Treatment of essential hypertension.
This fixed dose combination is indicated in adult patients whose blood pressure is not adequately
controlled on irbesartan or hydrochlorothiazide alone (see section 5.1).

Posology
CoAprovel can be taken once daily, with or without food.
Dose titration with the individual components (i.e. irbesartan and hydrochlorothiazide) may be
recommended.
When clinically appropriate direct change from monotherapy to the fixed combinations may be
considered:
 CoAprovel 150 mg/12.5 mg may be administered in patients whose blood pressure is not
adequately controlled with hydrochlorothiazide or irbesartan 150 mg alone;
 CoAprovel 300 mg/12.5 mg may be administered in patients insufficiently controlled by
irbesartan 300 mg or by CoAprovel 150 mg/12.5 mg.
 CoAprovel 300 mg/25 mg may be administered in patients insufficiently controlled by
CoAprovel 300 mg/12.5 mg.
Doses higher than 300 mg irbesartan/25 mg hydrochlorothiazide once daily are not recommended.
When necessary, CoAprovel may be administered with another antihypertensive medicinal product
(see sections 4.3, 4.4, 4.5 and 5.1).

Special Populations
Renal impairment
Due to the hydrochlorothiazide component, CoAprovel is not recommended for patients with severe
renal dysfunction (creatinine clearance < 30 ml/min). Loop diuretics are preferred to thiazides in this
population. No dosage adjustment is necessary in patients with renal impairment whose renal
creatinine clearance is ≥ 30 ml/min (see sections 4.3 and 4.4).
Hepatic impairment
CoAprovel is not indicated in patients with severe hepatic impairment. Thiazides should be used with
caution in patients with impaired hepatic function. No dosage adjustment of CoAprovel is necessary in
patients with mild to moderate hepatic impairment (see section 4.3).
Older people
No dosage adjustment of CoAprovel is necessary in older people.
Paediatric population
CoAprovel is not recommended for use in children and adolescents because the safety and efficacy
have not been established. No data are available.
Method of Administration
For oral use.

 Hypersensitivity to the active substances or to any of the excipients listed in section 6.1, or to other sulfonamide-derived substances (hydrochlorothiazide is a sulfonamide-derived substance)  Second and third trimesters of pregnancy (see sections 4.4 and 4.6)  Severe renal impairment (creatinine clearance < 30 ml/min)  Refractory hypokalaemia, hypercalcaemia  Severe hepatic impairment, biliary cirrhosis and cholestasis  The concomitant use of CoAprovel with aliskiren-containing products is contraindicated in patients with diabetes mellitus or renal impairment (glomerular filtration rate (GFR) <60 ml/min/1.73 m²) (see sections 4.5 and 5.1).

Hypotension - Volume-depleted patients: CoAprovel has been rarely associated with symptomatic
hypotension in hypertensive patients without other risk factors for hypotension. Symptomatic
hypotension may be expected to occur in patients who are volume and/or sodium depleted by vigorous
diuretic therapy, dietary salt restriction, diarrhoea or vomiting. Such conditions should be corrected
before initiating therapy with CoAprovel.
Renal artery stenosis - Renovascular hypertension: there is an increased risk of severe hypotension and
renal insufficiency when patients with bilateral renal artery stenosis or stenosis of the artery to a single
functioning kidney are treated with angiotensin converting enzyme inhibitors or angiotensin-II
receptor antagonists. While this is not documented with CoAprovel, a similar effect should be
anticipated.
Renal impairment and kidney transplantation: when CoAprovel is used in patients with impaired renal
function, a periodic monitoring of potassium, creatinine and uric acid serum levels is recommended.
There is no experience regarding the administration of CoAprovel in patients with a recent kidney

transplantation. CoAprovel should not be used in patients with severe renal impairment (creatinine
clearance < 30 ml/min) (see section 4.3). Thiazide diuretic-associated azotaemia may occur in patients
with impaired renal function. No dosage adjustment is necessary in patients with renal impairment
whose creatinine clearance is ≥ 30 ml/min. However, in patients with mild to moderate renal
impairment (creatinine clearance ≥ 30 ml/min but < 60 ml/min) this fixed dose combination should be
administered with caution.
Dual blockade of the renin-angiotensin-aldosterone system (RAAS): there is evidence that the
concomitant use of ACE-inhibitors, angiotensin II receptor blockers or aliskiren increases the risk of
hypotension, hyperkalaemia and decreased renal function (including acute renal failure). Dual
blockade of RAAS through the combined use of ACE-inhibitors, angiotensin II receptor blockers or
aliskiren is therefore not recommended (see sections 4.5 and 5.1). If dual blockade therapy is
considered absolutely necessary, this should only occur under specialist supervision and subject to
frequent close monitoring of renal function, electrolytes and blood pressure. ACE-inhibitors and
angiotensin II receptor blockers should not be used concomitantly in patients with diabetic
nephropathy.
Hepatic impairment: thiazides should be used with caution in patients with impaired hepatic function
or progressive liver disease, since minor alterations of fluid and electrolyte balance may precipitate
hepatic coma. There is no clinical experience with CoAprovel in patients with hepatic impairment.
Aortic and mitral valve stenosis, obstructive hypertrophic cardiomyopathy: as with other vasodilators,
special caution is indicated in patients suffering from aortic or mitral stenosis, or obstructive
hypertrophic cardiomyopathy.
Primary aldosteronism: patients with primary aldosteronism generally will not respond to
antihypertensive medicinal products acting through inhibition of the renin-angiotensin system.
Therefore, the use of CoAprovel is not recommended.

Metabolic and endocrine effects: thiazide therapy may impair glucose tolerance. In diabetic patients
dosage adjustments of insulin or oral hypoglycemic agents may be required. Latent diabetes mellitus
may become manifest during thiazide therapy.
Increases in cholesterol and triglyceride levels have been associated with thiazide diuretic therapy;
however at the 12.5 mg dose contained in CoAprovel, minimal or no effects were reported.
Hyperuricaemia may occur or frank gout may be precipitated in certain patients receiving thiazide
therapy.
Electrolyte imbalance: as for any patient receiving diuretic therapy, periodic determination of serum
electrolytes should be performed at appropriate intervals.
Thiazides, including hydrochlorothiazide, can cause fluid or electrolyte imbalance (hypokalaemia,
hyponatraemia, and hypochloremic alkalosis). Warning signs of fluid or electrolyte imbalance are
dryness of mouth, thirst, weakness, lethargy, drowsiness, restlessness, muscle pain or cramps,
muscular fatigue, hypotension, oliguria, tachycardia, and gastrointestinal disturbances such as nausea
or vomiting.
Although hypokalaemia may develop with the use of thiazide diuretics, concurrent therapy with
irbesartan may reduce diuretic-induced hypokalaemia. The risk of hypokalaemia is greatest in patients
with cirrhosis of the liver, in patients experiencing brisk diuresis, in patients who are receiving
inadequate oral intake of electrolytes and in patients receiving concomitant therapy with
corticosteroids or ACTH. Conversely, due to the irbesartan component of CoAprovel hyperkalaemia
might occur, especially in the presence of renal impairment and/or heart failure, and diabetes mellitus.
Adequate monitoring of serum potassium in patients at risk is recommended. Potassium-sparing
diuretics, potassium supplements or potassium-containing salts substitutes should be co-administered
cautiously with CoAprovel (see section 4.5).

There is no evidence that irbesartan would reduce or prevent diuretic-induced hyponatraemia. Chloride
deficit is generally mild and usually does not require treatment.
Thiazides may decrease urinary calcium excretion and cause an intermittent and slight elevation of
serum calcium in the absence of known disorders of calcium metabolism. Marked hypercalcaemia
may be evidence of hidden hyperparathyroidism. Thiazides should be discontinued before carrying out
tests for parathyroid function.
Thiazides have been shown to increase the urinary excretion of magnesium, which may result in
hypomagnaesemia.
Lithium: the combination of lithium and CoAprovel is not recommended (see section 4.5).
Anti-doping test: hydrochlorothiazide contained in this medicinal product could produce a positive
analytic result in an anti-doping test.
General: in patients whose vascular tone and renal function depend predominantly on the activity of
the renin-angiotensin-aldosterone system (e.g. patients with severe congestive heart failure or
underlying renal disease, including renal artery stenosis), treatment with angiotensin converting
enzyme inhibitors or angiotensin-II receptor antagonists that affect this system has been associated
with acute hypotension, azotaemia, oliguria, or rarely acute renal failure (see section 4.5). As with any
antihypertensive agent, excessive blood pressure decrease in patients with ischemic cardiopathy or
ischemic cardiovascular disease could result in a myocardial infarction or stroke.
Hypersensitivity reactions to hydrochlorothiazide may occur in patients with or without a history of
allergy or bronchial asthma, but are more likely in patients with such a history.
Exacerbation or activation of systemic lupus erythematosus has been reported with the use of thiazide
diuretics.
Cases of photosensitivity reactions have been reported with thiazides diuretics (see section 4.8). If
photosensitivity reaction occurs during treatment, it is recommended to stop the treatment. If a readministration
of the diuretic is deemed necessary, it is recommended to protect exposed areas to the
sun or to artificial UVA.
Pregnancy: angiotensin II Receptor Antagonists (AIIRAs) should not be initiated during pregnancy.
Unless continued AIIRA therapy is considered essential, patients planning pregnancy should be
changed to alternative antihypertensive treatments which have an established safety profile for use in
pregnancy. When pregnancy is diagnosed, treatment with AIIRAs should be stopped immediately,
and, if appropriate, alternative therapy should be started (see sections 4.3 and 4.6).
Acute Myopia and Secondary Acute Angle-Closure Glaucoma: sulfonamide drugs or sulfonamide
derivative drugs can cause an idiosyncratic reaction, resulting in transient myopia and acute angleclosure
glaucoma. While hydrochlorothiazide is a sulfonamide, only isolated cases of acute angleclosure
glaucoma have been reported so far with hydrochlorothiazide. Symptoms include acute onset
of decreased visual acuity or ocular pain and typically occur within hours to weeks of drug initiation.
Untreated acute angle-closure glaucoma can lead to permanent vision loss. The primary treatment is to
discontinue drug intake as rapidly as possible. Prompt medical or surgical treatments may need to be
considered if the intraocular pressure remains uncontrolled. Risk factors for developing acute angleclosure
glaucoma may include a history of sulfonamide or penicillin allergy (see section 4.8).
Lactose: Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or
glucose-galactose malabsorption should not take this medicine.
Non-melanoma skin cancer

An increased risk of non-melanoma skin cancer (NMSC) [basal cell carcinoma (BCC) and squamous
cell carcinoma (SCC)] with increasing cumulative dose of hydrochlorothiazide (HCTZ) exposure has
been observed in two epidemiological studies based on the Danish National Cancer Registry.
Photosensitizing actions of HCTZ could act as a possible mechanism for NMSC.
Patients taking HCTZ should be informed of the risk of NMSC and advised to regularly check their
skin for any new lesions and promptly report any suspicious skin lesions. Possible preventive
measures such as limited exposure to sunlight and UV rays and, in case of exposure, adequate
protection should be advised to the patients in order to minimize the risk of skin cancer. Suspicious
skin lesions should be promptly examined potentially including histological examinations of biopsies.
The use of HCTZ may also need to be reconsidered in patients who have experienced previous NMSC
(see also section 4.8).

Other antihypertensive agents: the antihypertensive effect of CoAprovel may be increased with the
concomitant use of other antihypertensive agents. Irbesartan and hydrochlorothiazide (at doses up to
300 mg irbesartan/25 mg hydrochlorothiazide) have been safely administered with other
antihypertensive agents including calcium channel blockers and beta-adrenergic blockers. Prior
treatment with high dose diuretics may result in volume depletion and a risk of hypotension when
initiating therapy with irbesartan with or without thiazide diuretics unless the volume depletion is
corrected first (see section 4.4).
Aliskiren-containing products or ACE-inhibitors: clinical trial data has shown that dual blockade of
the renin-angiotensin-aldosterone system (RAAS) through the combined use of ACE-inhibitors,
angiotensin II receptor blockers or aliskiren is associated with a higher frequency of adverse events
such as hypotension, hyperkalaemia and decreased renal function (including acute renal failure)
compared to the use of a single RAAS-acting agent (see sections 4.3, 4.4 and 5.1).
Lithium: reversible increases in serum lithium concentrations and toxicity have been reported during
concomitant administration of lithium with angiotensin converting enzyme inhibitors. Similar effects
have been very rarely reported with irbesartan so far. Furthermore, renal clearance of lithium is
reduced by thiazides so the risk of lithium toxicity could be increased with CoAprovel. Therefore, the
combination of lithium and CoAprovel is not recommended (see section 4.4). If the combination
proves necessary, careful monitoring of serum lithium levels is recommended.
Medicinal products affecting potassium: the potassium-depleting effect of hydrochlorothiazide is
attenuated by the potassium-sparing effect of irbesartan. However, this effect of hydrochlorothiazide
on serum potassium would be expected to be potentiated by other medicinal products associated with
potassium loss and hypokalaemia (e.g. other kaliuretic diuretics, laxatives, amphotericin,
carbenoxolone, penicillin G sodium). Conversely, based on the experience with the use of other
medicinal products that blunt the renin-angiotensin system, concomitant use of potassium-sparing
diuretics, potassium supplements, salt substitutes containing potassium or other medicinal products
that may increase serum potassium levels (e.g. heparin sodium) may lead to increases in serum
potassium. Adequate monitoring of serum potassium in patients at risk is recommended (see
section 4.4).

Medicinal products affected by serum potassium disturbances: periodic monitoring of serum
potassium is recommended when CoAprovel is administered with medicinal products affected by
serum potassium disturbances (e.g. digitalis glycosides, antiarrhythmics).
Non-steroidal anti-inflammatory drugs: when angiotensin II antagonists are administered
simultaneously with non-steroidal anti- inflammatory drugs (i.e. selective COX-2 inhibitors,
acetylsalicylic acid (> 3 g/day) and non-selective NSAIDs), attenuation of the antihypertensive effect
may occur.
As with ACE inhibitors, concomitant use of angiotensin II antagonists and NSAIDs may lead to an
increased risk of worsening of renal function, including possible acute renal failure, and an increase in

serum potassium, especially in patients with poor pre-existing renal function. The combination should
be administered with caution, especially in the elderly. Patients should be adequately hydrated and
consideration should be given to monitoring renal function after initiation of concomitant therapy, and
periodically thereafter.
Additional information on irbesartan interactions: in clinical studies, the pharmacokinetic of irbesartan
is not affected by hydrochlorothiazide. Irbesartan is mainly metabolised by CYP2C9 and to a lesser
extent by glucuronidation. No significant pharmacokinetic or pharmacodynamic interactions were
observed when irbesartan was coadministered with warfarin, a medicinal product metabolised by
CYP2C9. The effects of CYP2C9 inducers such as rifampicin on the pharmacokinetic of irbesartan
have not been evaluated. The pharmacokinetic of digoxin was not altered by co-administration of
irbesartan.
Additional information on hydrochlorothiazide interactions: when administered concurrently, the
following medicinal products may interact with thiazide diuretics:
Alcohol: potentiation of orthostatic hypotension may occur;
Antidiabetic medicinal products (oral agents and insulins): dosage adjustment of the antidiabetic
medicinal product may be required (see section 4.4);
Colestyramine and Colestipol resins: absorption of hydrochlorothiazide is impaired in the presence of
anionic exchange resins. CoAprovel should be taken at least one hour before or four hours after these
medications;
Corticosteroids, ACTH: electrolyte depletion, particularly hypokalaemia, may be increased;
Digitalis glycosides: thiazide induced hypokalaemia or hypomagnaesemia favour the onset of
digitalis-induced cardiac arrhythmias (see section 4.4);
Non-steroidal anti-inflammatory drugs: the administration of a non-steroidal anti-inflammatory drug
may reduce the diuretic, natriuretic and antihypertensive effects of thiazide diuretics in some patients;
Pressor amines (e.g. noradrenaline): the effect of pressor amines may be decreased, but not
sufficiently to preclude their use;
Nondepolarizing skeletal muscle relaxants (e.g. tubocurarine): the effect of nondepolarizing skeletal
muscle relaxants may be potentiated by hydrochlorothiazide;
Antigout medicinal products: dosage adjustments of antigout medicinal products may be necessary as
hydrochlorothiazide may raise the level of serum uric acid. Increase in dosage of probenecid or
sulfinpyrazone may be necessary. Co-administration of thiazide diuretics may increase the incidence
of hypersensitivity reactions to allopurinol;
Calcium salts: thiazide diuretics may increase serum calcium levels due to decreased excretion. If
calcium supplements or calcium sparing medicinal products (e.g. vitamin D therapy) must be
prescribed, serum calcium levels should be monitored and calcium dosage adjusted accordingly;
Carbamazepine: concomitant use of carbamazepine and hydrochlorothiazide has been associated with
the risk of symptomatic hyponatraemia. Electrolytes should be monitored during concomitant use. If
possible, another class of diuretics should be used;
Other interactions: the hyperglycaemic effect of beta-blockers and diazoxide may be enhanced by
thiazides. Anticholinergic agents (e.g. atropine, beperiden) may increase the bioavailability of
thiazide-type diuretics by decreasing gastrointestinal motility and stomach emptying rate. Thiazides
may increase the risk of adverse effects caused by amantadine. Thiazides may reduce the renal excretion of cytotoxic medicinal products (e.g. cyclophosphamide, methotrexate) and potentiate their
myelosuppressive effects.

Pregnancy
Angiotensin II Receptor Antagonists (AIIRAs)

The use of AIIRAs is not recommended during the first trimester of pregnancy (see section 4.4). The use of AIIRAs is contraindicated during the second and third trimesters of pregnancy (see sections 4.3 and 4.4).

Epidemiological evidence regarding the risk of teratogenicity following exposure to ACE inhibitors
during the first trimester of pregnancy has not been conclusive; however a small increase in risk
cannot be excluded. Whilst there is no controlled epidemiological data on the risk with Angiotensin II
Receptor Antagonists (AIIRAs), similar risks may exist for this class of drugs. Unless continued
AIIRA therapy is considered essential, patients planning pregnancy should be changed to alternative
antihypertensive treatments which have an established safety profile for use in pregnancy. When
pregnancy is diagnosed, treatment with AIIRAs should be stopped immediately, and, if appropriate,
alternative therapy should be started.
Exposure to AIIRA therapy during the second and third trimesters is known to induce human
foetotoxicity (decreased renal function, oligohydramnios, skull ossification retardation) and neonatal
toxicity (renal failure, hypotension, hyperkalaemia). (See section 5.3).
Should exposure to AIIRAs have occurred from the second trimester of pregnancy, ultrasound check
of renal function and skull is recommended.
Infants whose mothers have taken AIIRAs should be closely observed for hypotension (see
sections 4.3 and 4.4).
Hydrochlorothiazide
There is limited experience with hydrochlorothiazide during pregnancy, especially during the first
trimester. Animal studies are insufficient. Hydrochlorothiazide crosses the placenta. Based on the
pharmacological mechanism of action of hydrochlorothiazide its use during the second and third
trimester may compromise foeto-placental perfusion and may cause foetal and neonatal effects like
icterus, disturbance of electrolyte balance and thrombocytopenia.
Hydrochlorothiazide should not be used for gestational oedema, gestational hypertension or
preeclampsia due to the risk of decreased plasma volume and placental hypoperfusion, without a
beneficial effect on the course of the disease.
Hydrochlorothiazide should not be used for essential hypertension in pregnant women except in rare
situations where no other treatment could be used.
Since CoAprovel contains hydrochlorothiazide, it is not recommended during the first trimester of
pregnancy. A switch to a suitable alternative treatment should be carried out in advance of a planned
pregnancy.
Breast-feeding
Angiotensin II Receptor Antagonists (AIIRAs)

Because no information is available regarding the use of CoAprovel during breast-feeding, CoAprovel
is not recommended and alternative treatments with better established safety profiles during breastfeeding
are preferable, especially while nursing a newborn or preterm infant.
It is unknown whether irbesartan or its metabolites are excreted in human milk.
Available pharmacodynamic/toxicological data in rats have shown excretion of irbesartan or its
metabolites in milk (for details see 5.3).
Hydrochlorothiazide
Hydrochlorothiazide is excreted in human milk in small amounts. Thiazides in high doses causing
intense diuresis can inhibit the milk production. The use of CoAprovel during breast feeding is not
recommended. If CoAprovel is used during breast feeding, doses should be kept as low as possible.
Fertility
Irbesartan had no effect upon fertility of treated rats and their offspring up to the dose levels inducing
the first signs of parental toxicity (see section 5.3).

Based on its pharmacodynamic properties, CoAprovel is unlikely to affect the ability to drive and use
machines. When driving vehicles or operating machines, it should be taken into account that
occasionally dizziness or weariness may occur during treatment of hypertension.

Irbesartan/hydrochlorothiazide combination
Among 898 hypertensive patients who received various doses of irbesartan/hydrochlorothiazide
(range: 37.5 mg/6.25 mg to 300 mg/25 mg) in placebo-controlled trials, 29.5% of the patients
experienced adverse reactions. The most commonly reported ADRs were dizziness (5.6%), fatigue
(4.9%), nausea/vomiting (1.8%), and abnormal urination (1.4%). In addition, increases in blood urea
nitrogen (BUN) (2.3%), creatine kinase (1.7%) and creatinine (1.1%) were also commonly observed in
the trials.
Table 1 gives the adverse reactions observed from spontaneous reporting and in placebo-controlled
trials.
The frequency of adverse reactions listed below is defined using the following convention:
very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1,000 to < 1/100); rare
(≥ 1/10,000 to < 1/1,000); very rare (< 1/10,000). Within each frequency grouping, undesirable effects
are presented in order of decreasing seriousness.

Table 1: Adverse Reactions in Placebo-Controlled Trials and Spontaneous Reports
Investigations: Common: increases in blood urea nitrogen (BUN),
creatinine and creatine kinase
Uncommon: decreases in serum potassium and sodium
Cardiac disorders: Uncommon: syncope, hypotension, tachycardia, oedema
Nervous system disorders: Common: dizziness
Uncommon: orthostatic dizziness
Not known: headache
Ear and labyrinth disorders: Not known: tinnitus
Respiratory, thoracic and
mediastinal disorders:
Not known: cough
Gastrointestinal disorders: Common: nausea/vomiting

Uncommon: diarrhoea
Not known: dyspepsia, dysgeusia
Renal and urinary disorders: Common: abnormal urination
Not known: impaired renal function including isolated
cases of renal failure in patients at risk (see
section 4.4)
Musculoskeletal and connective
tissue disorders:
Uncommon: swelling extremity
Not known: arthralgia, myalgia
Metabolism and nutrition
disorders:
Not known: hyperkalaemia
Vascular disorders: Uncommon: flushing
General disorders and
administration site conditions:
Common: fatigue
Immune system disorders: Not known: cases of hypersensitivity reactions such as
angioedema, rash, urticaria
Hepatobiliary disorders: Uncommon:
Not known:
jaundice
hepatitis, abnormal liver function
Reproductive system and breast
disorders:
Uncommon: sexual dysfunction, libido changes
Additional information on individual components: in addition to the adverse reactions listed above for
the combination product, other adverse reactions previously reported with one of the individual
components may be potential adverse reactions with CoAprovel. Tables 2 and 3 below detail the
adverse reactions reported with the individual components of CoAprovel.
Table 2: Adverse reactions reported with the use of irbesartan alone
Blood and lymphatic system
disorders:
Not known: thrombocytopenia
General disorders and
administration site conditions:
Uncommon: chest pain
Immune system disorders: Not known: Anaphylactic reaction including anaphylactic
shock
Table 3: Adverse reactions reported with the use of hydrochlorothiazide alone
Investigations: Not known: electrolyte imbalance (including hypokalaemia
and hyponatraemia, see section 4.4),
hyperuricaemia, glycosuria, hyperglycaemia,
increases in cholesterol and triglycerides
Cardiac disorders: Not known: cardiac arrhythmias
Blood and lymphatic system
disorders:
Not known: aplastic anaemia, bone marrow depression,
neutropenia/agranulocytosis, haemolytic
anaemia, leucopenia, thrombocytopenia
Nervous system disorders: Not known: vertigo, paraesthesia, light-headedness,
restlessness
Eye disorders: Not known: transient blurred vision, xanthopsia, acute
myopia and secondary acute angle-closure
glaucoma
Respiratory, thoracic and
mediastinal disorders:
Not known: respiratory distress (including pneumonitis and
pulmonary oedema)
Gastrointestinal disorders: Not known: pancreatitis, anorexia, diarrhoea, constipation,
gastric irritation, sialadenitis, loss of appetite
Renal and urinary disorders: Not known: interstitial nephritis, renal dysfunction
Skin and subcutaneous tissue
disorders:
Not known: anaphylactic reactions, toxic epidermal
necrolysis, necrotizing angitis (vasculitis,
cutaneous vasculitis), cutaneous lupus

erythematosus-like reactions, reactivation of
cutaneous lupus erythematosus,
photosensitivity reactions, rash, urticaria
Musculoskeletal and connective
tissue disorders:
Not known: weakness, muscle spasm
Vascular disorders: Not known: postural hypotension
General disorders and
administration site conditions:
Not known: fever
Hepatobiliary disorders: Not known: jaundice (intrahepatic cholestatic jaundice)
Psychiatric disorders: Not known: depression, sleep disturbances
Neoplasms benign, malignant
and unspecified (incl cysts and
polyps)
Not known: non-melanoma skin cancer (basal cell
carcinoma and squamous cell carcinoma)
Non-melanoma skin cancer: Based on available data from epidemiological studies, cumulative dose dependent association
between HCTZ and NMSC has been observed (see also sections 4.4 and 5.1).

The dose dependent adverse events of hydrochlorothiazide (particularly electrolyte disturbances) may
increase when titrating the hydrochlorothiazide.
Reporting of suspected adverse reactions
Reporting of side effects:
The National Pharmacovigilance and Drug Safety Centre
(NPC) Fax: +966-11-205-7662
Call NPC at +966-11-2038222, Exts: 2317-2356-2353-2354-2334-2340. Toll free phone:
8002490000 E-mail:
npc.drug@sfda.gov.sa
Website:
www.sfda.gov.sa/npc

No specific information is available on the treatment of overdose with CoAprovel. The patient should
be closely monitored, and the treatment should be symptomatic and supportive. Management depends
on the time since ingestion and the severity of the symptoms. Suggested measures include induction
of emesis and/or gastric lavage. Activated charcoal may be useful in the treatment of overdose. Serum
electrolytes and creatinine should be monitored frequently. If hypotension occurs, the patient should
be placed in a supine position, with salt and volume replacements given quickly.
The most likely manifestations of irbesartan overdose are expected to be hypotension and tachycardia;
bradycardia might also occur.
Overdose with hydrochlorothiazide is associated with electrolyte depletion (hypokalaemia,
hypochloremia, hyponatraemia) and dehydration resulting from excessive diuresis. The most common
signs and symptoms of overdose are nausea and somnolence. Hypokalaemia may result in muscle
spasms and/or accentuate cardiac arrhythmias associated with the concomitant use of digitalis
glycosides or certain anti-arrhythmic medicinal products.
Irbesartan is not removed by haemodialysis. The degree to which hydrochlorothiazide is removed by
haemodialysis has not been established.

Pharmacotherapeutic group: angiotensin-II antagonists, combinations
ATC code: C09DA04.

Mechanism of action

CoAprovel is a combination of an angiotensin-II receptor antagonist, irbesartan, and a thiazide
diuretic, hydrochlorothiazide. The combination of these ingredients has an additive antihypertensive
effect, reducing blood pressure to a greater degree than either component alone.
Irbesartan is a potent, orally active, selective angiotensin-II receptor (AT1 subtype) antagonist. It is
expected to block all actions of angiotensin-II mediated by the AT1 receptor, regardless of the source
or route of synthesis of angiotensin-II. The selective antagonism of the angiotensin-II (AT1) receptors
results in increases in plasma renin levels and angiotensin-II levels, and a decrease in plasma
aldosterone concentration. Serum potassium levels are not significantly affected by irbesartan alone at
the recommended doses in patients without risk of electrolyte imbalance (see sections 4.4 and 4.5).
Irbesartan does not inhibit ACE (kininase-II), an enzyme which generates angiotensin-II and also
degrades bradykinin into inactive metabolites. Irbesartan does not require metabolic activation for its
activity.
Hydrochlorothiazide is a thiazide diuretic. The mechanism of antihypertensive effect of thiazide
diuretics is not fully known. Thiazides affect the renal tubular mechanisms of electrolyte reabsorption,
directly increasing excretion of sodium and chloride in approximately equivalent amounts. The
diuretic action of hydrochlorothiazide reduces plasma volume, increases plasma renin activity,
increases aldosterone secretion, with consequent increases in urinary potassium and bicarbonate loss,
and decreases in serum potassium. Presumably through blockade of the renin-angiotensin-aldosterone
system, co-administration of irbesartan tends to reverse the potassium loss associated with these
diuretics. With hydrochlorothiazide, onset of diuresis occurs in 2 hours, and peak effect occurs at
about 4 hours, while the action persists for approximately 6-12 hours.
The combination of hydrochlorothiazide and irbesartan produces dose-related additive reductions in
blood pressure across their therapeutic dose ranges. The addition of 12.5 mg hydrochlorothiazide to
300 mg irbesartan once daily in patients not adequately controlled on 300 mg irbesartan alone resulted
in further placebo-corrected diastolic blood pressure reductions at trough (24 hours post-dosing) of
6.1 mm Hg. The combination of 300 mg irbesartan and 12.5 mg hydrochlorothiazide resulted in an
overall placebo-subtracted systolic/diastolic reductions of up to 13.6/11.5 mm Hg.
Limited clinical data (7 out of 22 patients) suggest that patients not controlled with the
300 mg/12.5 mg combination may respond when uptitrated to 300 mg/25 mg. In these patients, an
incremental blood pressure lowering effect was observed for both systolic blood pressure (SBP) and
diastolic blood pressure (DBP) (13.3 and 8.3 mm Hg, respectively).
Once daily dosing with 150 mg irbesartan and 12.5 mg hydrochlorothiazide gave systolic/diastolic
mean placebo-adjusted blood pressure reductions at trough (24 hours post-dosing) of 12.9/6.9 mm Hg
in patients with mild-to-moderate hypertension. Peak effects occurred at 3-6 hours. When assessed by
ambulatory blood pressure monitoring, the combination 150 mg irbesartan and 12.5 mg
hydrochlorothiazide once daily produced consistent reduction in blood pressure over the 24 hours
period with mean 24-hour placebo-subtracted systolic/diastolic reductions of 15.8/10.0 mm Hg. When
measured by ambulatory blood pressure monitoring, the trough to peak effects of
CoAprovel 150 mg/12.5 mg were 100%. The trough to peak effects measured by cuff during office
visits were 68% and 76% for CoAprovel 150 mg/12.5 mg and CoAprovel 300 mg/12.5 mg,
respectively. These 24-hour effects were observed without excessive blood pressure lowering at peak
and are consistent with safe and effective blood-pressure lowering over the once-daily dosing interval.
In patients not adequately controlled on 25 mg hydrochlorothiazide alone, the addition of irbesartan
gave an added placebo-subtracted systolic/diastolic mean reduction of 11.1/7.2 mm Hg.
The blood pressure lowering effect of irbesartan in combination with hydrochlorothiazide is apparent
after the first dose and substantially present within 1-2 weeks, with the maximal effect occurring by 6-
8 weeks. In long-term follow-up studies, the effect of irbesartan/hydrochlorothiazide was maintained
for over one year. Although not specifically studied with the CoAprovel, rebound hypertension has not
been seen with either irbesartan or hydrochlorothiazide.

The effect of the combination of irbesartan and hydrochlorothiazide on morbidity and mortality has
not been studied. Epidemiological studies have shown that long term treatment with
hydrochlorothiazide reduces the risk of cardiovascular mortality and morbidity.
There is no difference in response to CoAprovel, regardless of age or gender. As is the case with other
medicinal products that affect the renin-angiotensin system, black hypertensive patients have notably
less response to irbesartan monotherapy. When irbesartan is administered concomitantly with a low
dose of hydrochlorothiazide (e.g. 12.5 mg daily), the antihypertensive response in black patients
approaches that of non-black patients.
Clinical efficacy and safety
Efficacy and safety of CoAprovel as initial therapy for severe hypertension (defined as SeDBP
≥ 110 mmHg) was evaluated in a multicentre, randomized, double-blind, active-controlled, 8-week,
parallel-arm study. A total of 697 patients were randomized in a 2:1 ratio to either
irbesartan/hydrochlorothiazide 150 mg/12.5 mg or to irbesartan 150 mg and systematically forcetitrated
(before assessing the response to the lower dose) after one week to
irbesartan/hydrochlorothiazide 300 mg/25 mg or irbesartan 300 mg, respectively.
The study recruited 58% males. The mean age of patients was 52.5 years, 13% were ≥ 65 years of age,
and just 2% were ≥ 75 years of age. Twelve percent (12%) of patients were diabetic, 34% were
hyperlipidemic and the most frequent cardiovascular condition was stable angina pectoris in 3.5% of
the participants.
The primary objective of this study was to compare the proportion of patients whose SeDBP was
controlled (SeDBP < 90 mmHg) at Week 5 of treatment. Forty-seven percent (47.2%) of patients on
the combination achieved trough SeDBP < 90 mmHg compared to 33.2% of patients on irbesartan
(p = 0.0005). The mean baseline blood pressure was approximately 172/113 mmHg in each treatment
group and decreases of SeSBP/SeDBP at five weeks were 30.8/24.0 mmHg and 21.1/19.3 mmHg for
irbesartan/hydrochlorothiazide and irbesartan, respectively (p < 0.0001).
The types and incidences of adverse events reported for patients treated with the combination were
similar to the adverse event profile for patients on monotherapy. During the 8-week treatment period,
there were no reported cases of syncope in either treatment group. There were 0.6% and 0% of patients
with hypotension and 2.8% and 3.1% of patients with dizziness as adverse reactions reported in the
combination and monotherapy groups, respectively.
Dual blockade of the renin-angiotensin-aldosterone system (RAAS)
Two large randomised, controlled trials (ONTARGET (ONgoing Telmisartan Alone and in
combination with Ramipril Global Endpoint Trial) and VA NEPHRON-D (The Veterans Affairs
Nephropathy in Diabetes)) have examined the use of the combination of an ACE-inhibitor with an
angiotensin II receptor blocker. ONTARGET was a study conducted in patients with a history of
cardiovascular or cerebrovascular disease, or type 2 diabetes mellitus accompanied by evidence of
end-organ damage. VA NEPHRON-D was a study in patients with type 2 diabetes mellitus and
diabetic nephropathy.
These studies have shown no significant beneficial effect on renal and/or cardiovascular outcomes and
mortality, while an increased risk of hyperkalaemia, acute kidney injury and/or hypotension as
compared to monotherapy was observed. Given their similar pharmacodynamic properties, these
results are also relevant for other ACE-inhibitors and angiotensin II receptor blockers.
ACE-inhibitors and angiotensin II receptor blockers should therefore not be used concomitantly in
patients with diabetic nephropathy.

ALTITUDE (Aliskiren Trial in Type 2 Diabetes Using Cardiovascular and Renal Disease Endpoints)
was a study designed to test the benefit of adding aliskiren to a standard therapy of an ACE-inhibitor
or an angiotensin II receptor blocker in patients with type 2 diabetes mellitus and chronic kidney
disease, cardiovascular disease, or both. The study was terminated early because of an increased risk
of adverse outcomes. Cardiovascular death and stroke were both numerically more frequent in the
aliskiren group than in the placebo group and adverse events and serious adverse events of interest
(hyperkalaemia, hypotension and renal dysfunction) were more frequently reported in the aliskiren
group than in the placebo group.
Non-melanoma skin cancer:
Based on available data from epidemiological studies, cumulative dosedependent association between
HCTZ and NMSC has been observed. One study included a population comprised of 71,533 cases of
BCC and of 8,629 cases of SCC matched to 1,430,833 and 172,462 population controls, respectively.
High HCTZ use (≥50,000 mg cumulative) was associated with an adjusted OR of 1.29 (95% CI: 1.23-
1.35) for BCC and 3.98 (95% CI: 3.68-4.31) for SCC. A clear cumulative dose response relationship
was observed for both BCC and SCC. Another study showed a possible association between lip cancer
(SCC) and exposure to HCTZ: 633 cases of lip-cancer were matched with 63,067 population controls,
using a risk-set sampling strategy. A cumulative dose-response relationship was demonstrated with an
adjusted OR 2.1 (95% CI: 1.7-2.6) increasing to OR 3.9 (3.0-4.9) for high use (~25,000 mg) and OR
7.7 (5.7-10.5) for the highest cumulative dose (~100,000 mg) (see also section 4.4).

Concomitant administration of hydrochlorothiazide and irbesartan has no effect on the
pharmacokinetics of either medicinal product.
Absorption
Irbesartan and hydrochlorothiazide are orally active agents and do not require biotransformation for
their activity. Following oral administration of CoAprovel, the absolute oral bioavailability is 60-80%
and 50-80% for irbesartan and hydrochlorothiazide, respectively. Food does not affect the
bioavailability of CoAprovel. Peak plasma concentration occurs at 1.5-2 hours after oral
administration for irbesartan and 1-2.5 hours for hydrochlorothiazide.
Distribution
Plasma protein binding of irbesartan is approximately 96%, with negligible binding to cellular blood
components. The volume of distribution for irbesartan is 53-93 litres. Hydrochlorothiazide is 68%
protein-bound in the plasma, and its apparent volume of distribution is 0.83-1.14 l/kg.
Linearity/non-linearity
Irbesartan exhibits linear and dose proportional pharmacokinetics over the dose range of 10 to 600 mg.
A less than proportional increase in oral absorption at doses beyond 600 mg was observed; the
mechanism for this is unknown. The total body and renal clearance are 157-176 and 3.0-3.5 ml/min,
respectively. The terminal elimination half-life of irbesartan is 11-15 hours. Steady-state plasma
concentrations are attained within 3 days after initiation of a once-daily dosing regimen. Limited
accumulation of irbesartan (< 20%) is observed in plasma upon repeated once-daily dosing. In a study,
somewhat higher plasma concentrations of irbesartan were observed in female hypertensive patients.
However, there was no difference in the half-life and accumulation of irbesartan. No dosage
adjustment is necessary in female patients. Irbesartan AUC and Cmax values were also somewhat
greater in older subjects (≥ 65 years) than those of young subjects (18-40 years). However the terminal
half-life was not significantly altered. No dosage adjustment is necessary in older people. The mean
plasma half-life of hydrochlorothiazide reportedly ranges from 5-15 hours.
Biotransformation

Following oral or intravenous administration of 14C irbesartan, 80-85% of the circulating plasma
radioactivity is attributable to unchanged irbesartan. Irbesartan is metabolised by the liver via
glucuronide conjugation and oxidation. The major circulating metabolite is irbesartan glucuronide
(approximately 6%). In vitro studies indicate that irbesartan is primarily oxidised by the
cytochrome P450 enzyme CYP2C9; isoenzyme CYP3A4 has negligible effect.
Elimination
Irbesartan and its metabolites are eliminated by both biliary and renal pathways. After either oral or
intravenous administration of 14C irbesartan, about 20% of the radioactivity is recovered in the urine,
and the remainder in the faeces. Less than 2% of the dose is excreted in the urine as unchanged
irbesartan. Hydrochlorothiazide is not metabolized but is eliminated rapidly by the kidneys. At least
61% of the oral dose is eliminated unchanged within 24 hours. Hydrochlorothiazide crosses the
placental but not the blood-brain barrier, and is excreted in breast milk.
Renal impairment
In patients with renal impairment or those undergoing haemodialysis, the pharmacokinetic parameters
of irbesartan are not significantly altered. Irbesartan is not removed by haemodialysis. In patients with
creatinine clearance < 20 ml/min, the elimination half-life of hydrochlorothiazide was reported to
increase to 21 hours.
Hepatic impairment
In patients with mild to moderate cirrhosis, the pharmacokinetic parameters of irbesartan are not
significantly altered. Studies have not been performed in patients with severe hepatic impairment.

Irbesartan/hydrochlorothiazide
The potential toxicity of the irbesartan/hydrochlorothiazide combination after oral administration was
evaluated in rats and macaques in studies lasting up to 6 months. There were no toxicological findings
observed of relevance to human therapeutic use.
The following changes, observed in rats and macaques receiving the irbesartan/hydrochlorothiazide
combination at 10/10 and 90/90 mg/kg/day, were also seen with one of the two medicinal products
alone and/or were secondary to decreases in blood pressure (no significant toxicologic interactions
were observed):
 kidney changes, characterized by slight increases in serum urea and creatinine, and
hyperplasia/hypertrophy of the juxtaglomerular apparatus, which are a direct consequence of the
interaction of irbesartan with the renin-angiotensin system;
 slight decreases in erythrocyte parameters (erythrocytes, haemoglobin, haematocrit);
 stomach discoloration, ulcers and focal necrosis of gastric mucosa were observed in few rats in a
6 months toxicity study at irbesartan 90 mg/kg/day, hydrochlorothiazide 90 mg/kg/day, and
irbesartan/hydrochlorothiazide 10/10 mg/kg/day. These lesions were not observed in macaques;
 decreases in serum potassium due to hydrochlorothiazide and partly prevented when
hydrochlorothiazide was given in combination with irbesartan.
Most of the above mentioned effects appear to be due to the pharmacological activity of irbesartan
(blockade of angiotensin-II-induced inhibition of renin release, with stimulation of the renin-producing
cells) and occur also with angiotensin converting enzyme inhibitors. These findings appear to have no
relevance to the use of therapeutic doses of irbesartan/hydrochlorothiazide in humans.
No teratogenic effects were seen in rats given irbesartan and hydrochlorothiazide in combination at
doses that produced maternal toxicity. The effects of the irbesartan/hydrochlorothiazide combination
on fertility have not been evaluated in animal studies, as there is no evidence of adverse effect on
fertility in animals or humans with either irbesartan or hydrochlorothiazide when administered alone.

However, another angiotensin-II antagonist affected fertility parameters in animal studies when given
alone. These findings were also observed with lower doses of this other angiotensin-II antagonist when
given in combination with hydrochlorothiazide.
There was no evidence of mutagenicity or clastogenicity with the irbesartan/hydrochlorothiazide
combination. The carcinogenic potential of irbesartan and hydrochlorothiazide in combination has not
been evaluated in animal studies.
Irbesartan
There was no evidence of abnormal systemic or target organ toxicity at clinically relevant doses. In
non-clinical safety studies, high doses of irbesartan (≥ 250 mg/kg/day in rats and ≥ 100 mg/kg/day in
macaques) caused a reduction of red blood cell parameters (erythrocytes, haemoglobin, haematocrit).
At very high doses (≥ 500 mg/kg/day) degenerative changes in the kidneys (such as interstitial
nephritis, tubular distention, basophilic tubules, increased plasma concentrations of urea and
creatinine) were induced by irbesartan in the rat and the macaque and are considered secondary to the
hypotensive effects of the medicinal product which led to decreased renal perfusion. Furthermore,
irbesartan induced hyperplasia/hypertrophy of the juxtaglomerular cells (in rats at ≥ 90 mg/kg/day, in
macaques at ≥ 10 mg/kg/day). All of these changes were considered to be caused by the
pharmacological action of irbesartan. For therapeutic doses of irbesartan in humans, the
hyperplasia/hypertrophy of the renal juxtaglomerular cells does not appear to have any relevance.
There was no evidence of mutagenicity, clastogenicity or carcinogenicity.
Fertility and reproductive performance were not affected in studies of male and female rats even at
oral doses of irbesartan causing some parental toxicity (from 50 to 650 mg/kg/day), including
mortality at the highest dose. No significant effects on the number of corpora lutea, implants, or live
foetuses were observed. Irbesartan did not affect survival, development, or reproduction of offspring.
Studies in animals indicate that the radiolabelled irbesartan is detected in rat and rabbit foetuses.
Irbesartan is excreted in the milk of lactating rats.
Animal studies with irbesartan showed transient toxic effects (increased renal pelvic cavitation,
hydroureter or subcutaneous oedema) in rat foetuses, which were resolved after birth. In rabbits,
abortion or early resorption was noted at doses causing significant maternal toxicity, including
mortality. No teratogenic effects were observed in the rat or rabbit.
Hydrochlorothiazide
Although equivocal evidence for a genotoxic or carcinogenic effect was found in some experimental
models, the extensive human experience with hydrochlorothiazide has failed to show an association
between its use and an increase in neoplasms.

Microcrystalline cellulose
Croscarmellose sodium
Lactose monohydrate
Magnesium stearate
Colloidal hydrated silica
Pregelatinised maize starch
Red and yellow ferric oxides (E172)

Not applicable.

3 years.

Do not store above 30°C.
Store in the original package in order to protect from moisture.

Cartons of 14 tablets in PVC/PVDC/Aluminium blisters.
Cartons of 28 tablets in PVC/PVDC/Aluminium blisters.
Cartons of 56 tablets in PVC/PVDC/Aluminium blisters.
Cartons of 98 tablets in PVC/PVDC/Aluminium blisters.
Cartons of 56 x 1 tablets in PVC/PVDC/Aluminium perforated unit dose blisters.
Not all pack sizes may be marketed.

Any unused medicinal product or waste material should be disposed of in accordance with local
requirements.