Karmagip (Tablets) Instructions for Use

ATC Code

C08CA01 (Amlodipine)

Active Substance

Amlodipine (Rec.INN registered by WHO)

Clinical-Pharmacological Group

Calcium channel blocker

Pharmacotherapeutic Group

BMCC (Bone Mineral Crystal Complex)

Pharmacological Action

A selective class II calcium channel blocker. The antihypertensive effect is due to a direct relaxing effect on vascular smooth muscles.

It is assumed that the antianginal effect of amlodipine is associated with its ability to dilate peripheral arterioles; this leads to a decrease in total peripheral vascular resistance, with no reflex tachycardia occurring.

As a result, the myocardial oxygen demand and the energy consumption of the heart muscle are reduced.

On the other hand, Amlodipine appears to cause dilation of large coronary arteries and coronary arterioles in both intact and ischemic areas of the myocardium.

This ensures the supply of oxygen to the myocardium during spasms of the coronary arteries.

Pharmacokinetics

When taken orally, it is absorbed slowly and almost completely from the gastrointestinal tract; C_max in blood plasma is reached within 6-9 hours.

Protein binding is 95-98%.

It undergoes minimal metabolism during the first pass through the liver and slow but significant hepatic metabolism to form metabolites with insignificant pharmacological activity.

T_1/2 averages 35 hours and in arterial hypertension may increase to an average of 48 hours, in elderly patients – up to 65 hours, and in patients with impaired liver function – up to 60 hours.

It is excreted mainly as metabolites: 59-62% by the kidneys, 20-25% through the intestines.

Indications

Arterial hypertension (as monotherapy or as part of combination therapy).

Stable angina, unstable angina, Prinzmetal’s angina (as monotherapy or as part of combination therapy).

ICD codes

Dosage Regimen

Take the tablets orally, once daily. Swallow the tablet whole with water, with or without food.

For arterial hypertension and stable angina, the initial dose for adults is 5 mg.

For unstable angina or Prinzmetal’s angina, the initial dose for adults is also 5 mg.

Adjust the dose based on individual therapeutic response and tolerability. The dose may be increased to a maximum dose of 10 mg once daily.

For small or fragile patients, or those with hepatic impairment, initiate therapy at 2.5 mg once daily as a starting dose.

No initial dose adjustment is required for geriatric patients or patients with renal impairment.

Monitor blood pressure closely during the titration period. The full therapeutic effect is usually achieved within 1-2 weeks.

Discontinuation of therapy, while not associated with a withdrawal syndrome, should be done gradually under medical supervision.

Adverse Reactions

From the cardiovascular system: peripheral edema, tachycardia, flushing of the skin; when used in high doses – arterial hypotension, arrhythmias, shortness of breath.

From the digestive system: nausea, abdominal pain; rarely – gingival hyperplasia.

From the central and peripheral nervous system: headache, fatigue, drowsiness, dizziness; with long-term use – paresthesia.

Allergic reactions: skin rash, itching.

Other: with long-term use – pain in the extremities.

Contraindications

Severe arterial hypotension (systolic blood pressure less than 90 mm Hg); obstruction of the left ventricular outflow tract (including severe aortic stenosis); hemodynamically unstable heart failure after myocardial infarction; children and adolescents under 18 years of age (efficacy and safety not established); hypersensitivity to amlodipine and other dihydropyridine derivatives.

Use in Pregnancy and Lactation

The safety of using amlodipine during pregnancy has not been established, so use is possible only if the intended benefit to the mother outweighs the potential risk to the fetus.

There are no data indicating the excretion of amlodipine in breast milk.

However, it is known that other slow calcium channel blockers (dihydropyridine derivatives) are excreted in breast milk.

In this regard, if it is necessary to use amlodipine during lactation, the issue of discontinuing breastfeeding should be considered.

Use in Hepatic Impairment

Use with caution in patients with impaired liver function.

Use in Renal Impairment

Use with caution in patients with impaired renal function.

Pediatric Use

There are no clinical data on the use of amlodipine in pediatrics.

Geriatric Use

No dose reduction is required for elderly patients.

Special Precautions

Use with caution in patients with hepatic insufficiency, chronic heart failure of non-ischemic etiology NYHA functional class III-IV, unstable angina, aortic stenosis, mitral stenosis, hypertrophic obstructive cardiomyopathy, acute myocardial infarction (and within 1 month after it), sick sinus syndrome (severe tachycardia, bradycardia), arterial hypotension, and with simultaneous use with inhibitors or inducers of the CYP3A4 isoenzyme.

During the use of amlodipine in patients with chronic heart failure (NYHA class III and IV) of non-ischemic origin, an increased incidence of pulmonary edema was noted, despite the absence of signs of worsening heart failure.

In elderly patients, the T_1/2 of amlodipine may increase and its clearance may decrease. Dose changes are not required, but more careful monitoring of patients in this category is necessary.

The efficacy and safety of amlodipine in hypertensive crisis have not been established.

Although calcium channel blockers do not have a withdrawal syndrome, it is advisable to discontinue treatment with amlodipine gradually.

There are no clinical data on the use of amlodipine in pediatrics.

Drug Interactions

It is possible to enhance the antianginal and antihypertensive effects of calcium channel blockers when used concomitantly with thiazide and loop diuretics, ACE inhibitors, beta-blockers and nitrates, as well as to enhance their antihypertensive effect when used concomitantly with alpha₁-blockers, antipsychotics.

Although a negative inotropic effect was usually not observed in studies of amlodipine, nevertheless, some calcium channel blockers may enhance the severity of the negative inotropic effect of antiarrhythmic drugs that cause QT interval prolongation (for example, amiodarone and quinidine).

Concomitant multiple administration of amlodipine at a dose of 10 mg and simvastatin at a dose of 80 mg leads to an increase in the bioavailability of simvastatin by 77%. In such cases, the dose of simvastatin should be limited to 20 mg.

Antiviral drugs (for example, ritonavir) increase the plasma concentrations of calcium channel blockers, including amlodipine.

With simultaneous use of sympathomimetics, estrogens, a decrease in the antihypertensive effect is possible due to sodium retention in the body.

Antipsychotics and isoflurane enhance the antihypertensive effect of dihydropyridine derivatives. With simultaneous use of inhalation anesthetics, an increase in the hypotensive effect is possible.

With simultaneous use of amiodarone, an enhancement of the antihypertensive effect is possible.

With simultaneous use of lithium carbonate, manifestations of neurotoxicity are possible (including nausea, vomiting, diarrhea, ataxia, tremor and/or tinnitus).

With simultaneous use, orlistat reduces the antihypertensive effect of amlodipine, which can lead to a significant increase in blood pressure and the development of a hypertensive crisis.

With simultaneous use of indomethacin and other NSAIDs, a decrease in the antihypertensive effect of amlodipine is possible due to inhibition of prostaglandin synthesis in the kidneys and fluid retention under the influence of NSAIDs.

With simultaneous use of quinidine, an enhancement of the antihypertensive effect is possible.

Calcium preparations may reduce the effect of calcium channel blockers.

With simultaneous use of diltiazem (an inhibitor of the CYP3A4 isoenzyme) at a dose of 180 mg and amlodipine at a dose of 5 mg in elderly patients (from 69 to 87 years) with arterial hypertension, an increase in the bioavailability of amlodipine by 57% is noted.

Concomitant use of amlodipine and erythromycin in healthy volunteers (from 18 to 43 years) does not lead to significant changes in amlodipine exposure (increase in AUC by 22%).

Although the clinical significance of these effects is not entirely clear, they may be more pronounced in elderly patients.

Potent inhibitors of the CYP3A4 isoenzyme (for example, ketoconazole, itraconazole) may lead to an increase in the plasma concentration of amlodipine to a greater extent than diltiazem.

Amlodipine and inhibitors of the CYP3A4 isoenzyme should be used with caution.

There are no data on the effect of inducers of the CYP3A4 isoenzyme on the pharmacokinetics of amlodipine.

Blood pressure should be carefully monitored when amlodipine and inducers of the CYP3A4 isoenzyme are used simultaneously.

Storage Conditions

Store at 2°C (36°F) to 25°C (77°F). Keep in original packaging, protected from light. Keep out of reach of children.

Dispensing Status

Rx Only

Important Safety Information

This information is for educational purposes only and does not replace professional medical advice. Always consult your doctor before use. Dosage and side effects may vary. Use only as prescribed.