Dynacirc CR

Hypertension

DynaCirc CR® (isradipine) is indicated in the management of hypertension. It may be used alone or concurrently with thiazide-type diuretics.

Mechanism of Action

Isradipine is a dihydropyridine calcium channel blocker. It binds to calcium channels with high affinity and specificity and inhibits calcium flux into cardiac and smooth muscle. The effects observed in mechanistic experiments in vitro and studied in intact animals and man are compatible with this mechanism of action and are typical of the class.

Except for diuretic activity,the mechanism of which is not clearly understood,the pharmacodynamic effects of isradipine observed in whole animals can also be explained by calcium channel blocking activity, especially dilating effects in arterioles which reduce systemic resistance and lower blood pressure, with a small increase in resting heart rate. Although like other dihydropyridine calcium channel blockers, isradipine has negative inotropic effects in vitro, studies conducted in intact anesthetized animals have shown that the vasodilating effect occurs at doses lower than those which affect contractility. In patients with normal ventricular function,isradipine's afterload reducing properties lead to some increase in cardiac output.

Effects in patients with impaired ventricular function have not been fully studied.

Clinical Effects

In randomized, placebo-controlled, double-blind, clinical trials, DynaCirc CR® (isradipine) Controlled Release Tablets have been shown to have antihypertensive effects proportional to doses between 5 and 20 mg,administered once daily. DynaCirc CR® (isradipine) produced statistically significant reductions in supine and standing blood pressure, compared with placebo, 24 hours postdose.The endpoint results of one parallel group dose-ranging trial showed mean responses 24 hours after ingestion of DynaCirc CR® (isradipine) (systolic/diastolic) -5.2/-2.8, -13.4/-9.7, -15.6/-10.2 and -15.5/-11.8 mmHg, for 5, 10, 15 and 20 mg doses, respectively, change from baseline greater than concurrent placebo.The antihypertensive effect of any one dose begins in about 2 hours and reaches a peak at about 8-10 hours postdose.At the recommended starting dose (5 mg) the trough response (24 hours after dosing) was about 76% that of the peak.At doses of 10,15 and 20 mg,the trough blood pressure response was about equal to that at peak effect.In association with the fall in blood pressure, resting heart rate is slightly increased, on average from 1-3 beats/minute. The antihypertensive response to DynaCirc CR® (isradipine) has not been detected to be influenced by gender or age.

Hemodynamics

In man, peripheral vasodilation produced by immediate-release DynaCirc® (isradipine) is reflected by decreased systemic vascular resistance and increased cardiac output. Hemodynamic studies conducted in patients with normal left ventricular function produced, following intravenous isradipine administration, increases in cardiac index, stroke volume index,coronary sinus blood flow,heart rate and peak positive left ventricular dP/dt.Systemic,coronary, and pulmonary vascular resistance was decreased. These studies were conducted with doses of isradipine which produced clinically significant decreases in blood pressure. The clinical consequences of these hemodynamic effects,if any,have not been evaluated.

Effects on heart rate are variable,dependent upon rate of administration and presence of underlying cardiac condition. While increases in both peak positive dP/dt and LV ejection fraction are seen when intravenous isradipine is given,it is impossible to conclude that these represent a positive inotropic effect due to simultaneous changes in preload and afterload. In patients with coronary artery disease undergoing atrial pacing during cardiac catheterization, intravenous isradipine diminished abnormalities of systolic performance.In patients with moderate left ventricular dysfunction,oral and intravenous isradipine in doses which reduce blood pressure by 12%-30%, resulted in improvement in cardiac index without increase in heart rate,and with no change or reduction in pulmonary capillary wedge pressure.Combina-tion of isradipine and propranolol did not significantly affect left ventricular dP/dt max. The clinical consequences of these effects have not been evaluated.

Electrophysiologic Effects

In general, no detrimental effects on the cardiac conduction system were seen with the use of immediate-release DynaCirc® (isradipine). Electrophysiologic studies were conducted on patients with normal sinus and atrioventricular node function. Intravenous isradipine in doses which reduce systolic blood pressure did not affect PR, QRS, AH* or HV* intervals.

No changes were seen in Wenckebach cycle length,atrial,and ventricular refractory periods.Slight prolongation of QTc interval of 3% was seen in one study.Effects on sinus node recovery time (CSNRT) were mild or not seen.

In patients with sick sinus syndrome, at doses which significantly reduced blood pressure, intravenous isradipine resulted in no depressant effect on sinus and atrioventricular node function.

*AH = conduction time from low right atrium to His bundle deflection, or AV nodal conduction time; HV = conduction time through His bundle and the bundle branch-Purkinje system.

Pharmacokinetics and Metabolism

With the immediate-release formulation DynaCirc® (isradipine) Capsules, 90%-95% of the orally administered dose is absorbed. Because of the biotransformation of isradipine during its first-pass through the portal circulation, the bioavailability of DynaCirc CR® (isradipine) ranges from 15%-24%.Isradipine is 95% bound to plasma proteins.

Peak concentrations of approximately 1 ng/mL/mg dosed occur about 1.5 hours after DynaCirc® (isradipine) Capsules administration. The elimination of isradipine is biphasic with an early half-life of 11/2-2 hours, and a terminal half-life of about 8 hours, resulting in trough concentrations of about 0.1 ng/mL/mg dosed of immediate-release DynaCirc® (isradipine) Capsules.

In single dose studies of DynaCirc CR® (isradipine) Controlled Release Tablets,after a 2-3 hour lag time,concentrations of isradipine plateau between 7 and 18 hours post-dosing (reaching aCmax of 3-4 ng/mL with an AUC of 62-73 ng•h/mL for a 10 mg dose) and then a concentration > 50% of the peak exists for 17-20 hours.

There is no evidence of dose dumping either in the presence or absence of food.Food has been shown to decrease the extent of bioavailability of DynaCirc CR® (isradipine) by up to 25%.

The pharmacokinetics of DynaCirc CR® (isradipine) Controlled Release Tablets are linear over the dose range of 5-20 mg,in that the plasma drug concentrations are proportional to the dose administered.

Isradipine is completely metabolized prior to excretion,and no unchanged drug is detected in the urine.The major routes of isradipine metabolism are ring oxidation of the dihydropyridine moiety to give the corresponding pyridine,and ester cleavage,with or without concomitant oxidation of the dihydropyridine moiety,giving the corresponding carboxylic acids. The cytochrome P-450 IIIA4 system is implicated in the formation of these metabolites, which are hemodynamically inactive. Approximately 60%-65% of an administered dose is excreted in the urine and 25%-30% in the feces. With immediate-release DynaCirc® (isradipine), mild renal impairment (creatinine clearance 30-80 mL/min) increases the AUC of isradipine by 45%. Progressive deterioration reverses this trend, and patients with severe renal failure (creatinine clearance < 10 mL/min) who have been on hemodialysis show a 20%-50% lower AUC than healthy volunteers. In elderly patients administered DynaCirc® (isradipine) Capsules, Cmax and AUC are increased by 13% and 40%,respectively; in patients with hepatic impairment,Cmax and AUC are increased by 32% and 52%,respectively (see DOSAGE AND ADMINISTRATION).

DynaCirc CR® (isradipine) Controlled Release Tablets should be swallowed whole.Do not chew,divide or crush tablets. Do not be concerned if you occasionally notice in your stool something resembling a tablet.In DynaCirc CR® (isradipine), the medication is contained within a nonabsorbable shell that has been specially designed to slowly release the drug for your body to absorb. When this process is completed, the empty tablet shell is eliminated in the stool.

Take the missed dose as soon as you remember. If it is almost time for your next dose, wait until then to take the medicine and skip the missed dose. Do not take extra medicine to make up the missed dose.

Your pharmacist can provide more information about isradipine.

Remember, keep this and all other medicines out of the reach of children, never share your medicines with others, and use this medication only for the indication prescribed.

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Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Follow the directions on your prescription label.

Your doctor may occasionally change your dose to make sure you get the best results from this medication.

Do not crush, chew, or break an extended-release tablet. Swallow the pill whole. Breaking the pill may cause too much of the drug to be released at one time.

Some tablet forms of isradipine are made with a shell that is not absorbed or melted in the body. Therefore, you may see what looks like part of a tablet in your stool. This is a normal side effect of isradipine and will not make the medication less effective.

Keep using this medicine as directed, even if you feel well. High blood pressure often has no symptoms, so you may not know when your blood pressure is high. You may need to use blood pressure medication for the rest of your life.

To be sure this medication is helping your condition, your blood pressure will need to be checked on a regular basis. Do not miss any scheduled appointments.

Store isradipine at room temperature away from moisture, heat, and light.

Isradipine is used alone or together with other medicines (such as hydrochlorothiazide) to treat high blood pressure (hypertension). High blood pressure adds to the workload of the heart and arteries. If it continues for a long time, the heart and arteries may not function properly. This can damage the blood vessels of the brain, heart, and kidneys, resulting in a stroke, heart failure, or kidney failure. High blood pressure may also increase the risk of heart attacks. These problems may be less likely to occur if blood pressure is controlled .

Isradipine is a calcium channel blocker. It works by affecting the movement of calcium into the cells of the heart and blood vessels. As a result, isradipine relaxes blood vessels and increases the supply of blood and oxygen to the heart while reducing its workload .

This medicine is available only with your doctor's prescription .

DynaCirc CR contains isradipine, a calcium antagonist. It is available for once-daily oral administration as a controlled-release 5-mg and 10-mg tablet. DynaCirc CR is a registered trademark for isradipine GITS (Gastrointestinal Therapeutic System) tablets.

The structural formula of isradipine is:

Chemically, isradipine is 3,5-Pyridinedicarboxylic acid, 4-(4-benzofurazanyl)-1,4-dihydro-2,6-dimethyl-, methyl 1-methylethyl ester, with a molecular weight of 371.39. The molecular formula is C19H21N3O5. Isradipine is a yellow, fine crystalline powder which is odorless or has a faint characteristic odor. Isradipine is practically insoluble in water (<10 mg/L at 37ºC), but is soluble in ethanol and freely soluble in acetone, chloroform, and methylene chloride.

Active Ingredient

Isradipine

Inactive Ingredients

Butylated hydroxytoluene, cellulose acetate, hypromellose, magnesium stearate, polyethylene glycol, polyethylene oxide, polysorbate 80, propylene glycol, red ferric oxide, silicon dioxide, sodium chloride, titanium dioxide, yellow ferric oxide.

System Components and Performance

Isradipine is delivered from the DynaCirc CR Controlled Release Tablet as follows: a semipermeable membrane surrounds an osmotically active drug core. The core is composed of 2 layers: an “active” layer containing the drug, and a pharmacologically inert but osmotically active “push” layer. After ingestion, the tablet overcoating is quickly dissipated in the gastrointestinal tract, allowing water to enter the tablet through the semipermeable membrane. The polyethylene oxide polymer swells in the osmotic (“push”) layer and exerts pressure against the “active” drug layer, releasing isradipine as a fine suspension through the laser-drilled tablet orifice which has been positioned on the “active” drug layer side. Drug delivery is essentially constant as long as the osmotic gradient remains constant and, after either 5 mg or 10 mg of isradipine is released, gradually falls to a negligible amount. The controlled rate of drug delivery into the gastrointestinal lumen is independent of pH or gastrointestinal motility. The delivery of isradipine in DynaCirc CR depends on the existence of an osmotic gradient between the contents of the bilayer core and the fluid in the GI tract. The biologically inert core of the tablet remains intact and, unless it becomes trapped, is eliminated in the feces.

Mechanism of Action

Isradipine is a dihydropyridine calcium channel blocker. It binds to calcium channels with high affinity and specificity and inhibits calcium flux into cardiac and smooth muscle. The effects observed in mechanistic experiments in vitro and studied in intact animals and man are compatible with this mechanism of action and are typical of the class.

Except for diuretic activity, the mechanism of which is not clearly understood, the pharmacodynamic effects of isradipine observed in whole animals can also be explained by calcium channel blocking activity, especially dilating effects in arterioles which reduce systemic resistance and lower blood pressure, with a small increase in resting heart rate. Although like other dihydropyridine calcium channel blockers, isradipine has negative inotropic effects in vitro, studies conducted in intact anesthetized animals have shown that the vasodilating effect occurs at doses lower than those which affect contractility. In patients with normal ventricular function, isradipine’s afterload-reducing properties lead to some increase in cardiac output.

Effects in patients with impaired ventricular function have not been fully studied.

Clinical Effects

In randomized, placebo-controlled, double-blind, clinical trials, DynaCirc CR has been shown to have antihypertensive effects proportional to doses between 5 and 20 mg, administered once daily. DynaCirc CR produced statistically significant reductions in supine and standing blood pressure, compared with placebo, 24 hours postdose. The endpoint results of one parallel-group, dose-ranging trial showed mean responses 24 hours after ingestion of DynaCirc CR (systolic/diastolic) -5.2/-2.8, -13.4/-9.7, -15.6/-10.2, and -15.5/-11.8 mmHg, for 5-, 10-, 15-, and 20-mg doses, respectively, change from baseline greater than concurrent placebo. The antihypertensive effect of any one dose begins in about 2 hours and reaches a peak at about 8 to 10 hours postdose. At the recommended starting dose (5 mg) the trough response (24 hours after dosing) was about 76% that of the peak. At doses of 10, 15, and 20 mg, the trough blood pressure response was about equal to that at peak effect. In association with the fall in blood pressure, resting heart rate is slightly increased, on average from 1 to 3 beats/minute. The antihypertensive response to DynaCirc CR has not been detected to be influenced by gender or age.

Hemodynamics

In man, peripheral vasodilation produced by immediate-release DYNACIRC is reflected by decreased systemic vascular resistance and increased cardiac output. Hemodynamic studies conducted in patients with normal left ventricular function produced, following intravenous isradipine administration, increases in cardiac index, stroke volume index, coronary sinus blood flow, heart rate, and peak positive left ventricular dP/dt. Systemic, coronary, and pulmonary vascular resistance was decreased. These studies were conducted with doses of isradipine which produced clinically significant decreases in blood pressure. The clinical consequences of these hemodynamic effects, if any, have not been evaluated.

Effects on heart rate are variable, dependent upon rate of administration and presence of underlying cardiac condition. While increases in both peak positive dP/dt and LV ejection fraction are seen when intravenous isradipine is given, it is impossible to conclude that these represent a positive inotropic effect due to simultaneous changes in preload and afterload. In patients with coronary artery disease undergoing atrial pacing during cardiac catheterization, intravenous isradipine diminished abnormalities of systolic performance. In patients with moderate left ventricular dysfunction, oral and intravenous isradipine in doses which reduce blood pressure by 12% to 30%, resulted in improvement in cardiac index without increase in heart rate, and with no change or reduction in pulmonary capillary wedge pressure. Combination of isradipine and propranolol did not significantly affect left ventricular dP/dt max. The clinical consequences of these effects have not been evaluated.

Electrophysiologic Effects

In general, no detrimental effects on the cardiac conduction system were seen with the use of immediate-release DYNACIRC. Electrophysiologic studies were conducted on patients with normal sinus and atrioventricular node function. Intravenous isradipine in doses which reduce systolic blood pressure did not affect PR, QRS, AH*, or HV* intervals.

No changes were seen in Wenckebach cycle length, atrial, and ventricular refractory periods. Slight prolongation of QTc interval of 3% was seen in one study. Effects on sinus node recovery time (CSNRT) were mild or not seen.

In patients with sick sinus syndrome, at doses which significantly reduced blood pressure, intravenous isradipine resulted in no depressant effect on sinus and atrioventricular node function.

* AH = conduction time from low right atrium to His bundle deflection, or AV nodal conduction time

* HV = conduction time through His bundle and the bundle branch-Purkinje system.

Pharmacokinetics and Metabolism

With the immediate-release formulation DYNACIRC, 90% to 95% of the orally administered dose is absorbed. Because of the biotransformation of isradipine during its first-pass through the portal circulation, the bioavailability of DynaCirc CR ranges from 15% to 24%. Isradipine is 95% bound to plasma proteins.

Peak concentrations of approximately 1 ng/mL/mg dosed occur about 1.5 hours after administration of immediate-release DYNACIRC. The elimination of isradipine is biphasic with an early half-life of 1½ to 2 hours, and a terminal half-life of about 8 hours, resulting in trough concentrations of about 0.1 ng/mL/mg dosed of immediate-release DYNACIRC.

In single-dose studies of DynaCirc CR, after a 2 to 3 hour lag time, concentrations of isradipine plateau between 7 and 18 hours post-dosing (reaching a Cmax of 3 to 4 ng/mL with an AUC of 62 to 73 ng•h/mL for a 10-mg dose) and then a concentration >50% of the peak exists for 17 to 20 hours.

There is no evidence of dose dumping either in the presence or absence of food. Food has been shown to decrease the extent of bioavailability of DynaCirc CR by up to 25%.

The pharmacokinetics of DynaCirc CR are linear over the dose range of 5 to 20 mg, in that the plasma drug concentrations are proportional to the dose administered.

Isradipine is completely metabolized prior to excretion, and no unchanged drug is detected in the urine. The major routes of isradipine metabolism are ring oxidation of the dihydropyridine moiety to give the corresponding pyridine, and ester cleavage, with or without concomitant oxidation of the dihydropyridine moiety, giving the corresponding carboxylic acids. The cytochrome P450 3A4 system is implicated in the formation of these metabolites, which are hemodynamically inactive. Approximately 60% to 65% of an administered dose is excreted in the urine and 25% to 30% in the feces. With immediate-release DYNACIRC, mild renal impairment (creatinine clearance 30 to 80 mL/min) increases the AUC of isradipine by 45%. Progressive deterioration reverses this trend, and patients with severe renal failure (creatinine clearance <10 mL/min) who have been on hemodialysis show a 20% to 50% lower AUC than healthy volunteers. In elderly patients administered immediate-release DYNACIRC, Cmax and AUC are increased by 13% and 40%, respectively; in patients with hepatic impairment, Cmax and AUC are increased by 32% and 52%, respectively (see DOSAGE AND ADMINISTRATION).

DynaCirc CR is contraindicated in individuals who have shown hypersensitivity to any of the ingredients in the formulation.