Triplixam, 10 mg+2, 5 mg+10 mg 30 pcs

Triplixam® is a combination drug that includes three antihypertensive components, each of which complements the action of the others to control BP in patients with arterial hypertension. Amlodipine is a “slow” calcium channel blocker (CMCB), a dihydropyridine derivative, indapamide is a sulfonamide diuretic, perindopril arginine is an inhibitor of the enzyme that converts angiotensin I to angiotensin II (ACE inhibitor).

The pharmacological properties of Triplixam® combine the properties of each of its active ingredients. In addition, the combination of amlodipine, indapamide and perindopril arginine enhances the antihypertensive effect of each component.

The mechanism of action

Amlodipine is a DMARD, a dihydropyridine derivative. Amlodipine inhibits transmembrane transition of calcium ions in cardiomyocytes and smooth muscle cells of the vascular wall.

Indapamide refers to sulfonamide derivatives with an indole ring and has pharmacological properties similar to thiazide diuretics, which inhibit sodium ion reabsorption in the cortical segment of the nephron loop. The renal excretion of sodium and chlorine ions and, to a lesser extent, potassium and magnesium ions increases, which is accompanied by increased diuresis and antihypertensive effect.

Perindopril is an inhibitor of the enzyme that converts angiotensin I to angiotensin II (ACE inhibitor). ACE, or kininase II, is an exopeptidase that converts angiotensin I into the vasoconstrictor angiotensin II. In addition, the enzyme stimulates the production of aldosterone by the adrenal cortex and the degradation of bradykinin, which has a vasodilator effect, to an inactive heptapeptide. The result is perindopril:

– reduces aldosterone secretion;

– by the principle of negative feedback increases plasma renin activity;

– with prolonged use, it reduces RPS, which is mainly due to the effect on the vessels in the muscles and kidneys. These effects are not accompanied by retention of sodium ions or fluid or development of reflex tachycardia with long-term use.

Perindopril has antihypertensive effects in patients with both low and normal plasma renin activity.

Perindopril has therapeutic effect due to the active metabolite perindoprilat. Other metabolites have no pharmacological activity.

Perindopril normalizes heart function by reducing preload and postload due to:

– vasodilatory action on the veins, possibly related to activation of the prostaglandin system;

– a decrease in RPS.

In the study of hemodynamic parameters in patients with chronic heart failure (CHF) it was revealed:

– decreased filling pressure in the left and right ventricles of the heart;

– decreased PPSS;

– increased cardiac output and increased cardiac index;

– increased muscular peripheral blood flow.

There was also an increase in exercise tolerance.

Pharmacodynamic effects

Amlodipine

The antihypertensive effects of amlodipine are due to a direct effect on the smooth muscle cells of the vascular wall. The detailed mechanism by which amlodipine exerts antianginal action is not well established, but it is known that amlodipine reduces the overall coronary burden through two actions:

-causes peripheral arterioles to dilate, decreasing the ROSS (post-load). This reduction of cardiac load reduces energy expenditure, and myocardial oxygen demand;

– causes dilation of coronary arteries and arterioles in both ischemic and intact areas. At the same time in patients with coronary artery spasm (Prinzmetal’s angina) coronary blood flow and myocardial oxygen supply are improved.

In patients with arterial hypertension (AH), taking amlodipine once daily provides a clinically significant reduction in BP in the “standing” and “lying” position for 24 hours. The antihypertensive effect develops slowly, and therefore the development of acute arterial hypotension is uncommon.

Amlodipine has no adverse metabolic effects and does not affect indexes of lipid metabolism. It does not cause changes in hypolipidemic indexes of blood plasma and can be used in patients with concomitant bronchial asthma, diabetes mellitus and gout.

Indapamide

A 24-hour antihypertensive effect has been demonstrated when using indapamide in monotherapy. The antihypertensive effect is seen when the drug is used in doses that have minimal diuretic effect.

The antihypertensive activity of indapamide is associated with improvement of elastic properties of large arteries, reduction of arteriolar and total peripheral vascular resistance.

Indapamide reduces left ventricular hypertrophy.

The thiazide and thiazide-like diuretics reach a plateau of therapeutic effect at a certain dose, whereas the incidence of side effects continues to increase with further increasing of the drug dose. Therefore, do not increase the dose of the drug if the therapeutic effect is not achieved at the recommended dose.

In short-, medium-, and long-term studies involving patients with arterial hypertension, it has been shown that indapamide:

-does not affect lipid metabolism parameters, including triglyceride levels.including triglycerides, cholesterol, LDL and HDL levels;

– has no effect on parameters of carbohydrate metabolism, including in patients with diabetes mellitus.

Perindopril

Perindopril is effective in therapy of arterial hypertension of any degree of severity. Against the background of its use there is a decrease of both systolic and diastolic BP in “lying” and “standing” position.

The antihypertensive effect of the drug reaches the maximum 4-6 hours after a single oral administration and lasts for 24 hours.

24 hours after oral administration there is significant (about 80%) residual ACE inhibition.

In patients with a positive response to treatment, normalization of BP occurs within a month and persists without the development of tachycardia.

The cessation of treatment is not accompanied by the development of a “ricochet” effect.

Perindopril has a vasodilator effect, helps to restore elasticity of large arteries and vascular wall structure of small arteries, and reduces left ventricular hypertrophy.

The simultaneous administration of thiazide diuretics increases the severity of the antihypertensive effect.

In addition, combination of ACE inhibitor and thiazide diuretic also decreases the risk of hypokalemia when taking diuretics.

Perindopril/indapamide

In patients with arterial hypertension, regardless of age, the combination of perindopril and indapamide has a dose-dependent antihypertensive effect on both diastolic and systolic BP in standing and lying position. Clinical studies have shown a more pronounced antihypertensive effect with combined therapy with perindopril and indapamide compared to monotherapy with separate components.

Clinical efficacy and safety

The effect of Triplixam® on morbidity and mortality has not been studied.

The efficacy and safety of amlodipine at 2.5-10 mg/day, the ACE inhibitor lisinopril at 10-40 mg/day as a first-line drug and the thiazide diuretic chlorthalidone at 12.5-25 mg/d was studied in the 5-year ALLHAT trial (involving 33,357 patients aged 55 years or older) in patients with mild to moderate AH and at least one additional risk factor for coronary complications, such as myocardial infarction or stroke suffered more than 6 months before study inclusion or other confirmed cardiovascular disease of atherosclerotic genesis; type 2 diabetes mellitus; high-density lipoprotein cholesterol (HDL-C) concentration less than 35 mg/dL; left ventricular hypertrophy by ECG or echocardiography; smoking.

The main criterion for efficacy assessment is the combined rate of fatal outcomes from CHD and the rate of nonfatal myocardial infarction. No significant differences were found between amlodipine and chlorthalidone groups according to the main evaluation criterion. The incidence of heart failure was significantly higher in the amlodipine group than in the chlorthalidone group, 10.2% and 7.7%, but the overall incidence of death was not significantly different in the amlodipine and chlorthalidone groups.

Perindopril/indapamide

In a study involving patients with arterial hypertension and left ventricular hypertrophy (left ventricular mass index >120 g/m2 in men and >100 g/m2 in women) the efficacy of therapy with 2 mg perindopril tert-butylamine (corresponding to 2.5 mg perindopril arginine) in combination with 0.625 mg indapamide compared with monotherapy with 10 mg enalapril, when taken once daily for 1 year, was evaluated by echocardiography. If necessary, titration of doses of perindopril tertbutylamine to 8 mg (corresponding to 10 mg perindopril arginine) and indapamide to 2.5 mg once daily or enalapril to 40 mg once daily was performed to maintain adequate BP control. In the perindopril/indapamide group, no dose increase was required in 34% of patients compared with 20% in the enalapril group.

At the end of treatment, left ventricular mass index values decreased more significantly in the perindopril/indapamide group (-10.1 g/m2) compared with the enalapril group (-1.1 g/m2).

The best effect on left ventricular mass index values was achieved with higher doses of the combination of perindopril and indapamide.

In terms of BP values, the difference between the groups was 5.8 mmHg for systolic BP and 2.3 mmHg for diastolic BP, respectively, in favor of the perindopril/indapamide group.

A study involving patients with type 2 diabetes mellitus examined the effect of lowering BP on the incidence of macrovascular events (death from cardiovascular causes, nonfatal myocardial infarction, non
fatal stroke) and microvascular complications (occurrence or worsening of the course of nephropathy and eye disease) in patients taking perindopril/indapamide combination compared with placebo, on standard therapy, as well as those taking modified-release gliclazide compared with standard therapy to maintain blood glucose levels in the normal range.

After 4.3 years of therapy, the relative risk of macrovascular and microvascular complications was reduced by 9% in the group taking the perindopril/indapamide combination. The benefit was achieved by a significant reduction in the relative risk of mortality by 14%, death due to cardiovascular causes by 18%, and renal complications by 21% in the group of patients receiving the perindopril/indapamide combination compared with placebo.

The subgroup of patients with arterial hypertension showed a 9% significant reduction in the relative risk of combined incidence of macrovascular and microvascular complications in the group receiving perindopril/indapamide combination compared to placebo.

The relative risk of mortality (by 16%), death due to cardiovascular causes (by 20%), and renal complications (by 20%) was also significantly reduced in this group in patients receiving perindopril/indapamide combination compared to patients receiving placebo.

The benefits of hypotensive therapy were independent of the benefits achieved on intensive glycemic control.

Double RAAS blockade

There are data from clinical trials of combination therapy with an ACE inhibitor with ARA II.

There have been clinical studies involving patients with a history of cardiovascular or cerebrovascular disease, or type 2 diabetes with confirmed target organ damage, as well as studies involving patients with type 2 diabetes and diabetic nephropathy.

These studies found no significant positive effect on the occurrence of renal and/or cardiovascular complications and mortality rates in patients receiving combination therapy, while the risk of hyperkalemia, acute renal failure and/or arterial hypotension increased compared to patients receiving monotherapy.

Given the similar within-group pharmacodynamic properties of ACE inhibitors and ARA II, these results would be expected for any other drug interaction between ACE inhibitors and ARA II classes.

Therefore, ACE inhibitors and ARA II should not be used concomitantly in patients with diabetic nephropathy.

There are data from a clinical trial investigating the beneficial effects of adding aliskiren to standard therapy with an ACE inhibitor or ARA II in patients with type 2 diabetes and chronic kidney disease or cardiovascular disease, or with a combination of these conditions. The study was terminated early due to an increased risk of adverse outcomes. Cardiovascular death and stroke occurred more frequently in the group of patients receiving aliskiren compared to the placebo group. Also adverse events and serious adverse events of special interest (hyperkalemia, arterial hypotension and renal dysfunction) were registered more frequently in the aliskiren group than in the placebo group.

Indications

Active ingredient

Composition

TRIPLIXAM 10 mg / 2.5 mg / 10 mg

The active ingredients : 1 tablet contains perindopril arginine 10 mg (corresponding to 6.790 mg perindopril), indapamide 2.5 mg and amlodipine besylate 13.870 mg (corresponding to 10 mg amlodipine)

excipients : Tablet: mixture of calcium carbonate and starch, microcrystalline cellulose, croscarmellose sodium, magnesium stearate, colloidal silicon dioxide, corn starch; film coating: glycerin, hypromellose, macrogol 6000, magnesium stearate, titanium dioxide (E 171).

How to take, the dosage

For oral administration.

1 tablet Triplixam® once daily, preferably in the morning before meals.

The use of a fixed combination is not indicated for initial therapy.

If necessary, the fixed combination dose of Triplixam® can be changed or individual selection of doses separately for each component can be recommended.

Patient special groups

Patients with impaired renal function (see Sections “Contraindications” and “Administration details”). In severe renal failure (creatinine clearance less than 30 ml/min) treatment with the drug is contraindicated. Patients with moderate renal insufficiency (creatinine clearance – 30-60 ml/min) administration of Triplixam® in dose 10 mg / 2.5 mg / 5 mg and 10 mg / 2.5 mg / 10 mg is contraindicated. Routine medical monitoring should include frequent monitoring of blood creatinine and potassium levels.

Patients in the elderly. Note that the excretion of perindoprilat is decreased in elderly patients. Administration of Triplixam® in elderly patients is possible with regard to renal function.

Patients with impaired liver function. Patients with severe hepatic dysfunction are contraindicated in the treatment of Triplixam®. Triplixam® should be administered with caution in patients with mild to moderate hepatic impairment due to the lack of amlodipine dosage recommendations.

Special Instructions

All of the following disclaimers, for each drug component, also apply to the fixed combination Triplixam® .

Lithium. Simultaneous use of lithium and the perindopril/indapamide combination is generally not recommended.

Double blockade of renin-angiotensin-(RAAS). There is evidence that concomitant administration of ACE inhibitors, angiotensin II receptor blockers or aliskiren increases the risk of hypotension, hyperkalemia and decreased renal function (including acute renal failure). Therefore, dual RAAS blockade by concomitant administration of ACE inhibitors, angiotensin II receptor blockers or aliskiren is not recommended (see section “Interaction with other medicinal products and other types of interactions”). If treatment with concomitant use of two RAAS blockers is considered absolutely necessary, it may only occur under the supervision of a specialist and with frequent close monitoring of renal function, electrolyte levels and blood pressure. ACE inhibitors and angiotensin II receptor blockers should not be used simultaneously in patients with diabetic nephropathy.

Potassium-saving drugs, dietary supplements containing potassium, or salt substitutes with potassium.

The concomitant use of perindopril with potassium-saving drugs or dietary supplements containing potassium is not recommended.

Neutropenia / agranulocytosis / thrombocytopenia / anemia. Neutropenia/agranulocytosis, thrombocytopenia and anemia have been reported among patients taking ACE inhibitors. Neutropenia is rare in patients with normal renal function and in the absence of other risk factors. Perindopril should be administered very cautiously in patients with collagenosis, during therapy with immunosuppressors, allopurinol, procainamide or in combination of these factors, especially if there is impaired renal function. In some of these patients, the development of serious infectious disease has been noted, in a few cases resistant to intensive antibiotic therapy.

If perindopril is prescribed for such patients, it is advisable to periodically monitor the number of white blood cells in the blood. They should also be notified of any manifestation of an infectious disease (sore throat, fever) (see Section “Adverse Reactions”).

Hypersensitivity / angioedema. Rare cases of angioedema of the face, extremities, lips, tongue, vocal cleft, and/or larynx have been reported with ACE inhibitors, including perindopril. This can occur at any time during treatment.

In such cases, perindopril should be discontinued immediately and the patient should be appropriately monitored until the symptoms have completely disappeared. If the swelling is limited to the face and lips, the patient usually improves without treatment, and antihistamines may be useful to relieve symptoms.

Contraindications

Side effects

The most common adverse reactions observed with perindopril, indapamide, and amlodipine separately are: Dizziness, headache, paresthesias, vertigo, somnolence, visual disturbances, tinnitus, palpitation, flushes, arterial hypotension (and related symptoms), cough, shortness of breath gastrointestinal disorders (abdominal pain, constipation, diarrhea, perversion of taste (dysgeusia), dyspepsia, nausea, vomiting), itching, skin rashes, maculopapular rashes, muscle spasms, asthenia , ankle swelling, edema and fatigue.

The following adverse reactions have been observed during treatment with perindopril, indapamide, or amlodipine and are distributed by frequency as follows: Very common (≥ 1/10); common (≥ 1/100, < 1/10); infrequent ( > 1/1000, < 1/100) rare ( > 1/10000, < 1/1000); very rare (< 1/10000); frequency unknown (cannot be determined from available information).

Infections and invasions. Rhinitis: perindopril, very rare; amlodipine, infrequent.

Hematological and lymphatic system disorders. Agranulocytosis: perindopril and indapamide – very rare; aplastic anemia: indapamide – very rare; pancytopenia: perindopril – very rare; leukopenia: perindopril, indapamide, amlodipine – very rare; neutropenia: perindopril, very rare; hemolytic anemia: perindopril, indapamide, very rare; thrombocytopenia: perindopril, indapamide, amlodipine, very rare; eosinophilia: perindopril, not frequent *.

The immune system. Hypersensitivity reactions: amlodipine – very rare, indapamide – infrequent.

Metabolism and metabolism disorders. Hyperkalemia, which disappears after drug withdrawal: perindopril – infrequent *; hyperglycemia: amlodipine – very rare; hypercalcemia: indapamide – very rare; hypoglycemia: perindopril – infrequent *; decreased potassium levels with hypokalemia, particularly serious in high-risk patients: indapamide – frequency unknown; hyponatremia: perindopril – infrequent * indapamide – frequency unknown.

Psychiatric side. Confusion of consciousness: perindopril – very rare, amlodipine – rare; insomnia: amlodipine – infrequent; mood changes (including anxiety): amlodipine – infrequent, perindopril – infrequent; depression: amlodipine – infrequent; sleep disorders: perindopril – infrequent.

Nervous system disorders. Dizziness: perindopril and amlodipine – often; headache: perindopril and amlodipine – often, indapamide – rarely; paresthesias: perindopril – often, indapamide – rarely, amlodipine – infrequently; vertigo: perindopril – frequent, indapamide – rare; confusion: perindopril – very rare; hypertension: amlodipine – very rare; peripheral neuropathy: amlodipine – very rare; hypoesthesia: amlodipine – infrequent; perversion of taste (dysgeusia): perindopril – frequent, amlodipine – infrequent; tremor: amlodipine – infrequent; syncope: perindopril – infrequent * indapamide – frequency unknown, amlodipine – infrequent; drowsiness: perindopril – infrequent * amlodipine – frequent; extrapyramidal disorders (extrapyramidal symptoms): amlodipine – frequency unknown; stroke, possibly due to excessive blood pressure reduction in high-risk patients: perindopril – very rare.

Visual organs. Visual impairment: perindopril – frequently, indapamide – frequency unknown, amlodipine – infrequently; double vision: amlodipine – infrequently; myopia: indapamide – frequency unknown; blurred vision: indapamide – frequency unknown.

Hearing and ear labyrinth side. Tinnitus: perindapril – frequently, amlodipine – infrequently.

Cardiac side. Angina: perindopril – very rarely; arrhythmias (including bradycardia, ventricular tachycardia and atrial fibrillation): perindopril, indapamide, amlodipine – very rarely; myocardial infarction may occur due to excessive reduction of blood pressure in high-risk patients: perindopril and amlodipine, very rare; palpitation: perindopril, infrequent * amlodipine, frequent; paroxysmal ventricular torsade de pointes, which can be fatal: indapamide, frequency unknown; tachycardia: perindopril, infrequent *.

Vascular system disorders. Tides: amlodipine – often; hypotension (and related symptoms): perindopril – often, indapamide – very rarely, amlodipine – infrequently; vasculitis: perindopril – infrequently * amlodipine – very rarely.

The respiratory system, thoracic and mediastinal organs. Cough: perindopril – often, amlodipine – very rarely; shortness of breath: perindopril – often, amlodipine – infrequently; bronchospasm: perindopril – infrequently; eosinophilic pneumonia: perindopril – very rarely.

Digestive system disorders. Abdominal pain: perindopril and amlodipine – often; constipation: perindopril – often, indapamide – rarely, amlodipine – infrequently; diarrhea: perindopril – often, amlodipine – infrequently; dyspepsia: perindopril – often, amlodipine – infrequently; nausea: perindopril and amlodipine – often, indapamide – rarely; vomiting: perindopril, frequent; indapamide and amlodipine, infrequent; dry mouth: perindopril and amlodipine, infrequent; indapamide, rare; altered defecation rhythm: amlodipine, infrequent; gum hyperplasia: amlodipine, very rare; pancreatitis perindopril, indapamide and amlodipine, very rare; gastritis: amlodipine, very rare.

Digestive system disorders. Hepatitis: perindopril and amlodipine – very rare, indapamide – frequency is unknown; jaundice: amlodipine – very rare; impaired liver function indapamide – very rare; in the presence of hepatic failure may occur hepatic encephalopathy: indapamide – frequency is unknown.

Skin and subcutaneous tissue disorders. Quincke’s edema: amlodipine – very rarely; pruritus: perindopril – often, amlodipine – infrequently; rash: perindopril – often, amlodipine – infrequently; maculopapular rash: indapamide – often; urticaria: perindopril – infrequently, indapamide and amlodipine – very rarely; angioedema: perindopril, infrequent, indapamide and amlodipine, very rare; alopecia: amlodipine, infrequent; purpura: indapamide and amlodipine, infrequent; skin discoloration: amlodipine, infrequent; hyperhidrosis: perindopril and amlodipine, infrequent; exanthem: amlodipine, infrequent; erythema multiforme: perindopril and amlodipine, very rare; Stevens-Johnson syndrome: indapamide and amlodipine, very rare; exfoliative dermatitis: amlodipine, very rare; toxic epidermal necrolysis: indapamide – very rare; photosensitization reactions: perindopril – infrequent * indapamide – frequency unknown, amlodipine – very rare; possible worsening of existing systemic lupus erythematosus: indapamide – frequency unknown; pemphigoid: perindopril – infrequent *.

Musculoskeletal and connective tissue disorders. Muscle spasms: perindopril – often, amlodipine – infrequently; ankle edema: amlodipine – often; arthralgia: perindopril – infrequently * amlodipine – infrequently; myalgia: perindopril – infrequently * amlodipine – infrequently; back pain: amlodipine – infrequently.

Kidney and urinary tract disorders. Urinary disorders, nycturia, frequent urination: amlodipine – infrequent; acute renal failure: perindopril – very rare; renal failure: perindopril – infrequent, indapamide – very rare.

With the reproductive system and the mammary glands. Erectile dysfunction: perindopril and amlodipine – infrequently; gynecomastia: amlodipine – infrequently.

General disorders. Asthenia: perindopril – often, amlodipine – infrequently; increased fatigue: indapamide – rarely, amlodipine – often; edema amlodipine – often; chest pain: perindopril – infrequently * amlodipine – infrequently; pain: amlodipine, infrequent; malaise: perindopril, infrequent * amlodipine, infrequent; peripheral edema perindopril, infrequent *; hyperthermia: perindopril, infrequent *.

Studies. Increase / decrease in body weight: amlodipine – infrequently; increase in blood bilirubin: perindopril – rarely; increase in liver enzymes: perindopril – rarely, indapamide – frequency is unknown, amlodipine – very rarely; increase in blood creatinine: perindopril – infrequently *; increase in blood urea: perindopril – infrequent *; decreased hemoglobin and hematocrit levels: perindopril – very rare; prolongation of QT interval on electrocardiogram: indapamide – frequency unknown; increased blood glucose levels: indapamide – frequency unknown; increased blood uric acid levels: indapamide – frequency unknown.

Injuries, poisoning and complications of ingestion. Falling: perindopril – infrequent *.

* Frequency was calculated from clinical trial data for adverse reactions that were found based on spontaneous reports.

Report suspected adverse reactions. Reporting suspected adverse reactions after the drug is registered is important. This will allow for continued monitoring of the benefit/risk ratio. Healthcare providers have been asked to report suspected adverse reactions through the national reporting system.

Overdose

There are no data on overdose of Triplixam®.

For the perindopril/indapamide combination a common adverse reaction in overdose is arterial hypotension, which may sometimes be accompanied by nausea, vomiting, seizures, dizziness, drowsiness, confusion, oliguria, which may progress to anuria (due to hypovolemia). There may be disorders of water-electrolyte balance (decrease of plasma potassium and sodium levels).

The first aid measures include rapid elimination of the drug from the body: gastric lavage and/or administration of activated charcoal, and then restoration of the water-electrolyte balance in a hospital setting until these values return to normal limits.

In case of significant hypotension, the patient should be placed in a horizontal position with a low headboard. If necessary, intravenous isotonic solution or any other method of restoring blood volume should be used.

Perindoprilat, the active form of perindopril, can be removed from the body by hemodialysis.

There are limited data on conscious overdose of amlodipine.

The evidence suggests that taking very high doses will result in excessive peripheral vasodilation and reflex tachycardia. Severe, probably prolonged systemic hypothermia and fatal shock have been reported.

The clinically pronounced hypotension caused by amlodipine overdose requires active cardiovascular care, in particular frequent monitoring of cardiac and respiratory function, elevation of limbs, and monitoring of circulating blood volume and urinary output.

Prescribing a vasoconstrictor may be useful to restore vascular tone and blood pressure if there are no contraindications.

The administration of calcium gluconate may help reverse the effects of calcium channel blockade.

In some cases, gastric lavage is appropriate. A study involving healthy volunteers showed that activated charcoal 2:00 after taking 10 mg of amlodipine reduced the rate of absorption of amlodipine in the body. Because amlodipine has a high level of binding to blood proteins, hemodialysis was found to be ineffective.

Similarities