Candesartan

Candesartan is an AT1 receptor blocker (also called a sartan). It is used for high blood pressure and heart failure and offers an important alternative for patients who cannot tolerate ACE inhibitors because of cough.

Candesartan is available as a single-ingredient product and in combination with hydrochlorothiazide (Candesartan/HCT). Well-known brand names are Atacand®, Atacand® Plus, and Blopress®.

Candesartan blocks the angiotensin II receptor (AT1 receptor):

Mechanism of action:

• Selectively blocks the AT1 receptor
• Angiotensin II cannot exert its vasoconstricting effect
• The blood vessels widen and blood pressure falls
• The release of aldosterone is inhibited

Difference from ACE inhibitors:

• Blocks the receptor directly (instead of inhibiting production)
• No effect on the breakdown of bradykinin
• Therefore cough occurs less often as a side effect
• Angioedema occurs less often

Onset of action: First reduction in blood pressure after 2 hours. Most of the blood pressure-lowering effect is reached within 4 weeks of regular use.

Candesartan is suitable for:

• Adults with high blood pressure
• Heart failure (when ACE inhibitors are not tolerated)
• Patients with ACE inhibitor cough (as an alternative)

Particularly recommended for:

• Intolerance to ACE inhibitors (cough)
• Diabetes with high blood pressure
• Kidney disease with proteinuria

Not suitable:

• Pregnancy and breastfeeding
• Severe liver impairment
• Bilateral renal artery stenosis
• Concomitant use with aliskiren in diabetes

High blood pressure:

• Starting dose: 8 mg once daily
• Usual dose: 8-16 mg once daily
• Maximum dose: 32 mg daily

Heart failure:

• Starting dose: 4 mg once daily
• Target dose: 32 mg once daily
• Slow increase every 2 weeks

Available strengths:

• 4 mg, 8 mg, 16 mg, 32 mg tablets

Combination products:

• Candesartan + hydrochlorothiazide (Candesartan/HCT, Atacand® Plus)

How to take:

• Once daily, always at the same time
• Regardless of meals
• With sufficient water

Dose adjustment:

• Start with 8 mg (high blood pressure) or 4 mg (heart failure)
• Increase possible after 2-4 weeks
• Check blood pressure regularly

Important notes:

• Do not stop suddenly
• Regular checks of kidney function and potassium
• Drink enough fluids
• Avoid potassium salts

Candesartan must not be taken in cases of:

• Hypersensitivity to candesartan
• Pregnancy in the 2nd and 3rd trimesters
• Severe liver impairment or cholestasis
• Concomitant use with aliskiren in diabetes

Caution in cases of:

• Impaired kidney function
• Renal artery stenosis (bilateral or in a single kidney)
• Elevated potassium levels
• Aortic stenosis, mitral stenosis
• Hypertrophic cardiomyopathy
• Concurrent dialysis

Pregnancy and breastfeeding: AT1 blockers are not recommended in the 1st trimester of pregnancy and are contraindicated in the 2nd and 3rd trimesters. They can cause severe harm to the unborn child. Treatment should not be started during pregnancy. If pregnancy is detected, treatment must be stopped immediately and, if necessary, another therapy started. Candesartan is not recommended during breastfeeding.

Common (1-10%):

• Dizziness
• Headache
• Elevated potassium levels
• Changes in kidney function
• Low blood pressure
• Respiratory tract infections

Uncommon (0.1-1%):

• Fatigue

Very rare:

• Back pain
• Nausea
• Angioedema (less common than with ACE inhibitors)
• Liver function disorders
• Skin rash

Advantage over ACE inhibitors: Cough is very rare and occurs less often than with ACE inhibitors. This is the main reason why sartans are prescribed as an alternative in cases of ACE inhibitor intolerance.

Contraindicated:

• Aliskiren in diabetes or kidney impairment

Caution with:

• Potassium-sparing diuretics (spironolactone, triamterene) → hyperkalemia
• NSAIDs (ibuprofen, diclofenac) → reduced effect, kidney damage
• Lithium → increased levels
• Other blood pressure-lowering medications → enhanced effect

Important: Similar interaction profile to ACE inhibitors. Regular laboratory checks recommended.