Indications, posology and method of administration
THERAPEUTIC INDICATIONS
Hypertension: Treatment of essential hypertension.
Chronic heart failure (CHF): Treatment of stable mild and moderate chronic heart failure in addition to standard therapies in elderly patients ≥ 70 years.
POSOLOGY AND METHOD OF ADMINISTRATION
Posology:
Hypertension:
Adults
The dose is 5 mg daily, preferably at the same time of the day.
The blood pressure lowering effect becomes evident after 1 – 2 weeks of treatment. Occasionally, the optimal effect is reached only after 4 weeks.
Combination with other antihypertensive agents
Beta – Blockers can be used alone or concomitantly with other antihypertensive agents. To date, an additional antihypertensive effect has been observed only when nebivolol is combined with hydrochlorothiazide 12.5 – 25 mg.
Patients with renal insufficiency
In patients with renal insufficiency, the recommended starting dose is 2.5 mg daily. If needed, the daily dose may be increased to 5 mg.
Patients with hepatic insufficiency
Data in patients with hepatic insufficiency or impaired liver function are limited. Therefore, the use of nebivolol tablets in these patients is contra-indicated.
Elderly
In patients over 65 years, the recommended starting dose is 2.5 mg daily. If needed, the daily dose may be increased to 5 mg. However, in view of the limited experience in patients above 75 years, caution must be exercised and these patients monitored closely.
Paediatric population
The efficacy and safety of nebivolol in children and adolescents aged below 18 years has not been established. No data are available. Therefore, use in children and adolescents is not recommended.
Chronic heart failure (CHF):
The treatment of stable chronic heart failure has to be initiated with a gradual uptitration of dosage until the optimal individual maintenance dose is reached.
Patients should have stable chronic heart failure without acute failure during the past six weeks. It is recommended that the treating physician should be experienced in the management of chronic heart failure.
For those patients receiving cardiovascular drug therapy including diuretics and/or digoxin and/or ACE inhibitors and/or angiotensin II antagonists, dosing of these drugs should be stabilised during the past two weeks prior to initiation of nebivolol treatment.
The initial uptitration should be done according to the following steps at 1 – 2 weekly intervals based on patient tolerability: 1.25 mg nebivolol, to be increased to 2.5 mg nebivolol once daily, then to 5 mg once daily and then to 10mg once daily.
The maximum recommended dose is 10 mg nebivolol once daily.
Initiation of therapy and every dose increase should be done under the supervision of an experienced physician over a period of at least 2 hours to ensure that the clinical status (especially as regards blood pressure, heart rate, conduction disturbances, signs of worsening of heart failure) remains stable.
Occurrence of adverse events may prevent all patients being treated with the maximum recommended dose. If necessary, the dose reached can also be decreased step by step and reintroduced as appropriate.
During the titration phase, in case of worsening of the heart failure or intolerance, it is recommended first to reduce the dose of nebivolol, or to stop it immediately if necessary (in case of severe hypotension, worsening of heart failure with acute pulmonary oedema, cardiogenic shock, symptomatic bradycardia or AV block).
Treatment of stable chronic heart failure with nebivolol is generally a long-term treatment.
The treatment with nebivolol is not recommended to be stopped abruptly since this might lead to a transitory worsening of heart failure. If discontinuation is necessary, the dose should be gradually decreased divided into halves weekly.
Patients with renal insufficiency
No dose adjustment is required in mild to moderate renal insufficiency since uptitration to the maximum tolerated dose is individually adjusted. There is no experience in patients with severe renal insufficiency (serum creatinine ≥ 250 μmol/L). Therefore, the use of nebivolol in these patients is not recommended.
Patients with hepatic insufficiency
Data in patients with hepatic insufficiency are limited. Therefore, the use of nebivolol in these patients is contra-indicated.
Elderly
No dose adjustment is required since up-titration to the maximum tolerated dose is individually adjusted.
Paediatric population
The efficacy and safety of nebivolol in children and adolescents aged below 18 years has not been established. Therefore, use in children and adolescents below 18 years of age is not recommended. No data are available.
Method of administration:
Oral use. Tablets may be taken with meals.
For the low dose of 1.25 mg, refer to other products with the same active ingredient.
Only use the 10 mg nebivolol tablet when a 10 mg dose is required.
CONTRAINDICATIONS
- Hypersensitivity to the active substance or to any of the excipients.
- Liver insufficiency or liver function impairment.
- Acute heart failure, cardiogenic shock or episodes of heart failure decompensation requiring i.v. inotropic therapy.
In addition, as with other beta-blocking agents, nebivolol is contra-indicated in:
- Sick sinus syndrome, including sino-atrial block.
- Second and third degree heart block (without a pacemaker).
- History of bronchospasm and bronchial asthma.
- Untreated phaeochromocytoma.
- Metabolic acidosis.
- Bradycardia (heart rate < 60 bpm prior to start therapy).
- Hypotension (systolic blood pressure < 90 mmHg).
- Severe peripheral circulatory disturbances.
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