Acerycal 5mg/5mg tablets

Ireland - English - HPRA (Health Products Regulatory Authority)

Buy It Now

Active ingredient:
Perindopril arginine; Amlodipine
Available from:
Les Laboratoires Servier
ATC code:
C09BB
INN (International Name):
Perindopril arginine; Amlodipine
Dosage:
5 mg/5 milligram(s)
Pharmaceutical form:
Tablet
Prescription type:
Product subject to prescription which may be renewed (B)
Therapeutic area:
ACE inhibitors and calcium channel blockers
Authorization status:
Marketed
Authorization number:
PA0568/018/001
Authorization date:
2008-06-13

2065_10.01.indd 1

30/10/2019 16:34

2065_10.01.indd 2

30/10/2019 16:34

2065_10.01.indd 3

30/10/2019 16:34

2065_10.01.indd 4

30/10/2019 16:34

2065_10.01.indd 5

30/10/2019 16:34

2065_10.01.indd 6

30/10/2019 16:34

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 1 of 18

Summary of Product Characteristics

1 NAME OF THE MEDICINAL PRODUCT

Acerycal 5mg/5mg tablets

2 QUALITATIVE AND QUANTITATIVE COMPOSITION

One tablet contains 3.395 mg perindopril equivalent to 5 mg perindopril arginine and 6.935 mg amlodipine besilate equivalent

to 5 mg amlodipine

Excipient with known effect: lactose monohydrate.

For the full list of excipients, see section 6.1.

3 PHARMACEUTICAL FORM

Tablet.

White, rod-shaped tablet, 8.5 mm long and 4.5 mm wide, engraved with 5/5 on one face and

on the other face.

4 CLINICAL PARTICULARS

4.1 Therapeutic Indications

Acerycal is indicated as substitution therapy for treatment of essential hypertension and/or stable coronary artery disease, in

patients already controlled with perindopril and amlodipine given concurrently at the same dose level.

4.2 Posology and method of administration

Posology

Oral route.

One tablet per day as a single dose, preferably to be taken in the morning and before a meal.

The fixed dose combination is not suitable for initial therapy.

If a change of posology is required, the dose of Acerycal could be modified or individual titration with free combination may

be considered.

Special populations

Renal impairment and elderly (see sections 4.4 and 5.2)

Elimination of perindoprilat is decreased in the elderly and in patients with renal failure. Therefore, the usual medical follow-up

will include frequent monitoring of creatinine and potassium.

Acerycal can be administered in patients with Clcr ≥ 60ml/min, and is not suitable for patients with Clcr < 60ml/min. In these

patients, an individual dose titration with the monocomponents is recommended.

Amlodipine used at similar doses in elderly or younger patients is equally well tolerated. Normal dosage regimens are

recommended in the elderly, but increase of the dosage should take place with care. Changes in amlodipine plasma

concentrations are not correlated with degree of renal impairment. Amlodipine is not dialysable.

Hepatic impairment: see sections 4.4 and 5.2

Dosage recommendations have not been established in patients with mild to moderate hepatic impairment; therefore dose

selection should be cautious and should start at the lower end of the dosing range (see sections 4.4 and 5.2). To find the

optimal starting dose and maintenance dose of patients with hepatic impairment, the patients should be individually titrated

using the free combination of amlodipine and perindopril. The pharmacokinetics of amlodipine have not been studied in

severe hepatic impairment. Amlodipine should be initiated at the lowest dose and titrated slowly in patients with severe

hepatic impairment.

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 2 of 18

Paediatric population

Acerycal should not be used in children and adolescents as the efficacy and tolerability of perindopril and amlodipine, in

combination, have not been established in children and adolescents.

4.3 Contraindications

Linked to perindopril:

- Hypersensitivity to the active substance or to any other ACE inhibitor,

- History of angioedema associated with previous ACE inhibitor therapy,

- Hereditary or idiopathic angioedema,

- Second and third trimesters of pregnancy (see sections 4.4 and 4.6),

- Concomitant use of Acerycal with aliskiren-containing products in patients with diabetes mellitus or renal impairment (GFR <

60 ml/min/1.73 m²) (see sections 4.5 and 5.1).

- Concomitant use with sacubitril/valsartan (see sections 4.4 and 4.5).

- Extracorporeal treatments leading to contact of blood with negatively charged surfaces (see section 4.5),

- Significant bilateral renal artery stenosis or stenosis of the artery to a single functioning kidney (see section 4.4).

Linked to amlodipine:

- Severe hypotension,

- Hypersensitivity to the active substance or to dihydropyridines derivatives,

- Shock, including cardiogenic shock,

- Obstruction of the outflow-tract of the left ventricle (e.g. high grade aortic stenosis),

- Haemodynamically unstable heart failure after acute myocardial infarction.

Linked toAcerycal:

All contraindications related to each monocomponent, as listed above, should apply also to the fixed combination of Acerycal.

- Hypersensitivity to any of the excipients listed in section 6.1.

4.4 Special warnings and precautions for use

All warnings related to each monocomponent, as listed below, should apply also to the fixed combination of Acerycal.

Linked to perindopril

Special warnings

Hypersensitivity/Angioedema:

Angioedema of the face, extremities, lips, mucous membranes, tongue, glottis and/or larynx has been reported rarely in

patients treated with ACE inhibitors, including perindopril (see section 4.8). This may occur at any time during therapy.In such

cases, Acerycal should promptly be discontinued and appropriate monitoring should be initiated and continued until complete

resolution of symptoms has occurred. In those instances where swelling was confined to the face and lips the condition

generally resolved without treatment, although antihistamines have been useful in relieving symptoms.

Angioedema associated with laryngeal oedema may be fatal. Where there is involvement of the tongue, glottis or larynx, likely

to cause airway obstruction, emergency therapy should be administered promptly. This may include the administration of

adrenaline and/or the maintenance of a patent airway. The patient should be under close medical supervision until complete

and sustained resolution of symptoms has occurred.

Patients with a history of angioedema unrelated to ACE inhibitor therapy may be at increased risk of angioedema while

receiving an ACE inhibitor (see section 4.3).

Intestinal angioedema has been reported rarely in patients treated with ACE inhibitors. These patients presented with

abdominal pain (with or without nausea or vomiting); in some cases there was no prior facial angioedema and C-1 esterase

levels were normal. The angioedema was diagnosed by procedures including abdominal CT scan, or ultrasound or at surgery

and symptoms resolved after stopping the ACE inhibitor. Intestinal angioedema should be included in the differential diagnosis

of patients on ACE inhibitors presenting with abdominal pain (see section 4.8).

The combination of perindopril with sacubitril/valsartan is contraindicated due to the increased risk of angioedema (see section

4.3). Sacubitril/valsartan must not be initiated until 36 hours after taking the last dose of perindopril therapy. If treatment with

sacubitril/valsartan is stopped, perindopril therapy must not be initiated until 36 hours after the last dose of sacubitril/valsartan

(see sections 4.3 and 4.5). Concomitant use of other NEP inhibitors (e.g. racecadotril) and ACE inhibitors may also increase the

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 3 of 18

risk of angioedema (see section 4.5). Hence, a careful benefit-risk assessment is needed before initiating treatment with NEP

inhibitors (e.g. racecadotril) in patients on perindopril.

Concomitant use of mTOR inhibitors (e.g. sirolimus, everolimus, temsirolimus):

Patients taking concomitant mTOR inhibitors (e.g. sirolimus, everolimus, temsirolimus) therapy may be at increased risk for

angioedema (e.g. swelling of the airways or tongue, with or without respiratory impairment) (see section 4.5).

Anaphylactoid reactions during low-density lipoproteins (LDL) apheresis:

Rarely, patients receiving ACE inhibitors during low-density lipoprotein (LDL) apheresis with dextran sulphate have experienced

life-threatening anaphylactoid reactions. These reactions were avoided by temporarily withholding ACE inhibitor therapy prior

to each apheresis.

Anaphylactoid reactions during desensitisation:

Patients receiving ACE inhibitors during desensitisation treatment (e.g. hymenoptera venom) have experienced anaphylactoid

reactions.In the same patients, these reactions have beenavoided when the ACE inhibitorswere temporarily withheld, but they

reappeared upon inadvertent rechallenge.

Neutropenia/Agranulocytosis/Thrombocytopenia/Anaemia:

Neutropenia/agranulocytosis, thrombocytopenia and anaemia have been reported in patients receiving ACE inhibitors. In

patients with normal renal function and no other complicating factors, neutropenia occurs rarely. Perindopril should be used

with extreme caution in patients with collagen vascular disease, immunosuppressant therapy, treatment with allopurinol or

procainamide, or a combination of these complicating factors, especially if there is pre-existing impaired renal function. Some

of these patients developed serious infections, which in a few instances did not respond to intensive antibiotic therapy. If

perindopril is used in such patients, periodic monitoring of white blood cell counts is advised and patients should be instructed

to report any sign of infection (e.g. sore throat, fever).

Renovascular hypertension:

There is an increased risk of hypotension and renal insufficiency when patient with bilateral renal artery stenosis or stenosis of

the artery to a single functioning kidney are treated with ACE inhibitors (see section 4.3). Treatment with diuretics may be a

contributory factor. Loss of renal function may occur with only minor changes in serum creatinine even in patients with

unilateral renal artery stenosis.

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 (see sections 4.5

and 5.1).

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.

Primary aldosteronism:

Patients with primary hyperaldosteronism generally will not respond to anti-hypertensive drugs acting through inhibition of

the renin-angiotensin system. Therefore, the use of this product is not recommended.

Pregnancy:

ACE inhibitors should not be initiated during pregnancy. Unless continued ACE inhibitors 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 (see sections 4.3 and 4.6).

Precautions for use

Hypotension:

ACE inhibitors may cause a fall in blood pressure. Symptomatic hypotension is seen rarely in uncomplicated hypertensive

patients and is more likely to occur in patients who have been volume-depleted e.g. by diuretic therapy, dietary salt restriction,

dialysis, diarrhoea or vomiting, or who have severe renin-dependent hypertension (see sections 4.5 and 4.8). In patients at high

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 4 of 18

risk of symptomatic hypotension, blood pressure, renal function and serum potassium should be monitored closely during

treatment with Acerycal.

Similar considerations apply to patients with ischaemic heart or cerebrovascular disease in whom an excessive fall in blood

pressure could result in a myocardial infarction or cerebrovascular accident.

If hypotension occurs, the patient should be placed in the supine position and, if necessary, should receive an intravenous

infusion of sodium chloride 9 mg/ml (0.9%) solution.A transient hypotensive response is not a contraindication to further doses,

which can be given usually without difficulty once the blood pressure has increased after volume expansion.

Aortic and mitral valve stenosis / hypertrophic cardiomyopathy:

As with other ACE inhibitors, perindopril should be given with caution to patients with mitral valve stenosis and obstruction in

the outflow of the left ventricle such as aortic stenosis or hypertrophic cardiomyopathy.

Renal impairement:

In cases of renal impairment (creatinine clearance < 60 ml/min) an individual dose titration with the monocomponents is

recommended (see section 4.2).

Routine monitoring of potassium and creatinine are part of normal medical practice for patients with renal impairment (see

section 4.8).

In some patients with bilateral renal artery stenosis or stenosis of the artery to a solitary kidney, who have been treated with

ACE inhibitors, increases in blood urea and serum creatinine, usually reversible upon discontinuation of therapy, have been

seen. This is especially likely in patients with renal insufficiency. If renovascular hypertension is also present there is an

increased risk of severe hypotension and renal insufficiency. Some hypertensive patients with no apparent pre-existing renal

vascular disease have developed increases in blood urea and serum creatinine, usually minor and transient, especially when

perindopril has been given concomitantly with a diuretic. This is more likely to occur in patients with pre-existing renal

impairment.

Hepatic failure:

Rarely, ACE inhibitors have been associated with a syndrome that starts with cholestatic jaundice and progresses to fulminant

hepatic necrosis and (sometimes) death. The mechanism of this syndrome is not understood. Patients receiving ACE inhibitors

who develop jaundice or marked elevations of hepatic enzymes should discontinue the ACE inhibitor and receive appropriate

medical follow-up (see section 4.8).

Race:

ACE inhibitors cause a higher rate of angioedema in black patients than in non-black patients.

As with other ACE inhibitors, perindopril may be less effective in lowering blood pressure in black people than in non-blacks,

possibly because of a higher prevalence of low-renin states in the black hypertensive population.

Cough:

Cough has been reported with the use of ACE inhibitors. Characteristically, the cough is non-productive, persistent and resolves

after discontinuation of therapy. ACE inhibitor-induced cough should be considered as part of the differential diagnosis of

cough.

Surgery/Anaesthesia:

In patients undergoing major surgery or during anaesthesia with agents that produce hypotension, Acerycal may block

angiotensin II formation secondary to compensatory renin release. The treatment should be discontinued one day prior to the

surgery. If hypotension occurs and is considered to be due to this mechanism, it can be corrected by volume expansion.

Hyperkaliemia:

Elevations in serum potassium have been observed in some patients treated with ACE inhibitors, including perindopril. Risk

factors for the development of hyperkalemia include those with renal insufficiency, worsening of renal function, age (> 70

years), diabetes mellitus, intercurrent events, in particular dehydratation, acute cardiac decompensation, metabolic acidosis,

and concomitant use of potassium-sparing diuretics (e.g. spironolactone, eplerenone, triamterene, or amiloride), potassium

supplements or potassium-containing salt substitutes; or those patients taking other drugs associated with increases in serum

potassium (e.g. heparin, co-trimoxazole also known as trimethoprim/sulfamethoxazole). The use of potassium supplements,

potassium-sparing diuretics, or potassium-containing salt substitutes particularly in patients with impaired renal function may

lead to a significant increase in serum potassium. Hyperkalemia can cause serious, sometimes fatal arrhythmias. If concomitant

use of perindopril and any of the above mentioned agents is deemed appropriate, they should be used with caution and with

frequent monitoring of serum potassium (see section 4.5).

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 5 of 18

Diabetic patients:

In diabetic patients treated with oral antidiabetic agents or insulin, glycaemic control should be closely monitored during the

first month of treatment with an ACE inhibitor (see section 4.5).

Linked to amlodipine:

Precautions for use

The safety and efficacy of amlodipine in hypertensive crisis has not been established.

Cardiac failure:

Patients with heart failure should be treated with caution.

In a long-term, placebo controlled study in patients with severe heart failure (NYHA class III and IV) the reported incidence of

pulmonary oedema was higher in the amlodipine treated group than in the placebo group (see section 5.1). Calcium channel

blockers, including amlodipine, should be used with caution in patients with congestive heart failure, as they may increase the

risk of future cardiovascular events and mortality.

Hepatic impairement:

The half-life of amlodipine is prolonged and AUC values are higher in patients with impaired liver function; dosage

recommendations have not been established. Amlodipine should therefore be initiated at the lower end of the dosing range

and caution should be used, both on initial treatment and when increasing the dose. Slow dose titration and careful monitoring

may be required in patients with severe hepatic impairment.

Elderly:

In the elderly increase of the dosage should take place with care (see sections 4.2 and 5.2).

Renal failure:

Amlodipine may be used in such patients at normal doses. Changes in amlodipine plasma concentrations are not correlated

with degree of renal impairment. Amlodipine is not dialysable.

Linked to Acerycal

All warnings related to each monocomponent, as listed above, should apply also to the fixed combination of Acerycal.

Precautions for use

Excipients:

Due to the presence of lactose, patients with rare hereditary problems of galactose intolerance, glucose-galactose

malabsorption, or the total lactase deficiency should not take this medicinal product.

Interactions;

The concomitant use of Acerycal with lithium, potassium-sparing drugs or potassium supplements, or dantrolene is not

recommended (see section 4.5).

4.5 Interaction with other medicinal products and other forms of interactions

Linked to perindopril

Clinical trial data has shown that dual blockade of the renin-angiotensin-aldosterone-system (RAAS) through the combined use

of ACE-inhibitors, angiotensin II receptor blockers or aliskiren is associated with a higher frequency of adverse events such as

hypotension, hyperkalaemia and decreased renal function (including acute renal failure) compared to the use of a single

RAAS-acting agent (see sections 4.3, 4.4 and 5.1).

Drugs inducing hyperkalaemia:

Some drugs or therapeutic classes may increase the occurrence of hyperkalaemia: aliskiren, potassium salts, potassium-sparing

diuretics, ACE inhibitors, angiotensin-II receptors antagonists, NSAIDs, heparins, immunosuppressant agents such as ciclosporin

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 6 of 18

or tacrolimus, trimethoprim and fixed dose combination with sulfamethoxazole (Co-trimoxazole). The combination of these

drugs increases the risk of hyperkalaemia.

Concomitant use contra-indicated (see section 4.3):

Aliskiren:

In diabetic or impaired renal patients, risk of hyperkalaemia, worsening of renal function and cardiovascular morbidity and

mortality increase.

Extracorporeal treatments:

Extracorporeal treatments leading to contact of blood with negatively charged surfaces such as dialysis or haemofiltration with

certain high-flux membranes (e.g. polyacrylonitril membranes) and low density lipoprotein apheresis with dextran sulphate due

to increased risk of severe anaphylactoid reactions (see section 4.3). If such treatment is required, consideration should be

given to using a different type of dialysis membrane or a different class of antihypertensive agent.

Sacubitril/valsartan:

The concomitant use of perindopril with sacubitril/valsartan is contra-indicated as the concomitant inhibition of neprilysin and

ACE may increase the risk of angioedema. Sacubitril/valsartan must not be started until 36 hours after the last dose of

perindopril therapy. Perindopril therapy must not be started until 36 hours after taking the last dose of sacubitril/valsartan. (see

section 4.3 and 4.4).

Concomitant use not recommended (see section 4.4):

Aliskiren:

In patients other than diabetic or impaired renal patients, risk of hyperkalaemia, worsening of renal function and cardiovascular

morbidity and mortality increase.

Concomitant therapy with ACE inhibitor and angiotensin-receptor blocker:

It has been reported in the literature that in patients with established atherosclerotic disease, heart failure, or with diabetes

with end organ damage, concomitant therapy with ACE inhibitor and angiotensin-receptor blocker is associated with a higher

frequency of hypotension, syncope, hyperkalaemia, and worsening renal function (including acute renal failure) as compared to

use of a single renin-angiotensin-aldosterone system agent. Dual blockade (e.g, by combining an ACE-inhibitor with an

angiotensin II receptor antagonist) should be limited to individually defined cases with close monitoring of renal function,

potassium levels, and blood pressure.

Estramustine:

Risk of increased adverse effects such as angioneurotic oedema (angioedema).

Co-trimoxazole (trimethoprim/sulfamethoxazole):

Patients taking concomitant co-trimoxazole (trimethoprim/sulfamethoxazole) may be at increased risk for hyperkalaemia (see

section 4.4).

Potassium-sparing diuretics (e.g. triamterene, amiloride...), potassium salts:

Hyperkalaemia (potentially lethal), especially in conjunction with renal impairment (additive hyperkalaemic effects).

The the combination of perindopril with the above-mentioned drugs is not recommended (see section 4.4). If concomitant use

is nonetheless indicated, they should be used with caution and with frequent monitoring of serum potassium. For use of

spironolactone in heart failure, see below.

Lithium:

Reversible increases in serum lithium concentrations and toxicity (severe neurotoxicity) have been reported during concurrent

use of ACE inhibitors. The combination of perindopril with lithium is not recommended. If the combination proves necessary,

careful monitoring of serum lithium levels is recommended (see section 4.4).

Concomitant use which requires special care:

Antidiabetic agents (insulins, oral hypoglycaemic agents):

Epidemiological studies have suggested that concomitant administration of ACE inhibitors and antidiabetic medicines (insulins,

oral

hypoglycaemic

agents)

cause

increased

blood-glucose

lowering

effect

with

risk

hypoglycaemia.

This

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 7 of 18

phenomenon appeared to be more likely to occur during the first weeks of combined treatment and in patients with renal

impairment.

Non-potassium-sparing diuretics:

Patients on diuretics, and especially those who are volume and/or salt depleted, may experience excessive reduction in blood

pressure

after

initiation

therapy

with

inhibitor.

possibility

hypotensive

effects

reduced

discontinuation of the diuretic, by increasing volume or salt intake prior to initiating therapy with low and progressive doses of

perindopril.

In arterial hypertension, when prior diuretic therapy can have caused salt/volume depletion, either the diuretic must be

discontinued before initiating the ACE inhibitor, in which case a non-potassium-sparing diuretic can be thereafter reintroduced

or the ACE inhibitor must be initiated with a low dosage and progressively increased.

In diuretic-treated congestive heart failure,

the ACE inhibitor should be initiated at a very low dosage, possibly after reducing

the dosage of the associated non-potassium-sparing diuretic.

In all cases, renal function (creatinine levels) must be monitored during the first few weeks of ACE inhibitor therapy.

Potassium-sparing diuretics (eplerenone, spironolactone):

With eplerenone or spironolactone at doses between 12.5 mg to 50 mg by day and with low doses of ACE inhibitors:

In the treatment of class II-IV heart failure (NYHA) with an ejection fraction <40%, and previously treated with ACE inhibitors

loop

diuretics,

risk

hyperkalaemia,

potentially

lethal,

especially

case

non-observance

prescription

recommendations on this combination.

Before initiating the combination, check the absence of hyperkalaemia and renal impairment.

A close monitoring of the kalaemia and creatininemia is recommended in the first month of the treatment once a week at the

beginning and, monthly thereafter.

Racecadotril:

ACE inhibitors (e.g. perindopril) are known to cause angioedema. This risk may be elevated when used concomitantly with

racecadotril (a drug used against acute diarrhea).

mTOR inhibitors (e.g. sirolimus, everolimus, temsirolimus):

Patients taking concomitant mTOR inhibitors therapy may be at increased risk for angioedema (see section 4.4).

Non-steroidal anti-inflammatory medicinal products (NSAIDs) including aspirin ≥3 g/day:

When ACE-inhibitors are administered simultaneously with non-steroidal anti-inflammatory drugs (i.e. acetylsalicylic acid at

anti-inflammatory dosage regimens, COX-2 inhibitors and non-selective NSAIDs), attenuation of the antihypertensive effect

may occur. Concomitant use of ACE-inhibitors and NSAIDs may lead to an increased risk of worsening of renal function,

including possible acute renal failure, and an increase in serum potassium, especially in patients with poor pre-existing renal

function. The combination should be administered with caution, especially in the elderly. Patients should be adequately

hydrated and consideration should be given to monitoring renal function after initiation of concomitant therapy, and

periodically thereafter.

Concomitant use which requires some care:

Gliptines (linagliptine, saxagliptine, sitagliptine, vildagliptine):

Increased risk of angio-oedema, due to dipeptidyl peptidase IV (DPP-IV) decreased activity by the gliptine, in patients

co-treated with an ACE inhibitor.

Sympathomimetics:

Sympathomimetics may reduce the antihypertensive effects of ACE inhibitors.

Gold:

Nitritoid reactions (symptoms include facial flushing, nausea, vomiting and hypotension) have been reported rarely in patients

on therapy with injectable gold (sodium aurothiomalate) and concomitant ACE inhibitor therapy including perindopril.

Linked to amlodipine

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 8 of 18

Concomitant use not recommended:

Dantrolene (infusion): In animals, lethal ventricular fibrillation and cardiovascular collapse are observed in association with

hyperkalemia after administration of verapamil and intravenous dantrolene. Due to risk of hyperkalemia, it is recommended

that the co-administration of calcium channel blockers such as amlodipine be avoided in patients susceptible to malignant

hyperthermia and in the management of malignant hyperthermia.

Concomitant use which requires special care:

CYP3A4 inducers: Upon co-administration of known inducers of the CYP3A4, the plasma concentration of amlodipine may vary.

Therefore, blood pressure should be monitored and dose regulation considered both during and after concomitant medication

particularly with strong CYP3A4 inducers (e.g. rifampicin, hypericum perforatum).

CYP3A4 inhibitors: Concomitant use of amlodipine with strong or moderate CYP3A4 inhibitors (protease inhibitors, azole

antifungals, macrolides like erythromycin or clarithromycin, verapamil or diltiazem) may give rise to significant increase in

amlodipine exposure. The clinical translation of these PK variations may be more pronounced in the elderly. Clinical monitoring

and dose adjustment may thus be required.

There is an increased risk of hypotension in patients receiving clarithromycin with amlodipine. Close observation of patients is

recommended when amlodipine is co administered with clarithromycin.

Concomitant use to be taken into consideration:

The blood pressure lowering effects of amlodipine adds to the blood pressure-lowering effects of other medicinal products

with antihypertensive properties.

Tacrolimus:

There is a risk of increased tacrolimus blood levels when co administered with amlodipine. In order to avoid toxicity of

tacrolimus, administration of amlodipine in a patient treated with tacrolimus requires monitoring of tacrolimus blood levels

and dose adjustment of tacrolimus when appropriate.

Mechanistic Target of Rapamycin (mTOR) Inhibitors

mTOR inhibitors such as sirolimus, temsirolimus, and everolimus are CYP3A substrates. Amlodipine is a weak CYP3A inhibitor.

With concomitant use of mTOR inhibitors, amlodipine may increase exposure of mTOR inhibitors.

Ciclosporine:

No drug interaction studies have been conducted with ciclosporine and amlodipine in healthy volunteers or other populations

with the exception of renal transplant patients, where variable trough concentration increases (average 0% - 40%) of

ciclosporine were observed. Consideration should be given for monitoring ciclosporine levels in renal transplant patients on

amlodipine, and ciclosporine dose reductions should be made as necessary.

Simvastatin:

Co-administration of multiple doses of 10 mg of amlodipine with 80 mg simvastatin resulted in a 77% increase in exposure to

simvastatin compared to simvastatin alone. Limit the dose of simvastatin in patients on amlodipine to 20 mg daily.

Others combinations:

In clinical interaction studies, amlodipine did not affect the pharmacokinetics of atorvastatin, digoxin, warfarin.

Administration of amlodipine with grapefruit or grapefruit juice is not recommended as bioavailability may be increased in

some patients resulting in increased blood pressure lowering effects.

Linked to Acerycal:

Concomitant use which requires special care:

Baclofen:

Increased antihypertensive effect. Monitor blood pressure and adapt antihypertensive dosage if necessary.

Concomitant use to be taken into consideration:

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 9 of 18

Antihypertensive agents (such as beta-blockers) and vasodilatators: Concomitant use of these agents may increase

the hypotensive effects of perindopril and amlodipine. Concomitant use with nitroglycerine and other nitrates or

other vasodilatators, may further reduce blood pressure and therefore should be considered with caution.

Corticosteroids, tetracosactide: reduction in antihypertensive effect (salt and water retention due to

corticosteroids).

Alpha-blockers (prazosin, alfuzosin, doxazosin, tamsulosin, terazosin): increased antihypertensive effect and

increased risk of orthostatic hypotension.

Amifostine: may potentiate the antihypertensive effect of amlodipine.

Tricyclic antidepressants/antipsychotics/anaesthetics: increased antihypertensive effect and increased risk of

orthostatic hypotension.

4.6 Fertility, pregnancy and lactation

Given the effects of the individual components in this combination product on pregnancy and lactation:

Acerycal is not recommended during the first trimester of pregnancy. Acerycal is contraindicated during the second and third

trimesters of pregnancy.

Acerycal is not recommended during lactation. A decision should therefore be made whether to discontinue nursing or to

discontinue Acerycal taking account the importance of this therapy for the mother.

Pregnancy:

Linked to perindopril

The use of ACE inhibitors is not recommended during the first trimester of pregnancy (see section 4.4). The use of ACE

inhibitors is contraindicated during the second and third trimester of pregnancy (see sections 4.3 and 4.4).

Epidemiological evidence regarding the risk of teratogenicity following exposure to ACE inhibitors during the first trimester of

pregnancy has not been conclusive; however a small increase in risk cannot be excluded. 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.

Exposure to ACE inhibitor therapy 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)

(see section 5.3).

Should exposure to ACE inhibitor have occurred from the second trimester of pregnancy, ultrasound check of renal function

and skull is recommended.

Infants whose mothers have taken ACE inhibitors should be closely observed for hypotension (see sections 4.3 and 4.4).

Linked to amlodipine

The safety of amlodipine in human pregnancy has not been established.

In animal studies, reproductive toxicity was observed at high doses (see section 5.3).Use in pregnancy is only recommended

when there is no safer alternative and when the disease itself carries greater risk for the mother and foetus.

Breast-feeding:

Linked to perindopril

Because no information is available regarding the use of perindopril during breastfeeding, perindopril is not recommended

and alternative treatments with better established safety profiles during breast-feeding are preferable, especially while nursing

a newborn or preterm infant.

Linked to amlodipine

Amlodipine is excreted in human milk. The proportion of the maternal dose received by the infant has been estimated with an

interquartile range of 3 – 7%, with a maximum of 15%. The effect of amlodipine on infants is unknown. A decision on whether

to continue/discontinue breast-feeding or to continue/discontinue therapy with amlodipine should be made taking into

account the benefit of breast-feeding to the child and the benefit of amlodipine therapy to the mother.

Fertility:

Linked to perindopril

There was no effect on reproductive performance or fertility.

Linked to amlodipine

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 10 of 18

Reversible biochemical changes in the head of spermatozoa have been reported in some patients treated by calcium channel

blockers. Clinical data are insufficient regarding the potential effect of amlodipine on fertility. In one rat study, adverse effects

were found on male fertility (see section 5.3).

4.7 Effects on ability to drive and use machines

No studies on the effects of Acerycal on the ability to drive and use machines have been performed. Amlodipine can have

minor or moderate influence on the ability to drive and use machines. If patients suffer from dizziness, headache, fatigue,

weariness or nausea, the ability to react may be impaired. Caution is recommended especially at the start of treatment.

4.8 Undesirable effects

A. Summary of safety profile

The most commonly reported adverse reactions with perindopril and amlodipine given separately are: oedema, somnolence,

dizziness, headache (especially at the beginning of the treatment), dysgeusia, paraesthesia, visual impairment (including

diplopia), tinnitus, vertigo, palpitations, flushing, hypotension (and effects related to hypotension), dyspnoea, cough,

abdominal pain, nausea, vomiting, dyspepsia, change of bowel habit, diarrheoa, constipation, prurit, rash, exanthema, joint

swelling (ankle swelling), muscle spasms, fatigue, asthenia.

B. Tabulated list of adverse reactions:

The following undesirable effects have been observed during clinical trials and/or post-marketing use with perindopril or

amlodipine given separately and ranked under the MedDRA classification by body system and under the following frequency:

Very common (≥1/10) ; common (≥1/100 to <1/10) ; uncommon (≥1/1000 to <1/100) ; rare (≥1/10000 to <1/1000) ; very rare

(<1/10000) ; not known (cannot be estimated from the available data).

MedDRA

System Organ

Class

Undesirable Effects

Frequency

Amlodipine

Perindopril

Infections and

infestations

Rhinitis

Uncommon

Very rare

Blood and the

lymphatic

System

Disorders

Eosinophilia

Uncommon*

Leukopenia/neutropenia (see section 4.4)

Very rare

Very rare

Agranulocytosis or pancytopenia (see section 4.4)

Very rare

Thrombocytopenia (see section 4.4)

Very rare

Very rare

Haemolytic anaemia enzyme specific in patients with a congenital

deficiency of G-6PDH (see section 4.4)

Very rare

Immune System

Disorders

Hypersensitivity

Very rare

Uncommon

Metabolism and

Nutrition

Disorders

Hypoglycaemia (see sections 4.4 and 4.5)

Uncommon*

Hyperkalaemia, reversible on discontinuation (see section 4.4)

Uncommon*

Hyponatraemia

Uncommon*

Hyperglycaemia

Very rare

Psychiatric

disorders

Insomnia

Uncommon

Mood altered (including anxiety)

Uncommon

Uncommon

Depression

Uncommon

Sleep disorder

Uncommon

Nervous System

disorders

Somnolence (especially at the beginning of the treatment)

Common

Dizziness (especially at the beginning of the treatment)

Common

Common

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 11 of 18

Headache (especially at the beginning of the treatment)

Common

Common

Dysgeusia

Uncommon

Common

Tremor

Uncommon

Hypoaesthesia

Paraesthesia

Uncommon

Uncommon

Common

Syncope

Uncommon

Uncommon

Confusional state

Rare

Very rare

Hypertonia

Very rare

Neuropathy peripheral

Very rare

Cerebrovascular accident possibly secondary to excessive hypotension in

high-risk patients (see section 4.4)

Very rare

Extrapyramidal disorder (extrapyramidal syndrome)

Not known

Eye Disorders

Visual impairment

Common

Common

Diplopia

Common

Ear and

labyrinth

disorders

Tinnitus

Uncommon

Common

Vertigo

Common

Cardiac

Disorders

Palpitations

Common

Uncommon*

Tachycardia

Uncommon*

Angina pectoris (see section 4.4)

Very rare

Myocardial infarction, possibly secondary to excessive hypotension in high

risk patients (see section 4.4)

Very rare

Very rare

Arrythmia (including bradycardia, ventricular tachycardia and atrial

fibrillation)

Uncommon

Very rare

Vascular

Disorders

Flushing

Common

Hypotension (and effects related to hypotension)

Uncommon

Common

Vasculitis

Very Rare

Uncommon*

Raynaud’s phenomenon

​-

Not Known

Respiratory,

Thoracic and

Mediastinal

Disorders

Dyspnoea

Common

Common

Cough

Uncommon

Common

Bronchospasm

Uncommon

Eosinophilic pneumonia

Very rare

Gastro-intestinal

Disorders

Gingival hyperplasia

Very rare

Abdominal pain

Common

Common

Nausea

Common

Common

Vomiting

Uncommon

Common

Dyspepsia

Common

Common

Change of bowel habit

Common

Dry mouth

Uncommon

Uncommon

Diarrheoa

Common

Common

Constipation

Common

Common

Pancreatitis

Very rare

Very rare

Gastritis

Very rare

Hepato-biliary

Disorders

Hepatitis, jaundice

Hepatitis either cytolitic or cholestatic (see section 4.4)

Very rare

Very rare

Hepatic enzymes increased (mostly consistent with cholestasis)

Very rare

Skin and

Subcutaneous

Tissue Disorders

Quincke's oedema

Angioedema of face, extremities, lips, mucous membranes, tongue, glottis

and/or larynx (see section 4.4)

Very rare

Very rare

Uncommon

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 12 of 18

Erythema multiform

Very rare

Very rare

Alopecia

Uncommon

Purpura

Uncommon

Skin discolouration

Uncommon

Hyperhidrosis

Uncommon

Uncommon

Prurit

Uncommon

Common

Rash, exanthema

Uncommon

Common

Urticaria (see section 4.4)

Uncommon

Uncommon

Photosentivity reactions

Very rare

Uncommon*

Pemphigoid

Uncommon*

Psoriasis aggravation

Rare

Stevens-Johnson Syndrome

Very rare

Exfoliative dermatitis

Very rare

Toxic epidermal necrolysis

Not known

Musculoskeletal

and Connective

Tissue Disorders

Joint swelling (ankle swelling)

Common

Arthralgia

Uncommon

Uncommon*

Myalgia

Uncommon

Uncommon*

Muscle spasms

Common

Common

Back pain

Uncommon

Renal and

Urinary

Disorders

Micturition disorder, nocturia, pollakiuria

Uncommon

Renal failure

Uncommon

Renal failure acute

Very rare

Reproductive

System and

Breast Disorders

Erectile dysfunction

Uncommon

Uncommon

Gynaecomastia

Uncommon

General

Disorders and

Administration

Site Condition

Oedema

Very common

Oedema peripheral

Uncommon*

Fatigue

Common

Chest pain

Uncommon

Uncommon*

Asthenia

Common

Common

Pain

Uncommon

Malaise

Uncommon

Uncommon*

Pyrexia

Uncommon*

Investigations

Weight increased, weight decreased

Uncommon

Blood urea increased

Uncommon*

Blood creatinine increased

Uncommon*

Blood bilirubin increase

Rare

Hepatic enzyme increase

Rare

Haemoglobin decreased and haematocrit decreased

Very rare

Injury,

poisoning and

procedural

complications

Fall

Uncommon*

* Frequency calculated from clinical trials for adverse events detected from spontaneous report

Cases of SIADH have been reported with other ACE inhibitors. SIADH can be considered as a very rare but possible

complication associated with ACE inhibitor therapy including perindopril.

Reporting of suspected adverse reactions

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 13 of 18

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 HPRA Pharmacovigilance, Earlsfort Terrace, IRL - Dublin 2; Tel: +353 1 6764971; Fax: +353 1 6762517.

Website: www.hpra.ie; E-mail: medsafety@hpra.ie.

4.9 Overdose

There is no information on overdosage with Acerycal in humans.

For amlodipine, experience with intentional overdose in humans is limited.

Symptoms: available data suggest that gross overdosage could result in excessive peripheral vasodilatation and possibly reflex

tachycardia. Marked and probably prolonged systemic hypotension up to and including shock with fatal outcome have been

reported.

Treatment: clinically significant hypotension due to amlodipine overdosage calls for active cardiovascular support including

frequent monitoring of cardiac and respiratory function, elevation of extremities and attention to circulating fluid volume and

urine output.

A vasoconstrictor may be helpful in restoring vascular tone and blood pressure, provided that there is no contraindication to its

use. Intravenous calcium gluconate may be beneficial in reversing the effects of calcium channel blockade.

Gastric lavage may be worthwhile in some cases. In healthy volunteers the use of charcoal up to 2 hours after administration of

amlodipine 10 mg has been shown to reduce the absorption rate of amlodipine.

Since amlodipine is highly protein-bound, dialysis is not likely to be of benefit.

For perindopril, limited data are available for overdosage in humans. Symptoms associated with the overdosage of ACE

inhibitors may include hypotension, circulatory shock, electrolyte disturbances, renal failure, hyperventilation, tachycardia,

palpitations, bradycardia, dizziness, anxiety, and cough.

The recommended treatment of overdosage is intravenous infusion of normal saline solution. If hypotension occurs, the

patient should be placed in the shock position. If available, treatment with angiotensin II infusion and/or intravenous

catecholamines may also be considered. Periondopril can be removed from the systemic circulation by haemodialysis (see

section 4.4). Pacemaker therapy is indicated for treatment-resistant bradycardia. Vital signs, serum electrolytes and creatinine

concentrations should be monitored continuously.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: ACE inhibitors and calcium channel blockers, ATC code: C09BB04.

Perindopril:

Mechanism of action

Perindopril is an inhibitor of the enzyme that converts angiotensin I into angiotensin II (Angiotensin Converting Enzyme ACE).

The converting enzyme, or kinase, is an exopeptidase that allows conversion of angiotensin I into the vasoconstrictor

angiotensin II as well as causing the degradation of the vasodilator bradykinin into an inactive heptapeptide. Inhibition of ACE

results in a reduction of angiotensin II in the plasma, which leads to increased plasma renin activity (by inhibition of the

negative feedback of renin release) and reduced secretion of aldosterone. Since ACE inactivates bradykinin, inhibition of ACE

also results in an increased activity of circulating and local kallikrein-kinin systems (and thus also activation of the

prostaglandin system). It is possible that this mechanism contributes to the blood pressure-lowering action of ACE inhibitors

and is partially responsible for certain of their side effects (e.g. cough).

Perindopril acts through its active metabolite, perindoprilat. The other metabolites show no inhibition of ACE activity in vitro.

Clinical efficacy and safety

Hypertension:

Perindopril is active in all grades of hypertension: mild, moderate, severe; a reduction in systolic and diastolic blood pressures

in both supine and standing positions is observed.

Perindopril reduces peripheral vascular resistance, leading to blood pressure reduction. As a consequence, peripheral blood

flow increases, with no effect on heart rate.

Renal blood flow increases as a rule, while the glomerular filtration rate (GFR) is usually unchanged.

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 14 of 18

The antihypertensive activity is maximal between 4 and 6 hours after a single dose and is sustained for at least 24 hours: trough

effects are about 87-100 % of peak effects.

The decrease in blood pressure occurs rapidly. In responding patients, normalisation is achieved within a month and persists

without the occurrence of tachyphylaxis.

Discontinuation of treatment does not lead to a rebound effect.

Perindopril reduces left ventricular hypertrophy.

In man, perindopril has been confirmed to demonstrate vasodilatory properties. It improves large artery elasticity and

decreases the media:lumen ratio of small arteries.

Stable coronary artery disease:

The EUROPA study was a multicentre, international, randomised, double-blind, placebo-controlled clinical trial lasting 4 years.

Twelve thousand two hundred and eighteen (12218) patients aged over 18 were randomised to 8 mg perindopril

tert-butylamine (equivalent to 10 mg perindopril arginine) (n=6110) or placebo (n=6108).

The trial population had evidence of coronary artery disease with no evidence of clinical signs of heart failure. Overall, 90% of

the patients had a previous myocardial infarction and/or a previous coronary revascularisation. Most of the patients received

the study medication on top of conventional therapy including platelet inhibitors, lipid lowering agents and beta-blockers.

The main efficacy criterion was the composite of cardiovascular mortality, non fatal myocardial infarction and/or cardiac arrest

with successful resuscitation. The treatment with 8 mg perindopril tert-butylamine (equivalent to 10 mg perindopril arginine)

once daily resulted in a significant absolute reduction in the primary endpoint of 1.9% (relative risk reduction of 20%, 95%CI

[9.4; 28.6] – p<0.001).

In patients with a history of myocardial infarction and/or revascularisation, an absolute reduction of 2.2% corresponding to a

RRR of 22.4% (95%CI [12.0; 31.6] – p<0.001) in the primary endpoint was observed by comparison to placebo.

Dual blockade of the renin-angiotensin-aldosterone system (RAAS) clinical trial data:

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 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.

Amlodipine:

Mechanism of action

Amlodipine is a calcium ion influx inhibitor of the dihydropyridine group (slow channel blocker or calcium ion antagonist) and

inhibits the transmembrane influx of calcium ions into cardiac and vascular smooth muscle.

The mechanism of the antihypertensive action of amlodipine is due to a direct relaxant effect on vascular smooth muscle. The

precise mechanism by which amlodipine relieves angina has not been fully determined but amlodipine reduces total ischaemic

burden by the following two actions:

- Amlodipine dilates peripheral arterioles and thus, reduces the total peripheral resistance (afterload) against which the heart

works. Since the heart rate remains stable, this unloading of the heart reduces myocardial energy consumption and oxygen

requirements.

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 15 of 18

- The mechanism of action of amlodipine also probably involves dilatation of the main coronary arteries and coronary

arterioles, both in normal and ischaemic regions. This dilatation increases myocardial oxygen delivery in patients with coronary

artery spasm (Prinzmetal's or variant angina).

Clinical efficacy and safety

In patients with hypertension, once daily dosing provides clinically significant reductions of blood pressure in both the supine

and standing positions throughout the 24 hour interval. Due to the slow onset of action, acute hypotension is not a feature of

amlodipine administration.

In patients with angina, once daily administration of amlodipine increases total exercise time, time to angina onset, and time to

1mm ST segment depression, and decreases both angina attack frequency and glyceryl trinitrate tablet consumption.

Amlodipine has not been associated with any adverse metabolic effects or changes in plasma lipids and is suitable for use in

patients with asthma, diabetes, and gout.

Coronary artery disease (CAD):

The effectiveness of amlodipine in preventing clinical events in patients with coronary artery disease (CAD) has been evaluated

in an independent, multi-center, randomized, double- blind, placebo-controlled study of 1997 patients; Comparison of

Amlodipine vs. Enalapril to Limit Occurrences of Thrombosis (CAMELOT). Of these patients, 663 were treated with amlodipine

5-10 mg, 673 patients were treated with enalapril 10-20 mg, and 655 patients were treated with placebo, in addition to

standard care of statins, beta-blockers, diuretics and aspirin, for 2 years. The key efficacy results are presented in Table 1. The

results indicate that amlodipine treatment was associated with fewer hospitalizations for angina and revascularization

procedures in patients with CAD.

Table 1. Incidence of significant clinical outcomes for CAMELOT

Cardiovascular event rates, No. (%)

Amlodipine vs. placebo

Outcomes

Amlodipine

Placebo

Enalapril

Hazard Ratio (95% CI)

P Value

Primary Endpoint

Adverse cardiovascular events

110 (16.6)

151 (23.1)

136 (20.2)

0.69 (0.54-0.88)

.003

Individual Components

Coronary revascularization

Hospitalization for angina

Nonfatal MI

Stroke or TIA

Cardiovascular death

Hospitalization for CHF

Resuscitated cardiac arrest

New-onset peripheral vascular disease

78 (11.8)

51 (7.7)

14 (2.1)

6 (0.9)

5 (0.8)

3 (0.5)

5 (0.8)

103 (15.7)

84 (12.8)

19 (2.9)

12 (1.8)

2 (0.3)

5 (0.8)

4 (0.6)

2 (0.3)

95 (14.1)

86 (12.8)

11 (1.6)

8 (1.2)

5 (0.7)

4 (0.6)

1 (0.1)

8 (1.2)

0.73 (0.54-0.98)

0.58 (0.41-0.82)

0.73 (0.37-1.46)

0.50 (0.19-1.32)

2.46 (0.48-12.7)

0.59 (0.14-2.47)

2.6 (0.50-13.4)

.002

Abbreviations: CHF, congestive heart failure; CI, confidence interval; MI, myocardial infarction; TIA, transient ischemic attack.

Heart failure:

Haemodynamic studies and exercise based controlled clinical trials in NYHA Class II-IV heart failure patients have shown that

amlodipine did not lead to clinical deterioration as measured by exercise tolerance, left ventricular ejection fraction and clinical

symptomatology.

A placebo controlled study (PRAISE) designed to evaluate patients in NYHA Class III-IV heart failure receiving digoxin, diuretics

and ACE inhibitors has shown that amlodipine did not lead to an increase in risk of mortality or combined mortality and

morbidity with heart failure.

In a follow-up, long term, placebo controlled study (PRAISE-2) of amlodipine in patients with NYHA III and IV heart failure

without clinical symptoms or objective findings suggestive or underlying ischaemic disease, on stable doses of ACE inhibitors,

digitalis, and diuretics, amlodipine had no effect on total cardiovascular mortality. In this same population amlodipine was

associated with increased reports of pulmonary oedema.

Treatment to prevent heart attack trial (ALLHAT):

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 16 of 18

A randomized double-blind morbidity-mortality study called the Antihypertensive and Lipid-Lowering Treatment to Prevent

Heart Attack Trial (ALLHAT) was performed to compare newer drug therapies: amlodipine 2.5-10 mg/d (calcium channel

blocker) or lisinopril 10-40 mg/d (ACE-inhibitor) as first-line therapies to that of the thiazide-diuretic, chlorthalidone 12.5-25

mg/d in mild to moderate hypertension.

A total of 33,357 hypertensive patients aged 55 or older were randomized and followed for a mean of 4.9 years. The patients

had at least one additional CHD risk factor, including: previous myocardial infarction or stroke > 6 months prior to enrollment

or documentation of other atherosclerotic CVD (overall 51.5%), type 2 diabetes (36.1%), HDL-C < 35 mg/dL (11.6%), left

ventricular hypertrophy diagnosed by electrocardiogram or echocardiography (20.9%), current cigarette smoking (21.9%).

The primary endpoint was a composite of fatal CHD or non-fatal myocardial infarction. There was no significant difference in

the primary endpoint between amlodipine-based therapy and chlorthalidone-based therapy: RR 0.98 (95% CI(0.90-1.07)

p=0.65). Among secondary endpoints, the incidence of heart failure (component of a composite combined cardiovascular

endpoint) was significantly higher in the amlodipine group as compared to the chlorthalidone group (10.2% vs 7.7%, RR 1.38,

(95% CI [1.25-1.52] p<0.001)). However, there was no significant difference in all-cause mortality between amlodipine-based

therapy and chlorthalidone-based therapy, RR 0.96 (95% CI [0.89-1.02] p=0.20).

5.2 Pharmacokinetic properties

The rate and extent of absorption of perindopril and amlodipine from Acerycal are not significantly different, respectively, from

the rate and extent of absorption of perindopril and amlodipine from individual tablet formulations.

Perindopril:

Absorption

After oral administration, the absorption of perindopril is rapid and the peak concentration is achieved within 1 hour. The

plasma half-life of perindopril is equal to 1 hour.

Perindopril is a prodrug. Twenty seven percent of the administered perindopril dose reaches the bloodstream as the active

metabolite perindoprilat. In addition to active perindoprilat, perindopril yields five metabolites, all inactive. The peak plasma

concentration of perindoprilat is achieved within 3 to 4 hours.

As ingestion of food decreases conversion to perindoprilat, hence bioavailability, perindopril arginine should be administered

orally in a single daily dose in the morning before a meal.

It has been demonstrated a linear relationship between the dose of perindopril and its plasma exposure.

Distribution

The volume of distribution is approximately 0.2 l/kg for unbound perindoprilat. Protein binding of perindoprilat to plasma

proteins is 20%, principally to angiotensin converting enzyme, but is concentration-dependent.

Elimination

Perindoprilat is eliminated in the urine and the terminal half-life of the unbound fraction is approximately 17 hours, resulting in

steady-state within 4 days.

Elderly, Heart Failure, Renal Failure

Elimination of perindoprilat is decreased in the elderly, and also in patients with heart or renal failure (see section 4.2).

Therefore, the usual medical follow-up will include frequent monitoring of creatinine and potassium.

Hepatic impairment

Dialysis clearance of perindoprilat is equal to 70 ml/min.

Perindopril kinetics are modified in patients with cirrhosis: hepatic clearance of the parent molecule is reduced by half.

However, the quantity of perindoprilat formed is not reduced and therefore no dosage adjustment is required (see sections 4.2

and 4.4).

Amlodipine:

Absorption, distribution, plasma protein binding

After oral administration of therapeutic doses, amlodipine is well absorbed with peak blood levels between 6-12 hours post

dose. Absolute bioavailability has been estimated to be between 64 and 80%. The volume of distribution is approximately 21

l/kg. In vitro studies have shown that approximately 97.5% of circulating amlodipine is bound to plasma proteins.

The bioavailability of amlodipine is not affected by food intake.

Biotransformation/Elimination

The terminal plasma elimination half-life is about 35-50 hours and is consistent with once daily dosing. Amlodipine is

extensively metabolised by the liver to inactive metabolites with 10% of the parent compound and 60% of metabolites

excreted in the urine.

Elderly

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 17 of 18

The time to reach peak plasma concentrations of amlodipine is similar in elderly and younger subjects. Amlodipine clearance

tends to be decreased with resulting increases in AUC and elimination half-life in elderly patients. Increases in AUC and

elimination half-life in patients with congestive heart failure were as expected for the patient age group studied.

Hepatic impairement:

Very limited clinical data are available regarding amlodipine administration in patients with hepatic impairment. Patients with

hepatic insufficiency have decreased clearance of amlodipine resulting in a longer half-life and an increase in AUC of

approximately 40-60%.

5.3 Preclinical safety data

Perindopril:

In the chronic oral toxicity studies (rats and monkeys), the target organ is the kidney, with reversible damage.

No mutagenicity has been observed in in vitro or in vivo studies.

Reproduction toxicology studies (rats, mice, rabbits and monkeys) showed no sign of embryotoxicity or teratogenicity.

However, angiotensin converting enzyme inhibitors, as a class, have been shown to induce adverse effects on late fetal

development, resulting in fetal death and congenital effects in rodents and rabbits: renal lesions and an increase in peri- and

postnatal mortality have been observed. Fertility was not impaired either in male or in female rats.

No carcinogenicity has been observed in long term studies in rats and mice.

Amlodipine:

Reproductive toxicology

Reproductive studies in rats and mice have shown delayed date of delivery, prolonged duration of labour and decreased pup

survival at dosages approximately 50 times greater than the maximum recommended dosage for humans based on mg/kg.

Impairment of fertility

There was no effect on the fertility of rats treated with amlodipine (males for 64 days and females 14 days prior to mating) at

doses up to 10 mg/kg/day (8 times* the maximum recommended human dose of 10 mg on a mg/m2 basis). In another rat

study in which male rats were treated with amlodipine besilate for 30 days at a dose comparable with the human dose based

on mg/kg, decreased plasma follicle-stimulating hormone and testosterone were found as well as decreases in sperm density

and in the number of mature spermatids and Sertoli cells.

Carcinogenesis, mutagenesis

Rats and mice treated with amlodipine in the diet for two years, at concentrations calculated to provide daily dosage levels of

0.5, 1.25, and 2.5 mg/kg/day showed no evidence of carcinogenicity. The highest dose (for mice, similar to, and for rats twice*

the maximum recommended clinical dose of 10 mg on a mg/m2 basis) was close to the maximum tolerated dose for mice but

not for rats.

Mutagenicity studies revealed no drug related effects at either the gene or chromosome levels.

* Based on patient weight of 50 kg

6 PHARMACEUTICAL PARTICULARS

6.1 List of excipients

Lactose monohydrate

Cellulose, microcrystalline (E460)

Silica, colloidal anhydrous (E551)

Magnesium stearate (E470B)

6.2 Incompatibilities

Not applicable.

6.3 Shelf life

3 years

6.4 Special precautions for storage

Health Products Regulatory Authority

07 October 2019

CRN008ZGK

Page 18 of 18

Keep the container tightly closed in order to protect from moisture. Store in the original package.

This medicinal product does not require any special temperature storage conditions.

6.5 Nature and contents of container

5, 7, 10, 14, 20, 28, 30 or 50 tablets in polypropylene container equipped with a low density polyethylene flow reducer and a

low density polyethylene stopper containing a desiccant gel.

Box of 1 container of 5, 7, 10, 14, 20, 28, 30 or 50 tablets.

Box of 2 containers of 28, 30 or 50 tablets.

Box of 3 containers of 28 tablets.

Box of 3 containers of 30 tablets.

Box of 4 containers of 30 tablets.

Box of 10 containers of 50 tablets.

Not all pack sizes may be marketed.

6.6 Special precautions for disposal

No special requirements.

7 MARKETING AUTHORISATION HOLDER

Les Laboratoires Servier

50, rue Carnot

92284 Suresnes Cedex

France

8 MARKETING AUTHORISATION NUMBER

PA0568/018/001

9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

Date of First Authorisation: 13th June 2008

10 DATE OF REVISION OF THE TEXT

October 2019

Similar products

Search alerts related to this product

View documents history

Share this information