Candesartan

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# Black Box Warning

# Overview
Candesartan is an angiotensin II receptor blocker that is FDA approved for the {{{indicationType}}} of hypertension and heart failure. There is a Black Box Warning for this drug as shown here.  Common adverse reactions include hypotension, backache, dizziness, pharyngitis, rhinitis and upper respiratory infection.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)
- Starting dosage:
- 16 mg/day, as monotherapy, in non-volume depleted patients.
- Use in hepatic impairment:
- Initiate with 8 mg/day. If blood pressure is not controlled by candesartan cilexetil alone, a diuretic may be added.
- Candesartan cilexetil may be administered with other antihypertensive agents.
- Initial dosage:
- 4 mg/day
- Target dosage, achieved by doubling the dose at approximately 2-week intervals, as tolerated by the patient:
- 32 mg/day

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of candesartan cilexetil in adult patients.

### NonGuideline-Supported Use
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# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
- 1 to < 17 Years of age
Candesartan cilexetil may be administered once daily or divided into two equal doses.
- In children 1 - 6 years of age:
- Initial dosage:
- 0.20 mg/kg/day PO
- Further dosages:
- 0.05 to 0.4 mg/kg per day PO
- Children 6 - 17 years of age:
- Less than 50 kg
- Initial dosage:
- 4 to 8 mg/day PO
- Further dosages:
- 2 to 16 mg per day PO
- Greater than 50 kg
- Initial dosage:
- 8 to 16 mg/day PO
- Further dosages:
- 4 to 32 mg/day PO
- For patients who can not swallow a pill, follow the instructions below for preparation of the suspension. The number of tablets and volume of vehicle specified below will yield 160 mL of a 1 mg/mL suspension:
- Prepare the vehicle by adding equal volumes of 1Ora-Plus (80 mL) and 1Ora-Sweet SF (80 mL) or, alternatively, use, 1,2Ora-Blend SF (160 mL).
- Add a small amount of vehicle to the required number of ATACAND tablets (five 32 mg tablets) and grind into a smooth paste using a mortar and pestle.
- Add the paste to a preparation vessel of suitable size.
- Rinse the mortar and pestle clean using the vehicle and add this to the vessel. Repeat, if necessary.
- Prepare the final volume by adding the remaining vehicle.
- Mix thoroughly.
- Dispense into suitably sized amber PET bottles.
- Label with an expiry date of 100 days and include the following instructions:
- Store at room temperature (below 30C/86F). Use within 30 days after first opening. Do not use after the expiry date stated on the bottle.
- Do not freeze.
- Shake well before each use.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of candesartan cilexetil in children.

### NonGuideline-Supported Use
There is limited information regarding Off-Label Non-Guideline-Supported Use of candesartan cilexetil in adult patients.

# Contraindications
- Hypersensitivity to candesartan.
- Do not co-administer aliskiren with candesartan cilexetil in diabetic patients.

# Warnings
- Pregnancy Category D
- Use of drugs that act on the renin-angiotensin system during the second and third trimesters of pregnancy reduces fetal renal function and increases fetal and neonatal morbidity and death. Resulting oligohydramnios can be associated with fetal lung hypoplasia and skeletal deformations.
- Potential neonatal adverse effects include:
- Skull hypoplasia
- Anuria
- Hypotension
- Renal failure
- Death
- When pregnancy is detected, discontinue candesartan cilexetil as soon as possible.
- Oral doses 10 mg of candesartan cilexetil/kg/day administered to pregnant rats during late gestation and continued through lactation were associated with reduced survival and an increased incidence of hydronephrosis in the offspring. The 10-mg/kg/day dose in rats is approximately 2.8 times the maximum recommended daily human dose (MRHD) of 32 mg on a mg/m2 basis (comparison assumes human body weight of 50 kg).
- Candesartan cilexetil given to pregnant rabbits at an oral dose of 3 mg/kg/day (approximately 1.7 times the MRHD on a mg/m2 basis) caused maternal toxicity (decreased body weight and death) but, in surviving dams, had no adverse effects on fetal survival, fetal weight, or external, visceral, or skeletal development.
- No maternal toxicity or adverse effects on fetal development were observed when oral doses up to 1000 mg of candesartan cilexetil/kg/day (approximately 138 times the MRHD on a mg/m2 basis) were administered to pregnant mice.
- Children < 1 year of age must not receive candesartan cilexetil for hypertension. Drugs that act directly on the renin-angiotensin system (RAS) can have effects on the development of immature kidneys.
- Candesartan cilexetil can cause symptomatic hypotension.
- Symptomatic hypotension is most likely to occur in patients who have been volume and/or salt depleted as a result of prolonged diuretic therapy, dietary salt restriction, dialysis, diarrhea, or vomiting.
- Patients with symptomatic hypotension may require temporarily reducing the dose of candesartan cilexetil, diuretic or both, and volume repletion. Volume and/or salt depletion should be corrected before initiating therapy with candesartan cilexetil.
- In the CHARM program (heart failure patients), hypotension was reported in 18.8% of patients on candesartan cilexetil versus 9.8% of patients on placebo. The incidence of hypotension leading to drug discontinuation in candesartan cilexetil-treated patients was 4.1% compared with 2.0% in placebo-treated patients. In the CHARM-Added program, where candesartan or placebo was given in addition to ACE inhibitors, hypotension was reported in 22.6% of patients treated with candesartan cilexetil versus 13.8% treated with placebo.
- Monitoring of blood pressure is recommended during dose escalation and periodically thereafter.
- Major Surgery/Anesthesia
- Hypotension may occur during major surgery and anesthesia in patients treated with angiotensin II receptor antagonists, including candesartan cilexetil, due to blockade of the renin-angiotensin system. Very rarely, hypotension may be severe such that it may warrant the use of intravenous fluids and/or vasopressors.
- Monitor renal function periodically in patients treated with candesartan cilexetil. Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system. Patients whose renal function may depend, in part, on the activity of the renin-angiotensin system (e.g., patient with renal artery stenosis, chronic kidney disease, severe heart failure, or volume depletion) may be at particular risk of developing oliguria, progressive azotemia or acute renal failure when treated with candesartan cilexetil. Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on candesartan cilexetil.
- In the CHARM program (heart failure patients), the incidence of abnormal renal function (e.g., creatinine increase) was 12.5% in patients treated with candesartan cilexetil versus 6.3% in patients treated with placebo. The incidence of abnormal renal function (e.g., creatinine increase) leading to drug discontinuation in candesartan cilexetil-treated patients was 6.3% compared with 2.9% in placebo-treated patients. In the CHARM-Added program, where candesartan or placebo was given in addition to ACE inhibitors, the incidence of abnormal renal function (e.g., creatinine increase) was 15% in patients treated with candesartan cilexetil versus 9% in patients treated with placebo.
- Drugs that inhibit the renin-angiotensin system can cause hyperkalemia.
- Monitor serum potassium periodically.
- In the CHARM program (heart failure patients), the incidence of hyperkalemia was 6.3% in patients treated with candesartan cilexetil versus 2.1% in patients treated with placebo. The incidence of hyperkalemia leading to drug discontinuation in candesartan cilexetil-treated patients was 2.4% compared with 0.6% in placebo-treated patients. In the CHARM-Added program where candesartan or placebo was given in addition to ACE inhibitors, the incidence of hyperkalemia was 9.5% in patients treated with candesartan cilexetil versus 3.5% in patients treated with placebo.

# Adverse Reactions

## Clinical Trials Experience
- Adult Hypertension:
- Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.
- Candesartan cilexetil has been evaluated for safety in more than 3600 patients/subjects, including more than 3200 patients treated for hypertension. About 600 of these patients were studied for at least 6 months and about 200 for at least 1 year. In general, treatment with candesartan cilexetil was well tolerated. The overall incidence of adverse events reported with candesartan cilexetil was similar to placebo.
- The rate of withdrawals due to adverse events in all trials in patients (7510 total) was 3.3% (ie, 108 of 3260) of patients treated with candesartan cilexetil as monotherapy and 3.5% (ie, 39 of 1106) of patients treated with placebo. In placebo-controlled trials, discontinuation of therapy due to clinical adverse events occurred in 2.4% (ie, 57 of 2350) of patients treated with candesartan cilexetil and 3.4% (ie, 35 of 1027) of patients treated with placebo.
- Pediatric hypertension
- Among children in clinical studies, 1 in 93 children age 1 to < 6 and 3 in 240 age 6 to < 17 experienced worsening renal disease. The association between candesartan and exacerbation of the underlying condition could not be excluded.
- Heart failure
- The adverse event profile of candesartan cilexetil in adult heart failure patients was consistent with the pharmacology of the drug and the health status of the patients. In the CHARM program, comparing candesartan cilexetil in total daily doses up to 32 mg once daily (n=3803) with placebo (n=3796), 21.0% of patients discontinued candesartan cilexetil for adverse events vs. 16.1% of placebo patients.
- Headache
- Dizziness
- Heart Failure
- Upper respiratory tract infection
- Pharyngitis
- Rhinitis
- Back pain

## Postmarketing Experience
- The following adverse reactions were identified during post-approval use of candesartan cilexetil. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
- Rare reports of rhabdomyolysis have been reported in patients receiving angiotensin II receptor blockers.
The following have been very rarely reported in post-marketing experience:
- Abnormal hepatic function
- Hepatitis
- Neutropenia
- Leukopenia
- Agranulocytosis
- Angioedema
- Hyperkalemia
- Hyponatremia
- Cough
- Pruritus
- Rash
- Urticaria

# Drug Interactions
- Lithium
- NSAIDS
- Dual inhibition of the renin-angiotensin system
- Reversible increases in serum lithium concentrations and toxicity have been reported during concomitant administration of lithium with ACE inhibitors, and with some angiotensin II receptor antagonists.
- An increase in serum lithium concentration has been reported during concomitant administration of lithium with candesartan cilexetil.
- Monitor serum lithium levels.
- Including Selective Cyclooxygenase-2 Inhibitors (COX-2 inhibitors).
- In elderly patients, volume-depleted (including those on diuretic therapy), or with compromised renal function, co-administration of NSAIDs, including selective COX-2 inhibitors, with angiotensin II receptor antagonists, including candesartan, may result in deterioration of renal function, including possible acute renal failure.
- These effects are usually reversible.
- Monitor renal function periodically in patients receiving candesartan and NSAID therapy.
- The antihypertensive effect of angiotensin II receptor antagonists, including candesartan may be attenuated by NSAIDs including selective COX-2 inhibitors.
- Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or aliskiren is associated with increased risks of hypotension, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy.
- Closely monitor blood pressure, renal function and electrolytes in patients on candesartan cilexetil and other agents that affect the RAS.
- Do not co-administer aliskiren with candesartan celexetil in patients with diabetes.
- Avoid use of aliskiren with candesartan celexetil in patients with renal impairment (GFR <60 ml/min).

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): D
- Use of drugs that act on the renin-angiotensin system during the second and third trimesters of pregnancy reduces fetal renal function and increases fetal and neonatal morbidity and death.
- Resulting oligohydramnios can be associated with fetal lung hypoplasia and skeletal deformations.
- Potential neonatal adverse effects include:
- Skull hypoplasia
- Anuria
- Hypotension
- Renal failure
- Death
- When pregnancy is detected, discontinue candesartan celexetil as soon as possible.
- These adverse outcomes are usually associated with use of similar drugs in the second and third trimester of pregnancy.
- Most epidemiological studies examining fetal abnormalities after exposure to antihypertensive use in the first trimester have not distinguished drugs affecting the renin-angiotensin system from other antihypertensive agents.
- Appropriate management of maternal hypertension during pregnancy is important to optimize outcomes for both mother and fetus.
- In the unusual case that there is no appropriate alternative to therapy with drugs affecting the renin-angiotensin system for a particular patient, apprise the mother of the potential risk to the fetus. Perform serial ultrasound examinations to assess the intra-amniotic environment.
- If oligohydramnios is observed, discontinue candesartan celexetil, unless it is considered lifesaving for the mother.
- Fetal testing may be appropriate, based on the week of pregnancy.
- Patients and physicians should be aware, however, that oligohydramnios may not appear until after the fetus has sustained irreversible injury.
- Closely observe infants with histories of in utero exposure to candesartan celexetil for hypotension, oliguria, and hyperkalemia.
Pregnancy Category (AUS): D
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of candesartan celexetil in women who are pregnant.

### Labor and Delivery
The effect of candesartan celexetil on labor and delivery in humans is unknown.

### Nursing Mothers
- It is not known whether candesartan is excreted in human milk, but candesartan has been shown to be present in rat milk.
- Because of the potential for adverse effects on the nursing infant, a decision should be made whether to discontinue nursing or discontinue candesartan celexetil, taking into account the importance of the drug to the mother.

### Pediatric Use
- Neonates with a history of in utero exposure to candesartan celexetil:
- If oliguria or hypotension occurs, direct attention toward support of blood pressure and renal perfusion.
- Exchange transfusions or dialysis may be required as a means of reversing hypotension and/or substituting for disordered renal function.
- The antihypertensive effects of candesartan celexetil were evaluated in hypertensive children 1 to < 17 years of age in randomized, double-blind clinical studies. The pharmacokinetics of candesartan celexetil have been evaluated in pediatric patients 1 to < 17 years of age.
- Children < 1 year of age must not receive candesartan celexetil for hypertension.

### Geriatic Use
There is no FDA guidance on the use of Candesartan in geriatric settings.

### Gender
There is no FDA guidance on the use of Candesartan with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Candesartan with respect to specific racial populations.

### Renal Impairment
- In hypertensive patients with renal insufficiency, serum concentrations of candesartan are elevated.
- After repeated dosing, the AUC and Cmax were noted to be approximately doubled in patients with severe renal impairment (creatinine clearance <30 mL/min/1.73m2) compared to patients with normal kidney function.
- The pharmacokinetics of candesartan in hypertensive patients undergoing hemodialysis are similar to those in hypertensive patients with severe renal impairment.
- Candesartan cannot be removed by hemodialysis.
- No initial dosage adjustment is necessary in patients with renal insufficiency.
- In heart failure patients with renal impairment, AUC0-72h was noted to be 36% and 65% higher in mild and moderate renal impairment, respectively. Cmax was 15% and 55% higher in mild and moderate renal impairment, respectively.

### Hepatic Impairment
- The pharmacokinetics of candesartan were compared in patients with mild and moderate hepatic impairment to matched healthy volunteers following a single oral dose of 16 mg candesartan cilexetil.
- The increase in AUC for candesartan was 30% in patients with mild hepatic impairment (Child-Pugh A) and 145% in patients with moderate hepatic impairment (Child-Pugh B). The increase in Cmax for candesartan was 56% in patients with mild hepatic impairment and 73% in patients with moderate hepatic impairment.
- The pharmacokinetics after candesartan cilexetil administration have not been investigated in patients with severe hepatic impairment. No initial dosage adjustment is necessary in patients with mild hepatic impairment. In hypertensive patients with moderate hepatic impairment, consideration should be given to initiation of candesartan at a lower dose

### Females of Reproductive Potential and Males
- There was no evidence of carcinogenicity when candesartan cilexetil was orally administered to mice and rats for up to 104 weeks at doses up to 100 and 1000 mg/kg/day, respectively. Rats received the drug by gavage, whereas mice received the drug by dietary administration. These (maximally-tolerated) doses of candesartan cilexetil provided systemic exposures to candesartan (AUCs) that were, in mice, approximately 7 times and, in rats, more than 70 times the exposure in man at the maximum recommended daily human dose (32 mg).
- Candesartan and its O-deethyl metabolite tested positive for genotoxicity in the in vitro Chinese hamster lung (CHL) chromosomal aberration assay. Neither compound tested positive in the Ames microbial mutagenesis assay or the in vitro mouse lymphoma cell assay.
- Candesartan (but not its O-deethyl metabolite) was also evaluated in vivo in the mouse micronucleus test and in vitro in the Chinese hamster ovary (CHO) gene mutation assay, in both cases with negative results.
- Candesartan cilexetil was evaluated in the Ames test, the in vitro mouse lymphoma cell and rat hepatocyte unscheduled DNA synthesis assays and the in vivo mouse micronucleus test, in each case with negative results. Candesartan cilexetil was not evaluated in the CHL chromosomal aberration or CHO gene mutation assay.
- Fertility and reproductive performance were not affected in studies with male and female rats given oral doses of up to 300 mg/kg/day (83 times the maximum daily human dose of 32 mg on a body surface area basis).

### Immunocompromised Patients
There is no FDA guidance one the use of Candesartan in patients who are immunocompromised.

# Administration and Monitoring

### Administration
Oral

### Monitoring
- Use of drugs that act on the renin-angiotensin system during the second and third trimesters of pregnancy reduces fetal renal function and increases fetal and neonatal morbidity and death. Resulting oligohydramnios can be associated with fetal lung hypoplasia and skeletal deformations.
- Potential neonatal adverse effects include:
- Skull hypoplasia
- Anuria
- Hypotension
- Renal failure
- Death
- When pregnancy is detected, discontinue candesartan cilexetil as soon as possible.
- Children < 1 year of age must not receive candesartan cilexetil for hypertension.
- Drugs that act directly on the renin-angiotensin system (RAS) can have effects on the development of immature kidneys.
- Candesartan cilexetil can cause symptomatic hypotension.
- Symptomatic hypotension is most likely to occur in patients who have been volume and/or salt depleted as a result of prolonged diuretic therapy, dietary salt restriction, dialysis, diarrhea, or vomiting.
- Patients with symptomatic hypotension may require temporarily reducing the dose of candesartan cilexetil, diuretic or both, and volume repletion. Volume and/or salt depletion should be corrected before initiating therapy with candesartan cilexetil.
- Monitoring of blood pressure is recommended during dose escalation and periodically thereafter.
- Monitor renal function periodically in patients treated with candesartan cilexetil. Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system. Patients whose renal function may depend, in part, on the activity of the renin-angiotensin system (e.g., patient with renal artery stenosis, chronic kidney disease, severe heart failure, or volume depletion) may be at particular risk of developing oliguria, progressive azotemia or acute renal failure when treated with candesartan cilexetil. Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on candesartan cilexetil.
- Drugs that inhibit the renin-angiotensin system can cause hyperkalemia.
- Monitor serum potassium periodically.

# IV Compatibility
There is limited information regarding the compatibility of candesartan cilexetil and IV administrations.

# Overdosage
- No lethality was observed in acute toxicity studies in mice, rats, and dogs given single oral doses of up to 2000 mg/kg of candesartan cilexetil. In mice given single oral doses of the primary metabolite, candesartan, the minimum lethal dose was greater than 1000 mg/kg but less than 2000 mg/kg.
- The most likely manifestation of overdosage with candesartan cilexetil would be:
- Hypotension
- Dizziness
- Tachycardia
- Bradycardia, could occur from parasympathetic (vagal) stimulation.
- If symptomatic hypotension should occur, supportive treatment should be instituted.
- Candesartan cannot be removed by hemodialysis.
- Treatment: To obtain up-to-date information about the treatment of overdose, consult your Regional Poison Control Center. Telephone numbers of certified poison control centers are listed in the Physicians Desk Reference (PDR).
- In managing overdose, consider the possibilities of multiple-drug overdoses, drug-drug interactions, and altered pharmacokinetics in your patient.

# Pharmacology

## Mechanism of Action
- Angiotensin II is formed from angiotensin I in a reaction catalyzed by angiotensin-converting enzyme (ACE, kininase II).
- Angiotensin II is the principal pressor agent of the renin-angiotensin system, with effects that include vasoconstriction, stimulation of synthesis and release of aldosterone, cardiac stimulation, and renal reabsorption of sodium.
- Candesartan blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor in many tissues, such as vascular smooth muscle and the adrenal gland. Its action is, therefore, independent of the pathways for angiotensin II synthesis.
- There is also an AT2 receptor found in many tissues, but AT2 is not known to be associated with cardiovascular homeostasis. - Candesartan has much greater affinity (>10,000-fold) for the AT1 receptor than for the AT2 receptor.
- Blockade of the renin-angiotensin system with ACE inhibitors, which inhibit the biosynthesis of angiotensin II from angiotensin I, is widely used in the treatment of hypertension.
- ACE inhibitors also inhibit the degradation of bradykinin, a reaction also catalyzed by ACE. Because candesartan does not inhibit ACE (kininase II), it does not affect the response to bradykinin. Whether this difference has clinical relevance is not yet known.
- Candesartan does not bind to or block other hormone receptors or ion channels known to be important in cardiovascular regulation.
- Blockade of the angiotensin II receptor inhibits the negative regulatory feedback of angiotensin II on renin secretion, but the resulting increased plasma renin activity and angiotensin II circulating levels do not overcome the effect of candesartan on blood pressure.

## Structure
- Candesartan cilexetil, a prodrug, is hydrolyzed to candesartan during absorption from the gastrointestinal tract.
- Candesartan is a selective AT1 subtype angiotensin II receptor antagonist.
- Candesartan cilexetil, a nonpeptide, is chemically described as ()-1-Hydroxyethyl 2-ethoxy-1--7-benzimidazolecarboxylate, cyclohexyl carbonate (ester).
Its empirical formula is C33H34N6O6, and its structural formula is:
- Candesartan cilexetil is a white to off-white powder with a molecular weight of 610.67. It is practically insoluble in water and sparingly soluble in methanol. Candesartan cilexetil is a racemic mixture containing one chiral center at the cyclohexyloxycarbonyloxy ethyl ester group. Following oral administration, candesartan cilexetil undergoes hydrolysis at the ester link to form the active drug, candesartan, which is achiral.

## Pharmacodynamics
- Candesartan inhibits the pressor effects of angiotensin II infusion in a dose-dependent manner.
- After 1 week of once daily dosing with 8 mg of candesartan cilexetil, the pressor effect was inhibited by approximately 90% at peak with approximately 50% inhibition persisting for 24 hours.
- Plasma concentrations of angiotensin I and angiotensin II, and plasma renin activity (PRA), increased in a dose-dependent manner after single and repeated administration of candesartan cilexetil to healthy subjects, hypertensive, and heart failure patients.
- ACE activity was not altered in healthy subjects after repeated candesartan cilexetil administration. The once-daily administration of up to 16 mg of candesartan cilexetil to healthy subjects did not influence plasma aldosterone concentrations, but a decrease in the plasma concentration of aldosterone was observed when 32 mg of candesartan cilexetil was administered to hypertensive patients. In spite of the effect of candesartan cilexetil on aldosterone secretion, very little effect on serum potassium was observed.
- Hypertension
- Adults
- In multiple-dose studies with hypertensive patients, there were no clinically significant changes in metabolic function, including serum levels of total cholesterol, triglycerides, glucose, or uric acid. In a 12-week study of 161 patients with non-insulin-dependent (type 2) diabetes mellitus and hypertension, there was no change in the level of HbA1c.
- In heart failure patients, candesartan  8 mg resulted in decreases in systemic vascular resistance and pulmonary capillary wedge pressure.

## Pharmacokinetics
- Distribution
- The volume of distribution of candesartan is 0.13 L/kg. Candesartan is highly bound to plasma proteins (>99%) and does not penetrate red blood cells. The protein binding is constant at candesartan plasma concentrations well above the range achieved with recommended doses. In rats, it has been demonstrated that candesartan crosses the blood-brain barrier poorly, if at all. It has also been demonstrated in rats that candesartan passes across the placental barrier and is distributed in the fetus.
- Metabolism and Excretion
- Total plasma clearance of candesartan is 0.37 mL/min/kg, with a renal clearance of 0.19 mL/min/kg. When candesartan is administered orally, about 26% of the dose is excreted unchanged in urine. Following an oral dose of 14C-labeled candesartan cilexetil, approximately 33% of radioactivity is recovered in urine and approximately 67% in feces. Following an intravenous dose of 14C-labeled candesartan, approximately 59% of radioactivity is recovered in urine and approximately 36% in feces. Biliary excretion contributes to the elimination of candesartan.
- Adults
- Candesartan cilexetil is rapidly and completely bioactivated by ester hydrolysis during absorption from the gastrointestinal tract to candesartan, a selective AT1 subtype angiotensin II receptor antagonist. Candesartan is mainly excreted unchanged in urine and feces (via bile). It undergoes minor hepatic metabolism by O-deethylation to an inactive metabolite. The elimination half-life of candesartan is approximately 9 hours. After single and repeated administration, the pharmacokinetics of candesartan are linear for oral doses up to 32 mg of candesartan cilexetil. Candesartan and its inactive metabolite do not accumulate in serum upon repeated once-daily dosing.
Following administration of candesartan cilexetil, the absolute bioavailability of candesartan was estimated to be 15%. After tablet ingestion, the peak serum concentration (Cmax) is reached after 3 to 4 hours. Food with a high fat content does not affect the bioavailability of candesartan after candesartan cilexetil administration.
- Pediatrics
- In children 1 to 17 years of age, plasma levels are greater than 10fold higher at peak (approximately 4 hours) than 24 hours after a single dose.
- Children 1 to < 6 years of age, given 0.2 mg/kg had exposure similar to adults given 8 mg.
- Children > 6 years of age had exposure similar to adults given the same dose.
- The pharmacokinetics (Cmax and AUC) were not modified by age, sex or body weight.
- Candesartan cilexetil pharmacokinetics have not been investigated in pediatric patients less than 1 year of age.
- From the dose-ranging studies of candesartan cilexetil, there was a dose related increase in plasma candesartan concentrations.
- The renin-angiotensin system (RAS) plays a critical role in kidney development. RAS blockade has been shown to lead to abnormal kidney development in very young mice. Children < 1 year of age must not receive ATACAND. Administering drugs that act directly on the renin-angiotensin system (RAS) can alter normal renal development.
- 'Geriatric and Sex
- The pharmacokinetics of candesartan have been studied in the elderly ( 65 years) and in both sexes. The plasma concentration of candesartan was higher in the elderly (Cmax was approximately 50% higher, and AUC was approximately 80% higher) compared to younger subjects administered the same dose. The pharmacokinetics of candesartan were linear in the elderly, and candesartan and its inactive metabolite did not accumulate in the serum of these subjects upon repeated, once-daily administration. No initial dosage adjustment is necessary. There is no difference in the pharmacokinetics of candesartan between male and female subjects.
- Renal Insufficiency
- In hypertensive patients with renal insufficiency, serum concentrations of candesartan were elevated. After repeated dosing, the AUC and Cmax were approximately doubled in patients with severe renal impairment (creatinine clearance <30 mL/min/1.73m2) compared to patients with normal kidney function. The pharmacokinetics of candesartan in hypertensive patients undergoing hemodialysis are similar to those in hypertensive patients with severe renal impairment. Candesartan cannot be removed by hemodialysis. No initial dosage adjustment is necessary in patients with renal insufficiency .
- In heart failure patients with renal impairment, AUC0-72h was 36% and 65% higher in mild and moderate renal impairment, respectively. Cmax was 15% and 55% higher in mild and moderate renal impairment, respectively.
- Pediatrics:
Candesartran cilexetil pharmacokinetics have not been determined in children with renal insufficiency.
- Hepatic Insufficiency
- The pharmacokinetics of candesartan were compared in patients with mild and moderate hepatic impairment to matched healthy volunteers following a single oral dose of 16 mg candesartan cilexetil. The increase in AUC for candesartan was 30% in patients with mild hepatic impairment (Child-Pugh A) and 145% in patients with moderate hepatic impairment (Child-Pugh B). The increase in Cmax for candesartan was 56% in patients with mild hepatic impairment and 73% in patients with moderate hepatic impairment. The pharmacokinetics after candesartan cilexetil administration have not been investigated in patients with severe hepatic impairment. No initial dosage adjustment is necessary in patients with mild hepatic impairment. In hypertensive patients with moderate hepatic impairment, consideration should be given to initiation of candesartran cilexetil at a lower dose.
- Heart Failure
- The pharmacokinetics of candesartan were linear in patients with heart failure (NYHA class II and III) after candesartan cilexetil doses of 4, 8, and 16 mg. After repeated dosing, the AUC was approximately doubled in these patients compared with healthy, younger patients. The pharmacokinetics in heart failure patients is similar to that in healthy elderly volunteers.

## Nonclinical Toxicology
- There was no evidence of carcinogenicity when candesartan cilexetil was orally administered to mice and rats for up to 104 weeks at doses up to 100 and 1000 mg/kg/day, respectively. Rats received the drug by gavage, whereas mice received the drug by dietary administration. These (maximally-tolerated) doses of candesartan cilexetil provided systemic exposures to candesartan (AUCs) that were, in mice, approximately 7 times and, in rats, more than 70 times the exposure in man at the maximum recommended daily human dose (32 mg).
- Candesartan and its O-deethyl metabolite tested positive for genotoxicity in the in vitro Chinese hamster lung (CHL) chromosomal aberration assay. Neither compound tested positive in the Ames microbial mutagenesis assay or the in vitro mouse lymphoma cell assay.
- Candesartan (but not its O-deethyl metabolite) was also evaluated in vivo in the mouse micronucleus test and in vitro in the Chinese hamster ovary (CHO) gene mutation assay, in both cases with negative results.
- Candesartan cilexetil was evaluated in the Ames test, the in vitro mouse lymphoma cell and rat hepatocyte unscheduled DNA synthesis assays and the in vivo mouse micronucleus test, in each case with negative results. Candesartan cilexetil was not evaluated in the CHL chromosomal aberration or CHO gene mutation assay.
- Fertility and reproductive performance were not affected in studies with male and female rats given oral doses of up to 300 mg/kg/day (83 times the maximum daily human dose of 32 mg on a body surface area basis).

# Clinical Studies
- Adult
- The antihypertensive effects of candesartran cilexetil were examined in 14 placebo-controlled trials of 4- to 12-weeks duration, primarily at daily doses of 2 to 32 mg per day in patients with baseline diastolic blood pressures of 95 to 114 mm Hg. Most of the trials were of candesartan cilexetil as a single agent, but it was also studied as add-on to hydrochlorothiazide and amlodipine. These studies included a total of 2350 patients randomized to one of several doses of candesartan cilexetil and 1027 to placebo. Except for a study in diabetics, all studies showed significant effects, generally dose related, of 2 to 32 mg on trough (24 hour) systolic and diastolic pressures compared to placebo, with doses of 8 to 32 mg giving effects of about 8-12/4-8 mm Hg. There were no exaggerated first-dose effects in these patients. Most of the antihypertensive effect was seen within 2 weeks of initial dosing and the full effect in 4 weeks. With once-daily dosing, blood pressure effect was maintained over 24 hours, with trough to peak ratios of blood pressure effect generally over 80%. Candesartan cilexetil had an additional blood pressure lowering effect when added to hydrochlorothiazide.
- The antihypertensive effects of candesartan cilexetil and losartan potassium at their highest recommended doses administered once-daily were compared in two randomized, double-blind trials. In a total of 1268 patients with mild to moderate hypertension who were not receiving other antihypertensive therapy, candesartan cilexetil 32 mg lowered systolic and diastolic blood pressure by 2 to 3 mm Hg on average more than losartan potassium 100 mg, when measured at the time of either peak or trough effect. The antihypertensive effects of twice daily dosing of either candesartan cilexetil or losartan potassium were not studied.
- The antihypertensive effect was similar in men and women and in patients older and younger than 65. Candesartan was effective in reducing blood pressure regardless of race, although the effect was somewhat less in blacks (usually a low-renin population). This has been generally true for angiotensin II antagonists and ACE inhibitors.
In long-term studies of up to 1 year, the antihypertensive effectiveness of candesartan cilexetil was maintained, and there was no rebound after abrupt withdrawal.
- There were no changes in the heart rate of patients treated with candesartan cilexetil in controlled trials.
- Pediatric
- The antihypertensive effects of candesartran cilexetil were evaluated in hypertensive children 1 to < 6 years old and 6 to < 17 years of age in two randomized, double-blind multicenter, 4-week dose ranging studies. There were 93 patients 1 to < 6 years of age, 74% of whom had renal disease, that were randomized to receive an oral dose of candesartan cilexetil suspension 0.05, 0.20 or 0.40 mg/kg once daily. The primary method of analysis was slope of the change in systolic blood pressure (SBP) as a function of dose. Since there was no placebo group, the change from baseline likely overestimates the true magnitude of blood pressure effect. Nevertheless, SBP and diastolic blood pressure (DBP) decreased 6.0/5.2 to 12.0/11.1 mmHg from baseline across the three doses of candesartan.
- In children 6 to  50 kg the candesartran cilexetil doses were 4, 16 or 32 mg once daily. Those enrolled were 47% Black and 29% were female; mean age +/- SD was 12.9 +/- 2.6 years.
- The placebo subtracted effect at trough for sitting systolic blood pressure/sitting diastolic blood pressure for the different doses were from 4.9/3.0 to 7.5/6.2 mmHg.
In children 6 to < 17 years there was a trend for a lesser blood pressure effect for Blacks compared to other patients. There were too few individuals in the age group of 1 - 6 years old to determine whether Blacks respond differently than other patients to candesartran cilexetil.
- Candesartan was studied in two heart failure outcome studies: 1. The Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity trial in patients intolerant of ACE inhibitors (CHARMAlternative), 2. CHARMAdded in patients already receiving ACE inhibitors. Both studies were international double-blind, placebo-controlled trials in patients with NYHA class II - IV heart failure and LVEF 40%. In both trials, patients were randomized to placebo or candesartran cilexetil (initially 4-8 mg once daily, titrated as tolerated to 32 mg once daily) and followed for up to 4 years. Patients with serum creatinine > 3 mg/dL, serum potassium > 5.5 mEq/L, symptomatic hypotension or known bilateral renal artery stenosis were excluded. The primary end point in both trials was time to either cardiovascular death or hospitalization for heart failure.
- CHARMAlternative included 2028 subjects not receiving an ACE inhibitor due to intolerance. The mean age was 67 years and 32% were female, 48% were NYHA II, 49% were NYHA III, 4% were NYHA IV, and the mean ejection fraction was 30%. Sixty-two percent had a history of myocardial infarction, 50% had a history of hypertension, and 27% had diabetes. Concomitant drugs at baseline were diuretics (85%), digoxin (46%), beta-blockers (55%), and spironolactone (24%). The mean daily dose of candesartran cilexetil was approximately 23 mg and 59% of subjects on treatment received 32 mg once daily.
- After a median follow-up of 34 months, there was a 23% reduction in the risk of cardiovascular death or heart failure hospitalization on candesartran cilexetil (p<0.001), with both components contributing to the overall effect (Table 1).
- In CHARMAdded, 2548 subjects receiving an ACE inhibitor were randomized to candesartran cilexetil or placebo. The specific ACE inhibitor and dose were at the discretion of the investigators, who were encouraged to titrate patients to doses known to be effective in clinical outcome trials, subject to patient tolerability. Forced titration to maximum tolerated doses of ACE inhibitor was not required.
- The mean age was 64 years and 21% were female, 24% were NYHA II, 73% were NYHA III, 3% were NYHA IV, and the mean ejection fraction was 28%. Fifty-six percent had a history of myocardial infarction, 48% had a history of hypertension, and 30% had diabetes. Concomitant drugs at baseline in addition to ACE inhibitors were diuretics (90%), digoxin (58%), beta-blockers (55%), and spironolactone (17%). The mean daily dose of candesartran cilexetil was approximately 24 mg and 61% of subjects on treatment received 32 mg once daily.
After a median follow-up of 41 months, there was a 15% reduction in the risk of cardiovascular death or heart failure hospitalization on candesartran cilexetil (p=0.011), with both components contributing to the overall effect (Table 2). There was no evident relationship between dose of ACE inhibitor and the benefit of candesartran cilexetil.
- In these two studies, the benefit of candesartran cilexetil in reducing the risk of CV death or heart failure hospitalization (18% p<0.001) was evident in major subgroups (see Figure), and in patients on other combinations of cardiovascular and heart failure treatments, including ACE inhibitors and beta-blockers. CV Death or Heart Failure Hospitalization in Subgroups  LV Systolic Dysfunction Trials

# How Supplied
- No. 3782  Tablets candesartan cilexetil, 4 mg, are white to off-white, circular/biconvex-shaped, non-film-coated scored tablets, coded ACF on one side and 004 on the other. They are supplied as follows:
- NDC 0186-0004-31 unit of use bottles of 30.
- No. 3780  Tablets candesartan cilexetil, 8 mg, are light pink, circular/biconvex-shaped, non-film-coated scored tablets, coded ACG on one side and 008 on the other. They are supplied as follows:
- NDC 0186-0008-31 unit of use bottles of 30.
- No. 3781  Tablets candesartan cilexetil, 16 mg, are pink, circular/biconvex-shaped, non-film-coated scored tablets, coded ACH on one side and 016 on the other. They are supplied as follows:
- NDC 0186-0016-31 unit of use bottles of 30
- NDC 0186-0016-54 unit of use bottles of 90
- NDC 0186-0016-28 unit dose packages of 100.
- No. 3791  Tablets candesartan cilexetil, 32 mg, are pink, circular/biconvex-shaped, non-film-coated scored tablets, coded ACL on one side and 032 on the other. They are supplied as follows:
- NDC 0186-0032-31 unit of use bottles of 30
- NDC 0186-0032-54 unit of use bottles of 90
- NDC 0186-0032-28 unit dose packages of 100.

## Storage
- Store at 25C (77F); excursions permitted to 15-30C (59-86F) .
- Keep container tightly closed.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
- Tablets
- Read the Patient information that comes with candesartan cilexetil before you start taking it and each time you get a refill. There may be new information. This leaflet does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about candesartan cilexetil, ask your doctor or pharmacist.
- What is the most important information I should know about candesartan cilexetil?
- Candesartan cilexetil can cause harm or death to an unborn baby. Talk to your doctor about other ways to lower your blood pressure if you plan to become pregnant. If you get pregnant while taking :- Candesartan cilexetil, tell your doctor right away.
- What is candesartan cilexetil?
- Candesartan cilexetil is a prescription medicine called an angiotensin receptor blocker (ARB).
- Candesartan cilexetil is used to:
- Treat high blood pressure in adults and children, 1 to 17 years of age
- Treat certain types of heart failure in adults, to reduce death and hospitalization for heart damage and heart failure
- Heart failure is a condition where the heart does not pump blood as well as it should.
candesartan cilexetil must not be used in children less than 1 year of age for high blood pressure.
- Who should not take candesartan cilexetil?
- Do not take candesartan cilexetil if you:
- are allergic to any of the ingredients in candesartan cilexetil. See the end of this leaflet for a complete list of ingredients in candesartan cilexetil.
- are diabetic and taking aliskiren.
- What should I tell my doctor before taking candesartan cilexetil?
- Before you take candesartan cilexetil, tell your doctor if you:
- have heart problems
- have liver problems
- have kidney problems
- currently have vomiting or diarrhea
- are scheduled for surgery or anesthesia. Low blood pressure can happen in people who take candesartan cilexetil and have major surgery and anesthesia.
- have any other medical conditions
- are pregnant or planning to become pregnant. See What is the most important information I should know about candesartan cilexetil?
- are breast-feeding or plan to breast-feed. It is not known if candesartan cilexetil passes into your breast milk. You and your doctor should decide if you will take candesartan cilexetil or breast-feed.
- You should not do both.
- Tell your doctor about all the medicines you take, including prescription and non-prescription medicines, vitamins and herbal supplements. candesartan cilexetil and other medicines may affect each other causing serious side effects. candesartan cilexetil may affect the way other medicines work, and other medicines may affect how candesartan cilexetil works.
- Especially tell your doctor if you take:
- lithium carbonate (Lithobid) or lithium citrate, medicines used in some types of depression
- other medicines for high blood pressure, especially water pills (diuretics)
- potassium supplements
- salt substitutes
- non-steroidal anti-inflammatory drugs (NSAIDs)
- Know the medicines you take. Keep a list of your medications with you to show your doctor and pharmacist when a new medication is prescribed. Talk to your doctor or pharmacist before you start taking any new medicine. Your doctor or pharmacist will know what medicines are safe to take together.
- How should I take candesartan cilexetil?
- Take candesartan cilexetil exactly as prescribed by your doctor.
- Do not change your dose or stop candesartan cilexetil without talking to your doctor, even if you are feeling well.
- If your child cannot swallow tablets, or if tablets are not available in the prescribed strength, your pharmacist will prepare candesartan cilexetil as a liquid suspension for your child. If your child switches between taking the tablet and the suspension, your doctor will change the dose as needed. Shake the bottle of suspension well before each dose.
- Candesartan cilexetil is taken by mouth with or without food.
- If you miss a dose of candesartan cilexetil, take it as soon as you remember. If it is almost time for your next dose, skip the missed dose. Take the next dose on time. Do not take 2 doses at one time. If you are not sure about your dosing call your doctor or pharmacist.
- If you take more candesartan cilexetil than prescribed, call your doctor, local poison control center, or go to the nearest emergency room.
- What should I avoid while taking candesartan cilexetil?
- Candesartan cilexetil can cause you to feel dizzy or tired. Do not drive, operate machinery, or do other dangerous activities until you know how candesartan cilexetil affects you.
- What are the possible side effects of candesartan cilexetil?
- Candesartan cilexetil may cause serious side effects, including:
- Injury or death to your unborn baby. See What is the most important information I should know about candesartan cilexetil?
- Low blood pressure (hypotension). Low blood pressure is most likely to happen if you:
- Take water pills (diuretics)
- Are on a low salt diet
- Get dialysis treatments
- Are dehydrated (decreased body fluids) due to vomiting and diarrhea
- Have heart problems
- If you feel dizzy or faint lie down and call your doctor right away.
- Low blood pressure can also happen if you have major surgery or anesthesia. You will be monitored for this and treated if needed. See What should I tell my doctor before taking candesartan cilexetil?
- Worsening kidney problems. Kidney problems may get worse in people that already have kidney disease or heart problems. Your doctor may do blood tests to check for this.
- Increased potassium in your blood. Your doctor may do a blood test to check your potassium levels as needed.
- Symptoms of allergic reaction. Call your doctor right away if you have any of these symptoms of an allergic reaction:
- Swelling of your face, lips, tongue or throat
- Rash
- Hives and itching
- The most common side effects of candesartan cilexetil are:
- Back pain
- Dizziness
- Cold or flu symptoms (upper respiratory tract infection)
- Sore throat (pharyngitis)
- Nasal congestion and stuffiness (rhinitis)
- Tell your doctor or pharmacist about any side effect that bothers you or that does not go away.
- These are not all the side effects of candesartan cilexetil. Ask your doctor or pharmacist for more information.
- Call your doctor for medical advice about side effects. You can report side effects to FDA at 1-800-FDA-1088.
- How should I store candesartan cilexetil?
- Do not keep medicine that is out of date or that you no longer need.
- Store candesartan cilexetil Tablets at room temperature below 86F (30C).
- Store candesartan cilexetil oral suspension at room temperature below 86F (30C).
- Use the oral suspension within 30 days after first opening the bottle. Do not use after the expiration date stated on the bottle.
- Do not freeze.
- Keep the container of candesartan cilexetil closed tightly.
- Keep candesartan cilexetil and all medicine out of the reach of children.
- General information about candesartan cilexetil.
- Medicines are sometimes prescribed for conditions that are not mentioned in patient information leaflets. Do not use v for a condition for which it was not prescribed. Do not give candesartan cilexetil to other people, even if they have the same problem you have. It may harm them.
- This leaflet summarizes the most important information about candesartan cilexetil. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about candesartan cilexetil that is written for health professionals.
This Patient Information has been approved by the U.S. Food and Drug Administration.

# Precautions with Alcohol
Alcohol-Candesartan interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- Atacand

# Look-Alike Drug Names
- Atacand - antacid

# Drug Shortage Status

# Price