Expiration date: 12/2025
The composition and form of issue:
Tablets. 1 tablet contains:
ramipril (NOAH 498) 2.5 mg
excipients: hypromellose starch pregelatinization MKC sodium fumarate dye iron oxide yellow (E172)
14 PCs. in blister, in box 2 blisters.
Tablets. 1 tablet contains:
ramipril (NOAH 498) 5 mg
excipients: starch hypromellose pregelatinization MKC sodium fumarate dye iron oxide red (E172)
14 PCs. in blister, in box 2 blisters.
Tablets. 1 tablet contains:
ramipril (NOAH 498) 10 mg
excipients: hypromellose starch pregelatinization MKC sodium fumarate
14 PCs in blister the paper cartons 2 blister.
Description pharmaceutical form:
Tritace 2,5 — light yellow oblong tablet with break line on both sides and engraved "to 2.5"/stylized image of the letter "h" on one side and "2,5/HMR" on the other.
Tritace 5 — light pink, with splashes of darker or lighter shade, oblong tablets with valium on both sides and engraved "5"/stylized image of the letter "h" on one side and "5/HMR" on the other.
Tritace 10 — white, or almost white oblong tablets with break line on both sides, "banners" on the sides in the area of risk and engraved "NMO/NMO" on one side.
Pharmacokinetics:
After oral ramipril is rapidly absorbed from the gastrointestinal tract (50-60%). Food intake slows the absorption but does not affect the completeness of absorption. Ramipril undergoes extensive first-pass metabolism/activation (mainly in the liver by hydrolysis) to form its only active metabolite, ramiprilat, whose activity in respect of inhibition of ACE is approximately 6 times higher than the activity of ramipril. In addition, as a result of metabolism of ramipril is formed not possess pharmacological activity diketopiperazine, which then undergoes conjugation with glucuronic acid. Ramiprilat metabolized to diketopiperazine acid and glukuronidiruetsa.
The bioavailability of ramipril after ingestion ranges from 15% (dose 2.5 mg) to 28% (dose 5 mg). The bioavailability of the active metabolite — ramiprilat after ingestion of 2.5 mg and 5 mg of ramipril is about 45% (compared to its bioavailability after intravenous administration at the same doses).
After taking the inside ramipril Cmax ramipril and ramiprilat in plasma are achieved in 1 and 2-4 h, respectively. The decrease in the plasma concentrations of ramiprilat occurs in several stages: phase distribution and excretion with T1/2 of ramiprilat approximately 3 h, and then the intermediate phase with a T1/2 of ramiprilat approximately 15 h, and the final phase with a very low concentration of ramiprilat in plasma and T1/2 of ramiprilat approximately 4-5 days. This final phase due to the slow release of ramiprilat from strong ties with the receptors of the enzyme. Despite the long terminal phase with a single during the day the reception of ramipril oral dose of 2.5 mg or more equilibrium plasma concentration of ramiprilat achieved after approximately 4 days of treatment. In exchange the appointment of a drug "effective" T1/2 in a dose dependent is 13-17 h.
Linking blood plasma proteins is approximately equivalent to ramipril 73% and of ramiprilat is 56%.
After intravenous administration the volume of distribution of ramipril and ramiprilat is approximately 90 and 500 l, respectively.
After intake of labeled radioactive isotope of ramipril (10 mg) 39% of the radioactivity excreted via the bowel and about 60% in the kidneys. After I/V administration of ramipril, 50-60% of the dose found in the urine in the form of ramipril and its metabolites. After I/V administration of ramiprilat about 70% of the dose found in the urine in the form of ramiprilat and its metabolites, in other words, the on/in the introduction of ramipril and ramiprilat significant part of the dose is excreted through the intestine with the bile passing the kidneys (50 and 30%, respectively). After ingestion of 5 mg of ramipril in patients with drainage of the bile ducts is almost the same amount of ramipril and its metabolites excreted by the kidneys and through the intestine during the first 24 h after administration.
Approximately 80-90% of the metabolites in the urine and bile were identified as metabolite ramiprilat and the ramiprilat. Ramipril glucuronide and ramipril diketopiperazine approximately 10-20% of the total, and the content in the urine nematerializiranih ramiprila is approximately 2%.
In animal studies it was shown that ramipril is excreted in breast milk.
When violations of the kidney with Cl creatinine less than 60 ml/min, excretion of ramiprilat and its metabolites by the kidneys slows down. This leads to increased plasma concentrations of ramiprilat, which decreases more slowly than in patients with normal renal function.
When receiving ramipril high dose (10 mg) impaired liver function leads to slower first-pass metabolism of ramipril to ramiprilat active and slower excretion of ramiprilat.
In healthy volunteers and in patients with arterial hypertension after 2 weeks of treatment with ramipril in a daily dose of 5 mg not observed clinically significant accumulation of ramipril and ramiprilat. In patients with chronic heart failure after 2 weeks of treatment with ramipril in a daily dose 5 mg notes 1,5–1,8-fold increase in plasma concentrations and AUC of ramiprilat.
In healthy volunteers elderly (65-76 years), the pharmacokinetics of ramipril and ramiprilat did not significantly differ from that in young healthy volunteers.
Description pharmacological action:
Formed under the influence of hepatic enzymes to the active metabolite of ramipril — ramiprilat — is a long acting inhibitor of ACE, representing peptidyldipeptide. ACE in plasma and tissues catalyzes the conversion of angiotensin I to angiotensin II and breakdown of bradykinin.
Therefore, when the reception ramiprila inside decreasing the formation of angiotensin II and accumulation of bradykinin, which causes vasodilation and decrease in blood pressure. Increased activity of the kallikrein-kinin system in the blood and tissues and causes the cardioprotective endotheliopathy action of ramipril due to the activation of prostaglandin system and, consequently, increasing PG synthesis, stimulating the formation of nitric oxide (NO) in endothelial cells.
Angiotensin II stimulates secretion of aldosterone, so the reception ramiprila leads to reduced secretion of aldosterone and increased serum concentrations of potassium ions.
By reducing the concentration of angiotensin II in the blood eliminates its inhibitory effect on renin secretion by the type of negative feedback, which leads to an increase in renin activity of blood plasma.
It is assumed that the development of some adverse reactions (particularly dry cough) is also associated with increased concentrations of bradykinin.
In patients with arterial hypertension reception ramiprila leads to a decrease in blood pressure in the lying and standing position, without compensatory increase in heart rate. Ramipril significantly reduces PR, virtually without causing changes in renal blood flow and glomerular filtration rate. Hypotensive effect begins to manifest after 1-2 hours after ingestion of a single dose of the drug, reaching the highest values through 3-9 h, and stored for 24 hours If you take hypotensive effect may gradually increase, stabilizing typically 3-4 weeks of regular intake of the drug and then persisting for a long time. The sudden discontinuation of the drug does not lead to a rapid and significant increase in blood pressure (absence of the syndrome of "lifting").
In patients with hypertension ramipril slows the development and progression of myocardial hypertrophy and vascular wall.
In patients with chronic heart failure ramipril reduces peripheral vascular resistance (decrease postnagruzki on the heart), increases venous capacity and decreases the filling pressure of the left ventricle, which, respectively, leads to a reduction of preload on the heart. In these patients, while taking ramipril, an increase in cardiac output, ejection fraction and improvement in endurance exercise.
In diabetic and non-diabetic nephropathy receiving ramipril slows the rate of progression of renal failure and time of occurrence of end-stage renal failure and thereby reduces the need for dialysis treatments or kidney transplantation. In the early stages of diabetic or non-diabetic nephropathy ramipril reduces the severity of albuminuria.
In patients with a high risk of developing cardiovascular diseases due to the presence of vascular lesions (diagnosed coronary heart disease, obliterating diseases of peripheral arteries a history of stroke in anamnesis) or diabetes with at least one additional risk factor (microalbuminuria, hypertension, increased concentrations of total cholesterol (UH), lower concentrations of cholesterol high density lipoproteins (HDL-C, Smoking) the addition of ramipril to standard therapy significantly reduces the incidence of myocardial infarction, stroke and mortality from cardiovascular causes. In addition, ramipril reduces total mortality and the need for revascularization procedures, and slows the occurrence or progression of chronic heart failure.
In patients with heart failure, which developed in the first days of acute myocardial infarction (2-9 days), while taking ramipril, ranging from 3 to 10 days of acute myocardial infarction, reduced risk of mortality (27%), the risk of sudden death (30%), the risk of progression of chronic heart failure to severe (III–IV functional class NYHA classification)/resistant to therapy (27%), the likelihood of subsequent hospitalization due to heart failure (26%).
In the General population of patients, and in patients with diabetes, as with hypertension and normal blood pressure parameters, ramipril significantly reduces the risk of development of nephropathy and the occurrence of microalbuminuria.
Indications:
essential hypertension
chronic heart failure (in combination therapy, particularly in combination with diuretics)
diabetic or non-diabetic nephropathy preclinical and symptomatic stages, including with severe proteinuria, especially when combined with hypertension
reduction in the risk of myocardial infarction, stroke or cardiovascular mortality in patients with high cardiovascular risk:
- patients with known CAD, myocardial infarction in the anamnesis or without it, including patients undergoing percutaneous transluminal coronary angioplasty, coronary artery bypass grafting
- patients with stroke in anamnesis
the patients with occlusive lesions of the peripheral arteries
- patients with diabetes with at least one additional risk factor (microalbuminuria, hypertension, increased plasma OH concentrations, reduced plasma concentrations of HDL-C, Smoking)
heart failure, which developed during the first few days (2-9 days) after acute myocardial infarction (see section "Pharmacodynamics").
Contraindications:
hypersensitivity to ramipril, other ACE inhibitors or to any component of the drug (see section "Composition and form")
angioedema (hereditary or idiopathic, and after taking ACE inhibitors) in history — the risk of rapid development of angioedema (see section "Side effects")
hemodynamically significant renal artery stenosis (bilateral or unilateral in the case of a solitary kidney)
arterial gipotenzia (sad less than 90 mm Hg. Hg), or condition with unstable hemodynamics
hemodynamically significant stenosis of the aortic or mitral valve, or hypertrophic obstructive cardiomyopathy (HACMP)
primary hyperaldosteronism
expressed kidney failure (Cl creatinine less than 20 ml/min/1.73 m2) (clinical experience is insufficient).
hemodialysis (clinical experience is insufficient)
pregnancy
lactation
nephropathy, the treatment of which is corticosteroids, NSAIDs, immunomodulators and/or other cytotoxic drugs (clinical experience is insufficient, see section "Interactions")
chronic cardiac insufficiency of the decompensation (clinical experience is insufficient)
the age of 18 years (clinical experience is insufficient)
hemodialysis or hemofiltration with the use of some membranes with negatively charged surface, such as high-flow membranes from polyacrylnitrile (risk of development of hypersensitivity reactions) (see "Interaction," "specific instructions")
LDL apheresis using dextran sulfate (risk of development of hypersensitivity reactions) (see section "Special instructions")
hyposensitization therapy in the hypersensitivity reactions to poison insects such as bees, wasps (see "Special instructions").
Additional contraindications to use of the drug Tritace® in the acute stage of myocardial infarction:
severe heart failure (functional class IV of NYHA classification)
unstable angina
life-threatening ventricular arrhythmias
"pulmonary" heart.
With caution:
a condition in which excessive reduction of blood pressure is especially dangerous (in atherosclerotic lesions of coronary and cerebral arteries)
conditions associated with increased activity of the renin-angiotensin-aldosterone system (RAAS) in which the inhibition of ACE has a risk of a sharp decline in blood pressure with deterioration of renal function:
- severe hypertension, especially malignant hypertension
- chronic heart failure, especially severe or about which to take other medicines with hypotensive action
- hemodynamically significant unilateral renal artery stenosis (in the presence of both kidneys)
- prior administration of diuretics
- violations vodno-elektrolitnogo balance as a result of insufficient fluid intake and salt, diarrhea, vomiting, sweating
infringements of function of a liver (lack of experience in the application: might as strengthening and weakening effects of ramipril in the presence in patients of liver cirrhosis with ascites and edema may be a significant activation of the RAAS, see above "the State, accompanied by increased activity of the RAAS")
the human kidney (Cl creatinine more than 20 ml/min/1.73 m2) because of the risk of hyperkalemia and leukopenia
condition after kidney transplantation
systemic connective tissue diseases, including systemic lupus erythematosus, scleroderma, concomitant therapy with drugs that can cause changes in the peripheral blood (possible inhibition of bone marrow hematopoiesis, the development of neutropenia or agranulocytosis, see Interaction)
diabetes mellitus (risk of hyperkalemia)
older age (risk increase gipotenzivnogo action)
hyperkalemia.
Application of pregnancy and breast-feeding:
Ramipril is contraindicated in pregnancy, as it can have an adverse effect on the fetus: impaired development of the kidneys of the fetus, reducing AD the fetus and newborn, violation of the kidney, hyperkalemia, hypoplasia of the skull bones, oligohydramnios, contracture of the limbs, deformation of the skull bones, hypoplasia of the lungs.
Therefore, before taking the drug in women of childbearing age should exclude pregnancy.
If a woman is planning pregnancy, treatment with ACE inhibitors should be discontinued.
In the case of pregnancy during treatment with the drug Tritace, you should ASAP stop taking it and put the patient on other medications, the application of which the risk to the child is the least.
If the treatment Tritace needed in the lactation period, breastfeeding must be discontinued.
Side effects:
The following undesirable effects are given in the description complies with the following gradations of their frequency of occurrence: very often — &ge10% often — >1–<10% sometimes — >0,1–<1% rare 0.01 and 0.1% very rare <0,01%, including individual messages, the frequency is unknown — according to the available data set the frequency of occurrence is not possible.
Disorders of the heart: sometimes myocardial ischemia, including the development of angina or myocardial infarction, tachycardia, arrhythmia (new or increasing), palpitations, peripheral edema.
Violations by vessels: often — excessive decrease in blood pressure, orthostatic violation of regulation of vascular tone (orthostatic hypotension), syncope sometimes — "tides" of blood to the skin rarely the emergence or strengthening of circulatory disorders on the background of stenotic vascular lesions, vasculitis frequency not known — the Raynaud's syndrome.
Disorders of the Central nervous system: often — headache, feeling of "lightness" in the head sometimes — dizziness, ageusia (loss of taste sensitivity), dysgeusia (violation of taste sensitivity) rarely — tremor, balance disorder frequency is unknown cerebral ischemia including ischemic stroke and transient disorders of cerebral circulation, disturbance of psychomotor reactions, paresthesia (burning sensation), parosmia (impaired perception of odors).
Violations of the organ of vision: rarely — visual disturbances, including blurred vision rare — conjunctivitis.
Violations of the organ of hearing: rarely is hearing loss, ringing in the ears.
Violations of the psyche: sometimes — depressed mood, anxiety, nervousness, restlessness, sleep disturbance, including drowsiness, rarely — confusion frequency is unknown — impaired attention.
Violations of the respiratory system: often — dry cough (increasing at night and in the supine position), bronchitis, sinusitis, shortness of breath sometimes bronchospasm, including worsening of bronchial asthma, nasal congestion.
Disorders of the digestive tract: often — inflammatory response in the stomach and intestines, indigestion, a feeling of discomfort in the abdomen, indigestion, diarrhea, nausea, vomiting sometimes — pancreatitis, including and fatalities (cases of pancreatitis with a fatal outcome while taking the ACE inhibitors were observed very rarely), increased activity of pancreatic enzymes in the blood plasma, intestinal angioedema, abdominal pain, gastritis, constipation, dry mucous membranes of the oral cavity rarely — glossitis frequency unknown — aphthous stomatitis (inflammatory reactions of the mucous membrane of the oral cavity).
Violations of the hepatobiliary system: rarely — increased activity of liver enzymes and concentration of conjugated bilirubin in plasma rarely cholestatic jaundice, hepatocellular lesions, the frequency is unknown acute hepatic failure, cholestatic or cytolytic hepatitis (fatal outcome has been observed very rarely).
Violations of the kidney and urinary tract: sometimes — a violation renal function, including acute renal failure, increase the excretion of urine, increased pre-existing proteinuria, increase of urea and creatinine in the blood.
Violations of the reproductive system and mammary glands: sometimes transient impotence due to erectile dysfunction, decreased libido frequency unknown — gynecomastia.
Violations by the blood and lymphatic system: sometimes — eosinophilia, rarely — leukopenia, including neutropenia and agranulocytosis, a decrease in the number of erythrocytes in peripheral blood, decrease in hemoglobin concentration, thrombocytopenia frequency is unknown — inhibition of bone marrow hematopoiesis, pancytopenia, hemolytic anemia.
Violations of the skin and mucous membranes: often — skin rashes, particularly maculopapular and sometimes angioedema, including and fatal (edema of the larynx may cause airway obstruction, leading to death), pruritus, hyperhidrosis (excessive sweating), rarely — exfoliative dermatitis, urticaria, onycholysis rarely — photosensitivity reaction unknown frequency is toxic epidermal necrolysis, Stevens-Johnson syndrome, erythema multiforme, pemphigus, worsening of psoriasis, psoriasiform dermatitis, lichenoid or pemphigoid (michaelina) rash or enanthema, alopecia.
Violations by musculoskeletal and connective tissue: often — muscle cramps, myalgia and sometimes arthralgia.
Violations of metabolism, nutrition and laboratory parameters: often — increasing the concentration of potassium in the blood sometimes anorexia, decreased appetite frequency is unknown decrease in concentration of sodium in the blood.
Violations by the immune system: frequency unknown, anaphylactic or anaphylactoid reactions (the inhibition of ACE increases the number of anaphylactic or anaphylactoid reactions to insect venoms), increasing the concentration of antinuclear antibodies.
General disorders: often — pain in the chest, tiredness and sometimes a fever rarely asthenia (weakness).
Drug interactions:
Contraindicated in combination
The use of some high-flow membranes with negatively charged surface (e.g. polyacrylnitrile membranes) during hemodialysis or hemofiltration, the use of dextran sulfate in apherese LDL — risk of severe anaphylactic reactions.
Not recommended combinations
With potassium salts, potassium-sparing diuretics (eg, amiloride, triamterene, spironolactone) — perhaps a more pronounced increase in the concentration of potassium in the blood serum (in case of simultaneous use requires careful monitoring of potassium concentration in the serum).
Combinations that should be used with caution
With antihypertensive drugs (especially diuretics) and other drugs that reduce blood pressure (nitrates, tricyclic antidepressants) — potentiation of hypotensive effect in combination with diuretics should monitor the level of sodium in the blood serum.
With sedation, narcotic painkillers — maybe a more pronounced decrease in blood pressure.
With a vasopressor sympathomimetics (epinephrine) — decrease the hypotensive effect of ramipril, requires careful control of HELL.
With allopurinol, procainamide, cytostatics, immunosuppressants, systemic corticosteroids and other drugs that may affect hematological parameters — combined use increases the risk of leukopenia.
With lithium salts — increased serum lithium and increased cardio and neurotoxic effect of lithium.
With hypoglycemic agents for oral administration (sulfonylureas, biguanides), insulin — a decrease in insulin resistance under the influence of ramipril may increase hypoglycemic effect of these drugs, until the development of hypoglycemia.
Combinations to be taken into account
NSAIDs (indomethacin, acetylsalicylic acid) may weaken the effect of ramipril, increase the risk of renal dysfunction and increase in the concentration of potassium in the blood serum.
With heparin may increase the concentration of potassium in the blood serum.
With sodium chloride — the weakening of the hypotensive effect of ramipril and less effective treatment of the symptoms of chronic heart failure.
With ethanol — increased vasodilation. Ramipril may potentiate the adverse effects of ethanol on the body.
With estrogen — attenuation of the hypotensive effect of ramipril (fluid retention).
Desensitizing therapy in case of hypersensitivity to poisons insect ACE inhibitors, including ramipril, increase the likelihood of developing severe anaphylactic or anaphylactoid reactions to insect venoms.
Method of application and dose:
Inside, swallowing it whole (without chewing) and drinking plenty (1/2 Cup) of water, regardless of meals (i.e. pills can be taken both before and during or after eating). The dose is adjusted depending on therapeutic effect and tolerability of patients.
Drug treatment Tritace is usually long, and its duration in each particular case is determined by the doctor.
If not assigned otherwise, normal renal function and liver recommended the following dosage regimen.
In case of essential hypertension
The usual starting dose is 2.5 mg 1 times per day in the morning (one table. Tritace 2.5 mg or 1/2 tab. Tritace 5 mg with valium). If when taking the drug at this dose for 3 weeks or more, you cannot normalize a HELL, then the dose may be increased to 5 mg of ramipril per day. The lack of effectiveness of a dose of 5 mg after 2-3 weeks she could still be doubled to the maximum recommended daily dose of 10 mg/day.
As an alternative to increasing the dose to 10 mg/day in case of insufficient antihypertensive effectiveness of a daily dose of 5 mg, may be added to the treatment of other antihypertensive agents, particularly diuretics or CCB.
In chronic heart failure
The recommended initial dose is 1.25 mg 1 times / day (1/2 tab. Tritace 2.5 mg with valium). Depending on the response to the therapy, the dose may be increased. It is recommended to double the dose every 1-2 weeks. If you want receiving a daily dose of 2.5 mg and above, it may be taken as once a day, and is divided into 2 admission.
Maximum recommended daily dose is 10 mg.
In diabetic or non-diabetic nephropathy
The recommended initial dose is 1.25 mg 1 times / day (1/2 tab. Tritace 2.5 mg valium). The dose may be increased to 5 mg once a day. Under these conditions a dose of 5 mg once daily in controlled clinical trials has not been studied.
To reduce the risk of myocardial infarction, stroke or cardiovascular mortality in patients with high cardiovascular risk
The recommended initial dose is 2.5 mg 1 times / day (1 table. Tritace 2.5 mg or 1/2 tab. Tritace 5 mg with valium).
Depending on tolerability by the patient, the dose can be gradually increased. It is recommended to double the dose after 1 week of treatment, and during the following 3 weeks of treatment is to increase it to the usual maintenance dose 10 mg 1 time per day.
Doses greater than 10 mg in controlled clinical trials has not been studied.
The use of the drug in patients with Cl creatinine less than 0.6 ml/s was studied.
In heart failure, which developed during the first few days (2-9 days) after acute myocardial infarction
The recommended initial dose of 5 mg per day, divided into 2 single doses of 2.5 mg, one of which is taken in the morning and the second night (table 1. Tritace 2.5 mg or 1/2 tab. Tritace 5 mg with valium). If the patient does not tolerate this initial dosage (there is no excessive decrease in blood pressure), he recommended for two days to give 1.25 mg 2 times a day (1/2 tab. Tritace 2.5 mg with valium).
Then, depending on patient response, the dose may be increased. It is recommended that the dose increase has doubled with an interval of 1-3 days. Later, the total daily dose, initially divided into two doses, may be given once.
The maximum recommended dose is 10 mg.
Currently experience in treating patients with severe heart failure (III–IV functional class NYHA classification), arising directly following acute myocardial infarction, is insufficient. If in such patients the decision on carrying out of treatment Tritace, it is recommended that treatment is started with the lowest possible dose — 1.25 mg once a day (1/2 tab. Tritace 2.5 mg with valium) and special caution should be observed at each increasing dose.
The use of the drug Tritace in certain group of patients
Patients with impaired renal function. When Cl creatinine from 50 to 20 ml/min/1.73 m2, the initial daily dose is usually 1.25 mg (1/2 table. Tritace 2.5 mg with valium). The maximum allowable daily dose of 5 mg.
Patients with incompletely corrected fluid loss and electrolytes, patients with severe hypertension, and patients for whom excessive BP reduction is some risk (for example in severe atherosclerotic lesions of the coronary and cerebral arteries). The initial dose is reduced to 1.25 mg (1/2 table. Tritace 2.5 mg with valium).
Patients with previous therapy dioretikami. You need the ability to cancel diuretics for 2-3 days (depending on the duration of action of the diuretic) before starting treatment with the drug Tritace or at least to reduce the dose of diuretics taken. The treatment of such patients should start with the lowest dose of 1,25 mg ramipril (1/2 table. Tritace 2.5 mg with valium) taken once a day, in the morning. After the first dose and every time after increasing the dose of ramipril and (or) "loop" diuretics patients should be under medical observation for at least 8 hours in order to avoid uncontrolled hypotensive reaction.
Elderly patients (over 65 years). The initial dose is reduced to 1.25 mg (1/2 table. Tritace 2.5 mg with valium).
Patients with impaired liver function. Reaction HELL on the drug Tritace may increase (due to slow excretion of ramiprilat) or fall (by slowing down the conversion of inactive to active ramipril ramiprilat). Therefore, at the beginning of treatment requires careful medical supervision. Maximum daily dose is 2.5 mg (1 table. Tritace 2.5 mg or 1/2 tab. Tritace 5 mg with valium).
Overdose:
Symptoms: excessive peripheral vasodilation with the development of expressed lower AD, shock, bradycardia, fluid and electrolyte disorders, acute renal failure, stupor.
Treatment: gastric lavage, appointment of adsorbents (within the first 30 min). In the case of Express reduce HELL to therapy to fill the BCC and the restoration of electrolyte balance can additionally be assigned the introduction of alpha1-adrenergic agonists (norepinephrine), dopamine and angiotensin II (angiotensinamide). In the case of refractory to medical treatment bradycardia may require temporary artificial pacemaker. In case of overdose should be monitored serum concentrations of creatinine and electrolytes.
Special instructions:
Before beginning treatment drug Tritace necessary to correct hyponatremia and hypovolemia. In patients previously taking diuretics, you need to cancel or at least reduce their dose
