倍博特英文说明书

1、HIGHLIGHTS OF PRESCRIBING INFORMATIONThese highlights do not include all the information needed to use Exforge safely and effectively. See full prescribing information for Exforge. Initial U.S. Approval: 2007 WARNING: AVOID USE IN PREGNANCYSee full prescribing information for complete boxed warning.

2、 When pregnancy is detected, discontinue Exforge as soon as possible.Drugs that act directly on the renin-angiotensin system can cause injuryand even death to the developing fetus. (5.1-RECENT MAJOR CHANGES-Indications and Usage (1 7/2008 Dosage and Administration, Initial Therapy (2.4 7/2008(ARB. E

3、xforge is indicated for the treatment of hypertension: In patients not adequately controlled on monotherapy (1 As initial therapy in patients likely to need multiple drugs to achieve theirblood pressure goals (1. -DOSAGE AND ADMINISTRATION-General Considerations: Majority of effect attained within 2

4、 weeks (2.1 May be administered with other antihypertensive agents (2.1 Hypertension May be used as add-on therapy for patients not controlled on monotherapy(2.2 Patients who experience dose-limiting adverse reactions on monotherapy may be switched to Exforge containing a lower dose of that componen

5、t (2.2 May be substituted for titrated components (2.3 When used as initial therapy: Initiate with 5/160 mg, then titrate upwardsas necessary to a maximum of 10/320 mg once daily (2.4 -DOSAGE FORMS AND STRENGTHS-Tablets (amlodipine/valsartan mg: 5/160, 10/160, 5/320, 10/320 (3 -WARNINGS AND PRECAUTI

6、ONS- Avoid fetal or neonatal exposure (5.1 Assess for hypotension. (5.2 Warn patients with severe obstructive coronary artery disease about the risk of myocardial infarction or increased angina (5.3 Titrate slowly in patients with impaired hepatic (5.4 or severely impaired renal (5.5 function -ADVER

7、SE REACTIONS-In placebo-controlled clinical trials, discontinuation due to side effectsoccurred in 1.8% of patients in the Exforge-treated patients and 2.1% in the placebo-treated group. The most common reasons for discontinuation of therapy with Exforge were peripheral edema and vertigo. The advers

8、e experiences that occurred in clinical trials (2% of patients at a higherincidence than placebo included peripheral edema, nasopharyngitis, upper respiratory tract infection and dizziness. (6 To report SUSPECTED ADVERSE REACTIONS, contact Novartis Pharmaceuticals Corporation at 1-888-669-6682 or FD

9、A at 1-800-FDA­-USE IN SPECIFIC POPULATIONS-Start amlodipine or add amlodipine at 2.5 mg in patients 75 years old or in patients with hepatic impairment. (8.5 Nursing Mothers: Choose breastfeeding or Exforge therapy, but not both. (8.3See 17 for PATIENT COUNSELING INFORMATION and FDA-approved p

10、atient labeling. Revised: July 2008FULL PRESCRIBING INFORMATION: CONTENTS*WARNING: USE IN PREGNANCY1 INDICATIONS AND USAGE 1.1 Hypertension 2. DOSAGE AND ADMINISTRATION 2.1 General Considerations 2.2 Add-on Therapy 2.3 Replacement Therapy 2.4 Initial Therapy 3 DOSAGE FORMS AND STRENGTHS 5 WARNINGS A

11、ND PRECAUTIONS 5.1 Fetal/Neonatal Morbidity and Mortality 5.2 Hypotension 5.3 Increased Angina and/or Myocardial Infarction 5.4 Impaired Hepatic Function 5.5 Impaired Renal Function - Hypertension 5.6 Congestive Heart Failure 6 ADVERSE REACTIONS 6.1 Clinical Trials Experience 6.2 Postmarketing Exper

12、ience 7 DRUG INTERACTIONS 7.1 Drug/Drug Interactions 7.2 CYP 450 Interactions 7.3 Drug/Food Interactions 7.4 Clinical Laboratory Findings 8. USE IN SPECIFIC POPULATIONS 8.1 Pregnancy 8.2 Labor and Delivery 8.3 Nursing Mothers 8.4 Pediatric Use 8.5 Geriatric Use 10. OVERDOSAGE 11. DESCRIPTION 12. CLI

13、NICAL PHARMACOLOGY 12.1 Mechanism of Action 12.2 Pharmacodynamics 12.3 Pharmacokinetics 13 NONCLINICAL TOXICOLOGY 13.1 Carcinogenesis and Mutagenesis and Impairment of Fertility 13.2 Animal Toxicology and/or Pharmacology 14 CLINICAL STUDIES 16 HOW SUPPLIED/STORAGE AND HANDLING 17 PATIENT COUNSELING

14、INFORMATION 17.1 Information for Patients 17.2 FDA-Approved Patient Labeling * Sections or subsections omitted from the full prescribing information are not listed.FULL PRESCRIBING INFORMATIONWARNING: AVOID USE IN PREGNANCYWhen pregnancy is detected, discontinue Exforge as soon as possible. Drugs th

15、at act directly on the renin-angiotensin system can cause injury and even death to the developing fetus. See Warnings and Precautions (5.11 INDICATIONS AND USAGE1.1 HypertensionExforge (amlodipine and valsartan is indicated for the treatment of hypertension.Exforge may be used in patients whose bloo

16、d pressure is not adequately controlled on either monotherapy. Exforge may also be used as initial therapy in patients who are likely to need multiple drugs to achieve their blood pressure goals.The choice of Exforge as initial therapy for hypertension should be based on an assessment of potential b

17、enefits and risks including whether the patient is likely to tolerate the lowest dose of Exforge.Patients with stage 2 hypertension (moderate or severe are at a relatively higher risk for cardiovascular events (such as strokes, heart attacks, and heart failure, kidney failure and vision problems, so

18、 prompt treatment is clinically relevant. The decision to use a combination as initial therapy should be individualized and should be shaped by considerations such as baseline blood pressure, the target goal and the incremental likelihood of achieving goal with a combination compared to monotherapy.

19、 Individual blood pressure goals may vary based upon the patients risk.Data from the high-dose multifactorial study see Clinical Studies (14 provide estimates of the probability of reaching a blood pressure goal with Exforge compared to amlodipine or valsartan monotherapy. The figures below provide

20、estimates of the likelihood of achieving systolic or diastolic blood pressure control with Exforge 10/320 mg, based upon baseline systolic or diastolic blood pressure. The curve of each treatment group was estimated by logistic regression modeling. The estimated likelihood at the right tail of each

21、curve is less reliable due to small numbers of subjects with high baseline blood pressures. Figure 1: Probability of Achieving Systolic Blood Pressure Figure 2: Probability of Achieving Diastolic Blood Pressure <140 mmHg at Week 8<90 mmHg at Week 8 Figure 3: Probability of Achieving Systolic B

22、lood Pressure Figure 4: Probability of Achieving Diastolic Blood Pressure <130 mmHg at Week 8<80 mmHg at Week 8For example, a patient with a baseline blood pressure of 160/100 mmHg has about a 67% likelihood of achieving a goal of <140 mmHg (systolic and 80% likelihood of achieving <90 m

23、mHg (diastolic onamlodipine alone, and the likelihood of achieving these goals on valsartan alone is about 47% (systolic or 62% (diastolic. The likelihood of achieving these goals on Exforge rises to about 80% (systolic or 85% (diastolic. The likelihood of achieving these goals on placebo is about 2

24、8% (systolic or 37% (diastolic.2. DOSAGE AND ADMINISTRATION2.1 General ConsiderationsAmlodipine is an effective treatment of hypertension in once daily doses of 2.5 mg10 mg while valsartan is effective in doses of 80320 mg. In clinical trials with once daily Exforge (amlodipine and valsartan using a

25、mlodipine doses of 510 mg and valsartan doses of 160320 mg, the antihypertensive effects increased with increasing doses.The hazards see Warnings and Precautions(5 of valsartan are generally independent of dose; those of amlodipine are a mixture of dose-dependent phenomena (primarily peripheral edem

26、a and dose-independent phenomena, the former much more common than the latter see Adverse Reactions (6.The majority of the antihypertensive effect is attained within 2 weeks after initiation of therapy or a change in dose. The dosage can be increased after 1 to 2 weeks of therapy to a maximum of one

27、 10/320 mg tablet once daily as need to control blood pressure See Clinical Studies (14. Exforge may be administered with or without food. Exforge may be administered with other antihypertensive agents. Elderly patients: Because of decreased clearance of amlodipine, therapy should usually be initiat

28、ed at 2.5 mg. Renal Impairment: No initial dosage adjustment is required for patients with mild or moderate renal impairment. Titrate slowly in patients with severe renal impairment. Hepatic Impairment: No initial dosage adjustment is required for patients with mild or moderate liver insufficiency.

29、Titrate slowly in patients with hepatic impairment. 2.2 Add-on TherapyA patient whose blood pressure is not adequately controlled with amlodipine (or another dihydropyridine calcium-channel blocker alone or with valsartan (or another angiotensin II receptor blocker alone may be switched to combinati

30、on therapy with Exforge.A patient who experiences dose-limiting adverse reactions on either component alone may be switched to Exforge containing a lower dose of that component in combination with the other to achieve similar blood pressure reductions. The clinical response to Exforge should be subs

31、equently evaluated and if blood pressure remains uncontrolled after 34 weeks of therapy, the dose may be titrated up to a maximum of 10/320 mg.2.3 Replacement TherapyFor convenience, patients receiving amlodipine and valsartan from separate tablets may instead wish to receive tablets of Exforge cont

32、aining the same component doses. 2.4 Initial TherapyA patient may be initiated on Exforge if it is unlikely that control of blood pressure would be achieved with a single agent. The usual starting dose is Exforge 5/160 mg once daily in patients who are not volume-depleted. DOSAGE FORMS AND STRENGTHS

33、 5/160 mg tablets, debossed with NVR/ECE (side 1/side 210/160 mg tablets, debossed with NVR/UIC5/320 mg tablets, debossed with NVR/CSF10/320 mg tablets, debossed with NVR/LUF35 WARNINGS AND PRECAUTIONS5.1 Fetal/Neonatal Morbidity and MortalityExforge can cause fetal harm when administered to a pregn

34、ant woman. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to the fetus.Drugs that act on the renin angiotensin system can cause fetal and neonatal morbidity and mortality when used in pregnancy.

35、 In several dozen published cases, ACE inhibitor use during the second and third trimesters of pregnancy was associated with fetal and neonatal injury, including hypotension, neonatal skull hypoplasia,anuria, reversible or irreversible renal failure, and death see Use in Specific Populations (8.1. 5

36、.2 Hypotension (amlodipine and valsartan in placebo-controlled studies. In patients with an activated renin-angiotensin system, such as volume-and/or salt-depleted patients receiving high doses of diuretics, symptomatic hypotension may occur in patients receiving angiotensin receptor blockers. Volum

37、e depletion should be corrected prior to administration of Exforge. Treatment with Exforge should start under close medical supervision.Initiate therapy cautiously in patients with heart failure or recent myocardial infarction and in patientsundergoing surgery or dialysis. Patients with heart failur

38、e or post-myocardial infarction patients given valsartan commonly have some reduction in blood pressure, but discontinuation of therapy because of continuingsymptomatic hypotension usually is not necessary when dosing instructions are followed. In controlled trials in heart failure patients, the inc

39、idence of hypotension in valsartan-treated patients was 5.5% compared to 1.8% in placebo-treated patients. In the Valsartan in Acute Myocardial Infarction Trial (VALIANT, hypotension in post-myocardial infarction patients led to permanent discontinuation of therapy in 1.4% of valsartan-treated patie

40、nts and 0.8% of captopril-treated patients.Since the vasodilation induced by amlodipine is gradual in onset, acute hypotension has rarely been reported after oral administration. Nonetheless, caution, as with any other peripheral vasodilator, should be exercised when administering amlodipine, partic

41、ularly in patients with severe aortic stenosis.If excessive hypotension occurs with Exforge, the patient should be placed in a supine position and, if necessary, given an intravenous infusion of normal saline. A transient hypotensive response is not acontraindication to further treatment, which usua

42、lly can be continued without difficulty once the blood pressure has stabilized.5.3 Risk of Myocardial Infarction or Increased AnginaRarely, patients, particularly those with severe obstructive coronary artery disease, have developed documented increased frequency, duration or severity of angina or a

43、cute myocardial infarction on starting calcium channel blocker therapy or at the time of dosage increase. The mechanism of this effect has not been elucidated.5.4 Impaired Hepatic FunctionStudies with Amlodipine: Amlodipine is extensively metabolized by the liver and the plasma elimination half-life

44、 (t½ is 56 hours in patients with impaired hepatic function, therefore, caution should be exercised when administering amlodipine to patients with severe hepatic impairment.Studies with Valsartan: As the majority of valsartan is eliminated in the bile, patients with mild-to-moderate hepatic imp

45、airment, including patients with biliary obstructive disorders, showed lower valsartan clearance (higher AUCs. Care should be exercised in administering valsartan to these patients. 5.5 Impaired Renal Function - Hypertension In studies of ACE inhibitors in hypertensive patients with unilateral or bi

46、lateral renal artery stenosis, increases in serum creatinine or blood urea nitrogen have been reported. In a 4-day trial of valsartan in 12 hypertensive patients with unilateral renal artery stenosis, no significant increases in serum creatinine or blood urea nitrogen were observed. There has been n

47、o long-term use of valsartan in patients with unilateral or bilateral renal artery stenosis, but an effect similar to that seen with ACE inhibitors should be anticipated.As a consequence of inhibiting the renin-angiotensin-aldosterone system, changes in renal function may occur particularly in volum

48、e depleted patients. In patients with severe heart failure whose renal function may depend on the activity of the renin-angiotensin-aldosterone system, treatment with angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists has been associated with oliguria and/or progressive az

49、otemia and (rarely with acute renal failure and/or death. Similar outcomes have been reported with valsartan. 5.6 Congestive Heart FailureStudies with Amlodipine: In general, calcium channel blockers should be used with caution in patients with heart failure. Amlodipine (5-10 mg per day has been stu

50、died in a placebo-controlled trial of 1,153 patients with NYHA Class III or IV heart failure on stable doses of ACE inhibitor, digoxin, and diuretics. Follow-up was at least 6 months, with a mean of about 14 months. There was no overall adverse effect on survival or cardiac morbidity (as defined by

51、life-threatening arrhythmia, acute myocardial infarction, or hospitalization forworsened heart failure. Amlodipine has been compared to placebo in four 8-12 week studies of patients with NYHA class II/III heart failure, involving a total of 697 patients. In these studies, there was no evidence of wo

52、rsened heart failure based on measures of exercise tolerance, NYHA classification, symptoms, or LVEF. Studies with Valsartan: Some patients with heart failure have developed increases in blood urea nitrogen, serum creatinine, and potassium on valsartan. These effects are usually minor and transient,

53、 and they are more likely to occur in patients with pre-existing renal impairment. Dosage reduction and/or discontinuation of the diuretic and/or valsartan may be required. In the Valsartan Heart Failure Trial, in which 93% of patients were on concomitant ACE inhibitors, treatment was discontinued f

54、or elevations in creatinine or potassium (total of 1.0% on valsartan vs. 0.2% on placebo. In the Valsartan in Acute Myocardial Infarction Trial (VALIANT, discontinuation due to various types of renal dysfunction occurred in 1.1% of valsartan-treated patients and0.8% of captopril-treated patients. Ev

55、aluation of patients with heart failure or post-myocardial infarction should always include assessment of renal function.ADVERSE REACTIONS6.1 Clinical Trials ExperienceBecause clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a d

56、rug cannot be directly compared to rates in the clinical trials of another drug and may not 6reflect the rates observed in practice. The adverse reaction information from clinical trials does, however, provide a basis for identifying the adverse events that appear to be related to drug use and for a

57、pproximatingrates.Studies with Exforge: Exforge (amlodipine and valsartan has been evaluated for safety in over 2,600 patients with hypertension; over 1,440 of these patients were treated for at least 6 months and over 540 of these patients were treated for at least one year. Adverse reactions have

58、generally been mild and transient in nature and have only infrequently required discontinuation of therapy.The overall frequency of adverse reactions was neither dose-related nor related to gender, age, or race. Inplacebo-controlled clinical trials, discontinuation due to side effects occurred in 1.8% of patients in the Exforge­treated patients and 2.1% in the placebo-treated group. The most common reasons for discontinuation of therapy with Exforge were peripheral edema (0.4%, and vertigo (0.2%.The adverse reactions that occurred in placebo-cont