PRECAUTIONS SECTION.

PRECAUTIONS. GENERAL. Like other antihypertensive agents, guanfacine hydrochloride should be used with caution in patients with severe coronary insufficiency, recent myocardial infarction, cerebrovascular disease, or chronic renal or hepatic failure.SedationGuanfacine, like other orally active central 2-adrenergic agonists, causes sedation or drowsiness, especially when beginning therapy. These symptoms are dose-related (see ADVERSE REACTIONS). When guanfacine is used with other centrally active depressants (such as phenothiazines, barbiturates, or benzodiazepines), the potential for additive sedative effects should be considered.. Rebound. Abrupt cessation of therapy with orally active central 2-adrenergic agonists may be associated with increases (from depressed on-therapy levels) in plasma and urinary catecholamines, symptoms of nervousness and anxiety and, less commonly, increases in blood pressure to levels significantly greater than those prior to therapy.Information for PatientsPatients who receive guanfacine should be advised to exercise caution when operating dangerous machinery or driving motor vehicles until it is determined that they do not become drowsy or dizzy from the medication. Patients should be warned that their tolerance for alcohol and other CNS depressants may be diminished. Patients should be advised not to discontinue therapy abruptly.. Laboratory Tests. In clinical trials, no clinically relevant laboratory test abnormalities were identified as causally related to drug during short-term treatment with guanfacine hydrochloride.. Drug Interactions. The potential for increased sedation when guanfacine is given with other CNS-depressant drugs should be appreciated.The administration of guanfacine concomitantly with known microsomal enzyme inducer (phenobarbital or phenytoin) to two patients with renal impairment reportedly resulted in significant reductions in elimination half-life and plasma concentration. In such cases, therefore, more frequent dosing may be required to achieve or maintain the desired hypotensive response. Further, if guanfacine is to be discontinued in such patients, careful tapering of the dosage may be necessary in order to avoid rebound phenomena (see Rebound above).AnticoagulantsTen patients who were stabilized on oral anticoagulants were given guanfacine, to mg/day, for weeks. No changes were observed in the degree of anticoagulation.In several well-controlled studies, guanfacine was administered together with diuretics with no drug interactions reported. In the long-term safety studies, guanfacine was given concomitantly with many drugs without evidence of any interactions. The principal drugs given (number of patients in parentheses) were: cardiac glycosides (115), sedatives and hypnotics (103), coronary vasodilators (52), oral hypoglycemics (45), cough and cold preparations (45), NSAIDs (38), antihyperlipidemics (29), antigout drugs (24), oral contraceptives (18), bronchodilators (13), insulin (10) and beta blockers (10).Drug/Laboratory Test InteractionsNo laboratory test abnormalities related to the use of guanfacine hydrochloride have been identified.. Carcinogenesis, Mutagenesis, Impairment of Fertility. No carcinogenic effect was observed in studies of 78 weeks in mice at doses more than 150 times the maximum recommended human dose and 102 weeks in rats at doses more than 100 times the maximum recommended human dose. In variety of test models, guanfacine was not mutagenic.No adverse effects were observed in fertility studies in male and female rats.. Pregnancy Category B. Administration of guanfacine to rats at 70 times the maximum recommended human dose and to rabbits at 20 times the maximum recommended human dose resulted in no evidence of harm to the fetus. Higher doses (100 and 200 times the maximum recommended human dose in rabbits and rats respectively) were associated with reduced fetal survival and maternal toxicity. Rat experiments have shown that guanfacine crosses the placenta.There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.. Labor and Delivery. Guanfacine hydrochloride is not recommended in the treatment of acute hypertension associated with toxemia of pregnancy. There is no information available on the effects of guanfacine on the course of labor and delivery.. Nursing Mothers. It is not known whether guanfacine hydrochloride is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when guanfacine is administered to nursing woman. Experiments with rats have shown that guanfacine is excreted in the milk.. Pediatric Use. Safety and effectiveness in children under 12 years of age have not been demonstrated. Therefore, the use of guanfacine in this age group is not recommended. There have been spontaneous postmarketing reports of mania and aggressive behavioral changes in pediatric patients with attention-deficit hyperactivity disorder (ADHD) receiving guanfacine. The reported cases were from single center. All patients had medical or family risk factors for bipolar disorder. All patients recovered upon discontinuation of guanfacine HCl. Hallucinations have been reported in pediatric patients receiving guanfacine for treatment of attention-deficit hyperactivity disorder.. Geriatric Use. Clinical studies of guanfacine did not include sufficient numbers of subjects aged 65 and over to determine whether they responded differently from younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients.In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal or cardiac function, and of concomitant disease or other drug therapy (see CLINICAL PHARMACOLOGY: Pharmacokinetics).. Drug Interactions. The potential for increased sedation when guanfacine is given with other CNS-depressant drugs should be appreciated. The administration of guanfacine concomitantly with known microsomal enzyme inducer (phenobarbital or phenytoin) to two patients with renal impairment reportedly resulted in significant reductions in elimination half-life and plasma concentration. In such cases, therefore, more frequent dosing may be required to achieve or maintain the desired hypotensive response. Further, if guanfacine is to be discontinued in such patients, careful tapering of the dosage may be necessary in order to avoid rebound phenomena (see Rebound above). AnticoagulantsTen patients who were stabilized on oral anticoagulants were given guanfacine, to mg/day, for weeks. No changes were observed in the degree of anticoagulation. In several well-controlled studies, guanfacine was administered together with diuretics with no drug interactions reported. In the long-term safety studies, guanfacine was given concomitantly with many drugs without evidence of any interactions. The principal drugs given (number of patients in parentheses) were: cardiac glycosides (115), sedatives and hypnotics (103), coronary vasodilators (52), oral hypoglycemics (45), cough and cold preparations (45), NSAIDs (38), antihyperlipidemics (29), antigout drugs (24), oral contraceptives (18), bronchodilators (13), insulin (10) and beta blockers (10). Drug/Laboratory Test InteractionsNo laboratory test abnormalities related to the use of guanfacine hydrochloride have been identified.

ADVERSE REACTIONS SECTION.

ADVERSE REACTIONS. Adverse reactions noted with guanfacine hydrochloride are similar to those of other drugs of the central 2-adrenoreceptor agonist class: dry mouth, sedation (somnolence), weakness (asthenia), dizziness, constipation, and impotence. While the reactions are common, most are mild and tend to disappear on continued dosing.Skin rash with exfoliation has been reported in few cases; although clear cause and effect relationships to guanfacine could not be established, should rash occur, guanfacine should be discontinued and the patient monitored appropriately.In the dose-response monotherapy study described under CLINICAL PHARMACOLOGY, the frequency of the most commonly observed adverse reactions showed dose relationship from 0.5 to mg as follows: Adverse Reaction Placebo n=59 0.5 mg n=60 mg n=61 mg n=60 mg n=59 Dry Mouth 0% 10% 10% 42% 54% Somnolence 8% 5% 10% 13% 39% Asthenia 0% 2% 3% 7% 3% Dizziness 8% 12% 2% 8% 15% Headache 8% 8% 13% 7% 3% Impotence 0% 0% 0% 7% 3% Constipation 0% 2% 0% 5% 15% Fatigue 2% 2% 5% 8% 10%The percent of patients who dropped out because of adverse reactions are shown below for each dosage group. Placebo 0.5 mg mg mg mg PercentDropouts 0% 2% 5% 13% 32%The most common reasons for dropouts among patients who received guanfacine were dry mouth, somnolence, dizziness, fatigue, weakness and constipation.In the 12-week, placebo-controlled, dose-response study of guanfacine administered with 25 mg chlorthalidone at bedtime, the frequency of the most commonly observed adverse reactions showed clear dose relationship from 0.5 to mg as follows: Adverse Reactions Placebo n=73 0.5 mg n=72 mg n=72 mg n=72 mg n=72 Dry Mouth (7%) (5%) (8%) (11%) 20 (28%) Somnolence (1%) (4%) (0%) (1%) 10 (14%) Asthenia (0%) (3%) (0%) (2%) (10%) Dizziness (2%) (1%) (4%) (8%) (4%) Headache (4%) (3%) (4%) (1%) (2%) Impotence (0%) (0%) (0%) (1%) (4%) Constipation (0%) (0%) (0%) (1%) (1%) Fatigue (3%) (0%) (3%) (6%) (4%)There were 41 premature terminations because of adverse reactions in this study. The percent of patients who dropped out and the dose at which the dropout occurred were as follows: Dose Placebo 0.5 mg mg mg mg PercentDropouts 6.9% 4.2% 3.2% 6.9% 8.3%Reasons for dropouts among patients who received guanfacine were: somnolence, headache, weakness, dry mouth, dizziness, impotence, insomnia, constipation, syncope, urinary incontinence, conjunctivitis, paresthesia and dermatitis.In second 12-week placebo-controlled combination therapy study in which the dose could be adjusted upward to mg per day in mg increments at 3-week intervals, i.e., setting more similar to ordinary clinical use, the most commonly recorded reactions were: dry mouth, 47%; constipation, 16%; fatigue, 12%; somnolence, 10%; asthenia, 6%; dizziness, 6%; headache, 4%; and insomnia, 4%.Reasons for dropouts among patients who received guanfacine were: somnolence, dry mouth, dizziness, impotence, constipation, confusion, depression and palpitations.In the clonidine/guanfacine comparison described in CLINICAL PHARMACOLOGY, the most common adverse reactions noted were as follows: Adverse Reactions Guanfacine (n=279) Clonidine (n=278) Dry Mouth 30 37% Somnolence 21% 35% Dizziness 11% 8% Constipation 10% 5% Fatigue 9% 8% Headache 4% 4% Insomnia 4% 3%Adverse reactions occurring in 3% or less of patients in the three controlled trials of guanfacine hydrochloride with diuretic were:o Cardiovascular: bradycardia, palpitations, substernal paino Gastrointestinal: abdominal pain, diarrhea, dyspepsia, dysphagia, nauseao CNS: amnesia, confusion, depression, insomnia, libido decreaseo ENT disorders: rhinitis, taste perversion, tinnituso Eye disorders: conjunctivitis, iritis, vision disturbanceo Musculoskeletal: leg cramps, hypokinesiao Respiratory: dyspneao Dermatologic: dermatitis, pruritus, purpura, sweatingo Urogenital: testicular disorder, urinary incontinenceo Other: malaise, paresthesia, paresisAdverse reaction reports tend to decrease over time. In an open-label trial of one years duration, 580 hypertensive subjects were given guanfacine, titrated to achieve goal blood pressure, alone (51%), with diuretic (38%), with beta blocker (3%), with diuretic plus beta blocker (6%), or with diuretic plus vasodilator (2%). The mean daily dose of guanfacine reached was 4.7 mg. Adverse Reaction Incidence of adverse reactions at any time during the study Incidence of adverse reactions at end of one year n=580 n=580 Dry Mouth 60% 15% Drowsiness 33% 6% Dizziness 15% 1% Constipation 14% 3% Weakness 5% 1% Headache 4% 0.2% Insomnia 5% 0%There were 52 (8.9%) dropouts due to adverse effects in this 1-year trial. The causes were: dry mouth (n 20), weakness (n 12), constipation (n 7), somnolence (n 3), nausea (n 3), orthostatic hypotension (n 2), insomnia (n 1), rash (n 1), nightmares (n 1), headache (n 1) and depression (n 1).Postmarketing ExperienceAn open-label postmarketing study involving 21,718 patients was conducted to assess the safety of guanfacine hydrochloride mg/day given at bedtime for 28 days. Guanfacine was administered with or without other antihypertensive agents. Adverse events reported in the postmarketing study at an incidence greater than 1% included dry mouth, dizziness, somnolence, fatigue, headache and nausea. The most commonly reported adverse events in this study were the same as those observed in controlled clinical trials.Less frequent, possibly guanfacine-related events observed in the postmarketing study and/or reported spontaneously include:o Body as Whole: asthenia, chest pain, edema, malaise, tremoro Cardiovascular: bradycardia, palpitations, syncope, tachycardiao Central Nervous System: paresthesias, vertigoo Eye Disorders: blurred visiono Gastrointestinal System: abdominal pain, constipation, diarrhea, dyspepsiao Liver and Biliary System: abnormal liver function testso Musculo-Skeletal System: arthralgia, leg cramps, leg pain, myalgiao Psychiatric: agitation, anxiety, confusion, depression, insomnia, nervousnesso Reproductive System, Male: impotenceo Respiratory System: dyspneao Skin and Appendages: alopecia, dermatitis, exfoliative dermatitis, pruritus, rasho Special Senses: alterations in tasteo Urinary System: nocturia, urinary frequencyRare, serious disorders with no definitive cause and effect relationship to guanfacine have been reported spontaneously and/or in the postmarketing study. These events include acute renal failure, cardiac fibrillation, cerebrovascular accident, congestive heart failure, heart block, and myocardial infarction.

CLINICAL PHARMACOLOGY SECTION.

CLINICAL PHARMACOLOGY. Guanfacine hydrochloride is an orally active antihypertensive agent whose principal mechanism of action appears to be stimulation of central -adrenergic receptors. By stimulating these receptors, guanfacine reduces sympathetic nerve impulses from the vasomotor center to the heart and blood vessels. This results in decrease in peripheral vascular resistance and reduction in heart rate.The dose-response relationship for blood pressure and adverse effects of guanfacine given once day as monotherapy has been evaluated in patients with mild to moderate hypertension. In this study patients were randomized to placebo or to 0.5 mg, mg, mg, mg or mg of guanfacine. Results are shown in the following table. useful effect was not observed overall until doses of mg were reached, although responses in white patients were seen at mg; 24 hour effectiveness of mg to mg doses was documented using 24 hour ambulatory monitoring. While the mg dose added an increment of effectiveness, it caused an unacceptable increase in adverse reactions. Mean Changes (mm Hg) from Baseline in Seated Systolic and Diastolic Blood Pressure for Patients Completing to Weeks of Treatment with Guanfacine Monotherapy Mean Change S/D Seated n= (range) Placebo 0.5 mg mg mg mg mg White PatientsBlack Patients 11 to 308 to 28 -1/-5-3/-5 -6/-80/-2 -8/-9-3/-5 -12/-11-7/-7 -15/-12-8/-9 -18/-16-19/-15 S/D Systolic/diastolic blood pressureControlled clinical trials in patients with mild to moderate hypertension who were receiving thiazide-type diuretic have defined the dose-response relationship for blood pressure response and adverse reactions of guanfacine given at bedtime and have shown that the blood pressure response to guanfacine can persist for 24 hours after single dose. In the 12-week placebo-controlled dose-response study, patients were randomized to placebo or to doses of 0.5, 1, and mg of guanfacine, in addition to 25 mg chlorthalidone, each given at bedtime. The observed mean changes from baseline, tabulated below, indicate the similarity of response for placebo and the 0.5 mg dose. Doses of 1, and mg resulted in decreased blood pressure in the sitting position with no real differences among the three doses. In the standing position, there was some increase in response with dose. Mean Decreases (mm Hg) in Seated and Standing Blood Pressure for Patients Treated with Guanfacine in Combination with Chlorthalidone Mean Change = Placebo 63 0.5 mg 63 mg 64 mg 58 mg 59 S/D SeatedS/D Standing -5/-7-3/-5 -5/-6-5/-4 -14/-13-11/-9 -12/-13-9/-10 -16/-13-15/-12 S/D Systolic/diastolic blood pressureWhile most of the effectiveness of guanfacine in combination (and as monotherapy in white patients) was present at mg, adverse reactions at this dose were not clearly distinguishable from those associated with placebo. Adverse reactions were clearly present at and mg (see ADVERSE REACTIONS).In second 12-week placebo-controlled study of 1, or mg of guanfacine hydrochloride administered with 25 mg of chlorthalidone once daily, significant decrease in blood pressure was maintained for full 24 hours after dosing. While there was no significant difference between the 12 and 24 hour blood pressure readings, the fall in blood pressure at 24 hours was numerically smaller, suggesting possible escape of blood pressure in some patients and the need for individualization of therapy.In double-blind, randomized trial, either guanfacine or clonidine was given at recommended doses with 25 mg chlorthalidone for 24 weeks and then abruptly discontinued. Results showed equal degrees of blood pressure reduction with the two drugs and there was no tendency for blood pressures to increase despite maintenance of the same daily dose of the two drugs. Signs and symptoms of rebound phenomena were infrequent upon discontinuation of either drug. Abrupt withdrawal of clonidine produced rapid return of diastolic and especially systolic blood pressure to approximately pretreatment levels, with occasional values significantly greater than baseline, whereas guanfacine withdrawal produced more gradual increase to pretreatment levels, but also with occasional values significantly greater than baseline.PharmacodynamicsHemodynamic studies in man showed that the decrease in blood pressure observed after singledose or long-term oral treatment with guanfacine was accompanied by significant decrease in peripheral resistance and slight reduction in heart rate (5 beats/min). Cardiac output under conditions of rest or exercise was not altered by guanfacine.Guanfacine hydrochloride lowered elevated plasma renin activity and plasma catecholamine levels in hypertensive patients, but this does not correlate with individual blood-pressure responses.Growth hormone secretion was stimulated with single oral doses of and mg of guanfacine. Long-term use of guanfacine had no effect on growth hormone levels.Guanfacine had no effect on plasma aldosterone. slight but insignificant decrease in plasma volume occurred after one month of guanfacine therapy. There were no changes in mean body weight or electrolytes.. Pharmacokinetics. Relative to an intravenous dose of mg, the absolute oral bioavailability of guanfacine is about 80%. Peak plasma concentrations occur from to hours with an average of 2.6 hours after single oral doses or at steady-state.The area under the concentration-time curve (AUC) increases linearly with the dose.In individuals with normal renal function, the average elimination half-life is approximately 17 hr (range 10 to 30 hr). Younger patients tend to have shorter elimination half-lives (13 to 14 hr) while older patients tend to have half-lives at the upper end of the range. Steady-state blood levels were attained within days in most subjects.In individuals with normal renal function, guanfacine and its metabolites are excreted primarily in the urine. Approximately 50% (40 to 75%) of the dose is eliminated in the urine as unchanged drug; the remainder is eliminated mostly as conjugates of metabolites produced by oxidative metabolism of the aromatic ring.The guanfacine-to-creatinine clearance ratio is greater than 1, which would suggest that tubular secretion of drug occurs.The drug is approximately 70% bound to plasma proteins, independent of drug concentration.The whole body volume of distribution is high (a mean of 6.3 L/kg), which suggests high distribution of drug to the tissues.The clearance of guanfacine in patients with varying degrees of renal insufficiency is reduced, but plasma levels of drug are only slightly increased compared to patients with normal renal function. When prescribing for patients with renal impairment, the low end of the dosing range should be used. Patients on dialysis also can be given usual doses of guanfacine hydrochloride as the drug is poorly dialyzed.