Symptoms and treatment:
To date, no case of overdosage has been reported.
Symptoms of overdose would be severe hypotension, shock, stupor, bradycardia, electrolyte disturbances and renal failure. Treatment must be symptomatic and supportive.
After ingestion of an overdose, the patients must be kept under close supervision, preferably in an intensive care unit. Serum electrolytes and creatinine must be monitored frequently. Therapeutic measures depend on the nature and severity of the symptoms. Measures to prevent absorption and to hasten elimination, such as administration of absorbents, must be applied if ingestion is recent, within 1 hour after intake. If hypotension occurs, the patient must be placed in a supine position and salt and volume supplementation must be given rapidly. Treatment with angiotensin II infusion and/or intravenous catecholamines must be considered. Bradycardia or extensive vagal reactions must be treated by administering atropine. The use of a pacemaker may be considered. It is not yet known whether Moex is removed by haemodialysis.
- History of angioneurotic oedema associated with previous ACE inhibitor therapy
- Hereditary/idiopathic angioneurotic oedema
The concomitant use of Moex with aliskiren-containing products is contraindicated in patients with diabetes mellitus or renal impairment (GFR < 60 ml/min/1.73 m2).
Not applicable.
The most commonly reported undesirable effects (more than 1% of patients treated with Moex in controlled trials) were cough (4.0%), headache (3.6%), dizziness (3.3%), fatigue (1.2%), flushing (1.2%), and rash (1.0%).
Other adverse experiences possibly or probably related, or of uncertain relationship to therapy, reported in controlled or uncontrolled clinical trials occurring in less than 1% of Moex patients and less frequent clinically significant events which have been attributed to ACE inhibitors include the following:
Cardiovascular:
Symptomatic hypotension, postural hypotension, or syncope was seen in ☠1% of patients; these reactions led to discontinuation of therapy in controlled trials in 2 patients (0.1%) who had received Moex monotherapy and in 1 patient (0.05%) who had received Moex with hydrochlorothiazide. Other reports included chest pain, angina/myocardial infarction, tachycardia, palpitations, rhythm disturbances, transient ischaemic attacks, cerebrovascular accident.
Renal:
Gastrointestinal:
Abdominal pain, dyspepsia, constipation, nausea, vomiting, diarrhoea, appetite/weight change, dry mouth, pancreatitis, hepatitis.
Intestinal Angioedema:
Respiratory:
Upper respiratory infection, pharyngitis, sinusitis/rhinitis, bronchospasm, dyspnoea.
Urogenital:
Renal insufficiency.
Dermatologic:
Occasionally allergic and hypersensitivity reactions can occur like rash, pruritus, urticaria, erythema multiforme, Stevens-Johnson syndrome, toxic epidermic necrolysis, psoriasis-like efflorescence, pemphigus and alopecia. This can be accompanied by fever, myalgia, arthralgia, eosinophilia and/or increased ANA-titres. ACE inhibitors have been associated with the onset of angioneurotic oedema in a small subset of patients involving the face and oropharyngeal tissues.
Neurological and psychiatric:
Headache or tiredness may occasionally occur; rarely there may be drowsiness, depression, sleep disturbances, impotence, tingling sensations, numbness or paraesthesia, disturbances of balance, confusion, tinnitus, blurred vision, and alterations of taste or a transient loss of taste.
Other
Sweating, flu syndrome, malaise.
Clinical Laboratory Test Findings:
Decreases in haemoglobin, haematocrit, platelets and white cell count and individual cases of agranulocytosis or pancytopenia, as well as elevation of liver enzymes and serum bilirubin have been reported in a few patients. In patients with congenital deficiency concerning G-6-PDH individual cases of haemolytic anaemia have been reported.
In rare cases, especially in patients with impaired kidney function or collagen disease, or those simultaneously receiving treatment with allopurinol, procainamide or certain drugs which suppress the defence reactions, there may be anaemia, thrombocytopenia, neutropenia, eosinophilia and in isolated cases, even agranulocytosis or pancytopenia.
Creatinine and blood urea nitrogen:
As with other ACE inhibitors, minor increases in blood urea nitrogen or serum creatinine, reversible upon discontinuation of therapy, were observed in approximately 1% of patients with essential hypertension who were treated with Moex. Increases are more likely to occur in patients receiving concomitant diuretics or in patients with compromised renal function.
Potassium:
Since moexipril decreases aldosterone secretion, elevation of serum potassium can occur. Potassium supplements and potassium-sparing diuretics should be given with caution and the patient's serum potassium should be monitored frequently.
Other:
Clinically important changes in standard laboratory tests were rarely associated with Moex administration. Elevations of liver enzymes and uric acid have been reported. In trials, less than 1% of moexipril-treated patients discontinued Moex treatment because of laboratory abnormalities.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme, website: www.mhra.gov.uk/yellowcard
Acute toxicity:
Findings of the acute toxicity studies in animals do not raise questions as to the safety of moexipril HCl as well as the main metabolite moexiprilate under the conditions of proposed clinical usage.
Subacute/chronic toxicity:
Subacute and chronic toxicity studies in rats and dogs with repeated oral administration of moexipril HCl up to 12 months, revealed mainly heart and kidney as target organs. The effects are completely comparable with those of other ACE inhibitors and can be interpreted as results of highly exaggerated pharmacological activity.
First unspecific drug-related side-effects after long-term administration were seen at 75 mg/kg, i.e. a dose which corresponds 150 times the maximum recommended total daily dose in humans when compared on the basis of body weight.
Reproduction studies:
Studies in rats and rabbits including all segments of reproduction revealed no direct effects of moexipril HCl on fertility, reproduction and abnormalities in F1 - or F2 - pups.
Regarding precautions in women of child bearing potential and use during pregnancy and lactation see 4.3 and 4.6.
Mutagenicity:
As conclusion of different 'in vitro' and one 'in vivo' mutagenicity studies, the mutagenic potential of moexipril HCl for human beings should be extremely low.
Carcinogenicity:
Neither the long-term toxicity studies in rats and dogs nor special carcinogenicity studies in mice and rats over 78 and 104 weeks respectively, indicated neoplastigenic properties of moexipril HCl. Therefore, it can be concluded that the carcinogenic risk for human beings will be extremely low.
For the treatment of hypertension as monotherapy in adult patients.
As second line therapy for the treatment of hypertension in combination with diuretics or calcium antagonists e.g. hydrochlorothiazide or nifedipinein adult patients.
Pharmacotherapeutic class: ACE inhibitor
ATC Code: C09AA13
In animals as well as in humans, interactions between the renin-angiotensin-aldosterone system and the kallikrein-kinin system provide an important biochemical basis for blood pressure homeostasis. In hypertension the normal feedback mechanism formed by the renin-angiotensin system (RAS) may be dysfunctional, resulting in a self-perpetuating hypertensive condition.
Angiotensin converting enzyme (ACE) inhibitors were developed to interrupt this system and thereby to lower blood pressure. Moex potently inhibits ACE and by this the formation of angiotensin II, the active agent of the RAS, thus blocking its vasoconstrictor and sodium-retaining effects with a consequent reduction in blood pressure.
Since ACE is identical to kininase II, an enzyme that degrades the potent vasodilator bradykinin, inhibition of ACE leads to an additional, non renin-mediated reduction in systemic blood pressure. The antihypertensive effects of ACE inhibitors are accompanied by a reduction in peripheral vascular resistance.
Two large randomised, controlled trials (ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial) and VA NEPHRON-D (The Veterans Affairs Nephropathy in Diabetes)) have examined the use of the combination of an ACE-inhibitor with an angiotensin II receptor blocker.
ONTARGET was a study conducted in patients with a history of cardiovascular or cerebrovascular disease, or type 2 diabetes mellitus accompanied by evidence of end-organ damage. VA NEPHRON-D was a study in patients with type 2 diabetes mellitus and diabetic nephropathy.
These studies have shown no significant beneficial effect on renal and/or cardiovascular outcomes and mortality, while an increased risk of hyperkalaemia, acute kidney injury and/or hypotension as compared to monotherapy was observed. Given their similar pharmacodynamic properties, these results are also relevant for other ACE-inhibitors and angiotensin II receptor blockers.
ACE-inhibitors and angiotensin II receptor blockers should therefore not be used concomitantly in patients with diabetic nephropathy.
ALTITUDE (Aliskiren Trial in Type 2 Diabetes Using Cardiovascular and Renal Disease Endpoints) was a study designed to test the benefit of adding aliskiren to a standard therapy of an ACE-inhibitor or an angiotensin II receptor blocker in patients with type 2 diabetes mellitus and chronic kidney disease, cardiovascular disease, or both. The study was terminated early because of an increased risk of adverse outcomes. Cardiovascular death and stroke were both numerically more frequent in the aliskiren group than in the placebo group and adverse events and serious adverse events of interest (hyperkalaemia, hypotension and renal dysfunction) were more frequently reported in the aliskiren group than in the placebo group.
The prodrug moexipril is rapidly absorbed and de-esterified to the active metabolite moexiprilate. The pharmacokinetic parameters for moexipril and moexiprilate were similar after both, single and multiple does of moexipril and appear to be dose-proportional.
Moexipril and moexiprilate are moderately bound to plasma proteins, predominately albumin. Therefore, concurrently administered drugs are unlikely to interfere with the binding of moexipril and moexiprilate in any clinically significant way. Metabolites of moexipril present in the diketopiperazine derivatives of moexipril and moexiprilate. Both, moexipril and moexiprilate are eliminated in the urine, and moexiprilate is eliminated in the faeces.
The pharmacokinetic profile of moexipril and moexiprilate should allow the same dosage recommendation in patients with mild to moderate renal dysfunction (Clcr > 40 ml/min) as in patients with normal renal function. With severe renal dysfunction, dosage reduction is recommended. In patients with liver cirrhosis, the pharmacokinetics of moexipril and moexiprilate were significantly altered as compared with normal subjects.
Ingestion of food immediately prior to Moex administration delays and reduces absorption therefore it should be taken before food.
There were no apparent pharmacokinetic drug interactions with HCTZ, digoxin, cimetidine, warfarin or nifedipine.
Moex should be used with caution in patients with:
- Renal artery stenosis (bilateral or stenosis of an anatomic or functional solitary kidney)
- Recent kidney transplantation
- Hemodynamic important aortic or mitral valve stenosis
- Hypertrophic cardiomyopathy
- Severely impaired renal function (creatinine clearance < 40 ml/min)
- Hyperkalaemia
- Decreased immune response
- Collagenous vascular diseases (e.g. lupus erythematosus, sclerodermia)
Concomitant systemic drug therapy suppressing the immune response (e.g. corticosteroids, cytostatic agents, antimetabolites) and allopurinol, procainamide, or lithium
There is a risk of life-threatening anaphylactic reactions when ACE inhibitors are used
- During dialysis or hemofiltration with poly-(acrylonitrile, natrium-2-methylallylsulfonat)-high-flux-membranes
- During low density lipoprotein (LDL) apheresis with dextrane sulphate
- During desensitization therapy for insect poisons (e.g. bee or wasp stings).
Consideration should be given to using a different type of dialysis membrane or different class of antihypertensive agent in such patients.
Owing to the lack of sufficient therapeutic experience, Moex is not recommended in:
- Patients with primary liver disease or impaired liver function
- Patients with untreated decompensated heart failure
Especially at the beginning of the ACE inhibitor therapy the blood pressure and the respective laboratory values must be monitored carefully in patients with:
- Impaired renal function (creatinine clearance 40-60 ml/min)
- Renal hypertension
- Cardiac failure
- Salt and/or fluid volume depletion
- Age of more than 65 years
Hypotension:
Moex may cause a profound fall of blood pressure, especially at the beginning of the therapy with symptoms of dizziness, feeling of weakness, and disturbances of vision. Rarely syncope may occur. Symptomatic hypotension is rare in uncomplicated hypertensive patients and is more likely to occur in patients who have been volume and/or salt depleted as a result of prolonged diuretic therapy, dietary salt restriction, dialysis, diarrhoea, or vomiting. Volume and/or salt depletion should be corrected before initiating therapy with Moex.
Excessive hypotension caused by ACE inhibitor therapy in patients with congestive heart failure, with or without concomitant renal insufficiency, may be associated with oliguria or azotemia and, rarely, with acute renal failure and death. Those patients must be followed closely at the beginning of therapy and whenever the dose of Moex is increased.If hypotension occurs, the patient should be placed in a supine position and, if necessary, sodium chloride infusion given. Moex treatment usually can be continued when adequate blood pressure and correction of the fluid volume is achieved.
Diuretic treated patients:
Renal vascular hypertension:
Before ACE inhibitor therapy is started, renal function has to be controlled. There is an increased risk of severe hypotension and renal insufficiency when patients with renal vascular hypertension are treated with Moex. Loss of renal function may occur with only mild changes in serum creatinine.
Impaired renal function:
As a consequence of inhibiting the renin-angiotensin-aldosterone system, changes in renal function may be anticipated in susceptible individuals. In patients with severe congestive heart failure, whose renal function may depend on the activity of the renin-angiotensin-aldosterone system, treatment with ACE inhibitors, including Moex, may be associated with oliguria and/or progressive azotemia and (rarely) with acute renal failure and/or death.
In hypertensive patients with renal artery stenosis in a solitary kidney or bilateral renal artery stenosis, increases in blood urea nitrogen and serum creatinine may occur. Experience with other ACE inhibitors suggests that these increases are usually reversible upon discontinuation of ACE inhibitor and/or diuretic therapy. In such patients, renal function should be monitored during the first few weeks of therapy.
Some hypertensive patients with no apparent pre-existing renal vascular disease have developed increases in blood urea nitrogen and serum creatinine, usually minor and transient, especially when Moex has been given concomitantly with a diuretic. This is more likely to occur in patients with pre-existing renal impairment. A reduction in the dose of Moex and/or discontinuation of the diuretic may be required.
Evaluation of hypertensive patients should always include assessment of renal function.
Impaired renal function decreases total clearance of moexiprilat and approximately doubles AUC.
Angioneurotic oedema:
Angioneurotic oedema of the face, lips, mucous membranes, tongue, glottis or larynx and of the extremities has been reported in patients treated with ACE inhibitors, especially during the first weeks of treatment. However, in rare cases severe angioneurotic oedema may develop even after long-term treatment with an ACE inhibitor. Treatment must promptly be discontinued and replaced by another class of antihypertensive medicinal products.
Angioneurotic oedema involving the tongue, glottis or larynx, may be fatal due to airway obstruction. Emergency therapy must include intravenous administration of corticosteroids, H1-receptor antagonists and H2-receptor antagonists. If the condition of the patient does not improve with the above mentioned therapy, epinephrine must be administered slowly intravenously monitored by ECG control.
In case of hereditary angioneurotic oedema due to C1-inactivator deficiency associated with ACE inhibitor therapy, additionally a C1-inactivator must be administered.
Furthermore, intubation or tracheotomy must be considered..
Intestinal angioneurotic oedema:
Intestinal angioneurotic oedema has been reported in patients treated with ACE inhibitors. These patients presented with abdominal pain (with or without nausea and vomiting). In some cases there was no prior history of facial angioneurotic oedema and C1-esterase levels were normal. Intestinal angioneurotic oedema was diagnosed by procedures including abdominal CT scan or ultrasound, or at surgery. Symptoms resolved after stopping the ACE inhibitor. Intestinal angioneurotic oedema should be included in the differential diagnosis of patients on ACE inhibitors presenting with abdominal pain.
Pregnancy:
ACE inhibitors should not be initiated during pregnancy. Unless continued ACE inhibitor therapy is considered essential, patients planning pregnancy should be changed to alternative antihypertensive treatments which have an established safety profile for use in pregnancy. When pregnancy is diagnosed, treatment with ACE inhibitors should be stopped immediately, and, if appropriate, alternative therapy should be started.
Cough:
During treatment with an ACE inhibitor a dry and non-productive cough may occur which disappears after discontinuation.
Hyperkalaemia:
In clinical trials, persistent hyperkalaemia (serum potassium > 5.4 mEq/l) occurred in approximately 2.6% of hypertensive patients. In clinical trials, 0.1% of patients (two patients) were discontinued from therapy due to elevated serum potassium. Risk factors for the development of hyperkalaemia with ACE inhibitors include renal insufficiency and/or heart failure, diabetes mellitus and the concomitant use of potassium-sparing diuretics, potassium supplements and/or potassium-containing salt substitutes, which should be used cautiously, if at all, with Moex.
Elderly:
Some elderly patients may be more responsive to Moex than younger patients. Control of renal function before start and during therapy is recommended. For dosage recommendations in elderly patients see 4.2.
Surgery/anaesthesia:
In patients undergoing surgery or during anaesthesia with agents that produce hypotension, Moex will block the effect of compensatory renin release. Hypotension that occurs as a result of this mechanism can be corrected by volume expansion
Neutropenia/agranulocytosis:
Other ACE inhibitors have been shown to cause agranulocytosis and bone marrow depression, rarely in uncomplicated patients, but more frequently in patients with renal impairment, especially if they also have a collagenosis such as systemic lupus erythematosus or dermatosclerosis. Available data from clinical trials of Moex are insufficient to show that it does not cause agranulocytosis at similar rates. Monitoring of white blood cell counts should be considered for patients with collagenosis, especially if the disease is associated with impaired renal function.
Lactose:
Patients with rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption must not take Moex.
Dual blockade of the renin-angiotensin-aldosterone system (RAAS):
There is evidence that the concomitant use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren increases the risk of hypotension, hyperkalaemia and decreased renal function (including acute renal failure). Dual blockade of RAAS through the combined use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is therefore not recommended.
If dual blockade therapy is considered absolutely necessary, this should only occur under specialist supervision and subject to frequent close monitoring of renal function, electrolytes and blood pressure.
ACE-inhibitors and angiotensin II receptor blockers should not be used concomitantly in patients with diabetic nephropathy.
The intake of ACE inhibitors may - as any antihypertensive therapy - induce hypotension with subsequent impairment of reactivity. Alcohol intake may enhance this effect.
General:
Moex should be administered orally in a single daily dose.).
Initial therapy:
In patients with uncomplicated essential hypertension not on diuretic therapy, the recommended initial dose is 7.5 mg once a day. Dosage should be adjusted according to blood pressure response. The maintenance dose is 7.5 to 15 mg moexipril daily, administered in a single dose. Some patients may benefit from a further increase to 30 mg per day.
Doses over 30 mg have been used, but do not appear to give a greater effect.
If blood pressure is not controlled with Moex alone, a low dose of a diuretic may be added. Hydrochlorothiazide 12.5 mg has been shown to provide an additive effect. With concomitant diuretic therapy, it may be possible to reduce the dose of Moex.
Diuretic treated patients:
In hypertensive patients who are currently being treated with a diuretic, symptomatic hypotension may occur occasionally following the initial dose of Moex. The diuretic should be discontinued, if possible, for two to three days before beginning therapy with Moex to reduce the likelihood of hypotension. The dosage of Moex should be adjusted according to blood pressure response. If the patient's blood pressure is not controlled with Moex alone, diuretic therapy may be resumed as described above.
If the diuretic cannot be discontinued or the diuretic has recently been withdrawn, an initial dose of 3.75 mg (half 7.5 mg tablet) should be used under medical supervision for at least two hours and until blood pressure has stabilised for at least an additional hour.
Patients on antihypertensive treatment:
As add-on therapy, Moex has been investigated in combination with nifedipine. If Moex is used as add-on therapy to nifedipine or other antihypertensive agents, the starting dose of Moex should be 3.75 mg (half 7.5 mg tablet)..
Elderly patients:
In elderly patients, an intial dosage of 3.75 mg (half 7.5 mg tablet) once daily is recommended followed by titration to the optimal response.
Renal failure:
- Severe Renal Failure (creatinine clearance < 40 ml/min): An initial dose of 3.75 mg of Moex (half 7.5 mg tablet) once daily must be given cautiously. Doses may be titrated upward to a maximum daily dose of 15 mg.
- Moderate Renal Impairment (creatinine clearance > 40 ml/min: Based on the available studies with Moex, no dose adaptation is necessary. However a decreased initial dose could be considered, e.g. 3.75 mg (half 7.5 mg tablet).
Patients with hepatic impairment:
In patients with hepatic impairment, an initial dose of 3.75 mg of moexipril hydrochloride (half 7.5 mg tablet) is recommended.
Afro-Caribbean patients:
Where Moex is used as a single agent in hypertension, Afro-Caribbean patients may show a reduced therapeutic response.
Paediatric population:
Not recommended. Safety and efficacy in children has not been established.
No special requirements.
