Drugs List

Therapeutic Indications

Uses

Risk reduction of cardiovascular events
Treatment of essential hypertension

Treatment of essential hypertension

Cardiovascular prevention: reduction of cardiovascular morbidity in patients with:
Manifest atherothrombotic cardiovascular disease (history of coronary heart disease, stroke or peripheral arterial disease)
Type 2 diabetes mellitus with documented target organ damage

Contraindications

Children under 18 years
Biliary obstruction
Breastfeeding
Cholestasis
Hereditary fructose intolerance
Pregnancy
Severe bilateral renal artery stenosis
Severe hepatic impairment
Severe unilateral stenosis of solitary functioning kidney

Precautions and Warnings

Patients over 70 years
Aortic stenosis
Bilateral renal artery stenosis
Diabetes mellitus
Galactosaemia
Glucose-galactose malabsorption syndrome
Hypertrophic obstructive cardiomyopathy
Hyponatraemia
Hypovolaemia
Ischaemic heart disease
Kidney transplantation
Lactose intolerance
Mild hepatic impairment
Mitral stenosis
Peripheral vascular disease
Renal impairment - glomerular filtration rate below 10ml/minute
Renovascular disorder
Severe congestive cardiac failure
Severe generalised atherosclerosis
Unilateral stenosis of solitary functioning kidney

Patients with primary aldosteronism may not benefit from this treatment
Reduce dose in patients with a glomerular filtration rate below 10ml/min
Switch to more suitable alternative before planned pregnancy
Advise ability to drive/operate machinery may be affected by side effects
Advise patient that first dose hypotension may occur
Afro-Caribbean or black patients may show reduced response
Correct volume and/or salt depletion before initiating therapy
Presentations with sorbitol unsuitable in hereditary fructose intolerance
Some formulations contain lactose
Evaluate renal function before and during treatment
Monitor serum electrolytes before and during treatment
Diabetic control may need adjustment
Monitor serum potassium regularly
Increased risk of hyperkalaemia with K+ suppl. and K+ sparing diuretic
Advise patient to seek advice at first indications of pregnancy
Advise patient not to take NSAIDs unless advised by clinician
Advise on problems of salt substitutes/high intake of potassium-rich food
Female: Ensure adequate contraception during treatment

Renal function and electrolytes should be checked before starting treatment and monitored during therapy, especially in patients with post myocardial infarction and those with heart failure. Side effects (such as hyperkalaemia) are more common in patients with renal impairment, the dose may need to be reduced. A specialist should be involved if renal function is significantly reduced.

Monitor plasma potassium, particularly in the elderly, patients with renal impairment, in the presence of other conditions (fever, dehydration) which affect renal function and patients in whom potassium supplements / retaining medication is essential.

In patients whose renal function may depend on the activity of the renin-angiotensin system (e.g. patients with severe congestive heart failure), treatment with ACE inhibitors has been associated with oliguria and/ or progressive azotaemia and in rare cases with acute renal failure and/ or death. As telmisartan is an angiotensin II antagonist, it cannot be excluded that the use of this medication may be associated with impairment of the renal function.

Avoid use in patients with known or suspected renovascular disease, unless the blood pressure cannot be controlled with other drugs. Use with particular precaution in patients who have undiagnosed and clinically silent renovascular disease.

Co-administration of NSAIDS may reduce the antihypertensive effect of angiotensin II receptor antagonists, increase serum potassium and exacerbate renal impairment.

Pregnancy and Lactation

Pregnancy

Telmisartan is contraindicated in pregnancy. When pregnancy is diagnosed, treatment should be immediately discontinued and if possible an alternative treatment started.

Angiotensin II receptor antagonists may be associated with similar risks as ACE inhibitors. Angiotensin II receptor antagonist exposure during the second and third trimesters is known to induce human foetotoxicity (decreased renal function, oligohydramnios, skull ossification retardation) and neonatal toxicity (renal failure, hypotension, hyperkalaemia).

The MHRA states that the use of angiotensin II receptor antagonists in late pregnancy has been associated with adverse effects on the foetal kidney and other congenital anomalies, therefore angiotensin II receptor antagonists should not be used at any stage during of pregnancy unless absolutely necessary and only then after the potential risks and benefits have been discussed with the patient.

Exposure to angiotensin II receptor antagonists during the first trimester has been inconclusive, however, a small increase in risk cannot be excluded and a detailed ultrasound is recommended.

If pregnancy is detected during therapy, telmisartan should be discontinued as soon as possible and alternative treatment should be offered. Guidelines advise that women who are taking angiotensin II receptor blockers are told that there is an increased risk of congenital abnormalities if these drugs are taken during pregnancy and other antihypertensive treatments should be discussed and offered.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Telmisartan is contraindicated during breastfeeding.

Schaefer (2007) suggests that accidental administration of a single dose does not require weaning, however, therapy should be changed to an antihypertensive which has been better studied in breastfeeding. The MHRA concludes that the use of angiotensin II receptor antagonists in breastfeeding mothers is not recommended. Alternative agents with more established safety profiles during breastfeeding are preferable, especially while nursing a newborn or preterm baby.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Abdominal pain
Acute renal failure
Anaemia
Anaphylactic reaction
Angioedema
Anxiety
Arthralgia
Asthenia
Back pain
Bradycardia
Chest pain
Cough
Creatine phosphokinase increased
Cystitis
Depression
Diarrhoea
Dizziness
Dry mouth
Dyspepsia
Dyspnoea
Eczema
Eosinophilia
Erythema
Extremity pain
Fixed drug eruption
Flatulence
Gastro-intestinal disturbances
Haemoglobin decrease
Hepatic disorders
Hyperkalaemia
Hypersensitivity reactions
Hyperuricaemia
Hypoglycaemia
Hypotension
Increased sweating
Increases in hepatic enzymes
Influenza-like symptoms
Insomnia
Interstitial lung disease
Muscle spasm
Myalgia
Orthostatic hypotension
Pharyngitis
Pruritus
Rash
Renal impairment
Sciatica
Sepsis
Serum creatinine increased
Sinusitis
Somnolence
Stomach pain
Syncope
Tachycardia
Tendinitis like symptoms
Thrombocytopenia
Toxic skin reaction
Upper respiratory tract infection
Urinary tract infections
Urticaria
Vertigo
Visual disturbances
Vomiting

Presentation

Oral formulations of telmisartan

Drugs List

Therapeutic Indications

Uses

Risk reduction of cardiovascular events
Treatment of essential hypertension

Treatment of essential hypertension

Cardiovascular prevention: reduction of cardiovascular morbidity in patients with:
Manifest atherothrombotic cardiovascular disease (history of coronary heart disease, stroke or peripheral arterial disease)
Type 2 diabetes mellitus with documented target organ damage

Dosage

Adults

Elderly

Patients with Renal Impairment

Patients with Hepatic Impairment

Contraindications

Children under 18 years
Biliary obstruction
Breastfeeding
Cholestasis
Hereditary fructose intolerance
Pregnancy
Severe bilateral renal artery stenosis
Severe hepatic impairment
Severe unilateral stenosis of solitary functioning kidney

Precautions and Warnings

Patients over 70 years
Aortic stenosis
Bilateral renal artery stenosis
Diabetes mellitus
Galactosaemia
Glucose-galactose malabsorption syndrome
Hypertrophic obstructive cardiomyopathy
Hyponatraemia
Hypovolaemia
Ischaemic heart disease
Kidney transplantation
Lactose intolerance
Mild hepatic impairment
Mitral stenosis
Peripheral vascular disease
Renal impairment - glomerular filtration rate below 10ml/minute
Renovascular disorder
Severe congestive cardiac failure
Severe generalised atherosclerosis
Unilateral stenosis of solitary functioning kidney

Patients with primary aldosteronism may not benefit from this treatment
Reduce dose in patients with a glomerular filtration rate below 10ml/min
Switch to more suitable alternative before planned pregnancy
Advise ability to drive/operate machinery may be affected by side effects
Advise patient that first dose hypotension may occur
Afro-Caribbean or black patients may show reduced response
Correct volume and/or salt depletion before initiating therapy
Presentations with sorbitol unsuitable in hereditary fructose intolerance
Some formulations contain lactose
Evaluate renal function before and during treatment
Monitor serum electrolytes before and during treatment
Diabetic control may need adjustment
Monitor serum potassium regularly
Increased risk of hyperkalaemia with K+ suppl. and K+ sparing diuretic
Advise patient to seek advice at first indications of pregnancy
Advise patient not to take NSAIDs unless advised by clinician
Advise on problems of salt substitutes/high intake of potassium-rich food
Female: Ensure adequate contraception during treatment

Renal function and electrolytes should be checked before starting treatment and monitored during therapy, especially in patients with post myocardial infarction and those with heart failure. Side effects (such as hyperkalaemia) are more common in patients with renal impairment, the dose may need to be reduced. A specialist should be involved if renal function is significantly reduced.

Monitor plasma potassium, particularly in the elderly, patients with renal impairment, in the presence of other conditions (fever, dehydration) which affect renal function and patients in whom potassium supplements / retaining medication is essential.

In patients whose renal function may depend on the activity of the renin-angiotensin system (e.g. patients with severe congestive heart failure), treatment with ACE inhibitors has been associated with oliguria and/ or progressive azotaemia and in rare cases with acute renal failure and/ or death. As telmisartan is an angiotensin II antagonist, it cannot be excluded that the use of this medication may be associated with impairment of the renal function.

Avoid use in patients with known or suspected renovascular disease, unless the blood pressure cannot be controlled with other drugs. Use with particular precaution in patients who have undiagnosed and clinically silent renovascular disease.

Co-administration of NSAIDS may reduce the antihypertensive effect of angiotensin II receptor antagonists, increase serum potassium and exacerbate renal impairment.

Pregnancy and Lactation

Pregnancy

Telmisartan is contraindicated in pregnancy. When pregnancy is diagnosed, treatment should be immediately discontinued and if possible an alternative treatment started.

Angiotensin II receptor antagonists may be associated with similar risks as ACE inhibitors. Angiotensin II receptor antagonist exposure during the second and third trimesters is known to induce human foetotoxicity (decreased renal function, oligohydramnios, skull ossification retardation) and neonatal toxicity (renal failure, hypotension, hyperkalaemia).

The MHRA states that the use of angiotensin II receptor antagonists in late pregnancy has been associated with adverse effects on the foetal kidney and other congenital anomalies, therefore angiotensin II receptor antagonists should not be used at any stage during of pregnancy unless absolutely necessary and only then after the potential risks and benefits have been discussed with the patient.

Exposure to angiotensin II receptor antagonists during the first trimester has been inconclusive, however, a small increase in risk cannot be excluded and a detailed ultrasound is recommended.

If pregnancy is detected during therapy, telmisartan should be discontinued as soon as possible and alternative treatment should be offered. Guidelines advise that women who are taking angiotensin II receptor blockers are told that there is an increased risk of congenital abnormalities if these drugs are taken during pregnancy and other antihypertensive treatments should be discussed and offered.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Telmisartan is contraindicated during breastfeeding.

Schaefer (2007) suggests that accidental administration of a single dose does not require weaning, however, therapy should be changed to an antihypertensive which has been better studied in breastfeeding. The MHRA concludes that the use of angiotensin II receptor antagonists in breastfeeding mothers is not recommended. Alternative agents with more established safety profiles during breastfeeding are preferable, especially while nursing a newborn or preterm baby.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Abdominal pain
Acute renal failure
Anaemia
Anaphylactic reaction
Angioedema
Anxiety
Arthralgia
Asthenia
Back pain
Bradycardia
Chest pain
Cough
Creatine phosphokinase increased
Cystitis
Depression
Diarrhoea
Dizziness
Dry mouth
Dyspepsia
Dyspnoea
Eczema
Eosinophilia
Erythema
Extremity pain
Fixed drug eruption
Flatulence
Gastro-intestinal disturbances
Haemoglobin decrease
Hepatic disorders
Hyperkalaemia
Hypersensitivity reactions
Hyperuricaemia
Hypoglycaemia
Hypotension
Increased sweating
Increases in hepatic enzymes
Influenza-like symptoms
Insomnia
Interstitial lung disease
Muscle spasm
Myalgia
Orthostatic hypotension
Pharyngitis
Pruritus
Rash
Renal impairment
Sciatica
Sepsis
Serum creatinine increased
Sinusitis
Somnolence
Stomach pain
Syncope
Tachycardia
Tendinitis like symptoms
Thrombocytopenia
Toxic skin reaction
Upper respiratory tract infection
Urinary tract infections
Urticaria
Vertigo
Visual disturbances
Vomiting

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Further Information

Last Full Review Date: June 2014

Reference Sources

Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 9th edition (2011) ed. Briggs, G., Freeman, R. and Yaffe, S. Lippincott Williams & Wilkins, Philadelphia.

Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press https://www.medicinescomplete.com Accessed on June 12, 2014.

Martindale: The Complete Drug Reference, 37th edition (2011) ed. Sweetman, S. Pharmaceutical Press, London.

Medications and Mothers' Milk, 14th Edition (2010) Hale,T. Hale Publishing, Amarillo, Texas.

Summary of Product Characteristics: Micardis 20mg tablets. Boehringer Ingelheim Ltd. Revised December 2013.
Summary of Product Characteristics: Micardis 40mg tablets. Boehringer Ingelheim Ltd. Revised December 2013.
Summary of Product Characteristics: Micardis 80mg tablets. Boehringer Ingelheim Ltd. Revised December 2013.

Summary of Product Characteristics: Tolura 20mg tablets. KRKA. Revised June 2010.
Summary of Product Characteristics: Tolura 40mg tablets. KRKA. Revised June 2010.
Summary of Product Characteristics: Tolura 80mg tablets. KRKA. Revised June 2010.

The Renal Drug Handbook. 3rd edition. (2009) ed. Ashley, C and Currie, Radcliffe Publishing Ltd, Abingdon.

MHRA Drug Safety Update: Breastfeeding with ACE inhibitors and angiotensin II receptor antagonists (Dated: May 2009)
Available at: https://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON088003
Last accessed: June 12, 2014.

National Institute for Health and Clinical excellence (NICE) clinical guidance 107: Hypertension in pregnancy. Issue date August 2010
Available at: https://guidance.nice.org.uk/CG107
Last accessed: June 12, 2014.

US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Telmisartan. Last revised: September 7, 2013.
Last accessed: June 12, 2014.