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Augmentation of the vasodilatory effects of isosorbide dinitrate by phosphodi-esterase inhibitors such as sildenafil,vardenafil,or tadalafil could result in severe hypotension. The time course and dose dependence of this interaction have not been studied.Reasonable supportive care should consist of those measures used to treat a nitrate overdose with elevation of the extremities and central volume expansion.
The precautions that need to be taken when using BiDil (isosorbide dinitrate and hydralazine hcl) are those appropriate to each of its components.
Treatment with hydralazine hydrochloride may produce a clinical picture simulating systemic lupus erythematosus including glomerulonephritis.
If systemic lupus erythematosus-like symptoms occur in patients treated with BiDil (isosorbide dinitrate and hydralazine hcl) , discontinuation of BiDil (isosorbide dinitrate and hydralazine hcl) should be considered only after a thorough benefit-to-risk assessment. Symptoms and signs of systemic lupus erythematosus usually regress when hydralazine hydrochloride is discontinued but residua have been detected many years later. Long-term treatment with steroids may be necessary. (See PRECAUTIONS. Laboratory Tests.)
Symptomatic hypotension, particularly with upright posture, may occur with even small doses of BiDil (isosorbide dinitrate and hydralazine hcl) .Therefore,BiDil (isosorbide dinitrate and hydralazine hcl) should be used with caution in patients who may be volume depleted or who,for whatever reason,are already hypotensive.
Careful clinical and hemodynamic monitoring is recommended when BiDil (isosorbide dinitrate and hydralazine hcl) is administered to patients with acute myocardial infarction to avoid the hazards of hypotension and tachycardia.
Hydralazine hydrochloride has been associated with peripheral neuritis,evidenced by paresthesia, numbness,and tingling,which may be related to an antipyridoxine effect.Pyridoxine should be added to BiDil (isosorbide dinitrate and hydralazine hcl) therapy if such symptoms develop.
Isosorbide dinitrate therapy may aggravate angina associated with hypertrophic cardiomyopathy.
If symptoms suggestive of systemic lupus erythematosus occur,such as arthral-gia,fever,chest pain,prolonged malaise,or other unexplained signs or symptoms, complete blood counts and antinuclear antibody titer determinations should be performed. A positive antinuclear antibody titer requires that the physician carefully weigh the benefits and risks of continued therapy with BiDil (isosorbide dinitrate and hydralazine hcl) .
Carcinogenesis, Mutagenesis, Impairment of Fertility
An increased incidence of lung tumors (adenomas and adenocarcinomas) was observed in a lifetime study in Swiss albino mice given hydralazine hydrochloride continuously in their drinking water at a dosage of about 250 mg/kg per day (6 times the MRHD provided by BiDil (isosorbide dinitrate and hydralazine hcl) on a body surface area basis). In a 2-year car-cinogenicity study of rats given hydralazine hydrochloride by gavage at dose levels of 15,30,and 60 mg/kg/day (up to 3 times the MRHD of BiDil (isosorbide dinitrate and hydralazine hcl) on a body surface area basis), microscopic examination of the liver revealed a small, but statistically significant increase in benign neoplastic nodules in males (high-dosage) and females (both high and intermediate dosage groups. Benign interstitial cell tumors of the testes were also significantly increased in the high-dose group.
Hydralazine hydrochloride is mutagenic in bacterial systems,and is positive in rat and rabbit hepatocyte DNA repair studies in vitro. Additional in vivo and in vitro studies using lymphoma cells, germinal cells,fibroblasts from mice,bone marrow cells from Chinese hamsters and fibroblasts from human cell lines did not demonstrate any mutagenic or clastogenic potential for hydralazine hydrochloride.
No long-term animal studies have been performed to evaluate the mutagenic or carcinogenic potential of isosorbide dinitrate. A modified two-litter reproduction study among rats fed isosorbide dinitrate at 25 or 100 mg/kg/day (up to 9 times the Maximum Recommended Human Dose of BiDil (isosorbide dinitrate and hydralazine hcl) on a body surface area basis) revealed no evidence of altered fertility or gestation.
Pregnancy Category C
Isosorbide dinitrate has been shown to cause a dose-related increase in embryo-toxicity (excess mummified pups) in rabbits at 70 mg/kg (12 times the MRHD of BiDil (isosorbide dinitrate and hydralazine hcl) on a body surface area basis).Hydralazine hydrochloride is teratogenic in mice at 66 mg/kg and possibly in rabbits at 33 mg/kg (2 and 3 times the MRHD of BiDil (isosorbide dinitrate and hydralazine hcl) on a body surface area basis).There are no animal studies assessing the teratogenicity of BiDil (isosorbide dinitrate and hydralazine hcl) .
A meta-analysis of randomized controlled trials comparing hydralazine hydrochloride with other antihypertensive agents for severe hypertension in pregnancy found that hydralazine hydrochloride was associated with significantly more maternal hypotension, placental abruption, caesarean sections and oliguria, with more adverse effects on fetal heart rate and with lower Apgar scores.
A combination of propranolol and hydralazine hydrochloride was administered to 13 patients with long-standing hypertension during 15 pregnancies.These preg-nancies resulted in 14 live births and one unexplained stillbirth. The only neonatal complications were two cases of mild hypoglycemia. Hydralazine hydrochloride and its metabolites have been detected using a non-selective assay in maternal and umbilical plasma in patients treated with the drug during pregnancy.
Isosorbide dinitrate has been used for effective acute and sub-chronic control of hypertension in pregnant women,but there are no studies using it in a chronic regimen and assessing its effects on pregnant women and/or the fetus.
There are no studies using BiDil (isosorbide dinitrate and hydralazine hcl) in pregnant women. Therefore,BiDil (isosorbide dinitrate and hydralazine hcl) should be used with caution during pregnancy and only if the potential benefit justifies the potential risk to the fetus.
The possible excretion of hydralazine in breast milk has not been determined.It is also not known whether isosorbide dinitrate is excreted in human milk.No studies have been performed with BiDil (isosorbide dinitrate and hydralazine hcl) .Caution should be exercised when BiDil (isosorbide dinitrate and hydralazine hcl) is admin-istered to a nursing woman.
The safety and effectiveness of BiDil (isosorbide dinitrate and hydralazine hcl) in children have not been established.
Clinical studies of BiDil (isosorbide dinitrate and hydralazine hcl) did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. Other reported clinical experience has not identified differences in response between elderly and younger patients. In general, dose selection for an elderly patient should be cautious,usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic and renal function,and of concomitant disease or other drug therapies.
Isosorbide dinitrate, its active metabolites,and hydralazine may be eliminated more slowly in elderly patients.
Last reviewed on RxList: 10/7/2008
This monograph has been modified to include the generic and brand name in many instances.
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