Twinsta tabs 80mg + 5mg #28

Twinsta user manual

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Twinsta is a combined antihypertensive drug, slow calcium channel blocker, angiotensin II receptor antagonist.

Release form and composition

The drug is available in the form of tablets: biconvex, oval, no shell, have two layers, one of which is gray-blue, the other is white or almost white; on one side of the white surface there is a company logo and engraving "A1" (in a dosage of 5 mg + 40 mg), "A2" (in a dosage of 10 mg + 40 mg), "A3" (in a dosage of 5 mg + 80 mg), "A4" (at a dosage of 10 mg + 80 mg), the other side is smooth (7 pcs. In blisters, in a cardboard box 2 or 4 blisters and instructions for use of Twinsta).
Active ingredients in 1 tablet:
    dosage 5 mg + 40 mg: amlodipine (in the form of amlodipine besylate) - 5 mg (6.935 mg), telmisartan - 40 mg;
    dosage 10 mg + 40 mg: amlodipine (in the form of amlodipine besylate) - 10 mg (13.87 mg), telmisartan - 40 mg;
    dosage 5 mg + 80 mg: amlodipine (in the form of amlodipine besylate) - 5 mg (6.935 mg), telmisartan - 80 mg;
    dosage 10 mg + 80 mg: amlodipine (in the form of amlodipine besylate) - 10 mg (13.87 mg), telmisartan - 80 mg.
Auxiliary components: sodium hydroxide, povidone K25, meglumine, sorbitol, magnesium stearate, microcrystalline cellulose, pregelatinized starch, corn starch, colloidal silicon dioxide, a mixture of dyes (iron oxide yellow, iron oxide black, brilliant blue FCF aluminum varnish).

Pharmacodynamics

Twinsta is a combined formulation antihypertensive drug. The drug contains two active components that enhance each other's action, which allows better control of blood pressure (blood pressure) in patients with essential hypertension:
    Amlodipine: A dihydropyridine derivative belonging to the class of slow calcium channel blockers.
    Telmisartan: an angiotensin II receptor antagonist (ARA II).
Due to the combination of these substances, the drug has an additive antihypertensive effect, lowering blood pressure to a greater extent than each component separately. When Twinsta is taken once a day, an effective and stable decrease in blood pressure is observed throughout the day.

Amlodipine

A dihydropyridine derivative, amlodipine (as a mixture of stereoisomers), is a third generation slow calcium channel blocker. It inhibits the transmembrane entry of calcium ions into vascular smooth muscle cells and cardiomyocytes. A decrease in peripheral vascular resistance and a decrease in blood pressure are due to the connection between the mechanism of the antihypertensive action of amlodipine and a direct relaxing effect on vascular smooth muscle cells.
In patients with a diagnosis of arterial hypertension, a clinically significant decrease in blood pressure throughout the day is achieved by using amlodipine 1 time during the day.
Due to the slow onset of action of the drug, orthostatic arterial hypotension is not typical when using amlodipine.
For patients with arterial hypertension and no impaired renal function, taking amlodipine in therapeutic doses increased the efficiency of plasma blood flow in the kidneys and the glomerular filtration rate, reduced renal vascular resistance, without leading to proteinuria and changes in filtration.
Amlodipine can be used in patients with gout, diabetes mellitus and bronchial asthma, since its intake does not lead to a change in blood plasma lipids and does not provoke any metabolic adverse effects.
A negative inotropic effect is not observed when taking amlodipine in patients with heart failure (neither the left ventricular ejection fraction nor exercise tolerance decreases).

Telmisartan

Telmisartan is a specific ARA II (type AT1) that is effective when taken orally. Has a high affinity for the AT1 subtype of angiotensin II receptors, through which the action of angiotensin II is realized. The latter is displaced from binding to the receptor, while telmisartan does not have an agonist effect on this receptor. The substance binds exclusively to the AT1 subtype of angiotensin II receptors, and this connection is long-term. It has no affinity for other receptors, including AT2 receptors. Reduces the concentration of aldosterone in the blood, does not block ion channels and does not inhibit renin in the blood plasma. Also, the substance does not inhibit ACE (kininase II), a bradykinin-degrading enzyme, due to which an increase in the side effects caused by bradykinin is not expected.
Taking 80 mg of telmisartan allows you to completely block the hypertensive effect of angiotensin II. After taking the first dose, the onset of antihypertensive action is noted after 3 hours, persists throughout the day and remains significant for two days. With regular use, a pronounced antihypertensive effect usually develops after 1–1.5 months.
In patients with arterial hypertension, telmisartan allows you to reduce diastolic and systolic blood pressure without affecting heart rate (heart rate).
The withdrawal syndrome does not develop in the event of an abrupt cessation of telmisartan, blood pressure gradually returns to its original level.

Pharmacokinetics

The rate and degree of absorption of the drug are equivalent to the bioavailability of amlodipine and telmisartan taken separately.
Pharmacokinetic characteristics of amlodipine:
    absorption: Cmax (maximum concentration) in blood plasma after oral administration of therapeutic doses of amlodipine is achieved after 6-12 hours. Absolute bioavailability - 64-80% (food intake has no effect on this indicator);
    distribution: Vd (volume of distribution) of amlodipine is ~ 21 l / kg. In vitro studies have shown that in patients with arterial hypertension ~ 97.5% of circulating amlodipine binds to blood plasma proteins. Under the condition of constant use of the drug, stable plasma concentrations are achieved after 7–8 days;
    metabolism: amlodipine is metabolized by 90% in the liver, in the process, inactive metabolites are formed;
    excretion: amlodipine is excreted from blood plasma in two phases. T1 / 2 (half-life) is ~ 30-50 hours. Amlodipine is excreted in the urine, mainly in the form of metabolites (60%), only a small part (10%) is excreted unchanged.
Pharmacokinetic characteristics of telmisartan:
    absorption: when taken orally from the gastrointestinal tract (GIT), it is rapidly absorbed. Bioavailability is 50%. When taken simultaneously with food, the decrease in AUC (area under the concentration-time curve) ranges from 6% when used at a dose of 40 mg to 19% when used at a dose of 160 mg. The concentration in the blood plasma levels out 3 hours after the use of the drug, regardless of the meal. AUC and, to a greater extent, Cmax in blood plasma increase disproportionately to the dose;
    distribution: telmisartan binds to blood plasma proteins (mainly alpha1-glycoprotein and albumin) by 99.5%. The apparent Vd at equilibrium concentration is 500 liters. There is no evidence of a clinically significant accumulation of telmisartan;
    metabolism: the metabolism of telmisartan is carried out by conjugation with glucuronic acid to form pharmacologically inactive metabolites;
    excretion: T1 / 2 - more than 20 hours. It is excreted in the feces unchanged, less than 2% is excreted in the urine. Total plasma clearance is high (900 ml / min) compared to hepatic blood flow (about 1500 ml / min).
In elderly patients, there may be an increase in T1 / 2 and AUC of the drug due to a decrease in the clearance of amlodipine, the pharmacokinetics of telmisartan does not differ from the pharmacokinetics in younger patients.
There are no significant changes in the pharmacokinetics of amlodipine in patients with impaired renal function. Telmisartan in patients of this category is not removed during hemodialysis due to its connection with blood plasma proteins. In addition, with renal failure, there are lower plasma concentrations of telmisartan, its T1 / 2 remains unchanged.
In the course of the conducted studies of the pharmacokinetics of Twinsta, it was found that in patients with impaired hepatic function due to a decrease in the clearance of amlodipine, the AUC values ​​increased by approximately 40-60%, the absolute bioavailability of telmisartan increased to almost 100%, the T1 / 2 of the latter did not change.
The values ​​of plasma concentrations of telmisartan in men and women differ. AUC and Cmax were approximately 2 and 3 times, respectively, higher in women than in men, with no significant effect on efficacy.

Indications for use

Twinsta is prescribed for the treatment of arterial hypertension, when monotherapy with amlodipine or telmisartan does not allow achieving adequate blood pressure control, or in patients who are indicated for combination therapy with these drugs.
Patients taking amlodipine and telmisartan as separate medications can take Twinsta as a substitute for this therapy.

Contraindications

Absolute:
    severe arterial hypotension;
    hemodynamically unstable heart failure after acute myocardial infarction;
    obstruction of the outflow tract of the left ventricle (including a high degree of aortic stenosis);
    obstructive diseases of the biliary tract;
    severe liver failure;
    shock;
    intolerance to fructose (due to the presence of sorbitol in Twinsta), glucose / galactose malabsorption syndrome or sucrase / isomaltase deficiency;
    co-administration with aliskiren in patients with impaired renal function (glomerular filtration rate less than 60 ml / min / 1.73 m2) or diabetes mellitus;
    age up to 18 years (safety and effectiveness have not been established);
    pregnancy and lactation;
    hypersensitivity to the active ingredients or excipients of the drug or other dihydropyridine derivatives.
Relative (the use of Twinsta tablets requires caution):
    renovascular arterial hypertension;
    arterial hypotension;
    hypertrophic obstructive cardiomyopathy, stenosis of the aortic and mitral valves;
    heart failure of non-ischemic etiology (III – IV functional class according to NYHA classification);
    sick sinus syndrome (severe tachycardia, bradycardia);
    unstable angina;
    acute myocardial infarction (and within 1 month after it);
    ischemic heart disease with severe obstructive coronary artery disease;
    diabetes;
    primary aldosteronism;
    renal / hepatic impairment of mild to moderate severity;
    impaired renal function, condition after kidney transplantation (no experience of use);
    bilateral stenosis of the renal arteries or stenosis of an artery of a solitary kidney;
    simultaneous use with inhibitors or inducers of the CYP3A4 isoenzyme;
    reduced volume of circulating blood due to vomiting or diarrhea, limited intake of table salt, prior to diuretic therapy;
    hyponatremia, hyperkalemia and other conditions characterized by activation of the renin-angiotensin-aldosterone system.

Instructions for use: method and dosage

The tablets are taken orally 1 time a day, regardless of the time of the meal.
The drug can be prescribed to patients receiving the same doses of amlodipine and telmisartan in the form of separate drugs in order to increase adherence to treatment and ease of therapy.
Twinsta is suitable for patients in whom adequate blood pressure control is not achieved by using only amlodipine or only telmisartan. In the case when taking amlodipine at a dose of 10 mg leads to the development of adverse reactions that limit the use of the drug (for example, peripheral edema), it is recommended to transfer the patient to Twinsta 5 + 40 mg once a day. This measure will allow, by reducing the dose of amlodipine, to maintain the overall expected hypotensive effect.
If the likelihood of achieving blood pressure control with the help of monotherapy with either of the two drugs is small, it is recommended to start treatment of hypertension with the use of Twinsta. The initial dose in this case should not exceed 5 + 40 mg once a day. Those patients who require a more significant reduction in blood pressure can increase the initial dose and take Twinsta 5 + 80 mg once a day.
If, after at least 2 weeks of therapy, there is a need for an additional decrease in blood pressure, the dose of the drug may be gradually increased to the maximum - Twinsta 10 + 80 mg 1 time per day.
Twinsta can be used in conjunction with other antihypertensive drugs.
In the presence of impaired renal function, including patients on hemodialysis, it is not necessary to change the dose of the drug. Amlodipine and telmisartan are not removed from the body during hemodialysis.
In the presence of mild to moderate hepatic dysfunction, Twinsta is used with caution. In such patients, the dose of telmisartan should not exceed 40 mg once a day.
Elderly patients do not need to adjust the dosage regimen.

Side effects

The incidence of side effects is classified as follows: very common (≥ 1/10); often (≥ 1/100, <1/10); infrequently (≥ 1/1000, <1/100); rarely (≥ 1/10 000, <1/1000); very rare (<1/10 000); the frequency is unknown (it is not possible to calculate the frequency from the available data).
Possible undesirable effects while taking amlodipine:
    mental disorders: the frequency is unknown - confusion, mood lability;
    nervous system: frequency unknown - extrapyramidal disorders;
    immune system: frequency unknown - hypersensitivity;
    organ of vision: frequency unknown - decreased vision;
    organ of hearing and vestibular apparatus: frequency unknown - tinnitus;
    cardiovascular system: frequency unknown - myocardial infarction, ventricular tachycardia, arrhythmia, atrial fibrillation;
    respiratory system: frequency unknown - shortness of breath, rhinitis;
    digestive system: frequency unknown - jaundice, hepatitis, pancreatitis, increased activity of hepatic transaminases (mainly reflecting cholestasis), gastritis, change in the rhythm of defecation;
    skin and subcutaneous tissue: frequency unknown - hyperhidrosis, urticaria, angioedema, alopecia, discoloration of the skin, purpura, exfoliative dermatitis, photosensitivity reaction, erythema multiforme, vasculitis, Stevens-Johnson syndrome;
    urinary system: frequency unknown - frequent urination, urinary disorders;
    general disorders: frequency unknown - pain, gynecomastia, increase / decrease in body weight;
    laboratory parameters: frequency unknown - hyperglycemia, leukopenia, thrombocytopenia.
Possible side effects while taking telmisartan:
    infections and invasions: infrequently - urinary tract infections, upper respiratory tract infections; rarely - sepsis (including fatal);
    immune system: rarely - anaphylactic reactions, hypersensitivity;
    organ of vision: rarely - visual disturbances;
    cardiovascular system: rarely - tachycardia;
    respiratory system: infrequently - shortness of breath;
    digestive system: infrequently - flatulence; rarely - violations of hepatic function, discomfort in the stomach;
    skin and subcutaneous tissue: rarely - drug / toxic rash; infrequently - hyperhidrosis; rarely - urticaria, angioedema;
    musculoskeletal system: rarely - pain in the tendons (symptoms resemble tendonitis);
    urinary system: frequency unknown - impaired renal function, including acute renal failure;
    general disorders: rarely - flu-like syndrome;
    laboratory parameters: infrequently - anemia, hyperkalemia, increased concentration of creatinine in the blood; rarely - eosinophilia, increased activity of creatine phosphokinase, decreased hemoglobin, thrombocytopenia, in patients with diabetes mellitus - hypoglycemia.
The above side effects arising from the use of one of the components of the drug (amlodipine or telmisartan) may increase during therapy with Twinsta, even if they were not observed in clinical trials or in the post-marketing period.
Possible undesirable effects while taking amlodipine and telmisartan together:
    infections and invasions: rarely - cystitis;
    mental disorders: rarely - anxiety, insomnia, depression;
    nervous system: often - dizziness; infrequently - headache, migraine, drowsiness, paresthesia; rarely - taste disturbance, tremor, fainting, decreased sensitivity or resistance to external factors, peripheral neuropathy;
    organ of hearing and vestibular apparatus: infrequently - vertigo;
    cardiovascular system: infrequently - palpitations, bradycardia, marked decrease in blood pressure, orthostatic hypotension;
    respiratory system: infrequently - cough;
    digestive system: infrequently - abdominal pain, nausea, diarrhea, increased activity of liver enzymes; rarely - vomiting, dyspepsia;
    skin and subcutaneous tissue: infrequently - itchy skin; rarely - rash, erythema, eczema;
    musculoskeletal system: infrequently - arthralgia, myalgia, muscle spasms (cramps of the calf muscles); rarely - pain in the limbs;
    urinary system: rarely - nocturia;
    reproductive system and mammary gland: infrequently - erectile dysfunction;
    general disorders: often - peripheral edema (a dose-dependent side effect of amlodipine was observed more often in patients receiving only amlodipine than in patients receiving a combination of telmisartan and amlodipine); infrequently - chest pain, a feeling of flushing to the face, increased fatigue, weakness (asthenia), edema; rarely - malaise, dryness of the oral mucosa, hypertrophy of the gingival mucosa.

Overdose

No cases of Twinsta's overdose have been reported.
Possible manifestations of an overdose are a combination of symptoms from the individual components of the drug:
    amlodipine - a pronounced decrease in blood pressure with the possible development of reflex tachycardia and symptoms of excessive peripheral vasodilation (the risk of persistent and severe arterial hypotension, including up to shock and death);
    Telmisartan - increased serum creatinine concentration, dizziness, acute renal failure; possibly bradycardia, tachycardia.
For the treatment of an overdose, symptomatic and supportive therapy is prescribed, carefully monitoring the patient's condition. Hemodialysis is not effective.
In some cases, in order to eliminate the symptoms of an overdose, treatment methods such as induction of vomiting, gastric lavage, and intake of activated charcoal can be used. During treatment, the patient needs to be moved to the supine position, the lower limbs must be raised.
Calcium gluconate may be given intravenously to prevent calcium channel blockade. In the case of a pronounced decrease in blood pressure, the introduction of plasma-substituting solutions is indicated.

Special instructions

During therapy with drugs that affect the renin-angiotensin-aldosterone system, especially in the presence of impaired renal function and / or heart failure, hyperkalemia may occur. In such patients, it is necessary to regularly monitor the content of potassium in the blood serum. Patients with impaired renal function also require periodic monitoring of the serum creatinine concentration. In some cases, due to the suppression of the renin-angiotensin-aldosterone system, especially when taking a combination of drugs that have an effect on this system (for example, the addition of aliskiren, a direct renin inhibitor, or an ACE inhibitor to ARA II), renal function is impaired (in including acute renal failure). Treatment, which is accompanied by a similar double blockade of the renin-angiotensin-aldosterone system, is not recommended and should be limited, such therapy is strictly individual and requires careful monitoring of renal function.
In the case of dependence of renal function and vascular tone mainly on the activity of the renin-angiotensin-aldosterone system (for example, in patients with kidney diseases, including renal artery stenosis, or chronic heart failure), when prescribing drugs that affect this system, it may develop hyperazotemia, acute arterial hypotension, oliguria, rarely acute renal failure.
In primary aldosteronism, antihypertensive drugs that inhibit the renin-angiotensin-aldosterone system are usually not effective. Telmisartan is not recommended for such patients.
In obstructive hypertrophic cardiomyopathy or aortic / mitral stenosis, vasodilators, including Twinsta, should be used with extreme caution.
With bilateral stenosis of the renal arteries or stenosis of an artery of a single functioning kidney, patients taking drugs that affect the renin-angiotensin-aldosterone system are at increased risk of developing renal failure and severe arterial hypotension.
Diagnosis of coronary artery disease (CHD) is difficult in patients with diabetes mellitus, since they may not have CHD symptoms. In this case, it is required to prescribe an appropriate examination in order to diagnose and treat coronary artery disease (for example, an exercise test) before starting treatment with Twinsta. Since in the presence of ischemic heart disease against the background of diabetes mellitus, the likelihood of fatal myocardial infarction and sudden cardiovascular death increases when treated with antihypertensive drugs such as ACE inhibitors and ARA II.
In the course of the clinical study, it was found that in patients with heart failure of non-ischemic etiology of III and IV functional class (according to the NYHA classification), when using amlodipine, pulmonary edema develops more often (despite the fact that significant differences in the frequency of worsening heart failure compared with placebo absent).
There are no data on the admission of Twinsta by patients with unstable angina in the acute period and within one month after myocardial infarction.
With vomiting or diarrhea, intensive therapy with diuretics, limited consumption of table salt, a decrease in circulating blood volume and the development of hyponatremia may occur, which in turn can cause symptomatic arterial hypotension, especially after taking the first dose of Twinsta. It is required to correct these conditions before starting to use the drug.
There is no experience of using Twinsta in patients who have recently undergone kidney transplantation. Hemodialysis does not remove amlodipine and telmisartan from the body. In patients with impaired renal function, serum creatinine and potassium should be monitored periodically.
In case of impaired liver function, Twinsta should be taken with caution, since there are no recommendations regarding the dosage of the drug in patients of this category.
The drug is effective in the treatment of patients of the Negroid race (in this population, the renin activity in the blood plasma is usually reduced).

Influence on the ability to drive vehicles and complex mechanisms

There is no data on the effect of Twinsta on the ability to drive vehicles and use mechanisms. However, it is necessary to take into account the occurrence of unwanted effects during treatment, including dizziness, fainting and drowsiness, and be careful when engaging in potentially hazardous activities. If any of the above effects are present, the patient is advised to refrain from driving and working with complex mechanisms.

Application during pregnancy and lactation

Special studies on the use of Twinsta during pregnancy and breastfeeding have not been carried out. However, there is evidence of the effect of individual components of the drug.

Amlodipine

According to the available information, calcium channel blockers, including amlodipine, do not adversely affect the fetus, but there is a risk of slowing down the labor process.

Telmisartan

ARA II is contraindicated for pregnant women. If pregnancy occurs while taking the drug, you should immediately cancel it and, if necessary, prescribe alternative therapy.
In preclinical studies, the presence of fetotoxicity of telmisartan was established, its teratogenic properties were not identified.
When used in the II and III trimesters of pregnancy, ARA II has a fetotoxic effect (oligohydramnios develops, renal function decreases, ossification of the fetal skull slows down) and neonatal toxicity (arterial hypotension, hyperkalemia, renal failure).
Women planning pregnancy should replace ARA II with other antihypertensive drugs that have an established safety profile when used during gestation (except when continuation of ARA II therapy is necessary).
If during pregnancy the use of ARA II continues, then, starting from the second trimester, it is recommended to conduct an ultrasound examination of the bones of the skull and kidneys of the fetus. Newborns whose mothers received ARA II should be carefully monitored for the development of arterial hypotension.
Special studies on the excretion of amlodipine and / or telmisartan in breast milk in women have not been conducted. In experimental studies on animals, it was found that telmisartan is excreted in the milk of lactating females. The decision to continue breastfeeding or to discontinue treatment is made by the doctor, taking into account the importance of therapy for the mother and possible adverse effects for the fetus.

Childhood use

For children and adolescents under 18 years of age, Twinsta is contraindicated (there is no data on the safety and efficacy of the drug in this category of patients).

With impaired renal function

    mild to moderate renal failure, impaired renal function, condition after kidney transplantation: use requires caution, no dose adjustment of Twinsta is required;
    hemodialysis: no dose adjustment is required.

For violations of liver function

    mild to moderate hepatic impairment: use requires caution. The dose of telmisartan should not exceed 40 mg once a day;
    severe hepatic impairment: the appointment of Twinsta is contraindicated.

Use in the elderly

Elderly patients do not need to adjust the dosage regimen.

Drug interactions

In the course of clinical studies, no interaction was found between the two active components included in the composition of this drug in fixed doses.
Special studies of drug interactions of Twinsta with other drugs have not been conducted.
Possible interactions with amlodipine:
    grapefruit or grapefruit juice: the antihypertensive effect of amlodipine is enhanced due to an increase in its bioavailability (this combination is not recommended; the combined administration of a single dose of 10 mg amlodipine taken orally and 240 ml of grapefruit juice in 20 healthy volunteers did not significantly affect the pharmacokinetic properties of amlodipine);
    inhibitors of the isoenzyme CYP3A4 (for example, diltiazem): inhibits the metabolism of amlodipine, probably affecting CYP3A4 (plasma concentrations of amlodipine are approximately doubled, thus enhancing its effect). Other inhibitors of CYP3A4, more active, such as itraconazole, ketoconazole, ritonavir, can increase the concentration of amlodipine in blood plasma even more than diltiazem;
    inducers of the isoenzyme CYP3A4 [St. John's wort (Hypericum perforatum), rifampicin, anticonvulsants, including primidone, phosphenytoin, carbamazepine, phenytoin, phenobarbital]: can reduce the concentration of amlodipine in the blood plasma (requires regular medical supervision after CYP4 inducers; during therapy their withdrawal, if possible, the dose of amlodipine should be changed);
    simvastatin: when taking simvastatin at a dose of 80 mg, regardless of the dose of amlodipine, the exposure of simvastatin increases up to 77% in comparison with the latter monotherapy (it is recommended to take no more than 20 mg of simvastatin per day);
    tasonermine or cyclosporine: the systemic exposure of these immunosuppressants may increase (it is necessary to regularly monitor the concentration of tasonermine or cyclosporine in the blood and adjust their doses if necessary);
    thiazide diuretics, beta-blockers, angiotensin-converting enzyme inhibitors, long-acting nitrates, nitroglycerin (used sublingually), nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics and hypoglycemic drugs for oral administration: no interaction detected;
    sildenafil: has an independent antihypertensive effect when taken simultaneously with amlodipine;
    cimetidine: does not significantly affect the pharmacokinetics of amlodipine;
    atorvastatin, digoxin or warfarin: amlodipine has no significant effect on the pharmacokinetics or pharmacodynamics of these drugs.
Possible interactions with telmisartan:
    lithium preparations: when used simultaneously with ACE inhibitors, an increase (reversible) in the concentration of lithium in the blood was observed, accompanied by toxic phenomena. In rare cases, similar changes were recorded with the appointment of ARA II, in particular, telmisartan (in the course of combined drug therapy, it is required to determine the lithium content in the blood);
    NSAIDs, including acetylsalicylic acid (in doses used as an anti-inflammatory agent), non-selective NSAIDs and cyclooxygenase-2 inhibitors: acute renal failure can develop against the background of a reduced volume of circulating blood. Telmisartan, like other drugs that affect the activity of the renin-angiotensin-aldosterone system, may have a synergistic effect (patients receiving telmisartan along with NSAIDs should compensate for the volume of circulating blood and conduct a study of renal function at the beginning of drug therapy). With the combined therapy of NSAIDs and antihypertensive drugs like telmisartan, the antihypertensive effect decreases by reducing the vasodilating effect of prostaglandins;
    digoxin, hydrochlorothiazide, warfarin, simvastatin, ibuprofen, glibenclamide, paracetamol: no clinically significant interaction was found. In one case out of 39, there was an increase in the average concentration of digoxin in the blood plasma by an average of 20% (when taking digoxin and telmisartan together, it is required to regularly determine the concentration of digoxin in the blood);
    other antihypertensive drugs: an increase in the hypotensive effect is possible (studies on the combined use of ramipril and telmisartan showed an increase in Cmax and AUC0-24 of ramipril and ramiprilat by 2.5 times; this interaction is not clinically significant).
Dual blockade of the renin-angiotensin-aldosterone system (for example, ACE inhibitor + ARA II or direct renin inhibitor aliskiren + ARA II) is not recommended due to possible impairment of renal function (including acute renal failure).
Possible interactions with the combination of amlodipine and telmisartan:
    baclofen and amifostine: due to their pharmacological properties, they enhance the hypotensive effect of all antihypertensive drugs, including Twinsta;
    ethanol, barbiturates, narcotic drugs, antidepressants: may increase orthostatic hypotension;
    corticosteroids (for systemic use): a decrease in the hypotensive effect is possible;
    potassium-sparing diuretics, potassium-containing food salt, potassium-containing additives, other drugs that increase the potassium content in the blood (for example, heparin): hyperkalemia may develop (these combinations must be used with caution, while monitoring the potassium content in the blood);
    other antihypertensive drugs: it is possible to enhance the antihypertensive effect of Twinsta.

Terms and conditions of storage

Keep out of the reach of children.
Store at a temperature not exceeding 25 ° C in original packaging.
Shelf life is 3 years.

Reviews about Twinsta

Users in reviews of Twinsta note the rapid action of the drug. When taking the drug, a decrease in blood pressure to the required level occurs within a day and remains stable against the background of further treatment. In addition, patients like the frequency of use (1 time per day) and the absence of a withdrawal syndrome when taking Twinsta is abruptly discontinued.
Buyers attribute the disadvantages of the product to its high cost and an impressive list of side effects.

Terms of sell

You can buy Twinsta without a prescription.