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Candesartan

Pronunciation

Pronunciation

(kan de SAR tan)

Index Terms

  • Candesartan Cilexetil

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Tablet, Oral, as cilexetil:

Atacand: 4 mg, 8 mg [scored]

Atacand: 16 mg [DSC]

Atacand: 16 mg [scored]

Atacand: 32 mg [DSC]

Atacand: 32 mg [scored]

Generic: 4 mg, 8 mg, 16 mg, 32 mg

Brand Names: U.S.

  • Atacand

Pharmacologic Category

  • Angiotensin II Receptor Blocker
  • Antihypertensive

Pharmacology

Candesartan is an angiotensin receptor antagonist. Angiotensin II acts as a vasoconstrictor. In addition to causing direct vasoconstriction, angiotensin II also stimulates the release of aldosterone. Once aldosterone is released, sodium as well as water are reabsorbed. The end result is an elevation in blood pressure. Candesartan binds to the AT1 angiotensin II receptor. This binding prevents angiotensin II from binding to the receptor thereby blocking the vasoconstriction and the aldosterone secreting effects of angiotensin II.

Absorption

Candesartan: Rapid and complete following conversion from candesartan cilexetil by GI esterases

Distribution

Vd: 0.13 L/kg

Metabolism

Converted to active candesartan, via ester hydrolysis during absorption from GI tract; hepatic (minor) via O-deethylation to inactive metabolite

Excretion

Feces (67%); urine (33%; 26% as unchanged drug)

Clearance: Total body: 0.37 mL/minute/kg; Renal: 0.19 mL/minute/kg; decreased with severe renal impairment

Onset of Action

2 to 3 hours; antihypertensive effect: Within 2 weeks

Peak effect: 6 to 8 hours; maximum antihypertensive effect: 4 to 6 weeks

Time to Peak

Children (1 to 17 years); Adults: 3 to 4 hours

Duration of Action

>24 hours

Half-Life Elimination

Dose dependent: 5 to 9 hours

Protein Binding

>99%

Special Populations: Renal Function Impairment

In hypertensive patients with CrCl <30 mL/minute/1.73 m2, the AUC and Cmax are approximately doubled. In heart failure patients with renal impairment, AUC is 36% and 65% higher and Cmax is 15% and 55% higher in patients with mild and moderate renal impairment, respectively.

Special Populations: Hepatic Function Impairment

The AUC and Cmax increased 30% and 56% in mild impairment and 145% and 73% in moderate impairment, respectively.

Special Populations: Elderly

Cmax is ~50% higher; AUC is ~80% higher.

Use: Labeled Indications

Heart failure: Treatment of heart failure (NYHA class II-IV)

Hypertension: Alone or in combination with other antihypertensive agents in treating hypertension

Guideline recommendations:

Heart failure: The ACCF/AHA 2013 heart failure guidelines recommend the use of ARBs (ie, candesartan, losartan, and valsartan) in patients with HF with reduced ejection fraction who cannot tolerate ACE inhibitors (due to cough) to reduce morbidity and mortality. They also suggest that ARBs are reasonable first-line alternatives to ACE inhibitors in patients already maintained on an ARB for other indications (ACCF/AHA [Yancy, 2013]).

Hypertension: The 2014 guideline for the management of high blood pressure in adults (Eighth Joint National Committee [JNC 8; James, 2013]) recommends initiation of pharmacologic treatment to lower blood pressure for the following patients:

• Patients ≥60 years of age with systolic blood pressure (SBP) ≥150 mm Hg or diastolic blood pressure (DBP) ≥90 mm Hg. Goal of therapy is SBP <150 mm Hg and DBP <90 mm Hg.

• Patients <60 years of age with SBP ≥140 mm Hg or DBP ≥90 mm Hg. Goal of therapy is SBP <140 mm Hg and DBP <90 mm Hg.

• Patients ≥18 years of age with diabetes and SBP ≥140 mm Hg or DBP ≥90 mm Hg. Goal of therapy is SBP <140 mm Hg and DBP <90 mm Hg.

• Patients ≥18 years of age with chronic kidney disease (CKD) and SBP ≥140 mm Hg or DBP ≥90 mm Hg. Goal of therapy is SBP <140 mm Hg and DBP <90 mm Hg.

Chronic kidney disease (CKD) and hypertension: Regardless of race or diabetes status, the use of an ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB) as initial therapy is recommended to improve kidney outcomes. In the general nonblack population (without CKD), including those with diabetes, initial antihypertensive treatment should consist of a thiazide-type diuretic, calcium channel blocker, ACEI, or ARB. In the general black population (without CKD), including those with diabetes, initial antihypertensive treatment should consist of a thiazide-type diuretic or a calcium channel blocker instead of an ACEI or ARB.

Coronary artery disease and hypertension: The American Heart Association, American College of Cardiology and American Society of Hypertension (AHA/ACC/ASH) 2015 scientific statement for the treatment of hypertension in patients with coronary artery disease (CAD) recommends the use of an ARB (or ACE inhibitor) as part of a regimen in patients with hypertension and chronic stable angina if there is prior MI, LV systolic dysfunction, diabetes mellitus, or CKD. A BP target of <140/90 mm Hg is reasonable for the secondary prevention of cardiovascular events. A lower target BP (<130/80 mm Hg) may be appropriate in some individuals with CAD, previous MI, stroke or transient ischemic attack, or CAD risk equivalents (AHA/ACC/ASH [Rosendorff 2015]).

Contraindications

Hypersensitivity to candesartan or any component of the formulation; concomitant use with aliskiren in patients with diabetes mellitus

Canadian labeling: Additional contraindications (not in U.S. labeling): Concomitant use with aliskiren in patients with moderate-to-severe renal impairment (GFR <60 mL/minute/1.73 m2); pregnancy; breast-feeding; children <1 year of age; rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption

Dosing: Adult

Hypertension: Oral: Note: Antihypertensive effect usually observed within 2 weeks; maximum antihypertensive effect seen within 4 to 6 weeks. Dosage must be individualized. Consider lower initial dosages in volume depleted patients; if possible, correct volume depletion prior to administration. Initial: 16 mg once daily; titrate to response; usual range: 8 to 32 mg daily in 1 to 2 divided doses; target dose (JNC 8 [James 2013]): 12 to 32 mg daily; maximum daily dose: 32 mg daily.

Heart failure: Oral: Initial: 4 mg once daily (US labeling) or alternatively 4 to 8 mg once daily (ACCF/AHA [Yancy 2013]); double the dose at 2-week intervals, as tolerated; target dose: 32 mg once daily (ACCF/AHA [Yancy 2013]).

Note: Concurrent therapy with an ACE inhibitor may provide additional benefit in patients with HF with reduced EF who remain symptomatic on standard therapy and are unable to receive an aldosterone antagonist (ACCF/AHA [Yancy 2013]).

Canadian labeling: Initial: 4 mg once daily; double the dose at 2-week intervals as tolerated; target dose: 32 mg once daily

Dosing: Geriatric

Refer to adult dosing. No initial dosage adjustment is necessary for elderly patients (although higher concentrations (Cmax) and AUC were observed in this population).

Dosing: Pediatric

Hypertension: Oral: Note: Antihypertensive effect usually observed within 2 weeks; maximum antihypertensive effect seen within 4 to 6 weeks. Consider lower initial dosages in volume depleted patients; if possible, correct volume depletion prior to administration. Use in children <6 years is not approved in the Canadian labeling.

Children 1 to <6 years: Initial: 0.2 mg/kg/day in 1 to 2 divided doses; titrate to response; usual range: 0.05 to 0.4 mg/kg/day; maximum daily dose: 0.4 mg/kg/day

Children ≥6 years and Adolescents <17 years: U.S. labeling:

<50 kg: Initial: 4 to 8 mg daily in 1 to 2 divided doses; titrate to response; usual range: 2 to 16 mg daily; maximum daily dose: 32 mg daily

≥50 kg: Initial: 8 to 16 mg daily in 1 to 2 divided doses; titrate to response; usual range: 4 to 32 mg daily; maximum daily dose: 32 mg daily

Children ≥6 years and Adolescents ≤17 years: Canadian labeling:

<50 kg: Initial: 4 mg once daily; titrate to response; maximum dose: 8 mg daily

≥50 kg: Initial: 8 mg once daily; titrate to response; maximum dose: 8 mg daily

Dosing: Renal Impairment

U.S. labeling:

Adults: No initial dosage adjustment necessary; however, in patients with severe renal impairment (CrCl <30 mL/minute/1.73 m2) AUC and Cmax were approximately doubled after repeated dosing.

Children ≥1 and Adolescents <17 years: There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied). Children with GFR <30 mL/minute/1.73 m2 should not receive candesartan.

Canadian labeling:

Adults:

Mild impairment: No dosage adjustment necessary.

Moderate or severe impairment: Consider initial dose of 4 mg once daily in patients with hypertension.

Dialysis: Consider initial dose of 4 mg once daily in patients with hypertension.

Children ≥6 and Adolescents ≤17 years: There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).

Dosing: Hepatic Impairment

U.S. labeling:

Mild impairment (Child-Pugh class A): No initial dosage adjustment necessary.

Moderate impairment (Child-Pugh class B): Initial: 8 mg daily (AUC increased by 145%) in adult patients with hypertension. There are no dosage adjustments provided in the manufacturer's labeling for pediatric patients.

Severe impairment (Child-Pugh class C): There are no dosage adjustments provided in manufacturer’s labeling (has not been studied); however, systemic exposure increases significantly in moderate impairment.

Canadian labeling:

Adults:

Mild to moderate impairment: No dosage adjustment necessary.

Severe impairment: Limited experience; consider initial dose of 4 mg once daily in adult patients with hypertension.

Children: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).

Extemporaneously Prepared

Oral suspension may be made in concentrations ranging from 0.1 to 2 mg/mL; typically 1 mg/mL oral suspension suitable for majority of prescribed doses; any strength tablet may be used. A 1 mg/mL (total volume: 160 mL) oral suspension may be made with tablets and a 1:1 mixture of Ora-Plus® and Ora-Sweet SF®. Prepare the vehicle by adding 80 mL of Ora-Plus® and 80 mL of Ora-Sweet SF® or, alternatively, use 160 mL of Ora-Blend SF®. Add a small amount of vehicle to five 32 mg tablets and grind into a smooth paste using a mortar and pestle. Transfer the paste to a calibrated amber PET bottle, rinse the mortar and pestle clean using the vehicle, add this to the bottle, and then add a quantity of vehicle sufficient to make 160 mL. The suspension is stable at room temperature for 100 days unopened or 30 days after the first opening; do not freeze; label “shake well before use.” (Atacand prescribing information, 2013).

Administration

Administer without regard to meals. An oral suspension may be prepared for children unable to swallow tablets (refer to Extemporaneously Prepared information).

Storage

Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F).

Drug Interactions

ACE Inhibitors: Angiotensin II Receptor Blockers may enhance the adverse/toxic effect of ACE Inhibitors. Angiotensin II Receptor Blockers may increase the serum concentration of ACE Inhibitors. Management: In US labeling, use of telmisartan and ramipril is not recommended. It is not clear if any other combination of an ACE inhibitor and an ARB would be any safer. Consider alternatives to the combination when possible. Consider therapy modification

Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Aliskiren: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Aliskiren may enhance the hypotensive effect of Angiotensin II Receptor Blockers. Aliskiren may enhance the nephrotoxic effect of Angiotensin II Receptor Blockers. Management: Aliskiren use with ACEIs or ARBs in patients with diabetes is contraindicated. Combined use in other patients should be avoided, particularly when CrCl is less than 60 mL/min. If combined, monitor potassium, creatinine, and blood pressure closely. Consider therapy modification

Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure lowering medications should be withheld for 24 hours prior to amifostine administration. If blood pressure lowering therapy cannot be withheld, amifostine should not be administered. Consider therapy modification

Amodiaquine: CYP2C8 Inhibitors may increase the serum concentration of Amodiaquine. Avoid combination

Amphetamines: May diminish the antihypertensive effect of Antihypertensive Agents. Monitor therapy

Antihepaciviral Combination Products: May increase the serum concentration of Candesartan. Management: Per antihepaciviral combination product US prescribing information, consider decreasing the candesartan dose and monitoring for evidence of hypotension and worsening renal function if these agents are used in combination. Consider therapy modification

Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Monitor therapy

Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Canagliflozin: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Canagliflozin may enhance the hypotensive effect of Angiotensin II Receptor Blockers. Monitor therapy

Ciprofloxacin (Systemic): Angiotensin II Receptor Blockers may enhance the arrhythmogenic effect of Ciprofloxacin (Systemic). Monitor therapy

CycloSPORINE (Systemic): Angiotensin II Receptor Blockers may enhance the hyperkalemic effect of CycloSPORINE (Systemic). Monitor therapy

Dapoxetine: May enhance the orthostatic hypotensive effect of Angiotensin II Receptor Blockers. Monitor therapy

Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Drospirenone: Angiotensin II Receptor Blockers may enhance the hyperkalemic effect of Drospirenone. Monitor therapy

DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. Monitor therapy

Eplerenone: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Monitor therapy

Heparin: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Monitor therapy

Heparin (Low Molecular Weight): May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Monitor therapy

Herbs (Hypertensive Properties): May diminish the antihypertensive effect of Antihypertensive Agents. Monitor therapy

Herbs (Hypotensive Properties): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Monitor therapy

Levodopa: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa. Monitor therapy

Lithium: Angiotensin II Receptor Blockers may increase the serum concentration of Lithium. Management: Lithium dosage reductions will likely be needed following the addition of an angiotensin II receptor antagonist. Consider therapy modification

Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Methylphenidate: May diminish the antihypertensive effect of Antihypertensive Agents. Monitor therapy

Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Nicorandil: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Monitor therapy

Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. Monitor therapy

Nonsteroidal Anti-Inflammatory Agents: Angiotensin II Receptor Blockers may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents. Specifically, the combination may result in a significant decrease in renal function. Nonsteroidal Anti-Inflammatory Agents may diminish the therapeutic effect of Angiotensin II Receptor Blockers. The combination of these two agents may also significantly decrease glomerular filtration and renal function. Monitor therapy

Obinutuzumab: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Consider therapy modification

Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Potassium Salts: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Monitor therapy

Potassium-Sparing Diuretics: Angiotensin II Receptor Blockers may enhance the hyperkalemic effect of Potassium-Sparing Diuretics. Monitor therapy

Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Sodium Phosphates: Angiotensin II Receptor Blockers may enhance the nephrotoxic effect of Sodium Phosphates. Specifically, the risk of acute phosphate nephropathy may be enhanced. Management: Consider avoiding this combination by temporarily suspending treatment with ARBs, or seeking alternatives to oral sodium phosphate bowel preparation. If the combination cannot be avoided, maintain adequate hydration and monitor renal function closely. Consider therapy modification

Tolvaptan: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Monitor therapy

Trimethoprim: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Monitor therapy

Yohimbine: May diminish the antihypertensive effect of Antihypertensive Agents. Monitor therapy

Adverse Reactions

Frequency not always defined.

Cardiovascular: Hypotension (heart failure 19%), angina pectoris, myocardial infarction, palpitations, tachycardia

Central nervous system: Anxiety, depression, dizziness, drowsiness, headache, paresthesia, vertigo

Dermatologic: Diaphoresis, skin rash

Endocrine & metabolic: Hyperkalemia (heart failure <1% to 6%), hyperglycemia, hypertriglyceridemia, hyperuricemia

Gastrointestinal: Dyspepsia, gastroenteritis

Genitourinary: Hematuria

Neuromuscular & skeletal: Back pain, increased creatine phosphokinase, myalgia, weakness

Renal: Increased serum creatinine (≤13% in patients with heart failure with drug discontinuation required in 6%)

Respiratory: Dyspnea, epistaxis, pharyngitis, rhinitis, upper respiratory tract infection

Miscellaneous: Fever

<1% (Limited to important or life-threatening): Atrial fibrillation, bradycardia, cardiac failure, cerebrovascular accident, confusion, hepatic insufficiency, hepatitis, hypersensitivity, leukopenia, loss of consciousness, pancreatitis, pneumonia, presyncope, pulmonary edema, renal failure, rhabdomyolysis, thrombocytopenia

ALERT: U.S. Boxed Warning

Fetal toxicity:

When pregnancy is detected, discontinue candesartan as soon as possible. Drugs that act directly on the renin-angiotensin system can cause injury and even death to the developing fetus.

Warnings/Precautions

Concerns related to adverse effects:

• Angioedema: Angioedema has been reported rarely with some angiotensin II receptor antagonists (ARBs) and may occur at any time during treatment (especially following first dose). It may involve the head and neck (potentially compromising airway) or the intestine (presenting with abdominal pain). Patients with idiopathic or hereditary angioedema or previous angioedema associated with ACE-inhibitor therapy may be at an increased risk. Prolonged frequent monitoring may be required, especially if tongue, glottis, or larynx are involved, as they are associated with airway obstruction. Patients with a history of airway surgery may have a higher risk of airway obstruction. Discontinue therapy immediately if angioedema occurs. Aggressive early management is critical. Intramuscular (IM) administration of epinephrine may be necessary. Do not readminister to patients who have had angioedema with ARBs.

• Hyperkalemia: May occur; risk factors include renal dysfunction, diabetes mellitus, concomitant use of potassium-sparing diuretics, potassium supplements and/or potassium containing salts. Use cautiously, if at all, with these agents and monitor potassium closely.

• Hypotension: Symptomatic hypotension may occur upon initiation in patients who are salt- or volume-depleted (eg, those treated with high-dose diuretics). Consider lower initial dosages in volume depleted patients; if possible, correct volume depletion prior to administration. This transient hypotensive response is not a contraindication to further treatment with candesartan.

• Renal function deterioration: May be associated with deterioration of renal function and/or increases in serum creatinine, particularly in patients with low renal blood flow (eg, renal artery stenosis, heart failure) whose glomerular filtration rate (GFR) is dependent on efferent arteriolar vasoconstriction by angiotensin II; deterioration may result in oliguria, acute renal failure, and progressive azotemia. Small increases in serum creatinine may occur following initiation; consider discontinuation only in patients with progressive and/or significant deterioration in renal function.

Disease-related concerns:

• Aortic/mitral stenosis: Use caution in patients with significant aortic/mitral stenosis.

• Heart failure: Use caution when initiating in heart failure; may need to adjust dose, and/or concurrent diuretic therapy, because of candesartan-induced hypotension.

• Hepatic impairment: Systemic exposure increases in hepatic impairment. U.S. manufacturer labeling recommends a dosage adjustment in patients with moderate hepatic impairment. Pharmacokinetics have not been studied in severe hepatic impairment.

• Renal artery stenosis: Use candesartan with caution in patients with unstented unilateral/bilateral renal artery stenosis. When unstented bilateral renal artery stenosis is present, use is generally avoided due to the elevated risk of deterioration in renal function unless possible benefits outweigh risks.

• Renal impairment: Use with caution with preexisting renal insufficiency. Pediatric patients with a GFR <30 mL/minute/1.73 m2 should not receive candesartan; has not been evaluated.

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Special populations:

• Pediatric: Avoid use in infants <1 year of age due to potential effects on the development of immature kidneys.

• Pregnancy: [US Boxed Warning]: Drugs that act on the renin-angiotensin system can cause injury and death to the developing fetus. Discontinue as soon as possible once pregnancy is detected.

• Surgical patients: In patients on chronic angiotensin receptor blocker (ARB) therapy, intraoperative hypotension may occur with induction and maintenance of general anesthesia; however, discontinuation of therapy prior to surgery is controversial. If continued preoperatively, avoidance of hypotensive agents during surgery is prudent (Hillis, 2011).

Monitoring Parameters

Supine blood pressure, electrolytes, serum creatinine, BUN, urinalysis, symptomatic hypotension, and tachycardia; in heart failure, serum potassium during dose escalation and periodically thereafter

2013 ACCF/AHA Heart Failure guideline recommendations: Within 1-2 weeks after initiation, reassess blood pressure (including postural blood pressure changes), renal function, and serum potassium; follow closely after dose changes. Patients with systolic blood pressure <80 mm Hg, low serum sodium, diabetes mellitus, and impaired renal function should be closely monitored (ACCF/AHA [Yancy, 2013]).

Pregnancy Risk Factor

D

Pregnancy Considerations

[US Boxed Warning]: Drugs that act on the renin-angiotensin system can cause injury and death to the developing fetus. Discontinue as soon as possible once pregnancy is detected. The use of drugs which act on the renin-angiotensin system are associated with oligohydramnios. Oligohydramnios, due to decreased fetal renal function, may lead to fetal lung hypoplasia and skeletal malformations. Use is also associated with anuria, hypotension, renal failure, skull hypoplasia, and death in the fetus/neonate. The exposed fetus should be monitored for fetal growth, amniotic fluid volume, and organ formation. Infants exposed in utero should be monitored for hyperkalemia, hypotension, and oliguria (exchange transfusions or dialysis may be needed). These adverse events are generally associated with maternal use in the second and third trimesters.

Untreated chronic maternal hypertension is also associated with adverse events in the fetus, infant, and mother. The use of angiotensin II receptor blockers is not recommended to treat chronic uncomplicated hypertension in pregnant women and should generally be avoided in women of reproductive potential (ACOG, 2013).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience back pain, flu-like symptoms, pharyngitis, or rhinitis. Have patient report immediately to prescriber signs of kidney problems (urinary retention, hematuria, change in amount of urine passed, or weight gain), signs of high potassium (abnormal heartbeat, confusion, dizziness, passing out, weakness, shortness of breath, numbness or tingling feeling), severe dizziness, or passing out (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.

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