What is Trimetazidine Dihydrochloride?
NAME OF THE MEDICINAL PRODUCT
Trimetazidine dihydrochloride 35 mg,film-coated tablet.
QUALITATIVE AND QUANTITATIVE COMPOSITION
Trimetazidine dihydrochloride………. 35 mg
For one film-coated tablet.
Trimetazidine is an effective and well tolerated anti-ischaemic agent which, in addition to providing symptom relief and functional improvement in patients with angina pectoris, has a cytoprotective action during ischaemia. The drug is suitable for initial use as monotherapy in patients with angina pectoris and, because of its different mechanism of action, as adjunctive therapy in those with symptoms not sufficiently controlled by nitrates, beta-blockers or calcium
Trimetazidine is chemically known as 2 [1-(2, 3, 4-trimethoxybenzyl)-piperazine dihydrochloride The orally administered antianginal agent trimetazidine increases cell tolerance to ischaemia by maintaining cellular homeostasis. To date, all analytical methods described in literature for the determination of trimetazidine in API, pharmaceutical dosage form and biological pharmaceutical dosage form and biological ??uids involve spectrophotometric, high performance liquid chromatography, liquid chromatography??mass spectrometry methods and high performance thin layer chromatography.[4-8] In the present work, we developed a simple, precise, accurate, selective and robust liquid chromatographic method for the determination of Trimetazidine in pharmaceutical dosage form as an alternative method.
Trimetazidine is indicated in adults as add-on therapy for the symptomatic treatment of patients with stable angina pectoris who are inadequately controlled by or intolerant to first-line antianginal therapies.
Posology and method of administration Posology
The dose is one tablet of 35mg of trimetazidine twice daily during meals.
The benefit of the treatment should be assessed after three months and trimetazidine should be discontinued if there is no treatment response.
Patients with renal impairment
In patients with moderate renal impairment (creatinine clearance [30-60] ml/min) (see sections 4.4 and 5.2), the recommended dose is 1 tablet of 35mg in the morning during breakfast.
Elderly patients may have increased trimetazidine exposure due to age-related decrease in renal function (see section 5.2). In patients with moderate renal impairment (creatinine clearance [30-60] ml/min), the recommended dose is 1 tablet of 35mg in the morning during breakfast. Dose titration in elderly patients should be exercised with caution (see section 4.4).
The safety and efficacy of trimetazidine in children aged below 18 years have not been established. No data are available.
Method of administration
Tablets must be taken orally twice daily, i.e., one in the morning and one in the evening during meals.
– Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
– Parkinson disease, parkinsonian symptoms, tremors, restlessleg syndrome, and other related movement disorders,
– Severe renal impairment (creatinine clearance < 30ml/min). Special warnings and precautions for use
This medicinal product is generally not recommended during lactation (see Pregnancy and Lactation).
This medicine is not a curative treatment for angina attacks, nor is it indicated as an initial treatment for unstable angina or myocardial infarction, nor in the pre-hospital phase or during
the first days of hospitalisation.
In the event of an angina attack, the coronaropathy should be reevaluated and an adaptation of the treatment considered (medicinal treatment and possibly revascularisation). Trimetazidine can cause or worsen parkinsonian symptoms (tremor, akinesia, hypertonia), which should be regularly investigated, especially in elderly patients. In doubtful cases, patients should be referred to a neurologist for appropriate investigations.
The occurrence of movement disorders such as parkinsonian symptoms, restlessleg syndrome, tremors, gait instability should lead to definitive withdrawal of trimetazidine.
These cases have a low prevalence and are usually reversible after treatment discontinuation. The majority of the patients recovered within 4 months after trimetazidine withdrawal. If parkinsonian symptoms persist more than 4 months after drug discontinuation, a neurologist opinion should be
sought.Falls may occur, related to gait instability or hypotension, in particular in patients taking antihypertensive treatment (see section 4.8).
Caution should be exercised when prescribing trimetazidine to patients in whom an increased exposure is expected:
– moderate renal impairment (see sections 4.2 and 5.2),
– elderly patients older than 75 years old (see section 4.2)
Interaction with other medicinal products and other forms of interaction
Fertility, pregnancy and lactation
There are no data from the use of trimetazidine in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity (see section 5.3.) As a precautionary measure, it is preferable to avoid the use of trimetazidine during pregnancy.
It is unknown whether trimetazidine is excreted in human milk. A risk to the newborns/infants cannot be excluded. Trimetazidine should not be used during breast-feeding.
Effects on ability to drive and use machines
Trimetazidine does not have haemodynamic e??ects in clinical studies, however cases of dizziness and drowsiness have been observed in post-marketing experience (see section 4.8),
which may affect ability to drive and use machines.
Adverse reactions, de??ned as adverse events considered at least possibly related to trimetazidine treatment are listed below using the following convention frequency:
very common (=1/10);
common (=1/100 to <1/10); uncommon (= 1/1,000 to <1/100); rare (=1/10,000 to <1/1,000); very rare (<1/10,000); not known (cannot be estimated from the available data).
Pharmacotherapeutic group: O ther cardiovascular
antianginal drug, ATC code: C01EB15
Mechanism of action
By preserving energy metabolism in cells exposed to hypoxia or ischaemia, trimetazidine prevents a decrease in intracellular ATP levels, thereby ensuring the proper
functioning of ionic pumps and transmembrane sodiumpotassium flow whilst maintaining cellular homeostasis.
Trimetazidine inhibits ??-oxidation of fatty acids by blocking long-chain 3-ketoacyl-CoA thiolase, which enhances glucose oxidation. In an ischaemic cell, energy obtained during glucose oxidation requires less oxygen consumption than in the ??-oxidation process. Potentiation of glucose oxidation optimizes cellular energy processes, thereby maintaining
proper energy metabolism during ischaemia.
In patients with ischaemic heart disease, trimetazidine acts as a metabolic agent, preserving the myocardial high-energy phosphate intracellular levels. Anti-ischemic effects are achieved
without concomitant haemodynamic effects.
Clinical eficacy and safety
Clinical studies have demonstrated the e??cacy and safety of trimetazidine in the treatment of patients with chronic angina, either alone or when the bene??t from other antianginal medicinal
products was insufficient.
In a 426-patients randomized, double blind, placebo-controlled study ( TRIMPOL-II), trimetazidine (60mg/day) added to metoprolol 100mg daily (50 mg b.i.d) for 12 weeks significantly improved statistically exercise tests parameters and clinical symptoms as compared to placebo: total exercise duration +20.1s,p= 0.023, total workload +0.54 METs, p=0.001, time to 1-mm STsegment depression +33.4s, p=0.003, time to onset of angina +33.9s, p<0.001, angina attacks/week -0.73, p=0.014 and short acting nitrates consumption/week, -0.63, p=0.032, without hemodynamic changes. In a 223 patients randomized, double blind, placebo-controlled study (Sellier), one 35 mg trimetazidine modified release tablet (b.i.d.) added to 50 mg atenolol (o.d.) for 8 weeks produced a significant increase (+34.4s, p=0.03) in the time to 1-mm STsegment depression in exercise tests, in a sub-group of patients (n=173), when compared to placebo, 12 hours after taking the drug. A significant difference was also evidenced for the time to onset of angina pectoris (p=0.049). No significant difference between groups could be found for the other secondary endpoints (total exercise duration, total workload and clinical endpoints). In a 1962 patients three-month randomised, double-blinded study (Vasco study) on top of atenolol 50 mg/d, two dosages of trimetazidine (70 mg/d and 140 mg/d) were tested versus placebo. In the overall population, including both asymptomatic and symptomatic patients, trimetazidine failed to demonstrate a benefit on both ergometric (total exercise duration, time to onset of 1mm ST and time to onset angina) and clinical endpoints. However, in the subgroup of symptomatic patients (n= 1574) defined in a post-hoc analysis, trimetazidine (140 mg) significantly improved total exercise duration (+23.8 s versus +13.1 s placebo; p=0.001) and time to onset of angina (+46.3 s versus +32.5 s placebo; p=0.005). Pharmacokinetic properties
By oral route, maximum concentration is observed, on average, 5 hours after taking the tablet. Over 24 hours, the plasma concentration is maintained at concentrations greater than or equal to 75% of the maximum concentration for 11 hours.
Steady state is reached by the 60th hour, at the latest.
The pharmacokinetic properties of Vastarel 35 mg are not influenced by meals.
The apparent distribution volume is 4.8 l/kg, trimetazidine protein binding is low: its value measured in vitro is 16%.
Trimetazidine is eliminated primarily in the urine, mainly in the unaltered form.
The elimination half-life of Vastarel 35 mg is, on average, 7 hours in young healthy volunteers, and 12 hours in subjects over the age of 65.
Total clearance of trimetazidine is the result of major renal clearance, which is directly correlated to creatinine clearance and, to a lesser extent, to hepatic clearance, which reduces with age.
List of excipients
Calcium hydrogen phosphate dihydrate, hypromellose,povidone, anhydrous colloidal silica, magnesium stearate,macrogol 6000.
Film coating: titanium dioxide (E 171), glycerol, hypromellose, macrogol 6000, red iron oxide (E172), magnesium stearate.
Shelf life : 3 years.
Special precautions for storage
No special precautions for storage.