlled trials. Methylphenidate treatment should not and need not, be indefinite. Methylphenidate treatment is usually discontinued during or after puberty. The physician who elects to use methylphenidate for extended periods (over 12 months) in children and adolescents with ADHD should periodically re-evaluate the long term usefulness of the drug for the individual patient with trial periods off medication to assess the patient's functioning without pharmacotherapy. It is recommended that methylphenidate is de-challenged at least once yearly to assess the child's condition (preferable during times of school holidays). Improvement may be sustained when the drug is either temporarily or permanently discontinued.

Dose reduction and discontinuation

Treatment must be stopped if the symptoms do not improve after appropriate dosage adjustment over a one-month period. If paradoxical aggravation of symptoms or other serious adverse events occur, the dosage should be reduced or discontinued.

Children under 6 years of age

Methylphenidate should not be used in children under the age of 6 years. Safety and efficacy in this age group has not been established.

 

 

Equasym XL Elderly Dosage

Methylphenidate should not be used in the elderly. Safety and efficacy has not been established in this age group.

Equasym XL Precautions, Reactions and Contraindications

Equasym XL Special Precautions

Equasym XL Special Precautions

Methylphenidate treatment is not indicated in all children with ADHD and the decision to use the drug must be based on a very thorough assessment of the severity and chronicity of the child's symptoms in relation to the child's age.

Long-term use (more than 12 months) in children and adolescents

The safety and efficacy of long term use of methylphenidate has not been systematically evaluated in controlled trials. Methylphenidate treatment should not and need not, be indefinite. Methylphenidate treatment is usually discontinued during or after puberty. Patients on long-term therapy (i.e. over 12 months) must have careful ongoing monitoring according to the guidance in Dosage Information and Precautions for cardiovascular status, growth, appetite, development of de novo or worsening of pre-existing psychiatric disorders. Psychiatric disorders to monitor for are described below, and include (but are not limited to) motor or vocal tics, aggressive or hostile behaviour, agitation, anxiety, depression, psychosis, mania, delusions, irritability, lack of spontaneity, withdrawal and excessive perseveration.

The physician who elects to use methylphenidate for extended periods (over 12 months) in children and adolescents with ADHD should periodically re-evaluate the long term usefulness of the drug for the individual patient with trial periods off medication to assess the patient's functioning without pharmacotherapy. It is recommended that methylphenidate is de-challenged at least once yearly to assess the child's condition (preferably during times of school holidays). Improvement may be sustained when the drug is either temporarily or permanently discontinued.

Use in adults

Methylphenidate is not licensed for use in adults with ADHD. Safety and efficacy have not been established in this age group.

Use in the elderly

Methylphenidate should not be used in the elderly. Safety and efficacy has not been established in this age group.

Use in children under 6 years of age

Methylphenidate should not be used in children under the age of 6 years. Safety and efficacy in this age group has not been established.

Cardiovascular status

Patients who are being considered for treatment with stimulant medications should have a careful history (including assessment for a family history of sudden cardiac or unexplained death or malignant arrhythmia) and physical exam to assess for the presence of cardiac disease, and should receive further specialist cardiac evaluation if initial findings suggest such history or disease. Patients who develop symptoms such as palpitations, exertional chest pain, unexplained syncope, dyspnoea or other symptoms suggestive of cardiac disease during methylphenidate treatment should undergo a prompt specialist cardiac evaluation.

Analyses of data from clinical trials of methylphenidate in children and adolescents with ADHD showed that patients using methylphenidate may commonly experience changes in diastolic and systolic blood pressure of over 10 mmHg relative to controls. The short- and long-term clinical consequences of these cardiovascular effects in children and adolescents are not known, but the possibility of clinical complications cannot be excluded as a result of the effects observed in the clinical trial data. Caution is indicated in treating patients whose underlying medical conditions might be compromised by increases in blood pressure or heart rate. See ContraIndications for conditions in which methylphenidate treatment in contraindicated.

Cardiovascular status should be carefully monitored. Blood pressure and pulse should be recorded on a centile chart at each adjustment of dose and then at least every 6 months.

The use of methylphenidate is contraindicated in certain pre-existing cardiovascular disorders unless specialist paediatric cardiac advice has been obtained (see 'Contraindications').

Sudden death and pre-existing cardiac structural abnormalities or other serious cardiac disorders

Sudden death has been reported in association with the use of stimulants of the central nervous system at usual doses in children, some of whom had cardiac structural abnormalities or other serious heart problems. Although some serious heart problems alone may carry an increased risk of sudden death, stimulant products are not recommended in children or adolescents with known cardiac structural abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the sympathomimetic effects of a stimulant medicine.

Misuse and Cardiovascular Events

Misuse of stimulants of the central nervous system may be associated with sudden death and other serious cardiovascular adverse events.

Cerebrovascular disorders

See ContraIndications for cerebrovascular conditions in which methylphenidate treatment in contraindicated. Patients with additional risk factors (such as a history of cardiovascular disease, concomitant medications that elevate blood pressure) should be assessed at every visit for neurological signs and symptoms after initiating treatment with methylphenidate.

Cerebral vasculitis appears to be a very rare idiosyncratic reaction to methylphenidate exposure. There is little evidence to suggest that patients at higher risk can be identified and the initial onset of symptoms may be the first indication of an underlying clinical problem. Early diagnosis, based on a high index of suspicion, may allow the prompt withdrawal of methylphenidate and early treatment. The diagnosis should therefore be considered in any patient who develops new neurological symptoms that are consistent with cerebral ischemia during methylphenidate therapy. These symptoms could include severe headache, numbness, weakness, paralysis, and impairment of coordination, vision, speech, language or memory.

Treatment with methylphenidate is not contraindicated in patients with hemiplegic cerebral palsy.

Psychiatric disorders

Co-morbidity of psychiatric disorders in ADHD is common and should be taken into account when prescribing stimulant products. In the case of emergent psychiatric symptoms or exacerbation of pre-existing psychiatric disorders, methylphenidate should not be given unless the benefits outweigh the risks to the patient.

Development or worsening of psychiatric disorders should be monitored at every adjustment of dose, then at least every 6 months, and at every visit; discontinuation of treatment may be appropriate.

Exacerbation of pre-existing Psychotic or manic symptoms

In psychotic patients, administration of methylphenidate may exacerbate symptoms of behavioural disturbance and thought disorder.

Emergence of new psychotic or manic symptoms

Treatment-emergent psychotic symptoms (visual/tactile/auditory hallucinations and delusions) or mania in children and adolescents without prior history of psychotic illness or mania can be caused by methylphenidate at usual doses. If manic or psychotic symptoms occur, consideration should be given to a possible causal role for methylphenidate, and discontinuation of treatment may be appropriate.

Aggressive or hostile behaviour

The emergence or worsening of aggression or hostility can be caused by treatment with stimulants. Patients treated with methylphenidate should be closely monitored for the emergence or worsening of aggressive behaviour or hostility at treatment initiation, at every dose adjustment and then at least every 6 months and every visit. Physicians should evaluate the need for adjustment of the treatment regimen in patients experiencing behaviour changes bearing in mind that upwards or downwards titration may be appropriate. Treatment interruption can be considered.

Suicidal tendency

Patients with emergent suicidal ideation or behaviour during treatment for ADHD should be evaluated immediately by their physician. Consideration should be given to the exacerbation of an underlying psychiatric condition and to a possible causal role of methylphenidate treatment. Treatment of an underlying psychiatric condition may be necessary and consideration should be given to a possible discontinuation of methylphenidate.

Tics

Methylphenidate is associated with the onset or exacerbation of motor and verbal tics. Worsening of Tourette's syndrome has also been reported. Family history should be assessed and clinical evaluation for tics or Tourette's syndrome in children should precede use of methylphenidate. Patients should be regularly monitored for the emergence or worsening of tics during treatment with methylphenidate. Monitoring should be at every adjustment of dose and then at least every 6 months or every visit.

Anxiety, agitation or tension

Methylphenidate is associated with the worsening of pre-existing anxiety, agitation or tension. Clinical evaluation for anxiety, agitation or tension should precede use of methylphenidate and patients should be regularly monitored for the emergence or worsening of these symptoms during treatment, at every adjustment of dose and then at least every 6 month or every visit.

Forms of bipolar disorder

Particular care should be taken in using methylphenidate to treat ADHD in patients with comorbid bipolar disorder (including untreated Type I Bipolar Disorder or other forms of bipolar disorder) because of concern for possible precipitation of a mixed/manic episode in such patients. Prior to initiating treatment with methylphenidate, patients with comorbid depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. Close ongoing monitoring is essential in these patients. Patients should be monitored for symptoms at every adjustment of dose, then at least every 6 months and at every visit.

Growth

Moderately reduced weight gain and growth retardation have been reported with the long-term use of methylphenidate in children.

The effects of methylphenidate on final height and final weight are currently unknown and being studied.

Growth should be monitored during methylphenidate treatment: height, weight and appetite should be recorded at least 6 monthly with maintenance of a growth chart. Patients who are not growing or gaining height or weight as expected may need to have their treatment interrupted.

Seizures

Methylphenidate should be used with caution in patients with epilepsy. Methylphenidate may lower the convulsive threshold in patient with prior history of seizures, in patients with prior EEG abnormalities in absence of seizures, and rarely in patients without a history of convulsions and no EEG abnormalities. If seizure frequency increases or new-onset seizures occur, methylphenidate should be discontinued.

Abuse, misuse and diversion

Patients should be carefully monitored for the risk of diversion, misuse and abuse of methylphenidate.

Methylphenidate should be used with caution in patients with known drug or alcohol dependency because of a potential for abuse, misuse or diversion.

Chronic abuse of methylphenidate can lead to marked tolerance and psychological dependence with varying degrees of abnormal behaviour. Frank psychotic episodes can occur, especially in response to parenteral abuse.

Patient age, the presence of risk factors for substance use disorder (such as co-morbid oppositional-defiant or conduct disorder and bipolar disorder), previous or current substance abuse should all be taken into account when deciding on a course of treatment for ADHD. Caution is called for in emotionally unstable patients, such as those with a history of drug or alcohol dependence, because such patients may increase the dosage on their own initiative.

For some high-risk substance abuse patients, methylphenidate or other stimulants may not be suitable and non-stimulant treatment should be considered.

Withdrawal

Careful supervision is required during drug withdrawal, since this may unmask depression as well as chronic over-activity. Some patients may require long-term follow up.

Careful supervision is required during withdrawal from abusive use since severe depression may occur.

Fatigue

Methylphenidate should not be used for the prevention or treatment of normal fatigue states.

Excipients: sucrose intolerance

This medicinal product contains sucrose: patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucrose-isomaltase insufficiency should not take this medicine.

Choice of methylphenidate formulation

The choice of formulation of methylphenidate-containing product will have to be decided by the treating specialist on an individual basis and depends on the intended duration of effect.

Drug screening

This product contains methylphenidate which may induce a false positive laboratory test for amphetamines, particularly with immunoassay screen test.

Renal or hepatic insufficiency

There is no experience with the use of methylphenidate in patients with renal or hepatic insufficiency.

Haematological effects

The long-term safety of treatment with methylphenidate is not fully known. In the event of Leukopenia, thrombocytopenia, anaemia or other alterations, including those indicative of serious renal or hepatic disorders, discontinuation of treatment should be considered.

Equasym XL Adverse Reactions

Equasym XL Adverse Reactions

The table below shows all adverse drug reactions (ADRs) observed during clinical trials and post-market spontaneous reports with Equasym XL and those, which have been reported with other methylphenidate hydrochloride formulations. If the ADRs with Equasym XL and the methylphenidate formulation frequencies were different, the highest frequency of both databases was used.

Frequency estimate: very common (GREATER-THAN OR EQUAL TO (8805) 1/10); common (GREATER-THAN OR EQUAL TO (8805) 1/100 to < 1/10); uncommon (GREATER-THAN OR EQUAL TO (8805) 1/1000 to < 1/100); rare (GREATER-THAN OR EQUAL TO (8805) 1/10000 to < 1/1000); very rare (<1/10000), not known (cannot be estimated from the available data).

System Organ Class

Adverse Drug Reaction

Infections and infestations

Common:

nasopharyngitis

Blood and lymphatic system disorders

Very rare:

Not known:

anaemia, leucopenia, thrombocytopenia, thrombocytopenic purpura

pancytopenia

Immune System Disorders

Uncommon:

hypersensitivity reactions such as angioneurotic oedema, anaphylactic reactions, auricular swelling, bullous conditions, exfoliative conditions, urticarias, pruritis, rashes and eruptions

Metabolism and nutrition disorders*

Common:

anorexia, decreased appetite, moderately reduced weight and height gain during prolonged use in children*

Psychiatric disorders*

Very common:

Common:

Uncommon:







Rare:

Very rare:







Not known:

insomnia, nervousness

anorexia, affect lability, aggression*, agitation*, anxiety*, depression*, irritability, abnormal behaviour, bruxism

psychotic disorders*, auditory, visual, and tactile hallucinations*, anger, suicidal ideation*, mood altered, mood swings, restlessness, tearfulness, tics*, worsening of pre-existing tics or Tourette's syndrome*, hypervigilance, sleep disorder

mania*, disorientation, libido disorder

suicidal attempt (including completed suicide)*, transient depressed mood*, abnormal thinking, apathy, repetitive behaviours, over-focussing

delusions*, thought disturbances*, confusional state, dependence

Cases of abuse and dependence have been described, more often with immediate release formulations (frequency not known)

Nervous system disorders

Very common:

Common:

Uncommon:

Very rare:







Not known:

headache

dizziness, dyskinesia, psychomotor hyperactivity, somnolence

sedation, tremor

convulsions, choreo-athetoid movements, reversible ischaemic neurological deficit Neuroleptic malignant syndrome (NMS; Reports were poorly documented and in most cases, patients were also receiving other drugs, so the role of methylphenidate is unclear)

cerebrovascular disorders* (including vasculitis, cerebral haemorrhages, cerebrovascular accidents, cerebral arteritis, cerebral occlusion), grand mal convulsions*, migraine

Eye disorders

Uncommon:

Rare:

diplopia, blurred vision

difficulties in visual accommodation, mydriasis, visual disturbance

Cardiac disorders

Common:

Uncommon:

Rare:

Very rare:

Not known:

arrhythmia, tachycardia, palpitations

chest pain

angina pectoris

cardiac arrest, myocardial infarction

supraventricular tachycardia, bradycardia, ventricular extrasystoles, extrasystoles

Vascular disorders*

Common:

Very rare:

hypertension

cerebral arteritis and/or occlusion, peripheral coldness, Raynaud's phenomenon

Respiratory, thoracic and mediastinal disorders

Common:

Uncommon:

cough, pharyngolaryngeal pain

dyspnoea

Gastrointestinal disorders

Common:

Uncommon:

abdominal pain, diarrhea, nausea, stomach discomfort and vomiting, dry mouth

constipation

Hepatobiliary disorders

Uncommon:

Very rare:

hepatic enzyme elevations

abnormal liver function, including hepatic coma

Skin and subcutaneous tissue disorders

Common:

Uncommon:

Rare:

Very rare:

alopecia, pruritus, rash, urticaria

angioneurotic oedema, bullous conditions, exfoliative conditions

hyperhidrosis, macular rash, erythema

erythema multiforme, exfoliative dermatitis, fixed drug eruption

Musculoskeletal and connective tissue disorders

Common:

Uncommon:

Very rare:

arthralgia

myalgia, muscle twitching

muscle cramps

Renal and urinary disorders

Uncommon:

haematuria

Reproductive system and breast disorders

Rare:

gynaecomastia

General disorders and administration site conditions

Common:

Uncommon:

Very rare:

Not known:

pyrexia, growth retardation during prolonged use in children*

chest pain, fatigue

sudden cardiac death*

chest discomfort, hyperpryrexia

Investigations

Common:

Uncommon:

Very rare:

changes in blood pressure and heart rate (usually an increase) *, weight decreased

cardiac murmur*, hepatic enzyme increased

blood alkaline phosphatase increased, blood bilirubin increased, platelet count decreased, white blood count abnormal

* See Precautions '

Equasym XL Contraindications

Equasym XL Contraindications

Equasym XL is contra-indicated in patients with:

• Known sensitivity to methylphenidate or to any of the excipients

• Glaucoma

• Phaeochromocytoma

• During treatment with non-selective, irreversible monoamine oxidase inhibitors, or within a minimum of 14 days following discontinuing those drugs, due to risk of hypertensive crises

• Hyperthyroidism or Thyrotoxicosis

• Diagnosis or history of severe depression, anorexia nervosa/anorexic disorders suicidal tendencies, psychotic symptoms, severe mood disorders, mania, schizophrenia, psychopathic/borderline personality disorder

• Diagnosis or history of severe and episodic (Type I) Bipolar (affective) disorder (that is not well-controlled)

• Pre-existing cardiovascular disorders including severe hypertension, heart failure, arterial occlusive disease, angina, haemodynamically significant congenital heart disease, cardiomyopathies, myocardial infarction, potentially life-threatening arrhythmias and channelopathies (disorders caused by the dysfunction of ion channels)

• Pre-existing cerebrovascular disorders cerebral aneurysm, vascular abnormalities including vasculitis or stroke

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