CILOSTAZOL

Posology The recommended dosage of cilostazol is 100 mg twice a day. 4). The physician should reassess the patient after 3 months of treatment with a view to discontinuing cilostazol where an inadequate effect is observed or symptoms have not been improved.

Patients receiving treatment with cilostazol should continue with their life-style modifications (smoking cessation and exercise), and pharmacological interventions (such as lipid lowering and antiplatelet treatment) to reduce the risk of cardiovascular events.

Cilostazol is not a substitute for such treatments. 5). Older people There are no special dosage requirements for the elderly. Paediatric population The safety and efficacy of cilostazol in children have not been established. Renal impairment No dose adjustment is necessary in patients with a creatinine clearance of >25 ml/min.

Cilostazol is contraindicated in patients with a creatinine clearance of ≤ 25 ml/min. Hepatic impairment No dosage adjustment is necessary in patients with mild hepatic disease. There are no data in patients with moderate or severe hepatic impairment.

Since cilostazol is extensively metabolised by hepatic enzymes, it is contraindicated in patients with moderate or severe hepatic impairment. Method of administration For oral use. Cilostazol should be taken 30 minutes before breakfast and the evening meal.

Taking cilostazol with food has been shown to increase the maximum plasma concentrations (Cmax) of cilostazol, which may be associated with an increased frequency of adverse reactions.

8. Caution should be exercised when co-administering cilostazol with any other agents that inhibit platelet aggregation. 5. 5 Interaction with other medicinal products and other forms of interaction Inhibitors of platelet aggregation Cilostazol is a PDE III inhibitor with antiplatelet activity.

d. for five days did not result in prolongation of bleeding time. Acetylsalicylic Acid (ASA) Short term (≤4 days) co-administration of ASA with cilostazol suggested a 23-25% increase in inhibition of ADP-induced ex vivo platelet aggregation when compared to ASA alone.

There were no apparent trends toward a greater frequency of haemorrhagic adverse effects in patients taking cilostazol and ASA compared to patients taking placebo and equivalent doses of ASA. Clopidogrel and other antiplatelet drugs Concomitant administration of cilostazol and clopidogrel did not have any effect on platelet count, prothrombin time (PT) or activated partial thromboplastin time (aPTT).

All healthy subjects in the study had a prolongation of bleeding time on clopidogrel alone and concomitant administration with cilostazol did not result in a significant additional effect on bleeding time. Caution is advised when co-administering cilostazol with any drug that inhibits platelet aggregation.

Consideration should be given to monitoring the bleeding time at intervals. 3). A higher rate of haemorrhage was observed with the concomitant use of clopidogrel, ASA and cilostazol in the CASTLE trial. Oral Anticoagulants like warfarin In a single-dose clinical study, no inhibition of the metabolism of warfarin or an effect on the coagulation parameters (PT, aPTT, bleeding time) was observed.

However, caution is advised in patients receiving both cilostazol and any anticoagulant agent, and frequent monitoring is required to reduce the possibility of bleeding. 3). Cytochrome P-450 (CYP) enzyme inhibitors Cilostazol is extensively metabolised by CYP enzymes, particularly CYP3A4 and CYP2C19 and to a lesser extent CYP1A2.

The dehydro metabolite, which has 4-7 times the potency of cilostazol in inhibiting platelet aggregation, appears to be formed primarily via CYP3A4. The 4`-trans-hydroxy metabolite, with potency one-fifth that of cilostazol, appears to be formed primarily via CYP2C19.

, some macrolides, azole antifungals, protease inhibitors) or CYP2C19 (like proton pump inhibitors, PPIs) increase the total pharmacological activity and could have the potential to enhance the undesirable effects of cilostazol. 2).

Administration of cilostazol with erythromycin (an inhibitor of CYP3A4) resulted in an increase in the AUC of cilostazol by 72%, accompanied by a 6% increase in AUC of the dehydro metabolite and a 119% increase in AUC of the 4`-trans-hydroxy metabolite.

Based on AUC, the overall pharmacological activity of cilostazol increases 34% when co-administered with erythromycin. , clarithromycin). Co-administration of ketoconazole (an inhibitor of CYP3A4 with cilostazol resulted in a 117% increase in the AUC of cilostazol, accompanied by a 15% decrease in the AUC of the dehydro metabolite and a 87% increase in the AUC of the 4`-trans- hydroxy metabolite.

Based on AUC, the overall pharmacological activity of cilostazol increases 35% when co-administered with ketoconazole. , itraconazole). Administration of cilostazol with diltiazem (a weak inhibitor of CYP3A4) resulted in an increase in the AUC of cilostazol of 44%, accompanied by a 4% increase in AUC of the dehydro metabolite and a 43% increase in the AUC of the 4`-trans-hydroxy metabolite.

Based on AUC, overall pharmacological activity of cilostazol increases 19 % when co-administered with diltiazem. Based on these data, no dose adjustment is necessary. Administration of a single dose of 100 mg cilostazol with 240 ml grapefruit juice (an inhibitor of intestinal CYP3A4) did not have a notable effect on the pharmacokinetics of cilostazol.

Based on these data, no dose adjustment is necessary. A clinically relevant effect on cilostazol is still possible at higher quantities of grapefruit juice. Administration of cilostazol with omeprazole (an inhibitor of CYP2C19) increased the AUC of cilostazol by 22%, accompanied by a 68% increase in the AUC of the dehydro metabolite and a decrease of 36% in the AUC of the 4`-trans hydroxy metabolite.

Based on AUC, the overall pharmacological activity increases by 47% when co-administered with omeprazole. Based on these data, the recommended dose of cilostazol is 50 mg bid in the presence of omeprazole. Cytochrome P-450 enzyme substrates Cilostazol has been shown to increase the AUC of lovastatin (sensitive substrate for CYP3A4) and its β-hydroxy acid by 70%.

, cisapride, halofantrine, pimozide, ergot derivates). Caution is advised in case of co- administration with statins metabolised by CYP3A4, for example simvastatin, atorvastatin and lovastatin. Cytochrome P-450 enzyme inducers The effect of CYP3A4 and CYP2C19 inducers (such as carbamazepine, phenytoin, rifampicin and St.

John’s wort) on cilostazol pharmacokinetics has not been evaluated. The […]

The suitability of treatment with cilostazol should be carefully considered alongside other treatment options such as revascularisation. Based on its mechanism of action, cilostazol may induce tachycardia, palpitation, tachyarrhythmia and/or hypotension.

The increase in heart rate associated with cilostazol is approximately 5 to 7 bpm; in patients at risk this consequently may induce angina pectoris. g. 3). Caution should be exercised when prescribing cilostazol for patients with atrial or ventricular ectopy and patients with atrial fibrillation or flutter.

Patients should be warned to report any episode of bleeding or easy bruising whilst on therapy. In case of retinal bleeding administration of cilostazol should be stopped. 5 for further information on bleeding risks. Due to cilostazol’s platelet aggregation inhibitory effect it is possible that an increased bleeding risk occurs in combination with surgery (including minor invasive measurements like tooth extraction).

If a patient is to undergo elective surgery and antiplatelet effect is not necessary, cilostazol should be stopped 5 days prior to surgery. 8). Most patients recovered on discontinuation of cilostazol. However, some cases of pancytopenia and aplastic anaemia had a fatal outcome.

In addition to reporting episodes of bleeding and easy bruising, patients should be warned to promptly report any other signs which might also suggest the early development of blood dyscrasia such as pyrexia and sore throat. A full blood count should be performed if infection is suspected or there is any other clinical evidence of blood dyscrasia.

Cilostazol should be discontinued promptly if there is clinical or laboratory evidence of haematological abnormalities. In the case of patients receiving strong inhibitors for CYP3A4 or CYP2C19, plasma levels of cilostazol were shown to be increased.

5 for further information). Caution is needed when co-administering cilostazol with any other agent which has the potential to reduce blood pressure due to the possibility that there may be an additive hypotensive effect with a reflex tachycardia.

8. Caution should be exercised when co-administering cilostazol with any other agents that inhibit platelet aggregation. 5.

g. g. acetylsalicylic acid, clopidogrel, heparin, warfarin, acenocoumarol, dabigatran, rivaroxaban or apixaban) • Patients with unstable angina pectoris, myocardial infarction within the last 6 months, or a coronary intervention in the last 6 months.