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Pharmacophore
(An International Research Journal)
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Asif Husain et al. / Pharmacophore 2011, Vol. 2 (6), 276-286
function may be anticipated in susceptible Irbesartan was not mutagenic in a battery of in
individuals. In patients whose renal function may vitro tests (Ames microbial test, rat hepatocyte
depend on the activity of the renin-angiotensin- DNA repair test, V79 mammalian-cell forward
aldosterone system (e.g., patients with severe gene-mutation assay). Irbesartan was negative in
congestive heart failure), treatment with several tests for induction of chromosomal
angiotensin-converting-enzyme inhibitors has aberrations (in vitro -human lymphocyte
been associated with oliguria and/or progressive assay; in vivo -mouse micronucleus study).
azotemia and (rarely) with acute renal failure Irbesartan also delays progression of diabetic
and/or death. Irbesartan would be expected to nephropathy and is also indicated for the
behave similarly. In studies of ACE inhibitors in reduction of renal disease progression in patients
patients with unilateral or bilateral renal artery with type 2 diabetes, hypertension and
stenosis, increases in serum creatinine or BUN microalbuminuria or proteinuria.
have been reported. There has been no known
use of irbesartan in patients with unilateral or SAFETY AND TOLERABILITY5, 11,12,16,17
bilateral renal artery stenosis, but a similar effect The safety of antihypertensive deserves a special
should be anticipated. importance because they are likely to be used
Pregnancy long term in general practice in a number of
patients. Irbesartan has a good tolerability profile
Female patients of childbearing age should be consistent over the wide dose range. Irbesartan
told about the consequences of second- and had no adverse effects on fertility or mating of
third-trimester exposure to drugs that act on the male or female rats at oral doses ≤650
renin-angiotensin system, and they should also mg/kg/day, the highest dose providing a
be told that these consequences do not appear to systemic exposure to irbesartan (AUC0-
have resulted from intrauterine drug exposure 24h bound plus unbound) about 5 times that
that has been limited to the first trimester. These found in humans receiving the maximum
patients should be asked to report pregnancies to recommended dose of 300 mg/day.
their physicians as soon as possible.
Adverse Reactions5, 15, 26, 27
Carcinogenesis, Mutagenesis, and
Impairment of Fertility Irbesartan has been evaluated for safety in more
than 4300 patients with hypertension and about
No evidence of carcinogenicity was observed 5000 subjects overall. This experience includes
when irbesartan was administered at doses of up 1303 patients treated for over 6 months and 407
to 500/1000 mg/kg/day (males/females, patients for 1 year or more. Treatment with
respectively) in rats and 1000 mg/kg/day in mice irbesartan was well-tolerated, with an incidence
for up to 2 years. For male and female rats, 500 of adverse events similar to placebo. These
mg/kg/day provided an average systemic events generally were mild and transient with no
exposure to irbesartan [AUC (0-24h) bound plus relationship to the dose of irbesartan. In placebo-
unbound] about 3 and 11 times, respectively, the controlled clinical trials, discontinuation of
average systemic exposure in humans receiving therapy due to a clinical adverse event was
the maximum recommended dose (MRD) or 300 required in 3.3% of patients treated with
mg irbesartan/day, whereas 1000 mg/kg/day irbesartan, versus 4.5% of patients given
(administered to females only) provided an placebo. In placebo-controlled clinical trials, the
average systemic exposure about 21 times that adverse event experiences that occurred in at
reported for humans at the MRD. For male and least 1% of patients treated with irbesartan
female mice, 1000 mg/kg/day provided an
(n=1965) and at a higher incidence versus
exposure to irbesartan about 3 and 5 times, placebo (n=641) included diarrhea (3% Vs 2%),
respectively, the human exposure at 300 mg/day. dyspepsia/heartburn (2% Vs 1%),
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musculoskeletal trauma (2% Vs 1%), fatigue development. Prematurity, intrauterine growth
(4% Vs 3%), and upper respiratory infection (9% retardation, and patent ductus arteriosus have
Vs 6%). also been reported, although it is not clear
whether these occurrences were due to exposure
The following adverse events occurred at an
to the drug. These adverse effects do not appear
incidence of 1% or greater in patients treated
to have resulted from intrauterine drug exposure
with irbesartan, but were at least as frequent or
that has been limited to the first trimester.
more frequent in patients receiving placebo:
abdominal pain, anxiety/nervousness, chest pain, Mothers whose embryos and fetuses are exposed
dizziness, edema, headache, influenza, to an angiotensin II receptor antagonist only
musculoskeletal pain, pharyngitis, during the first trimester should be so informed.
nausea/vomiting, rash, rhinitis, sinus Nonetheless, when patients become pregnant,
abnormality, tachycardia, and urinary tract physicians should have the patient discontinue
infection. Irbesartan use was not associated with the use of irbesartan as soon as possible.
an increased incidence of dry cough, as is Rarely (probably less often than once in every
typically associated with ACE inhibitor use. In thousand pregnancies), no alternative to a drug
placebo controlled studies, the incidence of acting on the renin-angiotensin system will be
cough in irbesartan treated patients was 2.8% Vs found. In these rare cases, the mothers should be
2.7% in patients receiving placebo. The apprised of the potential hazards to their fetuses,
incidence of hypotension or orthostatic and serial ultrasound examinations should be
hypotension was low in irbesartan treated performed to assess the intra-amniotic
patients (0.4%), unrelated to dosage, and similar environment. If oligohydramnios is observed,
to the incidence among placebo treated patients irbesartan should be discontinued unless it is
(0.2%). Dizziness, syncope, and vertigo were considered life-saving for the mother.
reported with equal or less frequency in patients Contraction stress testing (CST), a non-stress test
receiving irbesartan compared with placebo. (NST), or biophysical profiling (BPP) may be
appropriate depending upon the week of
Fetal/Neonatal Morbidity and Mortality
pregnancy. Patients and physicians should be
Drugs that act directly on the renin-angiotensin aware, however, that oligohydramnios may not
system can cause fetal and neonatal morbidity appear until after the fetus has sustained
and death when administered to pregnant irreversible injury. Infants with histories of in
women. Several dozen cases have been reported utero exposure to an angiotensin II receptor
in the world literature in patients who were antagonist should be closely observed for
taking angiotensin-converting-enzyme inhibitors. hypotension, oliguria, and hyperkalemia. If
When pregnancy is detected, irbesartan should oliguria occurs, attention should be directed
be discontinued as soon as possible. toward support of blood pressure and renal
The use of drugs that act directly on the renin- perfusion. Exchange transfusion or dialysis may
angiotensin system during the second and third be required as means of reversing hypotension
trimesters of pregnancy has been associated with and/or substituting for disordered renal function.
fetal and neonatal injury, including hypotension, Gender differences
neonatal skull hypoplasia, anuria, reversible or
No gender related differences in
irreversible renal failure, and death.
pharmacokinetics were observed in healthy
Oligohydramnios has also been reported,
elderly (age 65-80 years) or in healthy young
presumably resulting from decreased fetal renal
(age 18-40 years) subjects. In studies of
function; oligohydramnios in this setting has
hypertensive patients, there was no gender
been associated with fetal limb contractures,
difference in half-life or accumulation, but
craniofacial deformation, and hypoplastic lung
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somewhat higher plasma concentrations of however, should receive an initial dose of 75 mg.
irbesartan were observed in females (11-44%). Those patients requiring further blood pressure
No gender-related dosage adjustment is reduction may be titrated to 300 mg once daily.
necessary. It is unlikely that higher doses or twice daily
dosing will produce additional antihypertensive
Geriatric
effects. No dosage adjustment is necessary in
In elderly subjects (age 65-80 years), irbesartan elderly patients or those with hepatic impairment
elimination half-life was not significantly or mild to severe renal impairment. If blood
altered, but AUC and Cmax values were about pressure is not controlled by irbesartan alone,
20-50% greater than those of young subjects another antihypertensive may be added. Also,
(age 18-40 years). No dosage adjustment is low doses of a diuretic such as
necessary in the elderly. hydrochlorothiazide may be added to improve
DRUGS INTERACTIONS15, 26-30 therapeutic effect. The recommended initial dose
of irbesartan is 150 mg once daily. Patients
No significant drug-drug pharmacokinetic (or
requiring further reduction in blood pressure
pharmacodynamic) interactions have been found
should be titrated to 300 mg once daily.
in interaction studies with hydrochlorothiazide,
digoxin, warfarin and nifedipine. A low dose of a diuretic may be added, if blood
pressure is not controlled by irbesartan alone.
In vitro studies show significant inhibition of the
Hydrochlorothiazide has been shown to have an
formation of oxidized irbesartan metabolites
additive effect. Patients not adequately treated by
with the known cytochrome CYP 2C9
the maximum dose of 300 mg once daily are
substrates/inhibitors sulphenazole, tolbutamide,
unlikely to derive additional benefit from a
and nifedipine. However, in clinical studies the
higher dose or twice-daily dosing. No dosage
consequences of concomitant irbesartan on the
adjustment is necessary in elderly patients or in
pharmacodynamics of warfarin were negligible.
patients with hepatic impairment or mild to
Based on in vitro data, no interaction would be
severe renal impairment. Irbesartan may be
expected with drugs whose metabolism is
administered with other antihypertensive agents.
dependent upon cytochrome P450 isozymes.
Irbesartan may be administered with or without
In separate studies of patients receiving food. A lower initial dose of irbesartan (75 mg)
maintenance doses of warfarin, is recommended in patients with depletion of
hydrochlorothiazide, or digoxin, irbesartan intravascular volume or salt (e.g., patients treated
administration for 7 days had no effect on the vigorously with diuretics or on hemodialysis).
pharmacodynamics of warfarin (prothrombin
time) or pharmacokinetics of digoxin. The
Irbesartan Dosing for High Blood Pressure
pharmacokinetics of irbesartan was not affected
by co- administration of nifedipine or The recommended starting dosage of irbesartan
hydrochlorothiazide. for most people with high blood
pressure (hypertension) is 150 mg once a day.
DOSAGE5, 22-29
Based on the blood pressure response
Irbesartan is available as white and off-white and/or irbesartan side effects, the dosage may be
biconvex oval tablets in 75, 150 and 300 mg increased or decreased. With each change in
strengths. The drug may be administered with or dosage, it may take several weeks to see the full
without food and the recommended initial dose effects on blood pressure.
of irbesartan is 150 mg once daily. Patients
Irbesartan Dosing for Diabetic Nephropathy
treated vigorously with diuretics or on
hemodialysis (volume-depleted patients),
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The recommended starting dosage of irbesartan serum potassium levels are not significantly
for people with diabetic nephropathy is 300 mg affected at recommended doses. In hypertensive
once a day. patients, chronic oral doses of irbesartan (up to
300 mg) had no effect on glomerular filtration
Overdosage26, 30
rate, renal plasma flow or filtration fraction. In
No data are available in regard to overdosage in multiple dose studies in hypertensive patients,
humans. However, daily doses of 900 mg for 8 there were no clinically important effects on
weeks were well-tolerated. The most likely fasting triglycerides, total cholesterol, HDL-
manifestations of overdosage are expected to be cholesterol, or fasting glucose concentrations.
hypotension and tachycardia; bradycardia might There was no effect on serum uric acid during
also occur from overdose. Irbesartan is not chronic oral administration, and no uricosuric
removed by hemodialysis. To obtain up-to-date effect.
information about the treatment of overdosage, a
good resource is a certified Regional Poison CONCLUSION
Control Center. In managing overdose, consider Irbesartan is a potent, long-acting, nonpeptide
the possibilities of multiple-drug interactions, angiotensin II receptor antagonist having high
drug-drug interactions, and unusual drug kinetics selectivity for the AT1 subtype (angiotensin I). It
in the patient. Laboratory determinations of is potentially safe and more tolerable than other
serum levels of irbesartan are not widely classes of antihypertensive drugs. Irbesartan
available, and such determinations have, in any reduces the chances of cardiac failure,
event, no known established role in the myocardial infarction, sudden death, and death
management of irbesartan overdose. Acute oral from progressive systolic failure. Irbesartan is an
toxicity studies with irbesartan in mice and rats effective antihypertensive agent in patients with
indicated acute lethal doses were in excess of mild to moderate hypertension. The drug also
2000 mg/kg, about 25- and 50-fold the maximum reduces blood pressure when used as
recommended human dose (300 mg). monotherapy in patients with severe
In healthy subjects, single oral irbesartan doses hypertension or when used adjunctively in
of up to 300 mg produced dose-dependent patients with resistant hypertension. Importantly,
inhibition of the press or effect of angiotensin II Irbesartan appears to be as effective and well
infusions. Inhibition was complete (100%) 4 h tolerated as other commonly used
following oral doses of 150 or 300 mg and antihypertensive agents. The drug therefore
partial inhibition was sustained for 24 h (60% represents a useful therapeutic option in the
and 40% at 300 mg and 150 mg, respectively). In management of patients with hypertension and
hypertensive patients, angiotensin II receptor diabetic nephropathy will be particularly useful
inhibition following chronic administration of in patients not responding to, or intolerant of,
irbesartan causes a 1.5- to 2-fold rise in anti-hypertensive agents from other drug classes.
angiotensin II plasma concentration and a 2- to Irbesartan may be an appropriate choice for first-
3-fold increase in plasma renin levels. line treatment of patients with mild-to-moderate
Aldosterone plasma concentrations generally hypertension, heart failure, myocardial infarction
decline following irbesartan administration, but and diabetic nephropathy.
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Table 1: Pharmacokinetic profile of Irbesartan with other sartans
HN N
O
N N
N
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