Triapin (ramipril and felodipine)

How do I take Triapin?

• Always follow the instructions given by your doctor. These will also be printed on the dispensing label that your pharmacist has put on the packet of medicine.
• Triapin is usually taken once a day. You should try to take your tablet at the same time each day.
• Triapin tablets should be swallowed whole with a drink and not broken, crushed or chewed.
• The tablets can be taken either on an empty stomach or with a light meal. You should not take the tablets with a meal high in fat or carbohydrate, as this can affect the rate of absorption of felopidine.
• If you forget to take a dose at your usual time and you remember on the same day, you should take the forgotten dose, then take your next dose as usual the following day. If you forget to take a dose and you don't remember until the following day, you should leave out the forgotten dose and just take your next dose as usual when it is due. Do not take a double dose to make up for a missed dose.
• This medicine is a long-term treatment that needs to be taken regularly to keep your blood pressure under control. Unless otherwise directed by your doctor, you should keep taking it every day, even if you feel you don't have any symptoms of your condition.

What should I know before taking Triapin?

• If you feel dizzy while you are taking Triapin this can be relieved by lying down until the symptoms pass. If affected you should avoid performing potentially hazardous tasks such as driving or operating machinery. If you frequently feel dizzy you should let your doctor know, as your dose of this medicine may need reducing.
• Do not drink grapefruit juice while you are taking Triapin, as it can increase the level of felodipine in your blood. This could increase its effect on your blood pressure and make you feel dizzy, and could also increase the risk of experiencing side effects.
• Drinking alcohol while you are taking Triapin may enhance its blood pressure lowering effect, which can increase dizziness and may increase the risk of fainting.
• ACE inhibitors can sometimes cause an allergic reaction called angioedema. Stop taking Triapin and consult your doctor immediately if you experience difficulty breathing or swallowing, or swelling of your face, lips, tongue, throat, hands, feet or ankles while taking this medicine. This type of allergic reaction has been reported more frequently in black people.
• Your blood pressure, kidney function and the amount of potassium in your blood should be regularly monitored while you are taking Triapin.

Triapin should be used with caution in

• Elderly people.
• People with liver or kidney problems.
• People with low fluid volume or salt levels in the body, eg due to diuretic therapy, low-sodium diet, diarrhoea, vomiting or dehydration.
• People taking other medicines for high blood pressure, particularly diuretics.
• People with narrowing of the arteries that supply blood to the kidneys (renal artery stenosis).
• People with narrowing of the main artery in which blood is pumped out of the heart (aortic stenosis) or narrowing of one of the valves in the heart (mitral valve stenosis).
• People with heart disease characterised by thickening of the internal heart muscle and a blockage inside the heart (hypertrophic obstructive cardiomyopathy).
• People with heart failure.
• People with hardening of the arteries (atherosclerosis), eg in the heart (cardiovascular disease), brain (cerebrovascular disease) or legs (peripheral vascular disease).
• People with angina pectoris.
• People with diseases affecting connective tissue, eg scleroderma, systemic lupus erythematosus or rheumatoid arthritis (collagen vascular diseases).
• People with diabetes.
• People receiving therapy to remove certain types of fat from the blood using a machine (LDL apheresis).
• People having therapy to decrease allergy to bee or wasp stings (desensitisation).

Who should not take Triapin?

• People who are allergic to other ACE inhibitor medicines, eg captopril, or related calcium channel blockers (dihydropyridines), eg amlodipine, nifedipine.
• People with a history of swelling of the lips, face or tongue with no known cause (hereditary or idiopathic angioedema) or caused by previous use of an ACE inhibitor medicine.
• People with severely decreased liver function.
• People with severely decreased kidney function or people having dialysis for kidney failure.
• People with low blood pressure (hypotension) or unstable blood circulation.
• People with untreated heart failure.
• People who have had a heart attack (myocardial infarction) in the last month.
• People with angina that is increasing in severity, duration or frequency and is not well controlled by medical treatment (unstable angina).
• People with a serious defect in the heart's electrical message pathways, resulting in decreased function of the heart (2nd or 3rd degree heart block).
• Women who are pregnant or breastfeeding.
• Triapin tablets contain lactose and are not suitable for people with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption.
• This medicine is not recommended for children.
• This medicine should not be used if you are allergic to any of its ingredients. If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately.

Can I take Triapin while pregnant or breastfeeding?

Triapin must not be used during pregnancy, particularly during the second and third trimesters, as it may be harmful to the developing baby. Seek further medical advice from your doctor. If you get pregnant while taking Triapin, you should stop taking it and consult your doctor immediately.

• This medicine passes into breast milk. It should not be used by women who are breastfeeding. Other medicines with a more established safety profile during breastfeeding are available. Women who need treatment with this medicine should not breastfeed. Seek further medical advice from your doctor.

What are the possible side effects of Triapin?

Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with Triapin. Just because a side effect is stated here does not mean that all people using this medicine will experience that or any side effect.

Very common 

• Swelling of the ankles and feet (peripheral oedema).

Common 

• Headache.
• Flushing.
• Dizziness or feeling light-headed.
• Low blood pressure (hypotension).
• Drop in blood pressure causing dizziness or fainting on standing up.
• Dry cough.
• Shortness of breath.
• Inflammation of the sinuses (sinusitis).
• Bronchitis.
• Disturbances of the gut such as diarrhoea, constipation, nausea, vomiting, indigestion or abdominal pain.
• Rash.
• Muscle pain or spasms.
• Chest pain.
• Fatigue.
• Increased level of potassium in the blood (hyperkalaemia).

Uncommon 

• Blocked nose.
• Reduced appetite.
• Dry mouth.
• Anxiety and restlessness.
• Pins and needles sensations.
• Visual disturbances such as blurred vision.
• Change in sense of taste.
• Increased sweating.
• Itching.
• Pain in the joints.
• Decreased sex drive and erectile dysfunction.
• Awareness of your heartbeat (palpitations), fast heartbeat or abnormal heartbeats (arrhythmias).
• Inflammation of the pancreas (pancreatitis).
• Severe swelling of lips, face, tongue or throat.
• Problems with kidney function.

Rare 

• Feeling weak.
• Confusion.
• Disturbances in the normal levels of blood cells in the blood (tell you doctor if you get a sore throat, mouth ulcers, high temperature (fever), or feel tired or generally unwell while taking this medicine).
• Tremor.
• Problems with balance.
• Eye inflammation (conjunctivitis).
• Problems with hearing, including tinnitus.
• Problems with liver function, including jaundice or hepatitis 

Very rare 

• Mild swelling of the gums (gingival hyperplasia). This can be avoided with careful dental hygiene; ask your doctor or dentist for advice.
• Increased sensitivity of the skin to sunlight, usually resulting in a rash.

Can I take other medicines with Triapin?

It is important to tell your doctor or pharmacist what medicines you are already taking, including those bought without a prescription and herbal medicines, before you start treatment with Triapin. Similarly, check with your doctor or pharmacist before taking any new medicines while taking this one, to make sure that the combination is safe.

Triapin will have an additive effect with other medicines that decrease blood pressure, particularly other medicines used to treat high blood pressure (antihypertensives). In people taking antihypertensive medicines it may cause a large drop in blood pressure with the first dose, particularly in people taking diuretic medicines such as furosemide. This may cause dizziness, which can usually be relieved by lying down until the symptoms pass. If you are taking a diuretic medicine, your doctor may reduce your dose or ask you to stop taking it for a few days before you start taking Triapin. This is to prevent your blood pressure from dropping too low. If you frequently feel dizzy while taking this medicine in combination with other medicines that can lower blood pressure you should let your doctor know, as your doses may need adjusting. Other medicines that decrease blood pressure include the following:

• other ACE inhibitors, eg enalapril
• aldesleukin
• aliskiren
• alpha-blockers such as prazosin
• alprostadil
• angiotensin II receptor antagonists such as losartan
• antipsychotics such as chlorpromazine
• benzodiazepines, eg temazepam, diazepam
• baclofen
• beta-blockers such as propranolol
• calcium-channel blockers such as verapamil, nifedipine
• clonidine
• diazoxide
• diuretics, eg furosemide, bendroflumethiazide
• dopamine agonists, eg bromocriptine, apomorphine
• gold injection (sodium aurothiomalate)
• hydralazine
• levodopa
• MAOI antidepressants, eg phenelzine
• methyldopa
• minoxidil
• moxonidine
• moxisylyte
• nicorandil
• nitrates, eg glyceryl trinitrate
• tizanidine
• tricyclic antidepressants eg amitriptyline.
• Non-steroidal anti-inflammatory drugs (NSAIDs, eg indometacin, aspirin, naproxen, diclofenac, ibuprofen) may reduce the blood pressure lowering effect of this medicine, and may increase the risk of a decline in kidney function. You should avoid taking this type of painkiller while you are taking Triapin, unless it is recommended by your doctor.

There may be a risk of raised potassium levels in the blood (hyperkalaemia) if any of the following medicines are taken with ramipril, hence these are not normally recommended for use in combination with Triapin. If you are taking any of the following with this medicine, you should have regular blood tests to monitor the amount of potassium in your blood:

• aliskiren or angiotensin II receptor antagonists, eg losartan (these should not be used with Triapin, particularly in people with reduced kidney function or diabetes)
• ciclosporin
• drospirenone
• epoetin (this may also oppose the blood pressure lowering effect of ramipril)
• heparin
• potassium-containing salt substitutes (eg Lo-Salt)
• potassium salts, eg potassium citrate for cystitis
• potassium-sparing diuretics (eg spironolactone, triamterene, amiloride)
• potassium supplements
• tacrolimus
• trimethoprim.

Ramipril may increase the blood level of the medicine lithium and for this reason, it is not normally recommended for people taking lithium. People taking Triapin with lithium should have the level of lithium in their blood closely monitored.

Ramipril may possibly enhance the blood sugar lowering effect of insulin and oral antidiabetic medicines, and so could increase the risk of low blood sugar (hypoglycaemia). People with diabetes should therefore carefully monitor their blood sugar while taking Triapin, particularly in the first few weeks of treatment.

There may be an increased risk of a drop in the normal numbers of white blood cells in the blood if ramipril is taken in combination with any of the following medicines:

• allopurinol
• azathioprine
• immunosuppressant therapy
• procainamide.

If you are taking any of these in combination with Triapin, you should have regular blood tests to monitor the levels of your blood cells, particularly if you also have any kidney problems or diseases affecting connective tissue, eg scleroderma, systemic lupus erythematosus (collagen vascular diseases). Tell your doctor if you experience any signs of infection, such as fever, sore throat or mouth ulcers, as these could be signs of problems with your white blood cells.

There may be an increased risk of experiencing swelling of the face, throat and tongue (angioedema) if you are taking any of the following medicines when you start taking Triapin:

• everolimus
• sirolimus
• temsirolimus
• vildagliptin.

The following medicines may increase the breakdown of felodipine by the liver, which could make it less effective:

• carbamazapine
• phenobarbital
• phenytoin
• primidone
• rifampicin
• the herbal remedy St John's wort (Hypericum perforatum).

The following medicines may decrease the breakdown of felodipine by the liver, which could increase the risk of its side effects:

• clarithromycin
• erythromycin
• itraconazole
• ketoconazole
• protease inhibitors for HIV infection, eg ritonavir, nelfinavir, saquinavir
• telithromycin.

Felodipine may increase the blood level of the immunosuppressant medicine tacrolimus. If you are taking this medicine in combination with tacrolimus the level of tacrolimus in your blood should be monitored.

References:

https://www.evidence.nhs.uk/Search?q=triapin

http://www.netdoctor.co.uk/medicines/heart-and-blood/a7684/triapin-ramipril-and-felodipine/

http://www.medicines.ie/medicine/10455/SPC/Triapin+2.5mg+2.5mg+prolonged+release+tablet/#MACHINEOPS

https://www.hpra.ie/img/uploaded/swedocuments/2171717.PPA0465_318_001.dc21247c-2728-4cd0-9452-10a0f3691ed0.000001Product%20Leaflet%20Approved.160122.pdf

https://www.drugs.com/uk/triapin-5mg-5mg-prolonged-release-tablets-leaflet.html

http://www.mims.co.uk/drugs/cardiovascular-system/hypertension/triapin