Micardis Plus (Telmisartan and hydrochlorothiazide)

Micardis Plus is a combination of telmisartan (an angiotensin receptor blocker) and hydrochlorothiazide (a thiazide diuretic).

It is used to treat patients with hypertension.

Micardis plus dose in Adults

Micardis plus dose in the treatment of Hypertension:

Replacement therapy:
- Combination product can be substituted for individual titrated agents.
Treatment initiation with Micardis Plus when monotherapy fails:
- Patients currently on telmisartan monotherapy:
  - The initial dose in patients with on telmisartan 80 mg with uncontrolled BP.
    - Telmisartan 80 mg/hydrochlorothiazide 12.5 mg once daily given
    - manufacturer labeling suggests that dose may be titrated up to telmisartan 160 mg/hydrochlorothiazide 25 mg once daily if blood pressure continues uncontrolled after 2 to 4 weeks of therapy.
- Patients currently on hydrochlorothiazide monotherapy:
  - The initial dose in patients on hydrochlorothiazide 25 mg once a day with uncontrolled BP and patients who develop hypokalemia:
    - Telmisartan 80 mg/hydrochlorothiazide 12.5 mg once daily given
    - The manufacturer labeling suggests titrating the dose up to telmisartan 160 mg and hydrochlorothiazide 25 mg once a day if blood pressure remains uncontrolled after 2 to 4 weeks of therapy

Micardis plus dose in Childrens

Not recommended for use in children

Pregnancy Risk Factor: D

[US Boxed Warning]

Drugs that act on the RAAS (renin–angiotensin systems) can cause serious injury or death for the developing fetus.
Once pregnancy is confirmed, it should be stopped immediately.

Use of hydrochlorothiazide and telmisartan during lactation:

Breast milk also contains hydrochlorothiazide
It is unknown if telmisartan can be found in breast milk.
The manufacturer does not recommend breastfeeding due to the possibility of adverse reactions in breastfed infants.

Telmisartan and hydrochlorothiazide dose in kidney disease:

CrCl >30 mL/minute:
- No dosage adjustment required.
CrCl ≤30 mL/minute:
- Not advised.

Micardis plus dose in liver disease:

Mild to a moderate hepatic impairment or biliary obstructive disorders:
- Telmisartan 40 mg/hydrochlorothiazide 12.5 mg once daily given
Severe hepatic impairment:
- Not advised.

Side Effects of Micardis Plus (Telmisartan and hydrochlorothiazide) Include:

Central Nervous System:
- Dizziness
- Fatigue
Dermatologic:
- Erythema
Gastrointestinal:
- Diarrhea
- Nausea
- Abdominal Pain
- Dyspepsia
- Vomiting
Neuromuscular & Skeletal:
- Back Pain
Renal:
- Increased Blood Urea Nitrogen
- Increased Serum Creatinine
Respiratory:
- Upper Respiratory Tract Infection
- Sinusitis
- Flu-Like Symptoms
- Bronchitis
- Pharyngitis

Contraindication to Micardis plus (Telmisartan and hydrochlorothiazide) Include:

Hypersensitivity to telmisartan, hydrochlorothiazide, or any part of the formulation
concomitant use with the direct renin inhibitor, aliskiren, in patients with diabetes mellitus
anuria.
Limited evidence exists of allergenic cross-reactivity between angiotensin II receptor-blockers and thiazide related diuretics.
Concomitant use with the direct renin inhibitor, aliskiren, in patients with moderate-to-severe renal impairment (GFR <60 mL/minute/1.73 m2 )
pregnancy
Breastfeeding
fructose intolerance
galactose intolerance (eg, galactosemia, Lapp Lactase deficiency, glucose-galactose malabsorption).

Warnings and precautions

Angioedema
- Angioedema is a rare side effect of some angiotensin II receptor inhibitors (ARBs). It can occur anytime during treatment, especially after the first dose.
- Airway integrity could be compromised if the neck and head are involved. Abdominal pain may indicate intestinal involvement.
- Patients who have idiopathic angioedema, hereditary angioedema, or angioedema that was previously associated with ACE inhibitor therapy are at increased risk.
- Patients with larynx, tongue, or glottis edema may need to be monitored frequently and for a prolonged period of time.
- Patients who have had previous airway surgery may be at greater risk for obstruction.
- If angioedema develops, stop taking the medication immediately.
- It is crucial to be aggressive in early management.
- Intramuscular (IM) administration of epinephrine is necessary.
- Patients who have angioedema caused by ARBs should not be given.
Electrolyte disturbances:
- Hyperkalemia may occur when angiotensin II receptor antagonists are used.
- Risk factors include kidney dysfunction, diabetes mellitus and concomitant potassium-sparing diuretics and potassium supplements.
- These agents should be used with caution and potassium should be monitored closely.
- Hypokalemia, hypochloremic acidosis, hypomagnesemia and hyponatremia could be caused by Thiazide diuretics.
Gout:
- Hydrochlorothiazide is used to precipitate gout in patients who have a history of gout or are suffering from chronic renal failure.
- Doses of 25 mg and more may increase the risk.
Hypersensitivity reactions
- Hydrochlorothiazide may cause hypersensitivity reactions.
- Patients with a history bronchial or allergy disorder are at greater risk.
Hypotension
- Patients who have been treated with high-dose diuretics or salt-depleted might experience symptoms of hypotension.
- Correct volume depletion before administration.
- It is not contraindicated to use transient hypotension.
Ocular effects
- Acute transient myopia or acute angle-closure vision may be caused by hydrochlorothiazide. This usually occurs within hours to days of its initiation.
- Patients suffering from severe visual impairment or ocular pain should stop taking any medication immediately.
- If intraocular pressure is not controlled, additional treatments may be required.
- Penicillin and sulfonamide allergy patients are at high risk.
Photosensitivity
- Hydrochlorothiazide can cause it.
Renal function deterioration:
- It can lead to a decrease in renal function and/or an increase in serum creatinine in patients with low renal flow (eg, kidney artery stenosis or heart failure).
- Patients whose glomerular filter rate (GFR), is dependent on the efferent arterial vasoconstriction (angiotensin 2) may experience oliguria, severe renal failure and progressive azotemia.
- After initiation, small increases in serum creatinine may occur.
- Patients with significant and progressive deterioration of renal function should be considered for discontinuation.
Allergy to sulfonamide ("sulfa")
- FDA-approved product labeling contains a wide contraindication for patients who have had an allergic reaction to sulfonamides in the past.
- This includes many medications that contain a sulfonamide chemical family.
- Cross-reactivity exists between members of a particular class (eg, two antibiotics sulfonamides).
- Crossreactivity concerns have been raised previously for all compounds with the sulfonamide structural (SO NH).
- Nonantibiotic sulfonamides are unlikely to cause cross-reactions caused by antibody production (anaphylaxis).
- T-cell-mediated reactions (type IV), such as maculopapular eruption, are also less well-understood.
- Some clinicians opt to avoid these classes in cases of severe reactions (Stevens Johnson syndrome/TEN).
Aortic/mitral stenosis:
- Use telmisartan cautiously in patients with significant aortic/mitral stenosis.
Bariatric surgery
- Do not take diuretics during the first 24 hours after bariatric surgery.
- Electrolyte disturbances or dehydration may occur.
- Once oral fluid intake goals have been met, diuretics can be restarted if necessary
Diabetes:
- Patients with diabetes mellitus or prediabetes should be cautious when using hydrochlorothiazide
- You may notice a shift in glucose control
Hepatic impairment
- Patients with biliary obstruction disorders or hepatic impairment should be cautious.
- Avoid electrolyte imbalances and acid/base imbalances in severe or progressive hepatic diseases to avoid hepatic complications.
Hypercalcemia:
- Patients with hypercalcemia should avoid Thiazide diuretics as they can reduce renal calcium excretion.
Hypercholesterolemia:
- Patients with high or moderate cholesterol levels should be cautious.
- The increased levels of cholesterol and triglyceride are linked to Thiazide Diuretics.
Parathyroid disease
- Calcium excretion is also reduced by Thiazide diuretics
- Long-term use has been associated with pathologic changes in parathyroid glands, including hypophosphatemia and hypercalcemia.
- Should be stopped before testing for parathyroid function.
Renal artery stenosis
- Use telmisartan cautiously in patients with unstented unilateral/bilateral renal artery stenosis.
- This should not be done in bilateral unstented renal artery stenosis because of the increased risk of renal dysfunction.
Renal impairment
- Patients with mild or moderate kidney impairment should be cautious.
- In severe renal impairment, it is not recommended to use.
Systemic lupus erythematosus (SLE):
- SLE activation or exacerbation can also be caused by hydrochlorothiazide.

Telmisartan and hydrochlorothiazide: Drug Interaction

Risk Factor C (Monitor therapy)
Ajmaline	Sulfonamides may enhance the adverse/toxic effect of Ajmaline. Specifically, the risk for cholestasis may be increased.
Alcohol (Ethyl)	May enhance the orthostatic hypotensive effect of Thiazide and Thiazide-Like Diuretics.
Alfuzosin	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Allopurinol	Thiazide and Thiazide-Like Diuretics may enhance the potential for allergic or hypersensitivity reactions to Allopurinol. Thiazide and Thiazide-Like Diuretics may increase the serum concentration of Allopurinol. Specifically, Thiazide Diuretics may increase the concentration of Oxypurinol, an active metabolite of Allopurinol.
Aminolevulinic Acid (Topical)	Photosensitizing Agents may enhance the photosensitizing effect of Aminolevulinic Acid (Topical).
Amphetamines	May diminish the antihypertensive effect of Antihypertensive Agents.
Angiotensin II	Receptor Blockers may diminish the therapeutic effect of Angiotensin II.
Anticholinergic Agents	May increase the serum concentration of Thiazide and Thiazide-Like Diuretics.
Antidiabetic Agents	Thiazide and Thiazide-Like Diuretics may diminish the therapeutic effect of Antidiabetic Agents.
Antidiabetic Agents	Hyperglycemia-Associated Agents may diminish the therapeutic effect of Antidiabetic Agents.
Antipsychotic Agents (Second Generation [Atypical])	Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]).
Barbiturates	May enhance the orthostatic hypotensive effect of Thiazide and Thiazide-Like Diuretics.
Barbiturates	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Benperidol	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Beta2-Agonists	May enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics.
Brigatinib	May diminish the antihypertensive effect of Antihypertensive Agents. Brigatinib may enhance the bradycardic effect of Antihypertensive Agents.
Brimonidine (Topical)	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Calcium Salts	Thiazide and Thiazide-Like Diuretics may decrease the excretion of Calcium Salts. Continued concomitant use can also result in metabolic alkalosis.
CarBAMazepine	Thiazide and Thiazide-Like Diuretics may enhance the adverse/toxic effect of CarBAMazepine. Specifically, there may be an increased risk for hyponatremia.
Cardiac Glycosides	Telmisartan may increase the serum concentration of Cardiac Glycosides.
Corticosteroids (Orally Inhaled)	May enhance the hypokalemic effect of Thiazide and ThiazideLike Diuretics.
Corticosteroids (Systemic)	May enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics.
Cyclophosphamide	Thiazide and Thiazide-Like Diuretics may enhance the adverse/toxic effect of Cyclophosphamide. Specifically, granulocytopenia may be enhanced.
CycloSPORINE (Systemic)	Angiotensin II Receptor Blockers may enhance the hyperkalemic effect of CycloSPORINE (Systemic).
Dapoxetine	May enhance the orthostatic hypotensive effect of Angiotensin II Receptor Blockers.
Dexketoprofen	May enhance the adverse/toxic effect of Sulfonamides.
Dexmethylphenidate	May diminish the therapeutic effect of Antihypertensive Agents.
Diacerein	May enhance the therapeutic effect of Diuretics. Specifically, the risk for dehydration or hypokalemia may be increased.
Diazoxide	Thiazide and Thiazide-Like Diuretics may enhance the adverse/toxic effect of Diazoxide.
Diazoxide	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Drospirenone	Angiotensin II Receptor Blockers may enhance the hyperkalemic effect of Drospirenone.
DULoxetine	Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine.
Eplerenone	May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers.
Heparin	May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers.
Heparins (Low Molecular Weight)	May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers.
Herbs (Hypertensive Properties)	May diminish the antihypertensive effect of Antihypertensive Agents.
Herbs (Hypotensive Properties)	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Hypotension-Associated Agents	Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents.
Ipragliflozin	May enhance the adverse/toxic effect of Thiazide and Thiazide-Like Diuretics. Specifically, the risk for intravascular volume depletion may be increased.
Ivabradine	Thiazide and Thiazide-Like Diuretics may enhance the arrhythmogenic effect of Ivabradine.
Levodopa-Containing Products	Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa-Containing Products.
Licorice	May enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics.
Lormetazepam	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Methylphenidate	May diminish the antihypertensive effect of Antihypertensive Agents.
Molsidomine	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Multivitamins/Fluoride (with ADE)	May enhance the hypercalcemic effect of Thiazide and Thiazide-Like Diuretics.
Multivitamins/Minerals (with ADEK, Folate, Iron)	Thiazide and Thiazide-Like Diuretics may enhance the hypercalcemic effect of Multivitamins/Minerals (with ADEK, Folate, Iron).
Multivitamins/Minerals (with AE, No Iron)	Thiazide and Thiazide-Like Diuretics may increase the serum concentration of Multivitamins/Minerals (with AE, No Iron). Specifically, thiazide diuretics may decrease the excretion of calcium, and continued concomitant use can also result in metabolic alkalosis.
Naftopidil	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Neuromuscular-Blocking Agents (Nondepolarizing	Thiazide and Thiazide-Like Diuretics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents (Nondepolarizing).
Nicergoline	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Nicorandil	May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers.
Nicorandil	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Nitroprusside	Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside.
Nonsteroidal Anti-Inflammatory Agents	Thiazide and Thiazide-Like Diuretics may enhance the nephrotoxic effect of Nonsteroidal Anti-Inflammatory Agents. Nonsteroidal Anti-Inflammatory Agents may diminish the therapeutic effect of Thiazide and Thiazide-Like Diuretics.
Nonsteroidal Anti-Inflammatory Agents	Angiotensin II Receptor Blockers may enhance the adverse/toxic effect of Nonsteroidal Anti-Inflammatory Agents. Specifically, the combination may result in a significant decrease in renal function. Nonsteroidal Anti-Inflammatory Agents may diminish the therapeutic effect of Angiotensin II Receptor Blockers. The combination of these two agents may also significantly decrease glomerular filtration and renal function.
Opioid Agonists	May enhance the adverse/toxic effect of Diuretics. Opioid Agonists may diminish the therapeutic effect of Diuretics.
Oxcarbazepine	Thiazide and Thiazide-Like Diuretics may enhance the adverse/toxic effect of OXcarbazepine. Specifically, there may be an increased risk for hyponatremia.
Pentoxifylline	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Pholcodine	Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine.
Phosphodiesterase 5 Inhibitors	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Porfimer	Photosensitizing Agents may enhance the photosensitizing effect of Porfimer.
Potassium Salts	May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers.
Potassium-Sparing Diuretics	Angiotensin II Receptor Blockers may enhance the hyperkalemic effect of Potassium-Sparing Diuretics.
Prostacyclin Analogues	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Quinagolide	May enhance the hypotensive effect of Blood Pressure Lowering Agents.
Ranolazine	May enhance the adverse/toxic effect of Angiotensin II Receptor Blockers.
Reboxetine	May enhance the hypokalemic effect of Thiazide and Thiazide-Like Diuretics.
Selective Serotonin Reuptake Inhibitors	May enhance the hyponatremic effect of Thiazide and Thiazide-Like Diuretics.
Tacrolimus (Systemic)	Angiotensin II Receptor Blockers may enhance the hyperkalemic effect of Tacrolimus (Systemic).
Tolvaptan	May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers.
Toremifene	Thiazide and Thiazide-Like Diuretics may enhance the hypercalcemic effect of Toremifene.
Trimethoprim	May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers.
Valsartan	HydroCHLOROthiazide may enhance the hypotensive effect of Valsartan. Valsartan may increase the serum concentration of HydroCHLOROthiazide.
Verteporfin	Photosensitizing Agents may enhance the photosensitizing effect of Verteporfin.
Vitamin D Analogs	Thiazide and Thiazide-Like Diuretics may enhance the hypercalcemic effect of Vitamin D Analogs.
Yohimbine	May diminish the antihypertensive effect of Antihypertensive Agents.
Risk Factor D (Consider therapy modification)
Aliskiren	May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Aliskiren may enhance the hypotensive effect of Angiotensin II Receptor Blockers. Aliskiren may enhance the nephrotoxic effect of Angiotensin II Receptor Blockers. Management: Aliskiren use with ACEIs or ARBs in patients with diabetes is contraindicated. Combined use in other patients should be avoided, particularly when CrCl is less than 60 mL/min. If combined, monitor potassium, creatinine, and blood pressure closely.
Amifostine	Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure lowering medications should be withheld for 24 hours prior to amifostine administration. If blood pressure lowering therapy cannot be withheld, amifostine should not be administered.
Angiotensin-Converting Enzyme Inhibitors	Angiotensin II Receptor Blockers may enhance the adverse/toxic effect of Angiotensin-Converting Enzyme Inhibitors. Angiotensin II Receptor Blockers may increase the serum concentration of Angiotensin-Converting Enzyme Inhibitors. Management: In US labeling, use of telmisartan and ramipril is not recommended. It is not clear if any other combination of an ACE inhibitor and an ARB would be any safer. Consider alternatives to the combination when possible.
Bile Acid Sequestrants	May decrease the absorption of Thiazide and Thiazide-Like Diuretics. The diuretic response is likewise decreased.
Lithium	Thiazide and Thiazide-Like Diuretics may decrease the excretion of Lithium.
Lithium	Angiotensin II Receptor Blockers may increase the serum concentration of Lithium. Management: Lithium dosage reductions will likely be needed following the addition of an angiotensin II receptor antagonist.
Obinutuzumab	May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion.
Sodium Phosphates	Angiotensin II Receptor Blockers may enhance the nephrotoxic effect of Sodium Phosphates. Specifically, the risk of acute phosphate nephropathy may be enhanced. Management: Consider avoiding this combination by temporarily suspending treatment with ARBs, or seeking alternatives to oral sodium phosphate bowel preparation. If the combination cannot be avoided, maintain adequate hydration and monitor renal function closely.
Sodium Phosphates	Diuretics may enhance the nephrotoxic effect of Sodium Phosphates. Specifically, the risk of acute phosphate nephropathy may be enhanced. Management: Consider avoiding this combination by temporarily suspending treatment with diuretics, or seeking alternatives to oral sodium phosphate bowel preparation. If the combination cannot be avoided, hydrate adequately and monitor fluid and renal status.
Topiramate	Thiazide and Thiazide-Like Diuretics may enhance the hypokalemic effect of Topiramate. Thiazide and Thiazide-Like Diuretics may increase the serum concentration of Topiramate. Management: Monitor for increased topiramate levels/adverse effects (e.g., hypokalemia) with initiation/dose increase of a thiazide diuretic. Closely monitor serum potassium concentrations with concomitant therapy. Topiramate dose reductions may be necessary.
Risk Factor X (Avoid combination)
Aminolevulinic Acid (Systemic)	Photosensitizing Agents may enhance the photosensitizing effect of Aminolevulinic Acid (Systemic).
Bromperidol	Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Bromperidol may diminish the hypotensive effect of Blood Pressure Lowering Agents.
Dofetilide	HydroCHLOROthiazide may enhance the QTc-prolonging effect of Dofetilide. HydroCHLOROthiazide may increase the serum concentration of Dofetilide.
Levosulpiride	Thiazide and Thiazide-Like Diuretics may enhance the adverse/toxic effect of Levosulpiride.
Mecamylamine	Sulfonamides may enhance the adverse/toxic effect of Mecamylamine.
Promazine	Thiazide and Thiazide-Like Diuretics may enhance the QTc-prolonging effect of Promazine.
Ramipril	Telmisartan may enhance the adverse/toxic effect of Ramipril. Telmisartan may increase the serum concentration of Ramipril. Concentrations of the active metabolite, ramiprilat, may also be increased.

Monitor:

Blood pressure
serum electrolytes
BUN
creatinine

How to administer Micardis Plus ( Telmisartan and hydrochlorothiazide)?

Administer orally without regard to meals.

Mechanism of action of Telmisartan and hydrochlorothiazide:

Telmisartan:

Telmisartan is an angiotensin receptor antagonist.
Angiotensin II acts like a vasoconstrictor.
Angiotensin II is able to cause vasoconstriction and can stimulate the release aldosterone.
This causes an increase in blood pressure.
Telmisartan binds with the AT1 angiotensin II receptor.
This binding stops angiotensin I from binding to the receptor, thereby blocking the vasoconstriction as well as the aldosterone-secreting effects of angiotensin 2.

Hydrochlorothiazide:

Hydrochlorothiazide blocks sodium reabsorption from the distal tubules.
This results in increased excretion sodium, water and potassium as well as hydrogen ions.

See individual agents (Telmisartan & Hydrochlorothiazide)

International Brands of Telmisartan and hydrochlorothiazide:

Actelsar
Actelsar HCT
Actelstar HCT
Agimstan-H
Cardiz-CO
Cilzec Plus
Hangitor Plus
Kinzalcomb
Mibetel HCT
Mibetel Plus
Micardis HCT
Micardis Plus
Micombi
Mikardisplus
Mitosan Plus
Pritorplus
PritorPlus
Telcardis Plus
Telisid-H
Telma 80H
Telma H
Telma Plus
Telmican Plus
Telmione Plus
Telmisartan Plus HCT EG
Telmito Plus
Telmitrend Plus
Telstan-H
Tolucombi

Telmisartan and hydrochlorothiazide Brands in Pakistan:

Telmisartan [Tabs 4 Mg]
Telsitan-H	Macter International (Pvt) Ltd.

Telmisartan [Tabs 40 Mg]
Co Telmas	Global Pharmaceuticals
Co Telsan	Hilton Pharma (Pvt) Limited
Co-Ezitab	Werrick Pharmaceuticals
Co-Tasmi	Getz Pharma Pakistan (Pvt) Ltd.
Co-Telisartan	Schazoo Zaka
Cresar H	Tabros Pharma
De-Nile Plus	Pharma Health Pakistan (Pvt) Ltd
Gelfer	Genix Pharma (Pvt) Ltd
Mecardis-H	Maple Pharmaceuticals (Pvt) Ltd
Misar-H	Highnoon Laboratories Ltd.
Misartan -H	Indus Pharma (Pvt) Ltd.
Normisar	Nabiqasim Industries (Pvt) Ltd.
Normisar Plus	Nabiqasim Industries (Pvt) Ltd.
Telmis-H	Genix Pharma (Pvt) Ltd
Telsarta-D	Pharmevo (Pvt) Ltd.

Telmisartan [Tabs 80 Mg]
Co Telmas	Global Pharmaceuticals
Co Telsan	Hilton Pharma (Pvt) Limited
Co-Ezitab	Werrick Pharmaceuticals
Co-Tasmi	Getz Pharma Pakistan (Pvt) Ltd.
Cresar H	Tabros Pharma
Mecardis-H Forte	Maple Pharmaceuticals (Pvt) Ltd
Misar-H	Highnoon Laboratories Ltd.
Telsarta-D	Pharmevo (Pvt) Ltd.