BiDil

BIDIL — hydralazine hydrochloride and isosorbide dinitrate tablet, film coated
REMEDYREPACK INC.

INDICATIONS & USAGE

BiDil is a combination of isosorbide dinitrate, a nitrate vasodilator, and hydralazine hydrochloride, an arteriolar vasodilator, indicated for:

  • the treatment of heart failure as an adjunct therapy to standard therapy in self-identified black patients to improve survival, prolong time to hospitalization for heart failure and to improve patient-reported functional status (1.1)

Limitations of use:

  • There is little experience in patients with NYHA class IV heart failure (1.2)

BiDil is indicated for the treatment of heart failure as an adjunct to standard therapy in self-identified black patients to improve survival, to prolong time to hospitalization for heart failure, and to improve patient-reported functional status.

There is little experience in patients with NYHA class IV heart failure.

DOSAGE & ADMINISTRATION

BiDil should be initiated at a dose of one BiDil Tablet, three times a day. Titrate to a maximum of two tablets three times daily, if tolerated.

Although titration of BiDil can be rapid (3-5 days), some patients may experience side effects and may take longer to reach their maximum tolerated dose. The dosage may be decreased to as little as one-half BiDil Tablet three times a day if intolerable side effects occur. Efforts should be made to titrate up as soon as side effects subside.

DOSAGE FORMS & STRENGTHS

The BiDil (20 mg isosorbide dinitrate and 37.5 mg hydralazine hydrochloride) tablets are orange, biconvex, approximately 8 mm in diameter, scored, film-coated, and debossed with “20″ on one side over the score and “N” on the other side.

CONTRAINDICATIONS

BiDil is contraindicated in patients who are allergic to organic nitrates.

WARNINGS AND PRECAUTIONS

  • May cause symptomatic hypotension (5.1, 5.2)
  • Symptomatic Lupus Erythematosus Syndromes: Consider discontinuation if clinically appropriate (5.3)
  • Myocardial ischemia and angina ( 5.4)
  • Peripheral Neuritis: May be treated with Pyridoxine (5.5)

Avoid co-administration of BiDil with phosphodiesterase inhibitors such as sildenafil, vardenafil, or tadalafil because severe hypotension, syncope, or myocardial ischemia may result [see Drug Interactions (7.1)].

Symptomatic hypotension, particularly with upright posture, may occur with even small doses of BiDil. Hypotension is most likely to occur in patients who have been volume or salt depleted; correct prior to initiation of BiDil [see Adverse Reactions (6.1)].

Hydralazine hydrochloride has been reported to cause a drug-induced systemic lupus erythematosus (SLE) syndrome. Symptoms and signs usually regress when hydralazine hydrochloride is discontinued.

Hydralazine hydrochloride can cause tachycardia and hypotension potentially leading to myocardial ischemia and angina, particularly in patients with hypertrophic cardiomyopathy.

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 therapy if such symptoms develop.

ADVERSE REACTIONS

Most common adverse reactions (≥ 5% more on BiDil than on placebo) were headache and dizziness (6.1)

To report SUSPECTED ADVERSE REACTIONS, contact Arbor Pharmaceuticals, Inc. at 1-866-516-4950 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

Because clinical studies are conducted under widely varying conditions, adverse reaction rates observed in the clinical studies of a drug cannot be directly compared to rates in the clinical studies of another drug and may not reflect the rates observed in practice.

BiDil has been evaluated for safety in 517 heart failure patients in A-HeFT. A total of 317 of these patients received BiDil for at least 6 months, and 220 received BiDil for at least 12 months. In A-HeFT, 21% of the patients discontinued BiDil for adverse reactions compared to 12% who discontinued placebo. Overall, adverse reactions were more common in BiDil -treated than in placebo-treated patients. Table 1 lists adverse reactions reported with an incidence, after rounding, ≥ 2% higher on BiDil than on placebo in A-HeFT, regardless of causality. The most common reasons for discontinuing BiDil in the A-HeFT trial was headache (7%).

Table 1. Adverse Reactions Occurring in the A-HeFT Study in ≥ 2% of Patients Treated with BiDil.
BiDil
(N=517)
%
Placebo
(N=527)
%
Headache 50 21
Dizziness 32 14
Asthenia 14 11
Nausea 10 6
Hypotension 8 4
Sinusitis 4 2
Ventricular tachycardia 4 2
Paresthesia 4 2
Vomiting 4 2
Amblyopia 3 1

In the V-HeFT I and II clinical studies, a total of 587 patients with heart failure were treated with the combination of isosorbide dinitrate and hydralazine hydrochloride. The type, pattern, frequency and severity of adverse reactions reported in these studies were similar to those reported in A-HeFT, described above and no unusual adverse reactions were reported.

The following adverse reactions have been identified during post-approval use of BiDil. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Use of BiDil: The following adverse reactions have been identified with use of BiDil.

Cardiac Disorders:

Palpitations

Ear and labyrinth disorders:

Tinnitus, vertigo

Eye Disorders:

Eyelid edema, vision blurred

Gastrointestinal Disorders:

Abdominal discomfort, constipation

General Disorders and Administration Site Conditions:

Facial pain, flushing, chest discomfort, chest pain, peripheral edema

Musculoskeletal and Connective Tissue Disorders:

Pain in extremity, myalgia

Nervous Disorders:

Dysgeusia, hypoaesthesia, migraine, syncope

Renal and Urinary Disorders:

Chromaturia, pulmonary renal syndrome

Respiratory, Thoracic and Mediastinal Disorders:

Dyspnea

Reproductive System and Breast Disorders:

Erectile dysfunction

Skin and Subcutaneous Tissue Disorders:

Erythema, hyperhidrosis, pruritus, face swelling

Use of Hydralazine Hydrochloride or Isosorbide Dinitrate: The following reactions have been reported with use of either hydralazine hydrochloride or isosorbide dinitrate.

Blood and Lymphatic System Disorders:

Blood dyscrasias, agranulocytosis, purpura, eosinophilia, splenomegaly.

Eye Disorders:

Lacrimation, conjunctivitis.

Gastrointestinal Disorders:

Paralytic ileus.

Hepatobiliary Disorders:

Hepatitis.

Psychiatric Disorders:

Psychotic reactions, disorientation.

Renal and Urinary Disorders:

Difficulty in urination.

DRUG INTERACTIONS

  • Phosphodiesterase Inhibitors: May cause severe hypotension. Avoid concomitant use (7.1)

Avoid co-administration of BiDil with phosphodiesterase inhibitors such as sildenafil, vardenafil, or tadalafil because severe hypotension, syncope, or myocardial ischemia may result [see Warnings and Precautions (5.1)].

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