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Candesartan: Drug information

Candesartan: Drug information
(For additional information see "Candesartan: Patient drug information" and see "Candesartan: Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
ALERT: US Boxed Warning
Fetal toxicity:

When pregnancy is detected, discontinue candesartan as soon as possible. Drugs that act directly on the renin-angiotensin system can cause injury and even death to the developing fetus.

Brand Names: US
  • Atacand
Brand Names: Canada
  • ACCEL-Candesartan [DSC];
  • ACH-Candesartan;
  • AG-Candesartan;
  • APO-Candesartan;
  • Atacand;
  • Auro-Candesartan;
  • JAMP-Candesartan;
  • MINT-Candesartan;
  • NRA-Candesartan;
  • PMS-Candesartan;
  • SANDOZ Candesartan;
  • TARO-Candesartan;
  • TEVA-Candesartan
Pharmacologic Category
  • Angiotensin II Receptor Blocker;
  • Antihypertensive
Dosing: Adult
Acute coronary syndrome

Acute coronary syndrome:

Note: May be used as an alternative in patients who cannot tolerate an angiotensin-converting enzyme (ACE) inhibitor (eg, due to cough or angioedema) (Ref). Angiotensin II receptor blockers (ARBs) do not appear to elevate the risk of angioedema (Ref); however, patients must be educated that angioedema due to an ACE inhibitor can sometimes reoccur within months following discontinuation (Ref); referral to an allergist may be appropriate.

Non-ST-elevation acute coronary syndrome (alternative agent) (off-label use):

Note: Patients should be hemodynamically stable before initiation. Use as a component of an appropriate medical regimen, which may also include antiplatelet agent(s), a beta-blocker, and a statin. Continue ARB therapy indefinitely for patients with concurrent diabetes, left ventricular ejection fraction ≤40%, hypertension, or stable chronic kidney disease (CKD) (Ref). Dosing is based on general dosing range in the manufacturer's labeling.

Oral: Initial: 8 mg once daily; increase dose as tolerated up to 32 mg/day under close monitoring to avoid hypotension.

ST-elevation myocardial infarction (alternative agent) (off-label use):

Note: Patients should be hemodynamically stable before initiation. Use as a component of an appropriate medical regimen, which may also include antiplatelet agent(s), a beta-blocker, and a statin. Continue ARB therapy indefinitely (Ref). Dosing is based on general dosing range in the manufacturer's labeling.

Oral: Initial: 8 mg once daily; increase dose as tolerated up to 32 mg/day under close monitoring to avoid hypotension.

Heart failure with reduced ejection fraction

Heart failure with reduced ejection fraction (alternative agent):

Note: Alternative therapy in patients who cannot tolerate an angiotensin II receptor-neprilysin inhibitor (ARNI) or an ACE inhibitor (eg, due to cough or angioedema); consultation with a heart failure specialist and/or an allergist may be appropriate (Ref). ARBs do not appear to elevate the risk of angioedema (Ref); however, angioedema due to an ACE inhibitor can sometimes reoccur months following discontinuation (Ref).

Oral: Initial: 4 to 8 mg once daily; increase dose (eg, double) every ≥ 1 to 2 weeks based on response and tolerability to a target dose of 32 mg once daily (Ref). In hospitalized patients, may titrate more rapidly as tolerated (Ref).

Hypertension, chronic

Hypertension, chronic:

Note: For patients who warrant combination therapy (BP >20/10 mm Hg above goal or suboptimal response to initial monotherapy), may use with another appropriate agent (eg, long-acting dihydropyridine calcium channel blocker or thiazide diuretic) (Ref).

Oral: Initial: 8 mg once daily; evaluate response after approximately 2 to 4 weeks and titrate dose (eg, increase the daily dose by doubling), as needed, up to 32 mg once daily; if additional blood pressure control is needed, consider combination therapy. Patients with severe asymptomatic hypertension and no signs of acute end organ damage should be evaluated for medication titration within 1 week (Ref).

Migraine, prevention

Migraine, prevention (alternative agent) (off-label use):

Note: Among second-line agents for migraine prevention, consider use in patients with comorbid hypertension (Ref). An adequate trial for assessment of effect is considered to be at least 2 to 3 months at a therapeutic dose (Ref).

Oral: Initial: 4 to 8 mg once daily; may increase dose (eg, by doubling) weekly based on response and tolerability up to 16 mg once daily (Ref).

Proteinuric chronic kidney disease, diabetic or nondiabetic

Proteinuric chronic kidney disease, diabetic or nondiabetic (off-label use):

Oral: Initial: 8 mg once daily; titrate gradually (eg, by doubling the dose every 2 to 4 weeks) to the maximally tolerated dose, not to exceed 32 mg/day. If proteinuria target is not met despite optimized dosage, consider additional therapies (eg, sodium-glucose cotransporter-2 inhibitor) (Ref).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

Kidney impairment prior to treatment initiation:

Altered kidney function:

CrCl >30 mL/minute/1.73 m2: No dosage adjustment necessary (Ref).

CrCl ≤30 mL/minute/1.73 m2: Start with a lower initial dose (eg, 4 mg once daily); titrate gradually based on tolerability and efficacy with frequent monitoring of BP, kidney function, and potassium (Ref). Maximum recommended dose: 16 mg once daily (Ref).

Hemodialysis, intermittent (thrice weekly): Not significantly dialyzed (Ref):

Start with a lower initial dose (eg, 4 mg once daily); titrate gradually based on tolerability and efficacy with frequent monitoring of BP, kidney function, and potassium (Ref). Maximum recommended dose: 16 mg once daily (Ref).

Peritoneal dialysis: Not likely to be significantly dialyzed (Ref):

Start with a lower initial dose (eg, 4 mg once daily); titrate gradually based on tolerability and efficacy with frequent monitoring of BP, kidney function, and potassium (Ref). Maximum recommended dose: 16 mg once daily (Ref).

CRRT: Start with lower initial dose (eg, 4 mg once daily) and titrate gradually based on tolerability and efficacy with frequent monitoring of BP, kidney function, and potassium. Maximum recommended dose: 16 mg once daily (Ref).

PIRRT (eg, sustained, low-efficiency diafiltration): Start with lower initial dose (eg, 4 mg once daily) and titrate gradually based on tolerability and efficacy with frequent monitoring of BP, kidney function, and potassium. Maximum recommended dose: 16 mg once daily (Ref).

Alterations in kidney function during treatment:

Small, transient increases in serum creatinine are likely to occur within 4 weeks following initiation of therapy or an increase in dose. If serum creatinine increases by >30%, review for possible etiologies (eg, acute kidney injury, volume depletion, concomitant medications, renal artery stenosis) before determining if dose reduction or discontinuation of candesartan therapy should be considered (Ref).

Dosing: Hepatic Impairment: Adult

Mild impairment (Child-Pugh class A): No initial dosage adjustment necessary.

Moderate impairment (Child-Pugh class B): Initial: 8 mg daily (AUC increased by 145%) in adult patients with hypertension.

Severe impairment (Child-Pugh class C): There are no dosage adjustments provided in the manufacturer's labeling (has not been studied); however, systemic exposure increases significantly in moderate impairment. Should be used with caution in patients with ascites due to cirrhosis (Ref).

Dosing: Adjustment for Toxicity: Adult

Hyperkalemia: Assess for alternative or contributing factors (eg, diet, concomitant medications) of increased potassium, before determining if dose reduction or discontinuation of candesartan therapy should be considered (Ref).

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Candesartan: Pediatric drug information")

Note: Use of a lower initial dose is recommended in volume- and salt-depleted patients; if possible, correct volume depletion prior to administration; dosage must be individualized.

Hypertension

Hypertension:

Children 1 to <6 years: Oral: Initial: 0.2 mg/kg/day once daily; titrate to response (within 2 weeks, antihypertensive effect usually observed); usual range: 0.05 to 0.4 mg/kg/day divided once or twice daily; maximum daily dose: 0.4 mg/kg/day; higher doses have not been studied.

Children and Adolescents 6 to <17 years: Oral:

<50 kg: Initial: 4 to 8 mg/day once daily; titrate to response (within 2 weeks, antihypertensive effect usually observed); usual range: 2 to 16 mg/day divided once or twice daily; maximum daily dose: 32 mg/day; higher doses have not been studied.

>50 kg: Initial: 8 to 16 mg/day once daily; titrate to response (within 2 weeks, antihypertensive effect usually observed); usual range: 4 to 32 mg/day divided once or twice daily; maximum daily dose: 32 mg/day; higher doses have not been studied.

Adolescents ≥17 years: Oral: Initial: 16 mg once daily; titrate to response (within 2 weeks, antihypertensive effect usually observed; maximum effect seen within 4 to 6 weeks); usual range: 8 to 32 mg/day divided once or twice daily; blood pressure response is dose-related over the range of 2 to 32 mg; larger doses do not appear to have a greater effect and there is relatively little experience with such doses

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

Children and Adolescents 1 to <17 years:

CrCl ≥30 mL/minute/1.73 m2: There are no dosage adjustments provided in the manufacturer's labeling; has not been studied in pediatric patients with renal impairment.

CrCl <30 mL/minute/1.73 m2: Use is not recommended (has not been studied).

Not removed by dialysis.

Dosing: Hepatic Impairment: Pediatric

Mild hepatic impairment: No initial dosage adjustment required.

Moderate hepatic impairment: There are no pediatric-specific dosage adjustments provided in the manufacturer's labeling.

Severe hepatic impairment: There are no dosage adjustments provided in the manufacturer's labeling (has not been studied).

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

>10%:

Cardiovascular: Hypotension (19%)

Renal: Renal function abnormality (13%)

1% to 10%:

Central nervous system: Dizziness (4%)

Endocrine & metabolic: Hyperkalemia (6%)

Neuromuscular & skeletal: Back pain (3%)

Respiratory: Upper respiratory tract infection (6%), pharyngitis (2%), rhinitis (2%)

Frequency not defined:

Central nervous system: Headache

Renal: Exacerbation of renal disease (children & adolescents), increased serum creatinine

<1%, postmarketing, and/or case reports: Abnormal hepatic function tests, agranulocytosis, angioedema, cough, hepatitis, hyponatremia, leukopenia, neutropenia, pruritus, skin rash, urticaria

Contraindications

Hypersensitivity to candesartan or any component of the formulation; concomitant use with aliskiren in patients with diabetes mellitus.

Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Canadian labeling: Additional contraindications (not in US labeling): Concomitant use with aliskiren in patients with moderate to severe kidney impairment (GFR <60 mL/minute/1.73 m2); pregnancy; breastfeeding; children <1 year of age; rare hereditary problems of galactose intolerance, congenital lactase deficiency or glucose-galactose malabsorption.

Warnings/Precautions

Concerns related to adverse effects:

• Angioedema: Angiotensin II receptor antagonists (ARBs) do not appear to elevate the risk of angioedema (Rasmussen 2019; Toh 2012). Patients with a history of angioedema due to an angiotensin-converting enzyme (ACE) inhibitor must be educated that sometimes there can be recurrence within months following discontinuation (Beltrami 2011). No matter the cause of angioedema, prolonged frequent monitoring is required, especially if tongue, glottis, or larynx are involved, as they are associated with airway obstruction. Discontinue therapy immediately if angioedema occurs. Aggressive early management is critical. IM administration of epinephrine may be necessary. Do not readminister the ARB to patients who experience angioedema from this medication.

• Hyperkalemia: May occur; risk factors include kidney dysfunction, diabetes mellitus, concomitant use of potassium-sparing diuretics, potassium supplements and/or potassium containing salts. Use cautiously, if at all, with these agents and monitor potassium closely.

• Hypotension: Symptomatic hypotension may occur upon initiation in patients who are salt- or volume-depleted (eg, those treated with high-dose diuretics). Consider lower initial dosages in volume depleted patients; if possible, correct volume depletion prior to administration. This transient hypotensive response is not a contraindication to further treatment with candesartan.

• Kidney function deterioration: May be associated with deterioration of kidney function and/or increases in serum creatinine, particularly in patients with low renal blood flow (eg, renal artery stenosis, heart failure) whose GFR is dependent on efferent arteriolar vasoconstriction by angiotensin II; deterioration may result in oliguria, acute kidney failure, and progressive azotemia. Small increases in serum creatinine may occur following initiation; consider discontinuation only in patients with progressive and/or significant deterioration in kidney function.

Disease-related concerns:

• Aortic/mitral stenosis: Use caution in patients with significant aortic/mitral stenosis.

• Ascites: Generally, avoid use in patients with ascites due to cirrhosis or refractory ascites; if use cannot be avoided in patients with ascites due to cirrhosis, monitor blood pressure and kidney function carefully to avoid rapid development of kidney failure (AASLD [Biggins 2021]; AASLD [Runyon 2013]).

• Heart failure: Use caution when initiating in heart failure; may need to adjust dose, and/or concurrent diuretic therapy, because of candesartan-induced hypotension.

• Hepatic impairment: Systemic exposure increases in hepatic impairment; dosage adjustment may be necessary.

• Renal artery stenosis: Use candesartan with caution in patients with unstented unilateral/bilateral kidney artery stenosis. When unstented bilateral renal artery stenosis is present, use is generally avoided due to the elevated risk of deterioration in kidney function unless possible benefits outweigh risks.

• Kidney impairment: Use with caution with preexisting kidney insufficiency. Pediatric patients with a GFR <30 mL/minute/1.73 m2 should not receive candesartan; has not been evaluated.

Special populations:

• Pediatric: Avoid use in infants <1 year of age due to potential effects on the development of immature kidneys.

• Pregnancy: [US Boxed Warning]: Drugs that act on the renin-angiotensin system can cause injury and death to the developing fetus. Discontinue as soon as possible once pregnancy is detected.

• Race/Ethnicity: In Black patients, the BP-lowering effects of ARBs may be less pronounced. The exact mechanism is not known; differences in the renin-angiotensin-aldosterone system, low renin levels, and salt sensitivity more commonly found in Black patients may contribute (Brewster 2013; Helmer 2018; manufacturer's labeling).

• Surgical patients: In patients on chronic ARB therapy, intraoperative hypotension may occur with induction and maintenance of general anesthesia; however, discontinuation of therapy prior to surgery is controversial. If continued preoperatively, avoidance of hypotensive agents during surgery is prudent (Hillis 2011). Based on current research and clinical guidelines in patients undergoing non-cardiac surgery, continuing ARBs is reasonable in the perioperative period. If ARBs are held before surgery, it is reasonable to restart postoperatively as soon as clinically feasible (ACC/AHA [Fleisher 2014]).

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral, as cilexetil:

Atacand: 4 mg, 8 mg, 16 mg, 32 mg [scored; contains corn starch]

Generic: 4 mg, 8 mg, 16 mg, 32 mg

Generic Equivalent Available: US

Yes

Pricing: US

Tablets (Atacand Oral)

4 mg (per each): $7.70

8 mg (per each): $9.20

16 mg (per each): $9.89

32 mg (per each): $12.52

Tablets (Candesartan Cilexetil Oral)

4 mg (per each): $2.76 - $3.17

8 mg (per each): $2.76 - $3.17

16 mg (per each): $2.76 - $3.18

32 mg (per each): $4.17 - $4.30

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Tablet, Oral, as cilexetil:

Atacand: 4 mg, 8 mg, 16 mg, 32 mg

Generic: 4 mg, 8 mg, 16 mg, 32 mg

Administration: Adult

Oral: Administer without regard to meals. An oral suspension may be prepared for children unable to swallow tablets (refer to Extemporaneously Prepared information).

Administration: Pediatric

Oral: May be administered without regard to meals. An oral suspension may be prepared for children unable to swallow tablets (refer to Extemporaneous Preparation information).

Use: Labeled Indications

Heart failure with reduced ejection fraction: Treatment of heart failure (NYHA class II to IV) in adults with left ventricular systolic dysfunction (ejection fraction ≤40%) to reduce cardiovascular death and heart failure hospitalization.

Hypertension, chronic: Management of hypertension in adults and children ≥1 year of age.

Use: Off-Label: Adult

Migraine, prevention; Non-ST-elevation acute coronary syndrome; Proteinuric chronic kidney disease, diabetic or nondiabetic; ST-elevation myocardial infarction

Medication Safety Issues
Sound-alike/look-alike issues:

Atacand may be confused with antacid

Metabolism/Transport Effects

Substrate of CYP2C9 (minor); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

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. Risk D: Consider therapy modification

Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When used at chemotherapy doses, hold blood pressure lowering medications for 24 hours before amifostine administration. If blood pressure lowering therapy cannot be held, do not administer amifostine. Use caution with radiotherapy doses of amifostine. Risk D: Consider therapy modification

Amphetamines: May diminish the antihypertensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Angiotensin II: Receptor Blockers may diminish the therapeutic effect of Angiotensin II. Risk C: Monitor therapy

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: 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 when possible. Monitor blood pressure, renal function, and potassium if combined. Risk D: Consider therapy modification

Antihepaciviral Combination Products: May increase the serum concentration of Candesartan. Management: Consider decreasing the candesartan dose and monitoring for evidence of hypotension and worsening renal function if these agents are used in combination. Risk D: Consider therapy modification

Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Risk C: Monitor therapy

Arginine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Brigatinib: May diminish the antihypertensive effect of Antihypertensive Agents. Brigatinib may enhance the bradycardic effect of Antihypertensive Agents. Risk C: Monitor therapy

Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Bromperidol: May diminish the hypotensive effect of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Risk X: Avoid combination

Dapoxetine: May enhance the orthostatic hypotensive effect of Angiotensin II Receptor Blockers. Risk C: Monitor therapy

Dexmethylphenidate: May diminish the therapeutic effect of Antihypertensive Agents. Risk C: Monitor therapy

Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Drospirenone-Containing Products: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Risk C: Monitor therapy

DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. Risk C: Monitor therapy

Eplerenone: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Risk C: Monitor therapy

Finerenone: Angiotensin II Receptor Blockers may enhance the hyperkalemic effect of Finerenone. Risk C: Monitor therapy

Flunarizine: May enhance the therapeutic effect of Antihypertensive Agents. Risk C: Monitor therapy

Heparin: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Risk C: Monitor therapy

Heparins (Low Molecular Weight): May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Risk C: Monitor therapy

Herbal Products with Blood Pressure Increasing Effects: May diminish the antihypertensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Herbal Products with Blood Pressure Lowering Effects: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy

Indoramin: May enhance the hypotensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Levodopa-Foslevodopa: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa-Foslevodopa. Risk C: Monitor therapy

Lithium: Angiotensin II Receptor Blockers may increase the serum concentration of Lithium. Management: Initiate lithium at lower doses in patients receiving an angiotensin II receptor blocker (ARB). Consider lithium dose reductions in patients stable on lithium therapy who are initiating an ARB. Monitor lithium concentrations closely when combined. Risk D: Consider therapy modification

Loop Diuretics: May enhance the hypotensive effect of Angiotensin II Receptor Blockers. Loop Diuretics may enhance the nephrotoxic effect of Angiotensin II Receptor Blockers. Risk C: Monitor therapy

Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Methylphenidate: May diminish the antihypertensive effect of Antihypertensive Agents. Risk C: Monitor therapy

Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nicorandil: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Risk C: Monitor therapy

Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. Risk C: Monitor therapy

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. Risk C: Monitor therapy

Nonsteroidal Anti-Inflammatory Agents (Topical): May diminish the therapeutic effect of Angiotensin II Receptor Blockers. Risk C: Monitor therapy

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. Risk D: Consider therapy modification

Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Pholcodine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. Risk C: Monitor therapy

Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Polyethylene Glycol-Electrolyte Solution: Angiotensin II Receptor Blockers may enhance the nephrotoxic effect of Polyethylene Glycol-Electrolyte Solution. Risk C: Monitor therapy

Potassium Salts: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Risk C: Monitor therapy

Potassium-Sparing Diuretics: Angiotensin II Receptor Blockers may enhance the hyperkalemic effect of Potassium-Sparing Diuretics. Risk C: Monitor therapy

Prazosin: Antihypertensive Agents may enhance the hypotensive effect of Prazosin. Risk C: Monitor therapy

Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Ranolazine: May enhance the adverse/toxic effect of Angiotensin II Receptor Blockers. Risk C: Monitor therapy

Silodosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Sodium Phosphates: Angiotensin II Receptor Blockers may enhance the nephrotoxic effect of Sodium Phosphates. Specifically, the risk of acute phosphate nephropathy may be enhanced. Risk C: Monitor therapy

Sparsentan: May enhance the adverse/toxic effect of Angiotensin II Receptor Blockers. Risk X: Avoid combination

Tacrolimus (Systemic): Angiotensin II Receptor Blockers may enhance the hyperkalemic effect of Tacrolimus (Systemic). Risk C: Monitor therapy

Terazosin: Antihypertensive Agents may enhance the hypotensive effect of Terazosin. Risk C: Monitor therapy

Tolvaptan: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Risk C: Monitor therapy

Trimethoprim: May enhance the hyperkalemic effect of Angiotensin II Receptor Blockers. Risk C: Monitor therapy

Urapidil: Antihypertensive Agents may enhance the hypotensive effect of Urapidil. Risk C: Monitor therapy

Reproductive Considerations

Avoid use of an angiotensin II receptor blocker (ARB) in patients who may become pregnant and who are not using effective contraception (ADA 2022).

Medications considered acceptable for the treatment of chronic hypertension during pregnancy may generally be used in patients trying to conceive. ARBs are fetotoxic. Transition patients prior to conception to an agent preferred for use during pregnancy unless treatment with an ARB is absolutely necessary (ACC/AHA [Whelton 2018]; ACOG 2019; NICE 2019).

When candesartan is used for the treatment of proteinuric chronic kidney disease in patients who could become pregnant, discontinue use at the first positive pregnancy test (ADA 2022; Fakhouri 2023; Porta 2011).

Candesartan is effective for prevention of migraines. In general, preventive treatment for migraine in patients trying to become pregnant should be avoided. Options for patients planning a pregnancy should be considered as part of a shared decision-making process. Nonpharmacologic interventions should be considered initially. When needed, preventive treatment should be individualized considering the available safety data and needs of the patient should pregnancy occur. A gradual discontinuation of preventive medications is generally preferred when the decision is made to stop treatment prior to conception (ACOG 2022; AHS [Ailani 2021]).

Pregnancy Considerations

Drugs that act on the renin-angiotensin system can cause injury and death to the developing fetus. Exposure to an angiotensin II receptor blocker (ARB) during the first trimester of pregnancy may be associated with an increased risk of fetal malformations (ACOG 2019; ESC [Regitz-Zagrosek 2018]). Following exposure during the second or third trimesters, drugs that act on the renin-angiotensin system are associated with oligohydramnios. Oligohydramnios, due to decreased fetal kidney function, may lead to fetal lung hypoplasia and skeletal malformations. Oligohydramnios may not appear until after an irreversible fetal injury has occurred. ARB use during pregnancy is also associated with anuria, hypotension, kidney failure, skull hypoplasia, and death in the fetus/neonate. Monitor infants exposed to an ARB in utero for hyperkalemia, hypotension, and oliguria. Exchange transfusions or dialysis may be required to reverse hypotension or improve renal function.

Chronic maternal hypertension is also associated with adverse events in the fetus/infant. Chronic maternal hypertension may increase the risk of birth defects, low birth weight, premature delivery, stillbirth, and neonatal death. Actual fetal/neonatal risks may be related to the duration and severity of maternal hypertension. Untreated chronic hypertension may also increase the risks of adverse maternal outcomes, including gestational diabetes, preeclampsia, delivery complications, stroke, and myocardial infarction (ACOG 2019).

Discontinue ARBs as soon as possible once pregnancy is detected. Agents other than an ARB are recommended for the treatment of chronic hypertension during pregnancy (ACOG 2019; ESC [Cífková 2020]; ESC [Regitz-Zagrosek 2018]; SOGC [Magee 2022]). Closely monitor patients exposed to an ARB during pregnancy with serial ultrasounds.

ARBs are not recommended for the treatment of proteinuric chronic kidney disease during pregnancy. When treatment is needed in patients with diabetic nephropathy, candesartan should be discontinued at the first positive pregnancy test (Fakhouri 2023; Porta 2011).

In general, preventive treatment for migraine should be avoided during pregnancy. Options for pregnant patients should be considered as part of a shared decision-making process. Nonpharmacologic interventions should be considered initially. When needed, preventive treatment should be individualized considering the available safety data, the potential for adverse maternal and fetal events, and needs of the patient (ACOG 2022; AHS [Ailani 2021]). Candesartan is not recommended for migraine prevention during pregnancy (ACOG 2022).

Breastfeeding Considerations

Candesartan is present in breast milk.

Transfer of candesartan in breast milk was evaluated in three postpartum patients. The maternal dose in case one was candesartan 32 mg once daily (2.5 months' postpartum), and in cases two and three the dose was candesartan 8 mg once daily (8 and 13 months' postpartum). All three mothers had been treated for at least 2 weeks prior to the study. The maximum breast milk concentration occurred ~7 to 9 hours following the maternal dose. Candesartan was not measurable (<0.2 mcg/L) in the infant serum in cases two and three (sampling occurred ~2 to 3 hours after the maternal dose and was not evaluated in case one). In all three cases, the authors calculated the relative infant dose to be <1% of the weight-adjusted maternal dose (Coberger 2019). In general, breastfeeding is considered acceptable when the relative infant dose of a medication is <10% (Anderson 2016; Ito 2000).

Due to the potential for serious adverse reactions in the breastfeeding infant, breastfeeding is not recommended by the manufacturer.

In general, preventive treatment for migraine in lactating patients should be avoided. When needed, therapy should be individualized considering the available safety data and needs of the patient (AHS [Ailani 2021]). When treatment for hypertension is needed in a breastfeeding patient, consider use of an agent other than an angiotensin II receptor blocker (ESC [Cífková 2020]; NICE 2019).

Monitoring Parameters

Blood pressure, serum electrolytes (eg, potassium [especially in patients on concomitant potassium-sparing diuretics, potassium supplements and/or potassium containing salts]), serum creatinine, BUN.

Mechanism of Action

Candesartan is an angiotensin receptor antagonist. Angiotensin II acts as a vasoconstrictor. In addition to causing direct vasoconstriction, angiotensin II also stimulates the release of aldosterone. Once aldosterone is released, sodium as well as water are reabsorbed. The end result is an elevation in blood pressure. Candesartan binds to the AT1 angiotensin II receptor. This binding prevents angiotensin II from binding to the receptor thereby blocking the vasoconstriction and the aldosterone secreting effects of angiotensin II.

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: 2 to 3 hours; antihypertensive effect: Within 2 weeks

Peak effect: 6 to 8 hours; maximum antihypertensive effect: 4 to 6 weeks

Duration: >24 hours

Absorption: Candesartan: Rapid and complete following conversion from candesartan cilexetil by GI esterases

Distribution: Vd: 0.13 L/kg

Protein binding: >99%

Metabolism: Converted to active candesartan, via ester hydrolysis during absorption from GI tract; hepatic (minor) via O-deethylation to inactive metabolite

Bioavailability, absolute: Candesartan: 15%

Half-life elimination (dose dependent): 5 to 9 hours

Time to peak: Children (1 to 17 years); Adults: 3 to 4 hours

Excretion: Feces (67%); urine (33%; 26% as unchanged drug)

Clearance: Total body: 0.37 mL/minute/kg; Renal: 0.19 mL/minute/kg; decreased with severe kidney impairment

Pharmacokinetics: Additional Considerations (Adult Data Unless Noted)

Altered kidney function: In hypertensive patients with CrCl <30 mL/minute/1.73 m2, the AUC and Cmax are approximately doubled. In heart failure patients with kidney impairment, AUC is 36% and 65% higher and Cmax is 15% and 55% higher in patients with mild and moderate kidney impairment, respectively.

Hepatic function impairment: The AUC and Cmax increased 30% and 56% in mild impairment and 145% and 73% in moderate impairment, respectively.

Older adult: Cmax is ~50% higher; AUC is ~80% higher.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Atacand | Blopress | Candemax;
  • (AR) Argentina: Atacand | Candesartan richet | Dacten | Ronar | Tiadyl;
  • (AT) Austria: Atacand | Blopress | Candeblo | Candesartan 1A Pharma | Candesartan a-med | Candesartan actavis | Candesartan Arcana | Candesartan G.L. | Candesartan Genericon | Candesartan krka | Candesartan Pluspharma | Candesartan ratiopharm | Candesartan sandoz | Candesartan Stada;
  • (AU) Australia: Adesan | Apo candesartan | Atacand | Auro candesartan | Candesan | Candesartan an | Candesartan aspen | Candesartan ga | Candesartan gh | Candesartan rbx | Candesartan sandoz | Pharmacor candesartan | Stada candesartan;
  • (BD) Bangladesh: Arb | Candesa | Giran | Vesotan;
  • (BE) Belgium: Atacand | Candesartan Apotex | Candesartan EG | Candesartan krka | Candesartan mylan | Candesartan sandoz | Candesartan teva;
  • (BF) Burkina Faso: Aderan;
  • (BG) Bulgaria: Acrux | Atacand | Candecard | Candecon | Candegamma | Candesartan actavis | Candesartan ecopharm | Cantab | Cardesart | Carzap | Hyposart | Karbis | Repido;
  • (BR) Brazil: Atacand | Blopress | Cadenza | Candecor | Candemed | Candesartana cilexetila | Candessa | Cansarcor | Desarcor | Venzer;
  • (CH) Switzerland: Atacand | Blopress | Candesartan actavis | Candesartan Helvepharm | Candesartan Mepha | Candesartan sandoz | Candesartan spirig hc | Candesartan Takeda | Candesartan zentiva | Cansartan | Pemzek;
  • (CI) Côte d'Ivoire: Aderan | Atacand | Candisar;
  • (CL) Chile: Atacand | Bilaten | Blopress | Blox;
  • (CN) China: Ao bi xin | Blopress | Bo li gao | Da mai | Di zhi ya | Wei er ya | Xi jun ning;
  • (CO) Colombia: Atacand | Blopress | Candeprex | Candesam | Candesartan | Candesartan cilexetilo | Candesartan cilexetilo sandoz | Candesartan mk | Dexartan | Europres | Minart;
  • (CZ) Czech Republic: Atacand | Candegamma | Canocord | Carzap | Xaleec;
  • (DE) Germany: Amias | Atacand | Atacand protect | Blopress | Candaxiro | Cande Q | Candecor | Candegamma | Candesartan 1 a pharma | Candesartan aaa | Candesartan abz | Candesartan actavis | Candesartan al | Candesartan aurobindo | Candesartan Basics | Candesartan biomo | Candesartan cilexetil mylan | Candesartan hennig | Candesartan heumann | Candesartan Hexal | Candesartan hormosan | Candesartan krka | Candesartan puren | Candesartan ratiopharm | Candesartan Stada | Candesartan zentiva | Ratacand;
  • (DO) Dominican Republic: Acrosar | Adepra | Akavar | Aracure | Atacand | Balpress | Blopress | Blox | Calmex | Candersil | Candesar | Candesartan | Candesartan 8 mg wemed | Candesartan 8 nespharma | Candesartan Calox | Candesartan cilexetilo sandoz | Candesartan if | Candesartan Lam | Candevex | Capsartan | Cardres | Coriarten | Coropres | Corprexia | Cuidat | Decora | Eucand | Indutenol | Inlosep | Kerala | Minart | Safebul | Sulartan | Tensinex | Tovax | Xiletil;
  • (EC) Ecuador: Atacand | Blopress | Blox | Candesartan | Candesartan Genfar | Coropres | Minart;
  • (EE) Estonia: Atacand | Candesartan actavis | Canocord | Cantar | Carzan | Prescanden;
  • (EG) Egypt: Albustix | Atacand | Blopress | Candalkan | Candeblock | Candepressin | Candesar | Candesartan | Globacand;
  • (ES) Spain: Atacand | Blopress | Candesartan actavis | Candesartan Almus | Candesartan Alter | Candesartan Apotex | Candesartan apotex ag | Candesartan cinfa | Candesartan Combix | Candesartan Davur | Candesartan Kern | Candesartan krka | Candesartan Mabo | Candesartan mylan | Candesartan Normon | Candesartan pensa | Candesartan qualigen | Candesartan ranbaxy | Candesartan ratio | Candesartan ratiopharm | Candesartan sandoz | Candesartan Stada | Candesartan tarbis | Candesartan tecnigen | Candesartan teva | Karbis | Parapres;
  • (ET) Ethiopia: Candesartan sandoz;
  • (FI) Finland: Atacand | Candemox | Candesartan actavis | Candesartan aspen | Candesartan krka | Candesartan orion | Candesartan ranbaxy | Candestad | Candexetil | Kandrozid;
  • (FR) France: Atacand | Candesartan | Candesartan actavis | Candesartan Arrow | Candesartan biogaran | Candesartan cristers | Candesartan EG | Candesartan Evolugen | Candesartan krka | Candesartan mylan | Candesartan ranbaxy | Candesartan sandoz | Candesartan teva | Candesartan Zydus | Kenzen;
  • (GB) United Kingdom: Amias | Candesartan | Candesartan ranbaxy;
  • (GR) Greece: Atacand | Candesartan tad | Fyronexe;
  • (GT) Guatemala: Donosartan;
  • (HK) Hong Kong: Advant | Amican | Blopress | Candesartan;
  • (HR) Croatia: Atacand | Kandepres;
  • (HU) Hungary: Atacand | Karbis;
  • (ID) Indonesia: Blocand | Blopress | Candefar | Candepress | Canderin | Candersatan cilexetil | Candesartan | Candetens | Candotens;
  • (IE) Ireland: Atacand | Blopress | Candesartan | Candesartan krka | Candesartan mylan | Candesartan teva | Candist | Catasart;
  • (IL) Israel: Atacand | Candor;
  • (IN) India: Candelong | Candesar | Candestan | Candez | Cantar | Dilsave | Ipsita;
  • (IQ) Iraq: Candasart | Kandesat;
  • (IS) Iceland: Candpress;
  • (IT) Italy: Blopress | Candesartan | Candesartan actavis | Candesartan aurobindo italia | Candesartan doc generici | Candesartan EG | Candesartan krka | Candesartan mylan pharma | Candesartan pensa | Candesartan ranbaxy | Candesartan sandoz | Candesartan zentiva | Flortitens | Karbis | Ratacand;
  • (JO) Jordan: Andesart | Atacand | Blopress | Coronasart;
  • (JP) Japan: Blopress | Candesartan | Candesartan amel | Candesartan aska | Candesartan chemiphar | Candesartan isei | Candesartan jg | Candesartan kaken | Candesartan ko | Candesartan kyorin | Candesartan nichiiko | Candesartan nissin | Candesartan ohara | Candesartan pfizer | Candesartan sandoz | Candesartan teva | Candesartan towa | Candesartan zeria;
  • (KE) Kenya: Aderan | Advant | Arb | Atacand | Candecard | Candez | Gardia | Treatan;
  • (KR) Korea, Republic of: Acande | Adetan | Anatan | Atacand | Cancetil | Candecan | Candelotan | Candeltan | Candemore | Candera | Candertan | Candesan | Candesar | Candeta | Cansartan | Cansata | Cantacan | Cartan | Cavadil | Decartan | Dezaltan | Gloata | Hisartan | Hutecan | Kdc candesartan | Neocande | Samsung candesartan;
  • (KW) Kuwait: Atacand | Blopress;
  • (LB) Lebanon: Andesart | Atacand | Blopress | Candesartan biogaran | Pms candesartan;
  • (LT) Lithuania: Atacand | Candesartan actavis | Canocord | Carzan;
  • (LU) Luxembourg: Atacand | Candesartan EG | Candesartan ratiopharm;
  • (LV) Latvia: Atacand | Candegamma | Candesartan actavis | Canocord | Cantar | Carzan;
  • (MA) Morocco: Atacand;
  • (MX) Mexico: Atacand | Blopress | Candesartan | Chat | Coriatros | Safebul | Sarcan;
  • (MY) Malaysia: Atacand | Blopress | Candesartan sandoz;
  • (NG) Nigeria: Advant | Atacand | Candesartan;
  • (NL) Netherlands: Amias | Atacand | Blopress | Candesartan | Candesartan cilexetil auro | Candesartan cilexetil Aurobindo | Candesartan cilexetil Focus | Candesartan cilexetil Krka | Candesartan cilexetil teva | Candesartan cilexetil Xiromed | Candesartan ratiopharm | Ratacand;
  • (NO) Norway: Amias | Atacand | Candesartan aspen | Candesartan krka | Candesartan orion | Candesartan sandoz | Kandesartan;
  • (NZ) New Zealand: Atacand | Candestar;
  • (PE) Peru: Atacand | Babapress | Blopress | Blox | Candeless | Candesartan | Flosartan | Midopress;
  • (PH) Philippines: Atasart | Babapress | Blopress | Candez | Desaren | Frepan | Giran | Torcand;
  • (PK) Pakistan: Advant | Blopress | Candera | Candesar | Candia | Canditensin | Canex | Cansaar | Cansart | Carac | Cartex | Glocand | Kancand | Miscand | Prosartan | Quartz | Raysartan | Sedanta | Treatan;
  • (PL) Poland: Atacand | Candepres | Candesartan genoptim | Carzap | Kandesar | Kangen | Karbis | Ranacand;
  • (PR) Puerto Rico: Atacand;
  • (PT) Portugal: Atacand | Blopress | Candesartan | Candesartan actavis | Candesartan Alter | Candesartan aurobindo | Candesartan azevedos | Candesartan Basi | Candesartan cinfa | Candesartan Generis | Candesartan Generis Phar | Candesartan germed | Candesartan labesfal | Candesartan mylan | Candesartan osir | Candesartan pharmakern | Candesartan sandoz | Candesartan tad | Candesartan teva;
  • (PY) Paraguay: Atacand | Blox | Coropres | Dacten | Eticard | Indutenol | Prexin | Tadivon | Tiadyl | Vanox;
  • (QA) Qatar: Atacand | Blopress;
  • (RO) Romania: Atacand | Candesartan | Candesartan atb | Candesartan aurobindo | Candesartan cilexetil mcc | Candesartan labormed | Candesartan mylan | Candesartan sandoz | Candesartan torrent | Candesartan vim spectrum | Canzeno | Clastinol | Hipostyn | Karbis | Tandesar;
  • (RU) Russian Federation: Angiakand | Atacand | Candecor | Candesartan | Candesartan sz | Candesartan vertex | Hyposart | Ordiss | Xarten;
  • (SA) Saudi Arabia: Atacand | Blopress | Candepress | Candeza | Diceran;
  • (SE) Sweden: Amias | Atacand | Atacand ebb | Candesarstad | Candesartan actavis | Candesartan aspen | Candesartan krka | Candesartan orion | Candesartan ranbaxy | Candesartan sandoz | Candexetil | Kairasec | Kandesartan ebb | Kandrozid;
  • (SG) Singapore: Atacand | Blopress | Candesartan sandoz;
  • (SI) Slovenia: Atacand | Candea;
  • (SK) Slovakia: Atacand | Candesartan mylan | Candesartan ratiopharm | Candesartan sandoz | Carzap | Karbis | Stadacand;
  • (TH) Thailand: Blopress | Finil | Todesaar;
  • (TN) Tunisia: Aralead | Atacand | Blopress | Mono etiken;
  • (TR) Turkey: Atacand | Ayra | Candecard | Candenact | Candexil | Cantab | Tensart | Ucand;
  • (TW) Taiwan: Blopress | Candesartan | Candis | Lizhensin | Sartanin;
  • (UA) Ukraine: Atacand | Candesar | Casark | Kasark;
  • (UG) Uganda: Aderan | Atacand;
  • (UY) Uruguay: Atacand | Blopress | Cancor | Diapresan;
  • (VE) Venezuela, Bolivarian Republic of: Atacand | Blocax | Blopress | Calmex | Candesartan | Candesartan cilexetilo | Candesartana cilexetila | Coropres | Minart | Xartamed;
  • (VN) Viet Nam: Acantan | Candekern | Synartan;
  • (ZA) South Africa: Abecard | Atacand | Aterwin | Candagen | Mylacand;
  • (ZM) Zambia: Aderan;
  • (ZW) Zimbabwe: Atacand
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