Azilsartan Medoxomil

Azilsartan Medoxomil is indicated for the treatment of hypertension to lower blood pressure. Lowering blood pressure reduces the risk of fatal and nonfatal cardiovascular events, primarily stroke and myocardial infarction. Azilsartan Medoxomil may be used either alone or in combination with other antihypertensive agents.

Angiotensin II is formed from angiotensin I in a reaction catalyzed by angiotensin-converting enzymes (ACE, kinase II). Angiotensin II is the principal pressor agent of the renin-angiotensin system, with efects that include vasoconstriction, stimulation of synthesis and release of aldosterone, cardiac stimulation, and renal reabsorption of sodium. Azilsartan blocks the vasoconstrictor and aldosteronesecreting efects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor in many tissues, such as vascular smooth muscle and the adrenal gland. Its action is, therefore, independent of the pathway for angiotensin II synthesis. An AT2 receptor is also found in many tissues, but this receptor is not known to be associated with cardiovascular homeostasis. Azilsartan has more than a 10,000-fold greater afnity for the AT1 receptor than for the AT2 receptor.

Blockade of the renin-angiotensin system with ACE inhibitors, which inhibit the biosynthesis of angiotensin II from angiotensin I, is widely used in the treatment of hypertension. ACE inhibitors also inhibit the degradation of bradykinin, a reaction catalyzed by ACE. Because azilsartan does not inhibit ACE (kinase II), it should not afect bradykinin levels. Whether this diference has clinical relevance is not yet known. Azilsartan does not bind to or block other receptors or ion channels known to be important in cardiovascular regulation. Blockade of the angiotensin II receptor inhibits the negative regulatory feedback of angiotensin II on renin secretion, but the resulting increased plasma renin activity and angiotensin II circulating levels do not overcome the efect of azilsartan on blood pressure.

Azilsartan inhibits the pressor efects of an angiotensin II infusion in a dose-related manner. An azilsartan single dose equivalent to 32 mg azilsartan medoxomil inhibited the maximal pressor efect by approximately 90% at peak, and approximately 60% at 24 hours. Plasma angiotensin I and II concentrations and plasma renin activity increased while plasma aldosterone concentrations decreased after single and repeated administration of Azilsartan to healthy subjects; no clinically signifcant efects on serum potassium or sodium were observed.

Absorption: Azilsartan medoxomil is hydrolyzed to azilsartan, the active metabolite, in the gastrointestinal tract during absorption. Azilsartan medoxomil is not detected in plasma after oral administration. Dose proportionality in exposure was established for azilsartan in the azilsartan medoxomil dose range of 20 mg to 320 mg after single or multiple dosing. The estimated absolute bioavailability of azilsartan following administration of azilsartan medoxomil is approximately 60%. After oral administration of azilsartan medoxomil, peak plasma concentrations (Cmax) of azilsartan are reached within 1.5 to 3 hours. Food does not afect the bioavailability of azilsartan.

Distribution: The volume of distribution of azilsartan is approximately 16L. Azilsartan is highly bound to human plasma proteins (>99%), mainly serum albumin. Protein binding is constant at azilsartan plasma concentrations well above the range achieved with recommended doses. In rats, minimal azilsartan-associated radioactivity crossed the blood-brain barrier. Azilsartan passed across the placental barrier in pregnant rats and was distributed to the fetus.

Metabolism and Elimination: Azilsartan is metabolized to two primary metabolites. The major metabolite in plasma is formed by O-dealkylation, referred to as metabolite M-II, and the minor metabolite is formed by decarboxylation, referred to as metabolite M-I. Systemic exposures to the major and minor metabolites in humans were approximately 50% and less than 1% of azilsartan, respectively. M-I and M-II do not contribute to the pharmacologic activity of Azilsartan. The major enzyme responsible for azilsartan metabolism is CYP2C9.

The recommended dose in adults is 80 mg taken orally once daily. Consider a Starting dose of 40 mg for patients who are treated with high doses of diuretics. If blood pressure is not controlled with Azilsartan alone, additional blood pressure reduction can be achieved by taking Azilsartan with other antihypertensive agents.

No drug interactions have been observed in studies of Azilsartan Medoxomil or Azilsartan given with amlodipine, antacids, chlorthalidone, digoxin, fluconazole, glyburide, ketoconazole, metformin, pioglitazone and warfarin. The antihypertensive effect of Azilsartan may be attenuated by the non-steroidal anti-inflammatory drugs including selective COX-2 inhibitors. Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors or aliskiren is associated with increased risks of hypotension, hyperkalemia and changes in renal function.

It is contraindicated to co-administer Aliskiren with Azilsartan in patients with Diabetes.

The most common adverse reaction in adults is diarrhea. The other side effects are nausea, asthenia, fatigue, muscle spasm, dizziness and cough.

Pregnancy Category D. The risk to the fetus increases if Azilsartan Medoxomil is administered during the second or third trimesters of pregnancy. It is not known whether Azilsartan Medoxomil is excreted in human milk, as many drugs are excreted in human milk and because of the potential for adverse effects on the nursing infant, a decision should be made whether to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.

Use of Azilsartan Medoxomil during the second and third trimesters of pregnancy reduces fetal renal function and increases fetal and neonatal morbidity and death. In patients who are intravascularly volume-depleted (e.g., those treated with high-dose diuretics), symptomatic hypotension may occur. Changes in renal function including renal failure has been reported in renal impaired patient.

Pediatric Use: Neonates with a history of in utero exposure to azilsartan. If oliguria or hypotension occurs, support blood pressure and renal function. Exchange transfusions or dialysis may be required. Safety and effectiveness in pediatric patients under 18 years of age have not been established.

Geriatric Use: No dose adjustment with Azilsartan is necessary in elderly patients. Of the total patients in clinical studies with Azilsartan, 26% were elderly (65 years of age and older); 5% were 75 years of age and older. Abnormally high serum creatinine values were more likely to be reported for patients age 75 year or older. No other differences in safety or effectiveness were observed between elderly patients and younger patients, but the greater sensitivity of some older individuals cannot be ruled out.

Renal Impairment: Dose adjustment is not required in patients with mild-to-severe renal impairment or end-stage renal disease. Patients with moderate to severe renal impairment are more likely to report abnormally high serum creatinine values.

Hepatic Impairment: No dose adjustment is necessary for subjects with mild or moderate hepatic impairment. Azilsartan has not been studied in patients with severe hepatic impairment.

Limited data are available related to overdose in humans. In the event of and overdose, supportive therapy should be instituted as dictated by the patient’s clinical status. Azilsartan is not dialyzable.

Angiotensin-ll receptor blocker

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