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Drug Details

Adalat LA 60 mg prolonged-release tablets

• Presentation
  Prolonged-release tablet. Pink, round, convex prolonged-release tablet with a laser hole on one side and marked with Adalat 60.
• Description
  Each prolonged-release tablet contains 60 mg nifedipine. Each tablet contains a 10% overage of nifedipine to deliver the label claim.
• Indications
  

  For the treatment of all grades of hypertension.

  For the prophylaxis of chronic stable angina pectoris either as monotherapy or in combination with a beta-blocker.

• Adult Dosage
  

  Method of administration

  Oral use.

  The tablets should be swallowed whole with a glass of water, either with or without food. The tablets should be taken at approximately 24-hour intervals, i.e. at the same time each day, preferably during the morning. Adalat LA tablets must be swallowed whole; under no circumstances should they be bitten, chewed or broken up.

  Adalat LA should not be taken with grapefruit juice.

  Dosage regimen

  In mild to moderate hypertension, the recommended initial dose is one 20 mg tablet once-daily. In severe hypertension, the recommended initial dose is one 30 mg tablet once-daily. If necessary, the dosage can be increased according to individual requirements up to a maximum of 90 mg once-daily.

  For the prophylaxis of angina pectoris, the recommended initial dose is one 30 mg tablet once-daily. The dosage can be increased according to individual requirements up to a maximum of 90 mg once-daily.

  Patients in whom hypertension or anginal symptoms are controlled on Adalat capsules or Adalat retard may be safely switched to Adalat LA. Prophylactic anti-anginal efficacy is maintained when patients are switched from other calcium antagonists such as diltiazem or verapamil to Adalat LA. Patients switched from other calcium antagonists should initiate therapy at the recommended initial dose of 30 mg Adalat LA once-daily. Subsequent titration to a higher dose may be initiated as warranted clinically.

  Co-administration with CYP 3A4 inhibitors or CYP 3A4 inducers may result in the recommendation to adapt the nifedipine dose or not to use nifedipine at all.

  Duration of treatment

  Treatment may be continued indefinitely.

  Additional information on special populations

  Children and adolescents

  The safety and efficacy of Adalat LA in children below 18 years has not been established.

  Geriatric patients

  The pharmacokinetics of nifedipine are altered in the elderly so that lower maintenance doses of nifedipine may be required compared to younger patients.

  Patients with renal impairment

  Based on pharmacokinetic data, no dosage adjustment is required in patients with renal impairment.

• Contra Indications
  

  Adalat LA should not be administered to patients with known hypersensitivity to nifedipine, or to other dihydropyridines because of the theoretical risk of cross-reactivity, or to any of the excipients.

  Adalat LA is contraindicated in pregnancy before week 20 and during breastfeeding.

  Adalat LA should not be used in cases of cardiogenic shock, clinically significant aortic stenosis, unstable angina, or during or within one month of a myocardial infarction.

  Adalat LA should not be used for the treatment of acute attacks of angina.

  The safety of Adalat LA in malignant hypertension has not been established.

  Adalat LA should not be used for secondary prevention of myocardial infarction.

  Owing to the duration of action of the formulation, Adalat LA should not be administered to patients with hepatic impairment.

  Adalat LA should not be administered to patients with a history of gastro-intestinal obstruction, oesophageal obstruction, or any degree of decreased lumen diameter of the gastro-intestinal tract.

  Adalat LA must not be used in patients with a Kock pouch (ileostomy after proctocolectomy).

  Adalat LA is contra-indicated in patients with inflammatory bowel disease or Crohn's disease.

  Adalat LA should not be administered concomitantly with rifampicin since effective plasma levels of nifedipine may not be achieved owing to enzyme induction.

• Special Precautions
  

  Adalat LA tablets must be swallowed whole; under no circumstances should they be bitten, chewed or broken up.

  Caution should be exercised in patients with hypotension as there is a risk of further reduction in blood pressure and care must be exercised in patients with very low blood pressure (severe hypotension with systolic blood pressure less than 90 mm Hg).

  Careful monitoring of blood pressure must be exercised when administering nifedipine with I.V. magnesium sulphate, owing to the possibility of an excessive fall in blood pressure, which could harm both mother and foetus.

  Adalat LA may be used in combination with beta-blocking drugs and other antihypertensive agents but the possibility of an additive effect resulting in postural hypotension should be borne in mind. Adalat LA will not prevent possible rebound effects after cessation of other antihypertensive therapy.

  Adalat LA should be used with caution in patients whose cardiac reserve is poor. Deterioration of heart failure has occasionally been observed with nifedipine.

  Diabetic patients taking Adalat LA may require adjustment of their control.

  In dialysis patients with malignant hypertension and hypovolaemia, a marked decrease in blood pressure can occur.

  Nifedipine is metabolised via the cytochrome P450 3A4 system. Drugs that are known to either inhibit or to induce this enzyme system may therefore alter the first pass or the clearance of nifedipine.

  Drugs, which are known inhibitors of the cytochrome P450 3A4 system, and which may therefore lead to increased plasma concentrations of nifedipine include, for example:

  - macrolide antibiotics (e.g., erythromycin)

  - anti-HIV protease inhibitors (e.g., ritonavir)

  - azole antimycotics (e.g., ketoconazole)

  - the antidepressants, nefazodone and fluoxetine

  - quinupristin/dalfopristin

  - valproic acid

  - cimetidine

  Upon co-administration with these drugs, the blood pressure should be monitored and, if necessary, a reduction of the nifedipine dose should be considered.

  As the outer membrane of the Adalat LA tablet is not digested, what appears to be the complete tablet may be seen in the toilet or associated with the patient's stools. Also, as a result of this, care should be exercised when administering Adalat LA to patients, as obstructive symptoms may occur. Bezoars can occur in very rare cases and may require surgical intervention.

  In single cases, obstructive symptoms have been described without known history of gastrointestinal disorders.

  A false positive effect may be experienced when performing a barium contrast x-ray.

• Interactions
  

  Drugs that affect nifedipine

  Nifedipine is metabolised via the cytochrome P450 3A4 system, located both in the intestinal mucosa and in the liver. Drugs that are known to either inhibit or to induce this enzyme system may therefore alter the first pass (after oral administration) or the clearance of nifedipine.

  The extent as well as the duration of interactions should be taken into account when administering nifedipine together with the following drugs:

  Rifampicin: Rifampicin strongly induces the cytochrome P450 3A4 system. Upon co-administration with rifampicin, the bioavailability of nifedipine is distinctly reduced and thus its efficacy weakened. The use of nifedipine in combination with rifampicin is therefore contraindicated.

  Upon co-administration of known inhibitors of the cytochrome P450 3A4 system, the blood pressure should be monitored and, if necessary, a reduction in the nifedipine dose considered. In the majority of these cases, no formal studies to assess the potential for a drug interaction between nifedipine and the drug(s) listed have been undertaken, thus far.

  Drugs increasing nifedipine exposure:

  - macrolide antibiotics (e.g., erythromycin)

  - anti-HIV protease inhibitors (e.g., ritonavir)

  - azole anti-mycotics (e.g., ketoconazole)

  - fluoxetine

  - nefazodone

  - quinupristin/dalfopristin

  - cisapride

  - valproic acid

  - cimetidine 

  - diltiazem

  Upon co-administration of inducers of the cytochrome P450 3A4 system, the clinical response to nifedipine should be monitored and, if necessary, an increase in the nifedipine dose considered. If the dose of nifedipine is increased during co-administration of both drugs, a reduction of the nifedipine dose should be considered when the treatment is discontinued.

  Drugs decreasing nifedipine exposure:

  - rifampicin (see above)

  - phenytoin

  - carbamazepine

  - phenobarbital

  Effects of nifedipine on other drugs

  Nifedipine may increase the blood pressure lowering effect of concomitant applied antihypertensives.

  When nifedipine is administered simultaneously with ß-receptor blockers the patient should be carefully monitored, since deterioration of heart failure is also known to develop in isolated cases.

  Digoxin: The simultaneous administration of nifedipine and digoxin may lead to reduced digoxin clearance and, hence, an increase in the plasma digoxin level. The patient should therefore be subjected to precautionary checks for symptoms of digoxin overdosage and, if necessary, the glycoside dose should be reduced.

  Quinidine: Co-administration of nifedipine with quinidine may lower plasma quinidine levels, and after discontinuation of nifedipine, a distinct increase in plasma quinidine levels may be observed in individual cases. Consequently, when nifedipine is either additionally administered or discontinued, monitoring of the quinidine plasma concentration, and if necessary, adjustment of the quinidine dose are recommended. Blood pressure should be carefully monitored and, if necessary, the dose of nifedipine should be decreased.

  Tacrolimus: Tacrolimus is metabolised via the cytochrome P450 3A4 system. Published data indicate that the dose of tacrolimus administered simultaneously with nifedipine may be reduced in individual cases. Upon co-administration of both drugs, the tacrolimus plasma concentrations should be monitored and, if necessary, a reduction in the tacrolimus dose considered.

  Drug food interactions

  Grapefruit juice inhibits the cytochrome P450 3A4 system. Administration of nifedipine together with grapefruit juice thus results in elevated plasma concentrations and prolonged action of nifedipine due to a decreased first pass metabolism or reduced clearance. As a consequence, the blood pressure lowering effect of nifedipine may be increased. After regular intake of grapefruit juice, this effect may last for at least three days after the last ingestion of grapefruit juice. Ingestion of grapefruit/grapefruit juice is therefore to be avoided while taking nifedipine.

  Other forms of interaction

  Nifedipine may increase the spectrophotometric values of urinary vanillylmandelic acid, falsely. However, HPLC measurements are unaffected.

• Adverse Drug Reactions
  

  Adverse drug reactions (ADRs) based on placebo-controlled studies with nifedipine sorted by CIOMS III categories of frequency (clinical trial data base: nifedipine n = 2,661; placebo n = 1,486; status: 22 Feb 2006 and the ACTION study: nifedipine n = 3,825; placebo n = 3,840) are listed below:

  ADRs listed under "common" were observed with a frequency below 3% with the exception of oedema (9.9%) and headache (3.9%).

  The frequencies of ADRs reported with nifedipine-containing products are summarised in the table below. Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness. Frequencies are defined as common (1/100 to < 1/10), uncommon ( 1/1,000 to < 1/100) and rare ( 1/10,000 to < 1/1,000). The ADRs identified only during the ongoing postmarketing surveillance, and for which a frequency could not be estimated, are listed under “Not known”. 

  System Organ Class (MedDRA)	Common	Uncommon	Rare	Not Known
  Blood and Lymphatic System Disorders				Agranulocytosis Leucopenia
  Immune System Disorders		Allergic reaction Allergic oedema/angioedema (incl. larynx oedema*)	Pruritus Urticaria Rash	Anaphylactic/ anaphylactoid reaction
  Psychiatric Disorders		Anxiety reactions Sleep disorders
  Metabolism and Nutrition Disorders				Hyperglycaemia
  Nervous System Disorders	Headache	Vertigo Migraine Dizziness Tremor	Par-/Dysaesthesia	Hypoaesthesia Somnolence
  Eye Disorders		Visual disturbances		Eye pain
  Cardiac Disorders		Tachycardia Palpitations		Chest pain (Angina pectoris)
  Vascular Disorders	Oedema Vasodilatation	Hypotension Syncope
  Respiratory, Thoracic and Mediastinal Disorders		Nosebleed Nasal congestion		Dyspnoea
  Gastrointestinal Disorders	Constipation	Gastrointestinal and abdominal pain Nausea Dyspepsia Flatulence Dry mouth	Gingival hyperplasia	Bezoar Dysphagia Intestinal obstruction Intestinal ulcer Vomiting Gastroesophageal sphincter insufficiency
  Hepatobiliary Disorders		Transient increase in liver enzymes		Jaundice
  Skin and Subcutaneous Tissue Disorders		Erythema		Toxic Epidermal Necrolysis Photosensitivity allergic reaction Palpable purpura
  Musculoskeletal and Connective Tissue Disorders		Muscle cramps Joint swelling		Arthralgia Myalgia
  Renal and Urinary Disorders		Polyuria Dysuria
  Reproductive System and Breast Disorders		Erectile dysfunction
  General Disorders and Administration Site Conditions	Feeling unwell	Unspecific pain Chills

  ^* = may result in life-threatening outcome

  In dialysis patients with malignant hypertension and hypovolaemia a distinct fall in blood pressure can occur as a result of vasodilation.