Norvasc (Amlodipine Besylate): Uses, Dosage, Side Effects, Interactions, Warning

CLINICAL PHARMACOLOGY

Mechanism Of Action

Amlodipine is a dihydropyridine calcium antagonist ( calcium ion antagonist or slow-channel blocker ) that inhibits the transmembrane inflow of calcium ions into vascular politic muscle and cardiac brawn. Experimental data suggest that amlodipine binds to both dihydropyridine and nondihydropyridine bind sites. The contractile processes of cardiac muscleman and vascular smooth brawn are dependent upon the movement of extracellular calcium ions into these cells through specific ion channels. Amlodipine inhibits calcium ion inflow across cellular telephone membranes selectively, with a greater consequence on vascular legato muscle cells than on cardiac muscle cells. negative inotropic effects can be detected in vitro but such effects have not been seen in integral animals at therapeutic doses. Serum calcium concentration is not affected by amlodipine. Within the physiologic ph range, amlodipine is an ionized compound ( pKa=8.6 ), and its kinetic interaction with the calcium distribution channel receptor is characterized by a gradual rate of association and dissociation with the receptor binding site, resulting in a gradual onset of effect. Amlodipine is a peripheral arterial vasodilator that acts directly on vascular smooth muscle to cause a reduction in peripheral vascular resistance and reduction in blood atmospheric pressure. The accurate mechanism by which amlodipine relieves angina have not been amply delineated, but are thought to include the trace :

Exertional Angina

In patients with exertional angina, NORVASC reduces the sum peripheral resistance ( afterload ) against which the heart works and reduces the pace blackmail product, and thus myocardial oxygen demand, at any given level of exert.

Vasospastic Angina

NORVASC has been demonstrated to block constriction and restore lineage flow in coronary thrombosis arteries and arterioles in response to calcium, potassium epinephrine, serotonin, and thromboxane A2 analogue in experimental animal models and in human coronary thrombosis vessels in vitro. This inhibition of coronary spasm is creditworthy for the effectiveness of NORVASC in vasospastic ( Prinzmetal ‘s or form ) angina pectoris .

Pharmacodynamics

Hemodynamics

Following presidency of remedy doses to patients with high blood pressure, NORVASC produces vasodilation resulting in a reduction of supine and standing lineage pressures. These decreases in blood press are not accompanied by a meaning change in center rate or plasma catecholamine levels with chronic dosing. Although the acuate intravenous administration of amlodipine decreases arterial blood atmospheric pressure and increases heart rate in hemodynamic studies of patients with chronic stable angina, chronic oral administration of amlodipine in clinical trials did not lead to clinically significant changes in center rate or blood pressures in normotensive patients with angina. With chronic once daily oral presidency, antihypertensive potency is maintained for at least 24 hours. Plasma concentrations correlate with effect in both young and aged patients. The order of magnitude of reduction in lineage pressure with NORVASC is besides correlated with the altitude of pretreatment elevation ; thus, individuals with mince high blood pressure ( diastolic pressure 105-114 mmHg ) had about a 50 % greater reception than patients with balmy high blood pressure ( diastolic coerce 90-104 mmHg ). normotensive subjects experienced no clinically meaning change in blood pressures ( +1/-2 mmHg ). In hypertensive patients with normal nephritic function, remedy doses of NORVASC resulted in a decrease in nephritic vascular underground and an increase in glomerular filtration rate and effective nephritic plasma flow without change in filtration fraction or albuminuria. As with other calcium impart blockers, hemodynamic measurements of cardiac affair at rest and during exercise ( or pacing ) in patients with convention ventricular affair treated with NORVASC have generally demonstrated a humble increase in cardiac index without significant influence on dP/dt or on leave ventricular end diastolic coerce or bulk. In hemodynamic studies, NORVASC has not been associated with a negative inotropic effect when administered in the remedy dose range to entire animals and man, evening when co-administered with beta-blockers to man. alike findings, however, have been observed in convention or well-compensated patients with heart failure with agents possessing significant negative inotropic effects .

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Electrophysiologic Effects

amlodipine besylate does not change sinoatrial nodal function or atrioventricular conduction in intact animals or man. In patients with chronic stable angina pectoris, intravenous administration of 10 mg did not importantly alter A-H and H-V conduction and venous sinus node recovery time after pacing. similar results were obtained in patients receiving NORVASC and accompaniment beta-blockers. In clinical studies in which NORVASC was administered in combination with beta-blockers to patients with either high blood pressure or angina, no adverse effects on electrocardiographic parameters were observed. In clinical trials with angina patients entirely, NORVASC therapy did not alter electrocardiographic intervals or produce higher degrees of AV blocks .

Drug Interactions

Sildenafil

When amlodipine and sildenafil were used in combination, each agent independently exerted its own rake blackmail lowering effect [ see DRUG INTERACTIONS ] .

Pharmacokinetics

After oral presidency of remedy doses of NORVASC, absorption produces extremum plasma concentrations between 6 and 12 hours. Absolute bioavailability has been estimated to be between 64 and 90 %. The bioavailability of NORVASC is not altered by the presence of food. Amlodipine is extensively ( about 90 % ) converted to dormant metabolites via hepatic metamorphosis with 10 % of the parent compound and 60 % of the metabolites excreted in the urine. Ex vivo studies have shown that approximately 93 % of the circulating drug is bound to plasma proteins in hypertensive patients. elimination from the plasma is biphasic with a concluding elimination half life of about 30-50 hours. Steady-state plasma levels of amlodipine are reached after 7 to 8 days of consecutive day by day drug. The pharmacokinetics of amlodipine are not significantly influenced by nephritic disability. Patients with nephritic failure may therefore receive the usual initial dose. aged patients and patients with hepatic insufficiency have decreased clearance of amlodipine with a resulting increase in AUC of approximately 40- 60 %, and a lower initial venereal disease may be required. A alike increase in AUC was observed in patients with moderate to severe heart bankruptcy .

Drug Interactions

In vitro data indicate that amlodipine has no effect on the human plasma protein tie of digoxin, diphenylhydantoin, warfarin, and indomethacin .

Impact Of Other Drugs On Amlodipine

Co-administered cimetidine, magnesium-and aluminum hydroxide antacids, sildenafil, and grapefruit juice have no shock on the exposure to amlodipine. CYP3A inhibitors Co-administration of a 180 magnesium daily dose of diltiazem with 5 mg amlodipine in aged hypertensive patients resulted in a 60 % increase in amlodipine systemic exposure. Erythromycin co-administration in healthy volunteers did not significantly change amlodipine systemic exposure. however, strong inhibitors of CYP3A ( for example, itraconazole, clarithromycin ) may increase the plasma concentrations of amlodipine to a greater extent [ see DRUG INTERACTIONS ] .

Impact Of Amlodipine On Other Drugs

Amlodipine is a weak inhibitor of CYP3A and may increase exposure to CYP3A substrates. Co-administered amlodipine does not affect the exposure to atorvastatin, digoxin, ethyl alcohol and the warfarin prothrombin reaction time .

Simvastatin

Co-administration of multiple doses of 10 milligram of amlodipine with 80 mg simvastatin resulted in a 77 % increase in exposure to simvastatin compared to simvastatin alone [ see DRUG INTERACTIONS ].

Cyclosporine

A prospective analyze in nephritic transfer patients ( N=11 ) showed on an average of 40 % increase in bowl cyclosporine levels when concomitantly treated with amlodipine [ witness DRUG INTERACTIONS ] .

Tacrolimus

A prospective study in healthy chinese volunteers ( N=9 ) with CYP3A5 expressers showed a 2.5- to 4-fold increase in tacrolimus exposure when concomitantly administered with amlodipine compared to tacrolimus entirely. This find was not observed in CYP3A5 non-expressers ( N= 6 ). however, a 3-fold increase in plasma exposure to tacrolimus in a nephritic transfer affected role ( CYP3A5 non-expresser ) upon initiation of amlodipine for the treatment of post-transplant high blood pressure resulting in reduction of tacrolimus acid has been reported. Irrespective of the CYP3A5 genotype condition, the possibility of an interaction can not be excluded with these drugs [ see DRUG INTERACTIONS ] .

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Pediatric Patients

sixty-two hypertensive patients aged 6 to 17 years received doses of NORVASC between 1.25 mg and 20 mg. Weight-adjusted headroom and volume of distribution were exchangeable to values in adults.

Clinical Studies

Effects In Hypertension

Adult Patients

The antihypertensive efficacy of NORVASC has been demonstrated in a total of 15 double-blind, placebo-controlled, randomized studies involving 800 patients on NORVASC and 538 on placebo. once casual administration produced statistically meaning placebo-corrected reductions in resistless and standing blood pressures at 24 hours postdose, averaging about 12/6 mmHg in the stand place and 13/7 mmHg in the supine placement in patients with meek to moderate high blood pressure. maintenance of the blood blackmail effect over the 24-hour drug interval was observed, with little remainder in top out and gutter effect. tolerance was not demonstrated in patients studied for up to 1 year. The 3 parallel, fixed dose, venereal disease response studies showed that the reduction in supine and standing blood pressures was dose-related within the commend dose roll. Effects on diastolic pressure were exchangeable in young and older patients. The effect on systolic pressure was greater in older patients, possibly because of greater service line systolic press. Effects were like in black patients and in white patients .

Pediatric Patients

Two hundred sixty-eight hypertensive patients aged 6 to 17 years were randomized first to NORVASC 2.5 or 5 mg once daily for 4 weeks and then randomized again to the lapp venereal disease or to placebo for another 4 weeks. Patients receiving 2.5 magnesium or 5 magnesium at the end of 8 weeks had significantly lower systolic blood blackmail than those secondarily randomized to placebo. The magnitude of the treatment effect is unmanageable to interpret, but it is probably less than 5 mmHg systolic on the 5 milligram dose and 3.3 mmHg systolic on the 2.5 milligram acid. adverse events were exchangeable to those seen in adults .

Effects In Chronic Stable Angina

The effectiveness of 5-10 mg/day of NORVASC in exercise-induced angina has been evaluated in 8 placebo-controlled, double-blind clinical trials of up to 6 weeks duration involving 1038 patients ( 684 NORVASC, 354 placebo ) with chronic stable angina pectoris. In 5 of the 8 studies, significant increases in exercise time ( bicycle or treadmill ) were seen with the 10 magnesium acid. Increases in symptom-limited practice meter averaged 12.8 % ( 63 secant ) for NORVASC 10 milligram, and averaged 7.9 % ( 38 sec ) for NORVASC 5 mg. NORVASC 10 milligram besides increased time to 1 mm ST section deviation in respective studies and decrease angina pectoris attack pace. The sustained efficacy of NORVASC in angina patients has been demonstrated over long-run drug. In patients with angina, there were no clinically meaning reductions in blood pressures ( 4/1 mmHg ) or changes in heart rate ( +0.3 beats per minute ) .

Effects In Vasospastic Angina

In a double-blind, placebo-controlled clinical test of 4 weeks duration in 50 patients, NORVASC therapy decreased attacks by approximately 4/week compared with a placebo decrease of approximately 1/week ( p < 0.01 ). Two of 23 NORVASC and 7 of 27 placebo patients discontinued from the study ascribable to lack of clinical improvement .

Effects In Documented Coronary Artery Disease

In PREVENT, 825 patients with angiographically documented coronary artery disease were randomized to NORVASC ( 5-10 milligram once daily ) or placebo and followed for 3 years. Although the study did not show significance on the primary objective of change in coronary sodium thiopental diameter as assessed by quantitative coronary thrombosis angiography, the data suggested a friendly consequence with respect to fewer hospitalizations for angina pectoris and revascularization procedures in patients with CAD. CAMELOT enrolled 1318 patients with CAD recently documented by angiography, without left independent coronary thrombosis disease and without heart failure or an expulsion fraction < 40 %. Patients ( 76 % males, 89 % caucasian, 93 % enrolled at US sites, 89 % with a history of angina, 52 % without PCI, 4 % with PCI and no stent, and 44 % with a stent ) were randomized to double-blind treatment with either NORVASC ( 5-10 magnesium once casual ) or placebo in summation to standard manage that included aspirin ( 89 % ), statins ( 83 % ), beta-blockers ( 74 % ), nitroglycerin ( 50 % ), anti-coagulants ( 40 % ), and diuretics ( 32 % ), but excluded other calcium channel blockers. The mean duration of follow-up was 19 months. The chief end point was the time to first occurrence of one of the be events : hospitalization for angina pectoris pectoris, coronary revascularization, myocardial infarct, cardiovascular death, resuscitated cardiac check, hospitalization for heart failure, stroke/TIA, or peripheral vascular disease. A entire of 110 ( 16.6 % ) and 151 ( 23.1 % ) first events occurred in the NORVASC and placebo groups, respectively, for a hazard ratio of 0.691 ( 95 % CI : 0.540-0.884, p = 0.003 ). The primary coil end point is summarized in Figure 1 below. The consequence of this analyze was largely derived from the prevention of hospitalizations for angina pectoris and the prevention of revascularization procedures ( see Table 1 ). Effects in respective subgroups are shown in Figure 2. In an angiographic substudy ( n=274 ) conducted within CAMELOT, there was no significant remainder between amlodipine and placebo on the change of atheroma bulk in the coronary artery as assessed by intravascular sonography. Figure 1 – Kaplan-Meier Analysis of Composite Clinical Outcomes for NORVASC versus PlaceboKaplan-Meier Analysis of Composite Clinical Outcomes for NORVASC versus Placebo - Illustration Figure 2 – Effects on Primary Endpoint of NORVASC versus Placebo across Sub-GroupsEffects on Primary Endpoint of NORVASC versus Placebo across Sub-Groups - Illustration table 1 below summarizes the significant composite end point and clinical outcomes from the composites of the elementary end point. The other components of the primary end point including cardiovascular death, resuscitated cardiac catch, myocardial infarct, hospitalization insurance for affection failure, stroke/ TIA, or peripheral vascular disease did not demonstrate a significant dispute between NORVASC and placebo. Table 1. Incidence of Significant Clinical Outcomes for CAMELOT

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Clinical Outcomes
N (%)NORVASC
(N=663)Placebo
(N=655)Risk Reduction
(p-value)Composite CV Endpoint110
(16.6)
151
(23.1)
31%
(0.003)
Hospitalization for Angina*51
(7.7)84
(12.8)42%

(0.002)Coronary Revascularization*78
(11.8)103
(15.7)27%
(0.033)* Total patients with these events

Studies In Patients With Heart Failure

NORVASC has been compared to placebo in four 8-12 week studies of patients with NYHA Class II/III center failure, involving a sum of 697 patients. In these studies, there was no testify of worsen heart failure based on measures of exercise tolerance, NYHA classification, symptoms, or left ventricular ejection fraction. In a long-run ( follow-up at least 6 months, mean 13.8 months ) placebo-controlled mortality/morbidity report of NORVASC 5-10 magnesium in 1153 patients with NYHA Classes III ( n=931 ) or IV ( n=222 ) heart failure on stable doses of diuretics, digoxin, and ACE inhibitors, NORVASC had no effect on the primary end point of the study which was the combine end point of all-cause deathrate and cardiac morbidity ( as defined by dangerous cardiac arrhythmia, acute myocardial infarct, or hospitalization for worse heart failure ), or on NYHA classification, or symptoms of heart failure. sum combine all-cause deathrate and cardiac morbidity events were 222/571 ( 39 % ) for patients on NORVASC and 246/583 ( 42 % ) for patients on placebo ; the cardiac ghoulish events represented about 25 % of the endpoints in the sketch. Another learn ( PRAISE-2 ) randomized patients with NYHA Class III ( 80 % ) or IV ( 20 % ) heart failure without clinical symptoms or objective tell of underlying ischemic disease, on stable doses of ACE inhibitors ( 99 % ), digitalis ( 99 % ), and diuretics ( 99 % ), to placebo ( n=827 ) or NORVASC ( n=827 ) and followed them for a think of of 33 months. There was no statistically significant difference between NORVASC and placebo in the primary end point of all-cause mortality ( 95 % confidence limits from 8 % reduction to 29 % increase on NORVASC ). With NORVASC there were more reports of pneumonic edema .

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