Candesartan is an Angiotensin Receptor Blocker that acts on the RAAS (Renin-angiotensin-activating-system) and blocks the angiotensin receptors. It is indicated for the treatment of patients with Hypertension and symptomatic heart failure.  It is also used (off-label) for stable coronary artery disease and the secondary prevention of cardiovascular events in patients with acute coronary syndrome.

Candesartan Dose in Adults

Candesartan dose in the treatment of Hypertension:

• 8 mg orally once a day.
• The dose may be titrated up to a maximum of 32 mg once a day based on the patients' response.

Candesartan dose in the treatment of Heart failure:

• 4 - 8 orally mg once a day.
• Double the dose at intervals of two weeks to a maximum dose of 32 mg once a day.

Candesartan Dose in Childrens

Candesartan dose in the treatment of Hypertension:

• Children 1 - 6 years:
  • 0.2 mg/kg/day orally once a day.
  • The dose may be incrementally increased at two weeks intervals to a maximum dose of 0.4 mg/kg/day in one or two divided doses.
• Children and Adolescents 6 - 17 years:
  • weighing less than 50 kgs:
    • 4 to 8 mg/day orally once a day.
    • The dose may be incrementally increased at two weeks intervals to a maximum dose of 32 mg/day.
  • weighing more than 50 kgs:
    • 8 - 16 mg/day orally once a day.
    • The dose may be incrementally increased at two weeks intervals to a maximum dose of 32 mg/day.
• Adolescents older than 17 years:
  • 8 mg orally once a day.
  • The dose may be titrated up to a maximum of 32 mg once a day based on the patients' response.

Pregnancy Risk Factor D

[US Boxed Warning]

• Like other drugs that act on the RAAS system can cause injury or death in the developing fetus.
• Once pregnancy is confirmed, it should be stopped immediately.
• Candesartan crosses a placental barrier and is used in pregnancy. It can cause oligohydramnios, which can lead to fetal lung hypoplasia or skeletal malformations.
• Additionally, oligohydramnios might not be present until irreversible fetal injuries have occurred.
• It can also lead to hypotension, anuria and skull hypoplasia in infants/neonates.
• Hypertensive patients who are pregnant should avoid ARBs and ACE-Inhibitors.
• Alternative therapies should be considered if necessary.

Candesartan use during breastfeeding:

• Breastmilk does not contain candesartan.
• Manufacturers recommend that you stop using the drug, or breastfeed, after weighing the benefits and risks.

Candesartan dose in Renal disease:

• It should be used with caution in patients with severe renal impairment and ESRD.
• In patients with acute kidney injury, it should be avoided.

Candesartan dose in Liver disease:

• Mild hepatic impairment (Child-Pugh class A):
  • Dose adjustment is not necessary.
• Moderate hepatic impairment (Child-Pugh class B):
  • 8 mg once a day.
• Severe hepatic impairment (Child-Pugh class C):
  • It should best be avoided.
  • The manufacturer, however, has not provided any adjustment in the dose in patients with severe hepatic impairment.

Common Side Effects Of Candesartan Include:

• Cardiovascular:
  • Hypotension
• Renal:
  • Renal function abnormality

Less Common Side Effects Of Candesartan Include:

• Central nervous system:
  • Dizziness
• Endocrine & metabolic:
  • Hyperkalemia
• Neuromuscular & skeletal:
  • Back pain
• Respiratory:
  • Upper respiratory tract infection
  • Pharyngitis
  • Rhinitis

Frequency not defined:

• Central nervous system:
  • Headache
• Renal:
  • Exacerbation of renal disease
  • Increased serum creatinine

Contraindication to Candesartan include:

• Severe allergic reactions candesartan and any other component of the formulation
• Concomitant use of direct renin inhibitors - Aliskiren
• Pregnancy
• Breastfeeding
• Children less than 1 year old may use this product
• Galactose intolerance
• Lapp lactase deficiency
• glucose-galactose malabsorption

Warnings and Precautions

• Angioedema
  • Candesartan has been associated with angioedema. This can occur at any stage of treatment.
  • Patients who have angioedema that is associated with ACE inhibitors, idiopathic or hereditary may be at greater risk.
  • If patients experience swelling in the larynx, glottis or face, it is important to monitor them.
  • The drug should be stopped immediately and not be restarted. 
  • Aggressive management of the airway and Intramuscular epinephrine should be part of the resuscitation.

• Hyperkalemia:
  • Patients with impaired renal function, Diabetes mellitus, Patients who use potassium-sparing diuretics and patients taking potassium supplements or potassium-containing sodium salts are at increased risk of hyperkalemia. Candesartan should be used with caution.

• Hypotension
  • Hypotension is a risk factor for patients who are salt- and volume-depleted (e.g. patients on high-dose diuretics).
  • The patient must be well hydrated before initiating therapy.
  • Start therapy with a lower dose, and gradually increase the dosage.

• Mitral or aortic stenosis
  • Patients with severe stenosis of the aortic and mitral valves should be cautious about taking this drug.
• Ascites:
  • Patients with refractory or decompensated ascites and liver disease should not take candesartan. 
  • Patients with cirrhosis should be closely monitored for blood pressure and kidney function.

• Heart failure:
  • Patients with heart disease should not use it, especially if they are receiving concurrent diuretic therapy.

• Renal artery stenosis
  • Patients with bilateral renal arterial stenosis should not be used.
  • Patients with unilateral renal arterial stenosis may need to be cautious.

• Renal impairment
  • Patients suffering from renal disease should be cautious when taking the drug.
  • Candesartan should be avoided in children with a CrCl lower than 30 ml/min. This subgroup has not been extensively studied.

Candesartan: Drug Interaction

Note: Drug Interaction Categories:

• Risk Factor C: Monitor When Using Combination
• Risk Factor D: Consider Treatment Modification
• Risk Factor X: Avoid Concomitant Use

Monitor:

• Blood pressure & Heart rate
• Serum electrolytes
• Serum creatinine and BUN
• Urinalysis.

When used in patients with heart Failure, Monitor:

• Blood pressure in supine and upright posture within 1 - 2 weeks
• Renal function
• Serum potassium levels.

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Blood pressure goals in patients with Hypertension: 

• Target blood pressure of less than 130/80 mmHg in patients with hypertension and known cardiovascular disease or the 10-year ASCVD risk is greater than 10%.

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• The target blood pressure of less than 130/80 mmHg may be reasonable in patients with ASCVD risk.

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• Target blood pressure of less than 140/90 mmHg in patients aged 18 - 65 years with Diabetes and hypertension without cardiovascular disease and the 10-year ASCVD risk is less than 15%.

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• Target blood pressure of less than 130/80 mmHg in patients aged 18 - 65 years with Diabetes, hypertension, cardiovascular disease, or the 10-year ASCVD risk is greater than 15%.

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• Target blood pressure of less than 140/90 mmHg in patients aged more than 65 years and without major comorbid conditions.

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• Target blood pressure of less than 150/90 mmHg in patients aged more than 65 years and poor health or comorbid conditions.

How to take Candesartran?

• It can be administered orally without regard to meals.

Mechanism of action of Candesartan:

• Candesartan, an angiotensin receptor antagonist, is a drug called Candesartan. Angiotensin II, a powerful vasoconstrictor, stimulates the release aldosterone.
• Aldosterone can cause sodium and water retention. This, together with the vasoconstriction caused directly by angiotensin 2, results in a decrease in blood pressure.

The action beginsThe antihypertensive effect can be seen in as little as 2 to 3 hours. It is visible within two weeks. Candesartan's peak effect can be seen within 6-8 hours, while the maximum antihypertensive effect can be seen within 4 - 6 week.

TheDuration of the actionIt takes more than 24 hours. It happens quickly and completely.absorbedbinds to plasma proteins (>99%). Candesartan-cilexetil can be converted to the active drug through the gastrointestinal tract.

 It is abioavailability15% and thehalf-life eliminationIt takes between 5 and 9 hours.When plasma concentration reaches its peakIt takes between 3 and 4 hours. It is excreted mostly via feces.

Candesartan International brand names:

• ACCEL-Candesartan
• ACH-Candesartan
• ACT Candesartan
• APO-Candesartan
• Atacand
• Auro-Candesartan
• DOM-Candesartan
• JAMP-Candesartan
• MINT-Candesartan
• MYLAN-Candesartan
• PMS-Candesartan
• RAN-Candesartan
• RIVA-Candesartan
• SANDOZ Candesartan
• TEVA-Candesartan
• Advant
• Aldireca
• Amias
• Amican
• Anatan
• Arb
• Atacan
• Atacand
• Atasart
• Bilaten
• Blopress
• Blox
• Blox 8
• Candelong
• Candelotan
• Candepress
• Canderin
• Candesar
• Candesarkern
• Candez
• Candiloc
• Candist
• Candotens
• Cansartan
• Cantar
• Casartan
• Catasart
• Dacten
• Desaltan
• Finil 16
• Frepan
• Gionix
• Giran
• Hysart
• Kairasec
• Kandepres
• Kasark
• Kenzen
• Sartan
• Sartan-16
• Sartan-8
• Tenecand
• Tiadyl
• Todesaar
• Treatan
• Vanox

Candesartan in Pakistan: