Carvedilol


Concise Prescribing Info
Indications/Uses
Listed in Dosage.
Dosage/Direction for Use
Adult : PO Hypertension Initially, 12.5 mg once daily for 2 days, increased to 25 mg once daily. May gradually increase further at intervals of at least 2 weeks, if necessary. Max: 50 mg daily. Chronic stable angina Initially, 12.5 mg bid for 2 days, increased to 25 mg bid. May gradually increase further at intervals of at least 2 weeks, if necessary. Max: 100 mg/day in 2 divided doses. Heart failure Mild to severe: Initially, 3.125 mg bid for 2 weeks. If tolerated, increase gradually to 6.25 mg bid at intervals of at least 2 weeks, followed by 12.5 mg bid, then 25 mg bid. Max: <85 kg: 25 mg bid. >85 kg: 50 mg bid, if condition is not severe. Left ventricular dysfunction post myocardial infarction Initially, 6.25 mg bid, increased after 3-10 days (based on tolerability) to 12.5 mg bid, and up to target dose of 25 mg bid. Lower initial dose of 3.125 mg bid may be used in symptomatic patients and rate of up-titration may be slowed if clinically indicated.
Dosage Details
Oral
Left ventricular dysfunction post myocardial infarction
Adult: Initially, 6.25 mg bid, increased after 3-10 days (based on tolerability) to 12.5 mg bid, and up to target dose of 25 mg bid. Lower initial dose of 3.125 mg bid may be used in symptomatic patients and rate of up-titration may be slowed if clinically indicated.

Oral
Hypertension
Adult: Initially, 12.5 mg once daily for 2 days, increased to 25 mg once daily. May gradually increase further at intervals of at least 2 weeks, if necessary. Max: 50 mg daily.
Elderly: Initially, 12.5 mg once daily. May gradually increase further at intervals of at least 2 weeks, if necessary.

Oral
Heart failure
Adult: Mild to severe: Initially, 3.125 mg bid for 2 weeks. If tolerated, increase gradually to 6.25 mg bid at intervals of at least 2 weeks, followed by 12.5 mg bid, then 25 mg bid. Max: <85 kg: 25 mg bid. >85 kg: 50 mg bid, if condition is not severe.

Oral
Chronic stable angina
Adult: Initially, 12.5 mg bid for 2 days, increased to 25 mg bid. May gradually increase further at intervals of at least 2 weeks, if necessary. Max: 100 mg daily in 2 divided doses.
Elderly: Initially, 12.5 mg bid for 2 days, continued to 25 mg bid.
Special Patient Group
Pharmacogenomics:

Carvedilol is clinically used as a racemic mixture of R- and S-enantiomers. Clinical pharmacokinetic studies have shown that CYP2D6 plays a major role in the metabolism of R- and S-carvedilol. Carvedilol is subject to the effects of genetic polymorphism with CYP2D6 poor metabolisers exhibiting 2- to 3-fold higher plasma concentrations of R(+)-carvedilol compared with extensive metabolisers. In contrast, plasma levels of S(-)-carvedilol are increased only about 20% to 25% in poor metabolisers.

Both inhibitors and inducers of the CYP2D6 isoenzymes may alter the metabolism of carvedilol in a stereoselective manner and this may lead to either an increased or decreased plasma concentration of R- and S-carvedilol. Analysis of side effects in clinical trials showed that CYP2D6 poor metabolisers had a higher rate of dizziness during up-titration, presumably resulting from vasodilating effects of the higher concentrations of the α-blocking R(+)-enantiomer.
Hepatic Impairment
Severe: Contraindicated.
Administration
Should be taken with food.
Contraindications
Patient with decompensated heart failure requiring IV inotropic treatment, bronchial asthma or related bronchospastic conditions, 2nd- or 3rd-degree AV block without permanent pacemaker, severe bradycardia (<50 bpm), sick sinus syndrome, cardiogenic shock, untreated phaeochromocytoma, Severe hepatic impairment.
Special Precautions
Patient with salt and volume depletion, hypotension; ischaemic heart disease, Prinzmetal’s variant angina, diabetes mellitus, thyrotoxicosis, peripheral vascular disease, psoriasis. Avoid abrupt withdrawal. Renal and mild to moderate hepatic impairment. Elderly. Pregnancy and lactation.
Adverse Reactions
Significant: Hypotension with or without syncope, bradycardia.
Blood and lymphatic system disorders: Anaemia.
Cardiac disorders: Dyspnoea, pulmonary oedema.
Eye disorders: Visual impairment, eye irritation, dry eye.
Gastrointestinal disorders: Nausea, diarrhoea, vomiting, dyspepsia, abdominal pain.
General disorders and admin site conditions: Asthenia, fatigue.
Infections and infestations: Bronchitis.
Metabolism and nutrition disorders: Oedema, hypervolaemia, weight gain, hypercholesterolaemia, hyperglycaemia, hypoglycaemia.
Musculoskeletal and connective tissue disorders: Pain in extremities, arthralgia.
Nervous system disorders: Dizziness, headache.
Psychiatric disorders: Depression.
Renal and urinary disorders: Micturition disorders, abnormal renal function, renal failure.
Vascular disorders: Orthostatic hypotension, peripheral vascular disease.
Patient Counseling Information
This drug may cause syncope during initial therapy, if affected, do not drive or operate machinery.
MonitoringParameters
Monitor blood pressure, heart rate, BUN, blood glucose (diabetics), renal and liver function.
Overdosage
Symptoms: Severe hypotension, bradycardia, heart failure, cardiogenic shock, cardiac arrest, bronchospasm, vomiting, disturbed consciousness and generalised seizures. Management: Initiate supportive treatment. Monitor vital parameters. Administer atropine IV for excessive bradycardia. In the case of drug resistant bradycardia, initiate pacemaker therapy. To support ventricular function, administer glucagon IV or sympathomimetics (e.g. dobutamine, isoprenaline). For peripheral vasodilation, administer norepinephrine with continuous monitoring of the circulation. For bronchospasm, administer β-sympathomimetics (aerosol or IV) or aminophylline via slow IV inj or infusion. Slow IV inj of diazepam or clonazepam may be given for seizures.
Drug Interactions
Additive effect with Ca channel blockers (e.g. diltiazem, verapamil), amiodarone, MAO inhibitors, reserpine, guanfacine, methyldopa. May increase atrioventricular conduction time and decrease heart rate with digitalis glycosides. Increased serum concentrations of ciclosporin. Increased hypoglycaemic effect of insulin and oral antidiabetics. May cause synergistic, negative inotropic and hypotensive effect with anaesthetics. Serum concentration may be reduced by CYP450 inducers (e.g. rifampicin, barbiturates) or increased by CYP450 inhibitors (e.g. ketoconazole, cimetidine, fluoxetine, haloperidol, erythromycin). Increased vasoconstriction effect with ergotamine.
Food Interaction
Decreased rate of absorption and risk of orthostatic hypotension with food.
Action
Description: Carvedilol is a non-selective β-blocker. It reduces peripheral vascular resistance by selective α1 receptor blockade and suppresses renin-angiotensin system through non-selective β-blockade. Carvedilol has weak membrane stabilising properties and has no intrinsic sympathomimetic activity.
Onset: Antihypertensive: Within 30 minutes (α-blockade); within 1 hour (β-blockade).
Pharmacokinetics:
Absorption: Rapidly and extensively absorbed from the gastrointestinal tract, undergoes first pass effect. Rate of absorption is delayed with food. Absolute bioavailability: Approx 25-35% (immediate release). Time to peak plasma concentration: Approx 1 hour (immediate release); approx 5 hours (extended release).
Distribution: Distributed into extravascular tissues and is highly lipophilic. Plasma protein binding: >98% primarily to albumin. Volume of distribution: 115 L.
Metabolism: Extensively metabolised in the liver via CYPD2D6 and CYP2C9 enzymes by glucuronidation and aromatic ring oxidation, oxidative metabolites are further metabolised by conjugation via glucuronidation and sulfation.
Excretion: Primarily via faeces; urine (<2%, unchanged). Elimination half-life: 7-10 hours.
Chemical Structure

Chemical Structure Image
Carvedilol

Source: National Center for Biotechnology Information. PubChem Database. Carvedilol, CID=2585, https://pubchem.ncbi.nlm.nih.gov/compound/Carvedilol (accessed on Jan. 21, 2020)

Storage
Store below 30°C. Protect from moisture.
MIMS Class
ATC Classification
C07AG02 - carvedilol ; Belongs to the class of alpha and beta blocking agents. Used in the treatment of cardiovascular diseases.
References
Luzum J, Sweet K, Binkley P et al. CYP2D6 Genetic Variation and Beta-Blocker Maintenance Dose in Patients with Heart Failure. Pharm Res. 34:1615-1625. doi: 10.1007/s11095-017-2104-8. Accessed 15/11/2019. PMID: 28181117

Takekuma Y, Takenaka T, Kiyokawa M et al. Evaluation of Effects of Polymorphism for Metabolic Enzymes on Pharmacokinetics of Carvedilol by Population Pharmacokinetic Analysis. Biol. Pharm Bull. 30(3):537-542. doi: 10.1248/bpb.30.537. Accessed 15/11/2019. PMID: 17329852

Annotation of FDA Label for Carvedilol and CYP2D6. Pharmacogenomics Knowledgebase (PharmGKB). https://www.pharmgkb.org/. Accessed 15/11/2019.

Anon. Carvedilol. AHFS Clinical Drug Information [online]. Bethesda, MD. American Society of Health-System Pharmacists, Inc. https://www.ahfscdi.com. Accessed 26/11/2013.

Anon. Carvedilol. Lexicomp Online. Hudson, Ohio. Wolters Kluwer Clinical Drug Information, Inc. https://online.lexi.com. Accessed 26/11/2013.

Buckingham R (ed). Carvedilol. Martindale: The Complete Drug Reference [online]. London. Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 26/11/2013.

Carvedilol (Cipla USA Inc.). DailyMed. Source: U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/. Accessed 11/03/2019.

Clinical Annotation for CYP2D6*1, CYP2D6*10, CYP2D6*2, CYP2D6*4, CYP2D6*5; Carvedilol Heart Diseases. Pharmacogenomics Knowledgebase (PharmGKB). https://www.pharmgkb.org/. Accessed 15/11/2019.

Clinical Annotation for CYP2D6*1, CYP2D6*4; Carvedilol, Heart Failure. Pharmacogenomics Knowledgebase (PharmGKB). https://www.pharmgkb.org/. Accessed 15/11/2019.

Coreg (GlaxoSmithKline). U.S. FDA. https://www.fda.gov/. Accessed 15/11/2019.

Coreg Tablets and Coreg CR Extended Release Capsules. U.S. FDA. https://www.fda.gov/. Accessed 26/11/2013.

Joint Formulary Committee. Carvedilol. British National Formulary [online]. London. BMJ Group and Pharmaceutical Press. https://www.medicinescomplete.com. Accessed 26/11/2013.

Disclaimer: This information is independently developed by MIMS based on Carvedilol from various references and is provided for your reference only. Therapeutic uses, prescribing information and product availability may vary between countries. Please refer to MIMS Product Monographs for specific and locally approved prescribing information. Although great effort has been made to ensure content accuracy, MIMS shall not be held responsible or liable for any claims or damages arising from the use or misuse of the information contained herein, its contents or omissions, or otherwise. Copyright © 2020 MIMS. All rights reserved. Powered by MIMS.com
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