Nifedipine - instructions for use, dose, side effects, contraindications

Excipients: lactose monohydrate - 50,00 mg, microcrystalline cellulose - 48.20 mg, wheat starch - 5.00 mg, gelatin - 2.00 mg, magnesium stearate - 1.20 mg, talc - 3.60 mg;

auxiliary substances during coating: talc - 1,828 mg, ethyl cellulose 0.344 mg, propylene glycol glycerol oleate 0.068 mg, sucrose 74.376 mg, povidone K-30 0.384 mg, sodium carmellose 0.344 mg, titanium dioxide 1.600 mg, silicon dioxide colloidal anhydrous 0.256 mg, quinoline yellow dye (Eurolake Quinoline Yellow E 104) - 0.576 mg, dye sunset yellow (Eurolake Sunset Yellow EO) - 0.024 mg, macrogol 6000 - 0.060 mg, polysorbate 20 - 0.132 mg, glycerol - 0.008 mg.

Description:

Round tablets of biconvex form, covered with a coat, yellow.

Pharmacotherapeutic group:The blocker of "slow" calcium channels

ATX: & nbsp

C.08.C.A.05 Nifedipine

Pharmacodynamics:

Nifedipine is a selective blocker of "slow" calcium channels (BCCC), a derivative of 1,4-dihydropyridine. Has antihypertensive and antianginalact. Reduces the current of extracellular calcium ions inside cardiomyocytes and smooth muscle cells of the coronary and peripheral arteries. In therapeutic doses normalizes the transmembrane current of calcium ions, disrupted in a number of pathological conditions, especially in hypertension. Reduces spasm and dilates coronary and peripheral arterial vessels, reduces overall peripheral vascular resistance, reduces afterload and myocardial oxygen demand. This improves the blood supply of the ischemic zones of the myocardium without the development of the syndrome of "robbery," and also increases the number of functioning collaterals. Virtually does not affect the sinoatrial and atrioventricular nodes and does not have both pro- and antiarrhythmic effects. Does not affect the tone of the veins. Nifedipine strengthens the renal blood flow, causing a moderate sodium naresis.

In patients with normal blood pressure nifedipine has no influence on him or influences him to an insignificant degree.

Childhood

The data of studies of various doses and dosage forms of nifedipine are limited in comparison with other antihypertensive drugs, both in the treatment of acute hypertensive crisis, and in the treatment of hypertensive disease. The antihypertensive effect of nifedipine has been demonstrated, but there are no clear recommendations for its dosage, the safety of long-term use and the effect on the cardiovascular system in patients under 18 years of age are unknown. The drug form for patients of childhood is absent.

Pharmacokinetics:

Suction

After oral administration nifedipine almost completely absorbed from the gastrointestinal tract. Its systemic bioavailability after ingestion of an immediate-release dosage form is 45-56% because of the effect of "primary transmission" through the liver. The maximum concentrations in plasma and serum are established 30-60 minutes after administration. Simultaneous food intake leads to a slowing down of absorption, but does not reduce its level.

Distribution

The connection with plasma proteins (albumins) is about 95%. The half-distribution period after intravenous (IV) administration is 5-6 minutes.

Metabolism

After oral administration nifedipine metabolized in the walls of the intestine and liver, mainly due to the oxidation process. Metabolites do not have pharmacological activity. Nifedipine is excreted in the form of metabolites mainly through the kidneys and about 5-15% with bile through the intestine. Unchanged nifedipine is found in trace amounts in urine (less than 0.1%).

Excretion

The half-life in the final phase is approximately 1.7-3.4 hours. There was no accumulation of nifedipine after its administration at the recommended dose with prolonged use. In the case of renal dysfunction, there were no significant changes in pharmacokinetic properties of nifedipine compared to healthy volunteers. When the liver function is impaired, the half-life of nifedipine increases markedly, and the overall clearance decreases. In case of severe liver dysfunction, a reduction in the dose of nifedipine may be required (see section special instructions).

Indications:

- Ischemic heart disease: stable angina (stress angina), vasospastic angina (Prinzmetal angina);

- Arterial hypertension, including hypertensive crisis.

Contraindications:

- Hypersensitivity to nifedipine, other derivatives of 1,4-dihydropyridine (risk of developing cross-sensitivity hypersensitivity reactions) or to any auxiliary substance included in the drug (see section special instructions);

- cardiogenic shock;

- severe aortic stenosis;

- unstable angina;

- acute myocardial infarction (first 4 weeks);

- simultaneous use with rifampicin (see section Interaction with othersmedicinal products);

- age under 18 years (effectiveness and safety not established);

- deficiency of lactase, lactose intolerance, glucose-galactose malabsorption (the preparation contains lactose).

Carefully:

- A marked decrease in blood pressure (BP) (systolic blood pressure below 90 mmHg);

- patients with symptoms of chronic heart failure;

- liver failure;

- elderly age;

- simultaneous administration of drugs inhibiting or inducing isoenzyme CYP3A4;

- simultaneous administration of antihypertensive and anti-anginal drugs (dose adjustment is necessary - see section Dosing and Administration);

- patients on hemodialysis, with malignant hypertension and with a reduced volume of circulating blood (risk of a pronounced decrease in blood pressure);

- diabetes.

Pregnancy and lactation:

Pregnancy

Nifedipine should not be used during pregnancy, except in cases where other methods of therapy are contraindicated or ineffective. A drug Nifedipine it is possible to prescribe only patients with severe arterial hypertension who do not have a clinical response to standard therapy. Adequate and controlled studies of the use of nifedipine in pregnant women have not been conducted. According to the available clinical data, it is impossible to judge the specific prenatal risk and the development of adverse reactions in the newborn.

Tests in animals showed the presence of embryotoxicity, placental toxicity, fetotoxicity and teratogenicity when taking nifedipine during and after the organogenesis period.

The information available is insufficient to exclude the possibility of side effects, which are dangerous for the fetus and the newborn.At the same time, there are data on the increase in the probability of perinatal asphyxia, cesarean section, premature birth and intrauterine growth retardation. It is unclear whether these cases are due to a major illness (arterial hypertension), treatment or a specific effect of nifedipine.

Breastfeeding period

Nifedipine is excreted in breast milk. The concentration of nifedipine in breast milk is comparable to its concentration in the mother's blood serum. In the absence of the possibility of abolishing the feeding of the baby with breast milk when taking the drug Nifedipine it is recommended to refrain from breastfeeding or expressing milk, which will later be consumed by the newborn, 3-4 hours after its administration, in order to reduce the effect of nifedipine on the baby (data for the immediate release dosage form of nifedipine).

Fertility

When performing in vitro fertilization in isolated cases, the use of BCCC, like nifedipine, was associated with reversible biochemical changes in the sperm head, which can cause a violation of sperm function.In men whose attempts to conceive a child with a partner do not lead to the successful fertilization of the ovum and in which no other causes of reproductive harm have been found, the intake of BCCI should be considered as one of the causes of reproductive harm.

Dosing and Administration:

Inside, regardless of food intake, without chewing, squeezed a small amount of water.

The dosage regimen is set individually, depending on the degree of severity of the disease and the patient's response to ongoing therapy.

Initial dose: 1 tablet (10 mg) 3 times a day. If necessary, the dose of the drug can be increased to 2 tablets (20 mg) - 1-2 times a day.

Between the two methods of the drug should take at least 2 hours.

With hypertensive crisis - 10 mg under careful control of blood pressure and heart rate. After taking the patient, it is recommended to be in the "lying" position for 30-60 minutes.

With angina pectoris it is recommended to start therapy with 10 mg 3 times a day, with a gradual increase in the dose of 10 mg after 4-5 days.

The maximum daily dose is 40 mg.

Have elderly patients (over 65 years) the pharmacokinetics of nifedipine varies, so the maintenance dose of nifedipine may be reduced compared to younger patients.

Patients, receiving a combination (antianginal or antihypertensive) therapy, smaller doses are usually administered.

In severe violations of liver function the dose of the drug should be reduced.

In patients with impaired renal function correction of the dose is not required.

Side effects:

Undesirable reactions have been identified in placebo-controlled studies of nifedipine and are distributed according to frequency according to the categories CIOMS III (clinical trial data was based on: nifedipine intake (n = 2.661), placebo (n = 1.486), status: February 22, 2006 and study ACTION: nifedipine (n = 3.825); placebo (n = 3,840)), adverse reactions are listed below.

Undesirable reactions in the subgroup "often" were observed with a frequency of less than 3%, except for edema (9.9%) and headache (3.9%). In each subgroup, adverse reactions are presented in order to reduce their severity. The reaction frequency is presented according to the following classification: often (≥1 / 100, <1/10); infrequently (≥1 / 1000, <1/100); rarely (≥1 / 10,000, <1/1000). In the "frequency unknown" subgroup,which were identified in post-marketing observational studies and for which the incidence rate could not be established.

From the side of the blood and lymphatic system: frequency unknown - agranulocytosis, leukopenia.

From the immune system: infrequently - allergic reactions, edema due to the development of an allergic reaction / angioedema (including laryngeal edema *); rarely - skin itching, hives, rash; frequency unknown - anaphylactic / anaphylactoid reactions.

Disorders of the psyche: infrequently - a neurosis of fear, sleep disturbances.

From the side of metabolism and nutrition: frequency unknown - hyperglycemia.

From the nervous system: often - headache; infrequently - vertigo, migraine, dizziness, tremor; rarely - paresthesia, dysesthesia; frequency unknown - hypoesthesia, drowsiness.

From the side of the organ of vision: infrequently - impaired vision; frequency unknown - pain in the eyes.

From the heart: infrequently - tachycardia, palpitation; frequency unknown - chest pain (angina).

From the side of the vessels: often - edema (including peripheral edema), vasodilation; infrequent - marked decrease in blood pressure, fainting.

From the respiratory system, chest and mediastinum: infrequently - nosebleeds, nasal congestion; frequency is unknown - dyspnea.From the gastrointestinal tract: often constipation; infrequently - pain in the gastrointestinal tract and abdominal pain, nausea, dyspepsia, flatulence, dry mouth; rarely - gingival hyperplasia; frequency unknown - vomiting, insufficiency of gastroesophageal sphincter; It is applicable only for non-deformable controlled release dosage forms: bezoar, dysphagia, intestinal obstruction, ulceration of the intestinal mucosa.

From the liver and bile ducts: infrequently - a temporary increase in the activity of liver enzymes; frequency is unknown - jaundice.

From the side of the rut and subcutaneous tissues: infrequently, erythema; frequency unknown - toxic epidermal necrolysis, photosensitivity reactions of allergic nature, palpable purpura.

From the osteomuscular and connective tissue: infrequently - muscle cramps, swelling of the joint; frequency unknown - arthralgia, myalgia.

From the side of the kidneys and urinary tract: infrequently - polyuria, dysuria.

From the genitals and the breast: infrequently erectile dysfunction. General disorders and disorders at the site of administration: often - poor health; infrequently - nonspecific pain, chills.

* can lead to a life threatening condition.

In patients on hemodialysis, with malignant hypertension and reduced blood volume due to vasodilation may be a marked reduction in blood pressure.

Overdose:

Symptoms: in the case of severe intoxication nifedipine possible: disturbance of consciousness until coma, marked reduction of blood pressure, tachycardia, bradycardia resulting in suppression of atrioventricular conduction, hyperglycemia by inhibiting insulin secretion, metabolic acidosis, hypoxia, cardiogenic shock, pulmonary edema.

Treatment: actions should be primarily aimed at elimination of nifedipine from the body (do gastric lavage, Activated carbon) And the restoration of cardiac activity and respiration (symptomatic treatment, requires monitoring of vital body functions).

It is important to ensure the maximum possible removal of nifedipine from the body.

After taking nifedipine inside, it is recommended to wash the stomach through the probe and, if necessary, wash the small intestine to prevent its subsequent absorption.

Hemodialysis is ineffective, because in this way nifedipine is not excreted from the body, it is recommended to conduct plasmapheresis (high binding to blood plasma proteins, relatively low volume of distribution).

Heart rhythm disturbances in the form of a bradycardia are corrected by symptomatic treatment with beta-sympathomimetics and with a life-threatening bradycardia, it is possible to install an artificial pacemaker.

With a marked decrease in blood pressure as a result of cardiogenic shock and dilatation of the arterial bed shows a slow intravenous injection of 10% calcium chloride or calcium gluconate at a dose of 0.2 ml / kg (but not more than 10 ml) for 5 minutes, with ineffectiveness it is possible to re-administer the calcium content in blood serum, go for continuous infusion at a rate of 0.2 ml / kg / h, but not more than 10 ml / h. As a result of the introduction of calcium preparations, its content in the serum can reach the upper limits of the norm or to slightly elevated values.If these measures are ineffective, vasoconstrictors (dopamine or norepinephrine) may be used. The dose of these drugs is set individually based on the effect of therapy.

With a pronounced decrease in blood pressure - iv administration of dopamine or dobutamine.

In conduction disorders - atropine, isoprenaline or an artificial pacemaker.

With the development of heart failure - IV injection of strophanthin.

Catecholamines should be used only with a life threat (due to their reduced efficacy, a high dose is required, which increases the risk of arrhythmia).

It is recommended to control the concentration of glucose in the blood (insulin release may decrease) and electrolytes (potassium, calcium).

Care should be taken to administer drugs that increase the volume of circulating blood, in view of the risk of developing cardiac overload.

Interaction:

Drugs affecting nifedipine

Nifedipine is metabolized with isoenzyme CYP3A4 system of cytochrome P450, located in the intestinal mucosa and in the liver.

Drugs that suppress or induce this enzyme system can affect the effect of "primary transmission" (after ingestion) or clearance of nifedipine (see section Special instructions).

Consider the strength of the interaction and the duration of this effect when taking nifedipine simultaneously with the following drugs

Rifampicin

Rifampicin greatly increases the activity of the isoenzyme CYP3A4 system of cytochrome P450, which leads to a significant decrease in the bioavailability and effectiveness of nifedipine, so their simultaneous administration is contraindicated (see section Contraindications).

In the period of simultaneous application of nifedipine with the following weak or moderate inhibitors of the isoenzyme CYP3A4 should monitor blood pressure and, if necessary, adjust the dose of the drug Nifedipine (see section Method of administration and dose).

Macrolides (for example, erythromycin)

There have been no studies of the interaction between nifedipine and macrolides. It is known that some macrolides can inhibit the isoenzyme CYP3A4, which takes part in the metabolism of other drugs.Therefore, the potential increase in the concentration of nifedipine in blood plasma can not be ruled out when they are simultaneously taken (see section Special instructions).

Azithromycin does not inhibit isoenzyme CYP3A4, although it belongs in its structure to macrolide antibiotics.

Inhibitors of HIV proteases (eg, ritonavir, indinavir, nelfinavir, amprenavir)

Clinical studies of the interaction between nifedipine and HIV protease inhibitors have not been presented. It is known that preparations of this class inhibit isoenzyme CYP3A4. It has also been shown that this class of drugs inhibits isoenzyme CYP3A4 in vitro, which causes the metabolism of nifedipine. With simultaneous administration with nifedipine, one can not exclude a significant increase in its concentration in the blood plasma by reducing the effect of "primary transmission" and reducing its excretion (see section Special instructions).

Azole antifungal agents (for example, ketoconazole, fluconazole, itraconazole)

Clinical studies of the interaction between nifedipine and azole antifungal agents are not yet available. It is known that preparations of this class inhibit isoenzyme CYP3A4. With simultaneous ingestion with nifedipine, one can not exclude a significant increase in its systemic bioavailability due to a decrease in the effect of "primary transmission" (see section Special instructions).

Fluoxetine

Clinical studies of the interaction between nifedipine and fluoxetine are not presented. It is known that fluoxetine inhibits in vitro isoenzyme CYP3A4, which causes the metabolism of nifedipine. Therefore, it is not possible to exclude an increase in the concentration of nifedipine in blood plasma when they are simultaneously taken (see section Special instructions).

Nefazodone

Clinical studies of the interaction between nifedipine and nefazodone have not yet been presented. It is known that nefazodone inhibits isoenzyme CYP3A4, which causes the metabolism of nifedipine. Therefore, it is not possible to exclude an increase in the concentration of nifedipine in blood plasma when they are simultaneously taken (see section Special instructions).

Hinupristin / Dalfopristin

Simultaneous administration of quinupristin / dalfopristin with nifedipine may lead to an increase in the concentration of nifedipine in the blood plasma (see section Special instructions).

Valproic acid

Clinical studies of potentialinteractions between nifedipine and valproic acid are not reported. Since it was found that valproic acid can increase the concentration of a similar in structure BCCC, nimodipine, in blood plasma, we can not exclude an increase in the concentration of nifedipine in the blood plasma and as a result - enhance its therapeutic effect (see section Special instructions).

Cimetidine

In view of inhibition of the isoenzyme CYP3A4 cimetidine increases the concentration of nifedipine in the blood plasma and may enhance the antihypertensive effect (see section Special instructions).

Other types of interaction

Cisapride

Simultaneous administration of cisapride and nifedipine may increase the concentration of nifedipine in the blood plasma.

Inductors of isoenzyme CYP3A4 cytochrome P450, including antiepileptic drugs, such as phenytoin, carbamazet and phenobarbital

Phenytoin induces isoenzyme CYP3A4. With the simultaneous use of nifedipine with phenytoin, the bioavailability of nifedipine decreases and, thus, its effectiveness decreases. At simultaneous reception of these preparations it is necessary to estimate clinical effect of nifedipine and, if necessary, it is recommended increase its dose.If the dose of nifedipine is increased during simultaneous administration of both drugs, a reduction in the dose of nifedipine after the withdrawal of phenytoin is required. Clinical studies of the potential interaction between nifedipine and carbamazepine or phenobarbital are not available. Since it has been established that in view of the induction of enzymes, both drugs can reduce the concentration of a similar BMSC, nimodipine, in the blood plasma, it can not be ruled out that the concentration of nifedipine in the blood plasma decreases, and as a result, its therapeutic effect is reduced.

Effect of nifedipine on other drugs:

Preparations, lowering blood pressure

Joint use of nifedipine with other antihypertensive drugs can lead to mutual enhancement of the antihypertensive effect, such drugs, for example, include:

- Diuretics,

- Beta-blockers,

- Angiotensin converting enzyme inhibitors,

- Angiotensin I receptor antagonists,

- BCCI,

- Alfa-adrenoblockers,

- Inhibitors of phosphodiesterase type 5,

- Methyldopa,

- Magnesium sulfate.

With the simultaneous use of nifedipine and beta-blockers, patients should be carefully monitored,since in some cases, the progression of chronic heart failure may be aggravated.

Digoxin

The simultaneous use of nifedipine and digoxin can lead to a decrease in digoxin clearance and, as a consequence, an increase in its concentration in the blood plasma. Care should be taken to monitor the patient for signs of digoxin overdose and, if necessary, reduce the dose of digoxin, taking into account its concentration in the blood plasma.

Quinidine

When combined with quinidine in some patients, its concentration in the blood plasma may decrease, and later on, when nifedipine is discontinued, it can significantly increase. Therefore, with the simultaneous administration of nifedipine or its withdrawal after co-administration with quinidine, it is recommended to carefully monitor the concentration of quinidine in the blood plasma and, if necessary, adjust its dose. There was also reported an increase in the concentration of nifedipine in blood plasma during the simultaneous use of drugs, while some patients did not observe a change in the pharmacokinetic parameters of nifedipine.When adding quinidine to therapy with nifedipine, you should monitor BP and, if necessary, it is recommended to reduce the dose of nifedipine.

Tacrolimus

Tacrolimus is metabolized by isoenzyme CYP3A4 cytochrome P450. Recently published data indicate that the dose of tacrolimus in the case of simultaneous administration with nifedipine in some patients may be reduced. With simultaneous administration of drugs should monitor the concentration of tacrolimus in the blood plasma, and if necessary, it is recommended to reduce its dose.

Grapefruit juice

Grapefruit juice inhibits isoenzyme CYP3A4 systems of cytochrome P450. Taking nifedipine along with grapefruit juice can lead to an increase in the plasma concentration of nifedipine and an increase in its effect as a result of reduced metabolism when it is "first passed through the liver" or lowered the clearance. This can lead to an increase in the antihypertensive effect of nifedipine. With the regular intake of grapefruit juice, this effect can last at least 3 days after its last reception. Avoid taking grapefruit juice while taking nifedipine (see section Method of administration and dose).

Other forms of interaction

Nifedipine can cause a false increase in the concentration of vanillylmandelic acid in urine when determined spectrophotometrically, but does not affect the results of measurements using the HPLC method.

Special instructions:

Caution should be applied to the drug Nifedipine in patients with a marked decrease in blood pressure (systolic blood pressure below 90 mm Hg), with symptoms of chronic heart failure.

It should be carefully monitored blood pressure in pregnant women with the drug Nifedipine simultaneously with iv administration of magnesium sulfate due to the possibility of excessive reduction in blood pressure, which is dangerous for both the mother and the fetus.

For patients with impaired liver function, a careful observation, in severe clinical cases, a dose reduction may be required. Nifedipine is metabolized by isoenzyme CYP3A4 cytochrome P450. Drugs that suppress or induce this enzyme system can affect the effect of "primary transmission" or clearance of nifedipine (see section Interaction with other medicinal products).

To preparations inhibiting isoenzyme CYP3A4 cytochrome P450 and increasing the concentration of nifedipine in blood plasma, are:

- macrolides (for example, erythromycin),

- HIV protease inhibitors (eg, ritonavir),

- azole antifungal agents (e.g., ketoconazole),

- antidepressants - nefazodone and fluoxetine,

- quinupristin / dalfopristin,

- valproic acid,

- cimetidine.

With simultaneous reception of the drug Nifedipine with these drugs should monitor BP and, if necessary, adjust the dose of Nifedipine. The features of application in different patient groups are reflected in the section Method of administration and dose.

A drug Nifedipine, like other immediate-release nifedipine dosage forms, can cause excessive BP reduction with the advent of reflex tachycardia, which can lead to complications from the cardiovascular system (coronary heart disease and cerebral ischemia).

As with the use of other vasoactive drugs, very rarely spontaneous reports received notifications about the occurrence of angina pectoris on the background of taking nifedipine in an immediate-release dosage form, especially at the beginning of the treatment.Data from clinical studies confirm that the incidence of angina attacks is infrequent.

Patients with a history of angina may experience an increase in the frequency, duration and severity of angina attacks, especially at the beginning of treatment with the drug Nifedipine.

In isolated cases, the development of myocardial infarction with nifedipine was noted, but in this case it was impossible to recognize it from the picture of the ongoing disease.

During the treatment it is necessary to refrain from drinking alcohol.

In conditions of hypovolemia, the antihypertensive effect of the drug is enhanced.

With kidney disease, there is no need to adjust the dose.

Reduced pulmonary arterial pressure and hypovolemia after dialysis may enhance the effect of the drug, in which case the dose should be appropriately reduced.

It is rare to increase the activity of certain enzymes - alkaline phosphatase, creatine phosphokinase, lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, which usually has a transient character, but can sometimes be severe.Such changes in laboratory tests are rarely associated with clinical symptoms, but in some cases they are caused by autoimmune hepatitis against intrahepatic cholestasis and jaundice.

A positive result of Coombs test is possible against the background of existing hemolytic anemia or without it, but it is impossible to prove the existence of a causal relationship between these manifestations and the use of nifedipine.

Inhaled anesthetics can increase blood pressure lowering. If during the therapy the patient is required to undergo surgery under general anesthesia, it is necessary to inform the anesthetist about the nature of the therapy.

A drug Nifedipine contains lactose and therefore is not intended for patients with lactase deficiency, galactosemia or glucose / galactose malabsorption syndrome.

The dye E110 can cause allergic reactions, including bronchial asthma, especially in patients with intolerance to acetylsalicylic acid.

Effect on the ability to drive transp. cf. and fur:

At the time of taking the drug Nifedipine Possible emergence of adverse reactions, which, depending on individual tolerability, differ in intensity (see Fig.section Side effect). These reactions usually occur at the beginning of treatment, with a change in the regimen of therapy and when combined with alcohol. During the period of treatment, care must be taken when driving vehicles and engaging in other potentially hazardous activities requiring increased attention and speed of psychomotor reactions.

Form release / dosage:Tablets, coated with a coating, 10 mg.

Packaging:For 10 tablets in a blister made of polyvinyl chloride film and aluminum foil. 5 blisters with instructions for use in a cardboard pack.

Storage conditions:In a dry, the dark place at a temperature of no higher than 25 ° C. Keep out of the reach of children!

Shelf life:

3 years. Do not use after the expiration date.

Terms of leave from pharmacies:On prescription

Registration number:П N015233 / 01

Date of registration:12.05.2008 / 29.01.2013

Expiration Date:Unlimited

The owner of the registration certificate:Balkanfarma - Dupnitsa ADBalkanfarma - Dupnitsa AD Bulgaria

Manufacturer: & nbsp

BALKANPHARMA-DUPNITSA, AD Bulgaria

Representation: & nbspAktavis, Open Company Aktavis, Open Company

Information update date: & nbsp23.06.2018

Illustrated instructions

Instructions

Nifedipine (Nifedipine)