Candesartan

Class
Antihypertensives
Subclass
Angiotensin receptor blockers
Substance name
Candesartan cilexetil
Brand names
Atacand®
Common formulations
Tablet
Dosage and administration
Adults patients
Treatment
HFrEF • NYHA class II-IV
•
Start at: 4 mg PO daily
•
Maintenance: 32 mg PO daily
•
Maximum: 32 mg per day
Double starting dose at approximately 2-week intervals to tolerance.
Hypertension
•
Start at: 8 mg PO daily
•
Maintenance: 8-32 mg PO daily
•
Maximum: 32 mg per day
Diabetic retinopathy in patients with diabetes mellitus type 2 • Mild-to-moderate • Off-label
•
Start at: 16 mg PO daily for 1 month
•
Maintenance: 32 mg PO daily
Proteinuria in patients with CKD • Off-label
•
Start at: 8 mg PO daily
•
Maintenance: 8-32 mg PO daily
Prevention
Diabetic retinopathy in patients with T1DM • Off-label
•
Start at: 16 mg PO daily for 1 month
•
Maintenance: 32 mg PO daily
Migraine attacks • Off-label
•
8-32 mg PO daily, in 1-2 divided doses
Indications for use
Labeled indications
Adults
•
Treatment of HFrEF (NYHA class II-IV)
•
Treatment of hypertension
Off-label indications
Adults
•
Treatment of diabetic retinopathy in patients with diabetes mellitus type 2 (mild-to-moderate)
•
Treatment of proteinuria in patients with CKD
•
Prevention of diabetic retinopathy in patients with T1DM
•
Prevention of migraine attacks
Safety risks
Boxed warnings
Fetal toxicity
•
Do not use in pregnant patients. Discontinue candesartan as soon as possible when pregnancy is detected.
Contraindications
Hypersensitivity to candesartan or its components
Concomitant use of aliskiren in patients with diabetes
Warnings and precautions
Exacerbation of spontaneous intracranial hypotension
•
Use caution in patients with spontaneous intracranial hypotension.
Hyperkalemia
•
Use caution in patients taking other drugs increasing potassium levels. Monitor serum potassium levels regularly.
Hypotension
•
Use caution in patients with volume and/or salt depletion, including those receiving prolonged diuretic therapy. Correct volume and salt depletion before initiating candesartan. Monitor BP during dose escalation and periodically thereafter.
Renal failure
•
Use caution in patients with renal artery stenosis, CKD, severe HF, or volume depletion. Monitor renal function periodically.
Specific populations
Renal impairment
CrCl ≥ 30 mL/min
•
Use acceptable. No dose adjustment required.
CrCl < 30 mL/min
•
Use with caution. Start at dose of 4 mg. Maximal dose of 8 mg. Titrate slowly. Monitor renal function. Monitor for hyperkalemia.
Renal replacement therapy
Continuous renal replacement
•
Dose as in CrCl < 30 mL/min. Titrate with caution. Monitor renal function. Monitor for hyperkalemia.
Intermittent hemodialysis
•
Dose as in CrCl < 30 mL/min. Titrate with caution. Monitor renal function. Monitor for hyperkalemia.
Peritoneal dialysis
•
Dose as in CrCl < 30 mL/min. Titrate with caution. Monitor renal function. Monitor for hyperkalemia.
Hepatic impairment
Child-Pugh A (mild)
•
Use acceptable. No dose adjustment required.
Child-Pugh B (moderate)
•
Reduce dose. Start at dose of 8 mg daily.
Child-Pugh C (severe)
•
No guidance available.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: D
•
Do not use. Evidence of fetal harm in humans. Monitor neonates for hypotension and oliguria. Monitor for neonatal hyperkalemia. Discontinue candesartan when pregnancy is detected.
•
Use of RAAS inhibitors during the second and third trimesters can cause reduced fetal renal function leading to anuria and renal failure, oligohydramnios, fetal lung hypoplasia, and skeletal deformations, including skull hypoplasia, hypotension, and death.
Breastfeeding
Use only if benefits outweigh potential risks.
Very low levels in breastfed infants (< 5%).
May potentially cause adverse effects in breastfed infants.
Adverse reactions
Common 1-10%
•
Agranulocytosis, anemia, ↓ WBC count, ↓ blood neutrophil count, ↓ platelet count, ↓ serum sodium, ↑ liver enzymes, ↑ liver enzymes, ↑ serum TBIL, ↑ serum potassium, peripheral edema, pharyngitis, abdominal pain, back pain, chest pain, cough, depression, diarrhea, dizziness, dizziness, skin flushing, fatigue, headache, myalgia, nausea, pruritus, rhabdomyolysis, rhinitis, upper respiratory tract infections, urticaria
Uncommon < 1%
•
Angioedema, ↑ blood glucose, ↑ serum triglycerides, ↑ serum uric acid, myocardial infarction, angina pectoris, anxiety, asthenia, dyspepsia, dyspnea, fever, palpitations, paresthesia, skin rash, vertigo, somnolence, tachycardia
Unknown frequency
•
Hypotension, ↑ BUN, orthostatic hypotension, renal failure, syncope, teratogenesis
Interactions
Drug(s)
Check Interactions
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