Renal failure: The administration of Candesartan cilexetil to hypertensive patients with renal failure is recommended to do along with regular checks of potassium levels and serum creatinine levels. The experience of using Candesartan cilexetil in patients with severe renal failure and already at the end (Clcr <15 ml/min) is still very limited. In patients like this a dose increase needs to be done carefully accompanied by a blood pressure check.
Combination therapy with ACE inhibitors in heart failure: The risk of unwanted effects, especially damage to kidney function and hyperkalemia, can be increased when Candesartan cilexetil is used in combination with an ACE inhibitor. Patients with this treatment must be monitored regularly and carefully.
Hemodialysis: During dialysis, blood pressure can be very sensitive to inhibition of the AT11 receptor as the result of decreased plasma volume and activation of the renin-angiotensin-aldosterone system. Therefore, titration of Candesartan cilexetil must be done carefully by checking the blood pressure closely in hemodialysis patients.
Renal artery stenosis: Other drugs that affect the renin-angiotensin-aldosterone system, for example: ACE inhibitors can increase serum blood urea and creatinine in patients with bilateral renal artery stenosis or one kidney artery stenosis. The same effect can be anticipated with the angiotensin II receptor inhibitor.
Hypotension: Hypotension may occur during treatment with Candesartan cilexetil in heart failure patients. As described in other drugs acting on the renin-angiotensin-aldosterone system, hypotension can also occur in hypertensive patients with reduced intravascular volume as in patients receiving high-dose diuretics. Therefore, it is necessary to be careful when starting treatment and hypovolemia must be treated first before giving Candesartan cilexetil.
Anesthesia and surgery: Hypotension may occur during anesthesia and surgery in patients given angiotensin II inhibitors due to inhibition of the renin-angiotensin system. Very rarely, severe hypotension can arise which requires intravenous fluids and/or vasopressors.
Obstructive hypertrophic cardiomyopathy: As with the use of vasodilators, special attention to patients with hemodynamics associated with aortic and mitral valve stenosis, or obstructive hypertrophic cardiomyopathy need to be done.
Primary hyperaldosterone: Patients with primary hyperaldosterone generally will not respond to antihypertensive agents acting through inhibition of the renin-angiotensin-aldosterone system. Therefore, the use of Candesartan cilexetil is not recommended.
Hyperkalemia: Based on experience with using other drugs that affect the renin-angiotensin-aldosterone system, giving Candesartan cilexetil along with potassium-sparing diuretics, potassium supplements, salt substitutes containing potassium or other drugs that can increase potassium levels (such as: heparin) can cause an increase in potassium levels in serum in hypertensive patients. Hyperkalemia may occur in patients with heart failure who are given Candesartan cilexetil and during treatment with Candesartan cilexetil it is recommended to carry out regular checks of serum potassium, especially when in conjunction with ACE inhibitors and potassium-sparing diuretics such as spironolactone.
General: In patients whom the kidney function and vascular tone are highly dependent on the activity of the renin-angiotensin-aldosterone system (such as patients with congestive heart failure or kidney disease, including renal artery stenosis), treatment with other drugs that affect this system has been associated with the onset of acute hypotension, azotemia, oliguria or, rarely, acute renal failure. The same possible effect cannot be separated from the angiotensin II receptor inhibitors. As with other antihypertensive agents, excessive blood pressure reduction in ischemic or cerebrovascular ischemic patients can cause myocardial infarction or stroke. Patients with hereditary problems, which are rare, namely intolerant galactose, deficiencies of "The Lapp lactase" or glucose-galactose malabsorption may not use this drug.