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Dilzem®· (Diltiazem HCI}

DESCRIPTION The therapeutic benefrts achieved wrth diltiazem are believed to be related to its ability to Inhibit the influx of calcium ions during membrane depolarization of cardiac and vascular smooth muscle.

Mechanism of Acllon: Although precise mechanisms ol its anti-anginal acJions are st1ll being delineated, d•lttazem is believed to act In the following ways:

Angina Due to Coronary Artery Spasm: Dlltlazem has been shown to be a potent dilator ol both epicardial and subendocardial coronary arteries. Spontaneous and ergon<Mne-mduc:ed coronary artery spasm are Inhibited.

Exertional Angina: Diltlazem has been shown to produce Increases In exercise tolerance, probably due to Its ability to reduce myocardial oxygen demand. This is accornplished via reductions In h eart rate and systemic b lood pressure at submaxlmal and maximal exercise work loads.

Hypertension: The anbhypertenstve effect of dil1iazem is achieved primarily by relaxatton of vascular smooth muscle and the resul1ant decrease in peripheral vascular resistance. The magnitude of blood pressure reduction is related to.Jhe degree of hypectansion: the:>, hypertonslvo -.aJs experience an entihypertensive effect, whereas there is only a modest fall in blood pressure in normotensWe indMduaJs.

THERAPEUTIC INDICATIONS 1. Uns1able Angina Pectoria Including Ariglne Due to Coronary Artery Spaam, or Following Myoeardlallnlarc11on: Dilzem"' is Indicated In the treatment of angina pectoris due to coronary artery spasm. Dllzem"' has been shown to be effective "" the treatment of spontaneous ooronary artery spasm presenting as Prlnzmetars variant angina (resting angina With ST-segment elevation OCC\Jrring during anacl<s).

2. Chronic Stable Angina (Ciaaa lc Effort­Aaaoclated Angina): Odzem• is Indicated In the management <>f chronic stable anglfl8 In patients who cannot tolerate therapy with beta-blockers anG'or nitrates or who remail symptomatic despite adequate doses of these agents.

3. Hypertenalon: Dilzem•ls indicated for the .treatment of hypertension. It may be used alone or In combination with other antihypertensive medications, such as diuretics.

4. Kidney Tnlnsplantatlon: Odzern• is Indicated for the prevention of gra« failure following kidney transplantation. Oilzem• is indicated tor the reduction of cyclosporine-A nephrotoxicity during immunosuppressive therapy alter kidney transplantation.

POSOLOGY AND METHOD OF ADMINISTRATION lachemlc Heart Olseaae: (Exertlonal Ang1na Pectons Due to Atherosclerotic Coronary Artery Disease or Angina Pectoris at Rest Due to C<>ronary Artery Spasm): The inltlal dose Is t 20 mglday in equally divided doses, administered

preferably before meals, and at bedtime; dosage should be Increased gradually in equally divided doses (two to four times daily) at one to two day Intervals until optimum response Is obtained. The optimum dosage range appears to be 180 to 360 mg/day. Doses up to 480 mg/day may be adminlster&d in some cases.

Hypertension: Dosages must be adjusted to 'each patient's needs.

The initial dose Is 12Q-240 mglday In equally divided doses, administered preferably before meals, end at bedtime. Maximum antihypertensive effect Is usually observed at 14 days of chronic therapy; therefore, dosage adJUStments should be scheduled accordingly. The usual dosage range Is 240 to 360 lll!¥day.

There is an additive antihypertensive effect when OilzemCI is used with other antihypertensive agents. Therefore, the dosage of Ditzem• or the concomitant antihypertenslve(s) may need to be adfusted when eddong one to the other.

KldneyTranaplantatlon: The initial dose is 120 lll!¥dey in two equally diVided doses. Depending on the patient's blood pressure, dosage may be Increased up to a maximum ol 360 lll!¥day given In 3 equaiy divided doses. The optimum dosage range appears to be 180 to 360 mglday. •

Concomitant Use with other Cardiovascular Agents Nitroglycerin TMrapy: Sublingual NTG may be taken as required to abort acute angina! attacks durin"g Dilzem"' hydrochloride therapy.

Prophylactic Nitrate Therapy: Although there have been no controlled studies to evaluate the anti­anginal eNectiVeneo6 of tNs cornbol;\8tion. Oilzem" may be co-administered with short- and long­acting nitrates.

SPECIAL POPULATIONS Uoeln Ronal impairment There are no avaHable data concerning dosage reqUirements in patients with Impaired renal function. If the drug must be used in such patients, titration should be done cautiously.

Uae In Hepatic Impairment: There are no available data concerning dosage requtrements in patients with Impaired Mpallc function. If the drug must be used In such patients. titrauon should be done cautiously.

Use In Chlldran: Safety and offecllveness in children have not been established.

CONTRAINDICATIONS Oittiazem Is contraindicated in patients: • wrth hypersensitivity to any component of this

medication, • with sicl< ..,.,. syndrome e"""P'In the prusenoo

of a functioning ventricular pacemaker, • With second or third-degree AV block except

in the presence of a functioning ventricular pecernel<er,

• with hypotension (less than 90 mm Hg systolic), • wrth acute myocardoallnlarc1Jon, • with pulmonary congestion documented by

x-ray on admission,

SPECIAL WARNINGS AND PRECAUTIONS FOR USE Cs!disc CondtJclion: Oiltiazern prolongs AV node refractory periods without significantly prolonging sinus node recovery time, except In patients with sick sinus syndrome. This effect may<arely resuh in abnormally slow he"art rates (per1icularty in patients wrth sick sinus syndrome) or second- or

third-degree AV block. Concomitant use of diltiazem With bela-blockers or dlgotalis may resuh In addiljve effects on cardiac conduction (see Interaction wllh Other Medicinal Producu and Other Forms of Interaction).

CongestM> Heart Fallum: Ahhough diltlazem has a negative inotropic effect "" isolated animal tissue preparations, hemodynamic studies In humans with normal ventricular fUnction have not llhown a reduction in cardiac Index nor consistent negative effects on contractility (dp/dt). Experience with dlltiazem used alone or In combination With beta-blockers In patients with impaired ventricular fur1ction is very limited. Caution should be exercised when using the drug In such patients.

Hypotension: Decreases in blood pressure associated With therapy may occasionalty result in symptomatiC hypotension.

Acute Hepatic Injury: In rare Instances, slgnlllcant elevations In enzymes such as alkaline phosphatase, LDH, SGOT, SGPT, and other phenomena consistent with acute hepatic Injury have been noted. These reactions have been reversible upon discontinuation of drug therapy.

Laboratory Monitoring: Dihiazem hydrochloride is extensively metabohted by the liver and excreted by the kidneys and in bile. As whh any drug given over prolonged periods, laboratory parameters should be monitored at regular intervals.

C>ooeral: Oennatological events may be transient and may disappear desplle continued use of dittiazem. However, skin eruptions progressing to erythema multiform andlor exfoliative derma­titis (epidermal necrotysis) have atso been infrequently reported. Should a dermatologlc reaction persist the drug should be discontinued. (see Undesirable ENacts).

The drug should be Used with cauUon in patients With impaired renal or hapatic function.

INTERACTION WITH OTHER MEDICINAL PRODUCTS AND OTHER FORMS •OF INTERACTION Due to the potential for additive effects, caut ion and careful t•tration are warranted In patients concomitantly receiving any agent(s) known to affect cardiac eonlrachhty and/or conduction.

Diltlazem undergoes biotransformation by cytochrome P-450 (CYP) 3A4, mixed function oxidase. Diltlazem may competnively inhibit tha metabolisnr of concomitant drugs which undergo the same route of biotransformation, thus lncrea51ng their plasma concentration. The extent of interaction end potentiation of effects depends on the variablhty of effect on (CYP) 3A4.

88ta-Biocicsrs: There are lew controlled studies of the etfect•veness ot the concomitant use of diltiazem and beta-blockers or of the safety of this combination In patients with impaired ventricular function or conduction abnonnalities.

Administration of diltlazem hydrochloride concomitantly with propranolol in normal voluntaers resulted In Increased propranolol levels in al subjects end the bloevallability of propranolol was Increased approxmately 50%. If combination therapy is initiated or withdrawn in conjunction With propranolol, an adjustment of the propranolol dose may be warranted (see Special Womlnga and Special Precou11ona lor Ute).

Hz antagonists: A study in healthy volunteers

has shown a significant increase in peak diltiazem plasma levels (58%) and in AUC (53%) after a one-week course of cimetidine at 1200 mg/day and diltiazem 60 mg/day. Ranitidine produced smaller, nonsignificant Increases. Patients receiving diltiazem therapy should be carefully monnored tor a change in pharmacological effect when initiating and discontinuing therapy with cimetidine. An adjustment in the d1hlazem dose may be warranted. ·

{);gitalis: Since there have been connicting results regarding the effect of digoxin levels, it is recommended that digoxin levels be monitored when initiating, adjusting, and discontinuing diltiazem therapy to avoid possible over- 0< under­digHallzation.

Anesthetics: The depression of cardiac contrac­tiiHy, conductivity, and autO<naticity as well as the vascular dilation associated with anesthetics may be potentiated by calcium channel blockers. When used concomitantly, anesthetics and calcium blockers should be titrated carefully.

Cyclosporine: In patients with renal transplant receiving both medications concomitantly, diltiazem increases the plasma level of cyclosporine by as much as 30%. Therefore, the dosage of cyclosporlne must be reduced wh&n administering ~iltiazem and cyclosporjne concomitantly.

Carbamazepine: Concomitant use of diltiazem and carbamazepine may enhance the plasma leveJs of carbamazepine, and consequently the risk of toxicily. '

Warfarin, Rlfampin, Lithium: There have been reports in the literature of diltiazem interactions with warfarin, r1fampin or lithium.

PREGNANCY AND LACTATION Pregnancy: There are no adequate, well-controlled studies in pregnant women; therefore, dihiazem Should be administered to pregnant women only if the potential benefit to the patient justifies any risk to the patient and fetus.

lactation: Diltiazem is excreted in human breast milk. One report suggests that concentrations in breast milk may approximate serum levels. Therefore, alternative methods of infant feeding should be instituted.

Effects on ability to drtve and use machines The effect of diltiazem on the ability to drive or use machinery has not been systematically evaluated.

UNDESIRABLE EFFECTS In studies carried out to date, serious adverse reactions with Dftzem•have been rare; however, n should be recognized that patients with impaired

. vent ricular function.-and cardiac conduction abnormalities have usually been excluded from these studies. In 900 patients with hypertension, the most common adVerse events were:

MedORA Syatem Undesirable Organ Class Effects

Nervous system headache (8%), disorders diuiness· (6%)

Caroiac disorders atrioventricular bkx:k first degree (3%). sinus bradycardia" (3%)

Vascular dtsorders flushing (3%)

General disorders asthenia (5%), and administration oedema• (9%) site condibons .

·Only ede'ma and perhaps bradycardia and dizziness were dose related. The most common adverse events (> 1%) observed in clinical studies of over 2t00 angina and hypertensive patients receiving diltia~em were:

MedORA System Organ Class

Undesirable Effects

Nervous system disorders

headache (4.5%), diZziness (3.4%)

Cardiac dtsorders atrioventricular block first degree (1.8%), bnodycardia (1.5%)

Vascular disorders flushing (1.7%)

Gastrointestinal disorders

nausea (1.6%)

Skin and lllsh(1.5%) subcutaneous tissue disorders MusculoskErietal, connective tissue

joint sweMtng

and bone disorders General d isorders asthenia (2.8%), fatigue, and administration -a(5.4%) site conditions

Less common adverse events included the following:

MedORA System Undesirable Effects Organ ClaiS

Metabolism and anorexia, hypergtycaemla nutrition disorders

Psychiatric disorders confusional state, depressk>n, hallucination, insomn•a. nervousness, personaiHy change, sleep disorder ·

Nervous system amnesia, paresthesla, disorders somnolence, syncope,

tremor

Eye disorders amblyopia, eye Irritation Ear and labyrinth tinnitus disorders

Cardiac disorders angina pectoris, arrhythmia, atrioventricular block, cardiac failure con~tiv8, e~ra systoles, palpitations, stnus arrest, tachycardia

Vascular disorders hypotension

Respiratory, thoracic, dyspnoea, epistaxis, and mediastinal nasal congestion disorders

Gastrointestinal disorders

Hepato-biliaty disorders

Skin and subcutaneous tissue disorders

Musculoskeletal. connective tissue and booe disorders

Renal and urinary disorders

constipation, diarrhea, dyspepsia, vomiting,

granulomatous lfver disease

angioedema, el)'1hema mulbforme, petechiae, pruritus. photosensltMty reaction , stevens-johnson syndrome, toxic epidermal necrotysis, urticana

arthralgia, musculo9keletal pain, myalgia

nocturia, polyuria

Reproductive system gynaecomastia, sexual and breast disorders dysfunction

General disorders and gait dtsturbance administration site conditions

Investigations alanine aminotransferase increased. aspartate aminotransferase increased, blood creatine phosphoktnase increased, btood alkaline phosphatase increased, blood laclate dehydrogenase increased. weight Ulcreased (see section Special Warnings and Specl•l Precautions for Use)

In post~marketing experience, the following additional undesirable effect(s) have been reported:

MedORA System Undeslrabte Effects Organ Clau Gastrointestinal gmgiVal hyperplaSia disorders Skin and subcutaneous acute generalized bssue disorders exanthematous pustulosts

OVERDOSE Over dosage experience with oral Oilzem • has been limited. Single oral doses of 300 mg have been well tolerated by heanhy volunteers. In the event of overdosage or exaggerated response, appropriate supportive medical care should be employed in addibon to gastric lavage.

The following measures may be considered. • Bradycardia: Administer atropine (0.60 to 1.0

mg): ~there is no response to vagal blockade, cautiously admlo.ister isoproterenol.

• High-Degree AV Blocl<: Treat as tor bradycardia above; fixed high.-degree AV block should be treated with cardiac pacing.

• Cardiac Failure: Administer inotropic agents (osoproterenol dopamine, or dobutamine) and diuretics.

• Hypotension: Administer vasopressors (eg, dopamine or levarterenol bitartrate).

Actual treatment and dosage shoukt depend on the severity of the clinical situation.

SHELFUFE 24 Months

HOW SUPPLIED • Oilzem e tablets 30 mg is available in blister

stnps of 3 x 10's. • Dilzeme tabfets 60 mg is available in blister

strips of 3 x 1 O's. • Dilzem • Retard tablets 90 mg is available in

blister strips of 2 x 1 O's. • Dilzem• SA tablets 180 mg is available in

blister strips of 2 x 1 O's.

DOSAGE Use as directed by the physician.

INSTRUCTIONS Avoid exposure to heat & sunlight. Store below 30°C. Keep out of the reach of children.

CAUTION To be sold on the prescription of a registered medical practnioner only.

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Manufactured by: Pfizer Pakistan ltd. B-2, S.I.T.E., Karachi, Pakistan .