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

Excipients: lactose monohydrate 295.85 mg, croscarmellose sodium 12.00 mg, povidone-K25 12.00 mg, meglumine 12.00 mg, sodium hydroxide 3.35 mg, magnesium stearate 3.80 mg.

Composition per tablet 80 mg:

Active substance: telmisartan - 80.00 mg.

Excipients: lactose monohydrate (sugar milk) - 474.90 mg, croscarmellose sodium - 24.00 mg, povidone-K25 - 24.00 mg, meglumine - 24.00 mg, sodium hydroxide - 6.70 mg, magnesium stearate - 6.40 mg.

Description:Round flat cylindrical tablets white or white with a yellowish tint of color with a facet and a risk.

Pharmacotherapeutic group:Angiotensin II receptor antagonist

ATX: & nbsp

C.09.C.A.07 Telmisartan

Pharmacodynamics:

Telmisartan is a specific angiotensin II receptor antagonist (ARA II) (type AT₁), has a high affinity for the AT subtype₁ receptors of angiotensin II, through which the action of angiotensin II is realized. It displaces angiotensin II from the bond to the receptor, not having the action of an agonist for this receptor.

Telmisartan binds only to the subtype AT₁ receptors of angiotensin II.

Communication is of a lasting nature. Has no affinity for other receptors, including AT₂ receptors and other, less studied receptors of angiotensin. The functional significance of these receptors, as well as the effect of their possible excessive stimulation with angiotensin II, whose concentration is increased by telmisartan, have not been studied. Telmisartan reduces the concentration of aldosterone in the blood plasma, does not reduce the activity of renin in the blood plasma and does not block the ion channels. Telmisartan does not inhibit the angiotensin-converting enzyme (ACE, kininase II), which also catalyzes the degradation of bradykinin. This avoids the side effects associated with the action of bradykinin (eg, dry cough).

Arterial hypertension

Telmisartan at a dose of 80 mg completely blocks the hypertensive effect of angiotensin II in patients. The onset of antihypertensive action is noted within 3 hours after the first administration of telmisartan. The drug remains for 24 hours and remains significant up to 48 hours. The pronounced antihypertensive effect usually develops after 4-8 weeks of regular use of telmisartan.

In patients with hypertension telmisartan reduces both systolic and diastolic blood pressure (BP), without affecting the heart rate (heart rate).

In the case of a sharp withdrawal of telmisartan, blood pressure gradually (within a few days) returns to its initial values without the development of the "withdrawal" syndrome.

In comparative clinical studies, it has been shown that the antihypertensive effect of telmisartan is comparable to the antihypertensive effect of drugs of other classes (amlodipine, atenolol, enalapril, hydrochlorothiazide and lisinopril). The incidence of "dry" cough was significantly lower in patients who received telmisartan, compared with those who received ACE inhibitors.

Prevention of cardiovascular diseases

In patients aged 55 years and older with coronary heart disease, stroke, transient ischemic attack, peripheral arterial disease, or type 2 diabetes mellitus (eg, retinopathy, left ventricular hypertrophy, macro- or microalbuminuria) in a history of cardiovascular risk -Vascular complications. Telmisartan had an effect similar to the effect of ramipril in lowering the primary combined endpoint: cardiovascular mortality, non-fatal myocardial infarction, nonfatal stroke or hospitalization due to chronic heart failure.

Telmisartan was also effective, as was ramipril in terms of reducing the frequency of secondary points: cardiovascular mortality, myocardial infarction without a fatal outcome, or a stroke without a fatal outcome.

The effectiveness of reducing the risk of cardiovascular mortality by telmisartan doses less than 80 mg has not been studied.

Dry cough and angioedema were less often described in the background of taking telmisartan in contrast to ramipril, with arterial hypotension more likely to occur when taking telmisartan.

Patients of childhood and adolescence

The safety and efficacy of telmisartan in children and adolescents under the age of 18 years have not been established.

Pharmacokinetics:

Suction

After ingestion telmisartan quickly absorbed from the gastrointestinal tract. Bioavailability is about 50%. When taking telmisartan concomitantly with food, a decrease in the area under the concentration-time curve (AUC) for telmisartan varies from 6% (at a dose of 40 mg) to 19% (at a dose of 160 mg). After 3 hours after ingestion, the concentration of telmisartan in the blood plasma levels out regardless of the time taken to take food.

Linearity / nonlinearity

It is not assumed that a small decrease AUC can cause a decrease in therapeutic effectiveness. The linear relationship between dose and concentration of the drug in the blood plasma is absent. At doses over 40 mg, the maximum concentration in the blood plasma (FROMmOh) and, to a lesser extent. AUC increase disproportionately.

Distribution

Telmisartan actively binds to blood plasma proteins (more than 99.5%), mainly with albumin and alpha-1 acid glycoprotein. The average value of the apparent volume of distribution in the equilibrium state is approximately 500 liters.

Metabolism

Telmisartan is metabolized by conjugation of the starting material with glucuronide.The conjugate does not have pharmacological activity.

Excretion

Telmisartan is characterized by the pharmacokinetics of biexponential decay with a finite half-life of more than 20 hours. FROMmah and, to a lesser extent, AUC increase with dose disproportionately. There is no evidence that the accumulation of telmisartan when taken at recommended doses is of clinical significance.

After the administration of the drug inside (and intravenously) telmisartan is excreted practically only through the intestine, mostly unchanged. The total amount excreted by the kidneys is less than 1% of the dose. The total plasma clearance is high (of the order of 1000 ml / min) in comparison with the hepatic blood flow (about 1500 ml / min).

Pharmacokinetics in specific patient groups

Gender differences

Concentrations in blood plasma were higher in women than in men. There were differences in plasma concentration Cmah and AUC in women compared to men, they were approximately 3 and 2 times higher, respectively, but there was no corresponding effect on efficacy.

Elderly patients

The pharmacokinetics of telmisartan in elderly patients and patients younger than 65 years does not differ.

Patients with renal insufficiency

A dose change in patients with renal insufficiency is not required, including patients on hemodialysis. Patients with severe renal failure and patients on hemodialysis are recommended a lower initial dose of 20 mg per day (see section "Special instructions"). Telmisartan actively binds to blood plasma proteins in patients with renal insufficiency and is not excreted in dialysis.

Patients with hepatic insufficiency

Pharmacokinetic studies involving patients with liver failure revealed an increase in absolute bioavailability to almost 100%. The half-life in patients with liver failure does not change.

Indications:

- Arterial hypertension;

- reduction in cardiovascular morbidity and mortality in patients aged 55 years and older with a high risk of cardiovascular disease.

Contraindications:

- Hypersensitivity to the active ingredient or to the auxiliary components of the preparation;

- pregnancy and the period of breastfeeding;

- obstructive diseases of the biliary tract;

- severe liver dysfunction (Child-Pugh class C);

- simultaneous use with aliskiren or aliskiren-containing drugs in patients with diabetes mellitus and / or moderate or severe impairment of the function of the night (glomerular filtration rate (GFR) is less than 60 ml / min / 1.73 m² surface area of the body);

- concurrent use with angiotensin-converting enzyme inhibitors in patients with diabetic nephropathy;

- deficiency of lactase, lactose intolerance, glucose-galactose malabsorption;

- age to 18 years (efficacy and safety not established).

Carefully:

Two-sided stenosis of the renal arteries, stenosis of the single kidney artery, mild and moderate renal and / or hepatic impairment, condition after kidney transplantation (no experience of application); decrease in circulating blood volume (BCC) due to previous diuretic therapy, restriction of salt intake, diarrhea or vomiting; hyponatremia, hyperkalemia, chronic heart failure (CHF), stenosis of the aortic and / or mitral valve, hypertrophic obstructive cardiomyopathy (GOKMP),primary hyperaldosteronism (efficacy and safety not established), use in patients of the Negroid race.

Pregnancy and lactation:

Application of the drug Telmisartan during pregnancy and during breastfeeding is contraindicated.

Pregnancy

At present, there is no reliable information on the safety of telmisartan in pregnant women. In animal studies, the reproductive toxicity of the drug was identified.

When confirming the fact of pregnancy, the drug Telmisartan should be stopped immediately. If necessary, an alternative hypotensive therapy (other classes of antihypertensive drugs that are approved for use in pregnancy).

As the results of clinical observations have shown, the use of APAII during the second and third trimesters of pregnancy has a toxic effect on the fetus (impaired renal function, oligohydramnion, delayed ossification of the skull) and newborn (kidney failure, arterial hypotension and hyperkalemia). With the use of APAII Ultrasound examination of the kidneys and fetal skull is recommended during the second trimester of pregnancy.

Newborns whose mothers took the drug ARA II during pregnancy, should be monitored, since it is possible to develop arterial hypotension in a newborn.

Breastfeeding period

There is no information as to whether the telmisartan in breast milk. Studies on animals indicate the penetration of telmisartan into the milk of lactating animals.

Application of the drug Telmisartan contraindicated during breastfeeding. If it is necessary to use the drug Telmisartan during lactation, breastfeeding should be discontinued.

Dosing and Administration:

Inside, regardless of the time of eating.

Arterial hypertension

The initial recommended dose is 1 tablet (40 mg) of the drug Telmisartan once a day. In some patients, 20 mg of telmisartan per day can be effective. A dose of 20 mg can be obtained by dividing the tablet 40 mg in half by the risk. In cases where the therapeutic effect is not achieved, the maximum recommended dose of the drug Telmisartan can be increased to 80 mg once daily.Alternatively, the drug can be taken in combination with thiazide diuretics, for example, hydrochlorothiazide, which, when combined with telmisartan, had an additional antihypertensive effect. If it is necessary to increase the dose, it should be taken into account that the maximum antihypertensive effect usually develops 4-8 weeks after the start of treatment (see the section "Pharmacodynamics").

Reduction of cardiovascular morbidity and mortality

The recommended dose is 1 tablet of the drug Telmisartan 80 mg once a day.

It is recommended to regularly monitor blood pressure and, if necessary, adjust the dose of drugs that reduce blood pressure.

Special patient groups

Renal insufficiency

For patients with mild to moderate renal dysfunction, dose adjustment is not required. The experience with telmisartan in patients with severe renal failure or patients on hemodialysis is limited. These patients are recommended a lower initial dose of 20 mg per day (see section "Special instructions").

Liver failure

In patients with mild and moderate impairment of liver function (class A and B according to the Child-Pugh classification, respectively), the daily dose of the drug Telmisartan should not exceed 40 mg.In patients with severe impairment of liver function (class C according to the Child classification-I drink), the use of the drug is contraindicated (see section "Contraindications").

Elderly patients

For elderly patients, dose adjustment is not required.

Side effects:

In general, the incidence of adverse events noted for telmisartan (41.4%) is comparable to that for placebo (43.9%). The incidence of adverse events was not dose-related and did not correlate with gender, age, or race.

Adverse adverse reactions are presented according to the frequency of occurrence: Often (≥ 1/10); often (from ≥ 1/100 to <1/10); infrequently (from> 1/1000 to <1/100); rarely (from ≥ 1/10000 to <1/1000); rarely (< 1/10000), unknown frequency (based on the available data it is impossible to assess).

Infections and infestations: infrequently - upper respiratory tract infection, including pharyngitis and sinusitis; infection of the urinary tract, including cystitis; unknown frequency: sepsis, including fatal.

Disorders from the blood and lymphatic system: infrequently - Anemia; rarely - thrombocytopenia; unknown frequency - eosinophilia.

Immune system disorders: rarely hypersensitivity; unknown frequency anaphylactic reactions.

Disorders of nutrition and metabolism: infrequently - hyperkalemia.

Mental disturbances: infrequently - Depression, insomnia; rarely - Anxiety.

Disturbances from the nervous system: infrequently - Syncope.

Disorders from the side of the organ of vision: rarely - impaired vision.

Disturbances from the organ of hearing and balance: infrequently - Vertigo.

Disorders from the cardiovascular system: infrequently - a bradycardia, marked decrease in arterial pressure *, orthostatic hypotension; rarely - tachycardia.

* Often observed in patients with controlled arterial pressure who received telmisartan treatment to reduce the risk of cardiovascular mortality in addition to standard treatment.

Disturbances from the respiratory system, chest and mediastinal organs: infrequently - dyspnea; rarely - Interstitial lung disease (by results of postmarketing use, causal relationship not established).

Disorders from the digestive system: infrequently - pain in the abdomen, diarrhea, indigestion, flatulence, vomiting; rarely - indigestion, discomfort, dryness of the oral mucosa, dysgeusia.

Disorders from the hepatobiliary system: rarely - a violation of liver function / liver disease (according to the results of postmarketing observations, in most cases, a violation of liver function / liver disease have been identified in Japan).

Disturbances from the skin, subcutaneous tissue: infrequently - Hyperhidrosis, itchy skin, skin rash; rarely - erythema, angioedema, edema (including fatal), drug rash, toxic skin rash, eczema; unknown frequency - hives.

Disturbances from musculoskeletal system and connective tissue: infrequently - myalgia, back pain (eg, sciatica), muscle spasms; rarely - arthralgia, pain in the limbs; unknown frequency - Pain in the tendon area (tendinitis-like symptoms).

Disorders from the urinary system: infrequently - Renal failure, including acute renal failure.

General disorders and disorders at the site of administration: infrequently - pain in the chest, asthenia (weakness); rarely - influenza-like condition.

Laboratory indicators: infrequently - Increase in the concentration of creatinine in the blood; rarely - increase in the concentration of uric acid in the blood, increased activity of "liver" enzymes, increased creatine kinase activity in serum; decreased hemoglobin; hypoglycemia (in patients with diabetes mellitus).

Overdose:

Cases of overdose have not been identified.

Symptoms: marked decrease in blood pressure and tachycardia: may also be observed bradycardia, dizziness, increase in serum creatinine concentration in the serum and acute renal failure.

Treatment: telmisartan is not excreted by hemodialysis. Careful monitor the condition of patients and carry out symptomatic, as well as supportive treatment. The approach to treatment depends on the time elapsed after taking the drug, and the severity of the symptoms. Recommended measures include provoking vomiting and / or gastric lavage, it is advisable to take activated charcoal.The content of electrolytes and creatinine in the blood plasma should be regularly monitored. If there is a marked decrease in blood pressure, the patient should take a horizontal position with raised legs, while the volume of circulating blood and electrolytes must be quickly replenished.

Interaction:

Double blockade of the renin-angiotensin-aldosterone system (RAAS)

The results of clinical studies have shown that the double blockade of RAAS due to combined use of ACE inhibitors, APA II or aliskiren is associated with an increased incidence of adverse events such as hypotension, hyperkalemia and renal dysfunction (including acute renal failure) compared with the use of only one drug , operating on the RAAS.

The concomitant use of telmisartan with aliskiren is contraindicated in patients with diabetes mellitus or renal insufficiency (GFR less than 60 mL / min / 1.73 m²body surface area) and is not recommended for other patients.

Simultaneous use of telmisartan and ACE inhibitors is contraindicated in patients with diabetic nephropathy (see section "Contraindications").

Drugs that can cause hyperkalemia

Like other drugs that operate on RAAS, telmisartan may provoke a risk of hyperkalemia. The risk can be increased in case of simultaneous application with other medicines that can cause hyperkalemia (salt substitutes containing potassium, potassium-sparing diuretics (spironolactone, eplerenone, triamterene or amiloride), ACE inhibitors, APA II, NSAIDs, including selective COX-2 inhibitors), heparin, immunosuppressants (ciclosporin or tacrolimus) and trimethoprim). It is necessary to be careful with simultaneous application and periodically monitor the potassium content in blood plasma with simultaneous application.

Digoxin

With the joint use of telmisartan with digoxin, an average increase in Cmof digoxin in the blood plasma by 49% and a minimum concentration of 20%. At the beginning of treatment, when choosing a dose and stopping treatment with telmisartan, the concentration of digoxin in the blood plasma should be carefully monitored to maintain it within the therapeutic range.

Potassium-sparing diuretics or potassium-containing food additives

ARA II, such as telmisartan, reduce the diuretic-induced loss of potassium. Potassium-sparing diuretics, for example, spironolactone, eplerenone, triamterene or amiloride, potassium-containing dietary supplements or salt substitutes can lead to a significant increase in potassium levels in the blood plasma. If a concomitant use is indicated, since there is documented hypokalemia, they should be used with caution and against a background of regular monitoring of potassium in the blood plasma.

Lithium preparations

When co-administration of lithium preparations with ACE inhibitors and ARA II, including telmisartan, there was a reversible increase in the concentration of lithium in the blood plasma and its toxic effect. If it is necessary to use this combination of drugs, it is recommended to carefully monitor the concentration of lithium in the blood plasma.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Treatment non-steroidal anti-inflammatory drugs (NSAIDs), including acetylsalicylic acid in doses of 3 g per day or more, inhibitors of cyclooxygenase-2 (COX-2) and nonselective NSAIDs,can attenuate the antihypertensive effect of APA II (by inhibiting the vasodilating effect of prostaglandins). In some patients with impaired renal function (eg, in patients with dehydration, elderly patients with impaired renal function), the combined use of ARA II and COX-2-depressant drugs may lead to further impairment of renal function, including the development of acute renal failure, which, as a rule, is reversible. Therefore, the joint use of drugs should be performed with caution, especially in elderly patients. Proper fluid intake should also be ensured, in addition, at the beginning of the joint application and periodically the kidney function should be monitored periodically thereafter.

Diuretics (thiazide or "loop")

Previous treatment with high doses of diuretics, such as furosemide (looped diuretic) and hydrochlorothiazide (thiazide diuretic), can lead to hypovolemia and the risk of developing arterial hypotension at the beginning of telmisartan treatment.

Ramipril

With the simultaneous use of telmisartan and ramipril An increase in AUC_0-24 and Cmramipril and ramiprilata 2.5 times. The clinical significance of this phenomenon is not established.

Other antihypertensive drugs

Telmisartan may increase the antihypertensive effect other antihypertensive medicines.

Based on the pharmacological properties of baclofen and amifostine, it can be assumed that they will enhance the therapeutic effect of all antihypertensive agents, including telmisartan. In addition, orthostatic hypotension may increase with the use of alcohol, barbiturates, drugs or antidepressants.

Corticosteroids (for systemic use)

Glucocorticosteroids weaken the antihypertensive effect of telmisartan.

Special instructions:

Before and during drug treatment Telmisartan it is necessary to control blood pressure, kidney function, potassium content in the blood serum. Transient arterial hypotension is not a contraindication for further treatment with the drug Telmisartan after stabilization of blood pressure. In the case of repeated occurrence of severe arterial hypotension, the dose should be reduced or the drug should be withdrawn.In the presence of renal failure, treatment is carried out with caution under the control of serum creatinine concentration.

Liver failure

Telmisartan should not be used in patients with cholestasis, bile duct obstruction, or severe liver dysfunction (Child-Pugh class C) (see "Contraindications"), since telmisartan, mainly, is excreted with bile. It is assumed that these patients lowered the hepatic clearance telmisartan. Telmisartan should be used with extreme caution in patients with mild or moderate hepatic impairment (Child-Pugh class A and B).

Renovascular hypertension

In the treatment of drugs acting on RAAS, patients with bilateral renal artery stenosis and stenosis of the artery of a single kidney increase the risk of severe arterial hypotension and renal failure.

Renal failure and kidney transplantation

When using the drug Telmisartan in patients with impaired renal function, periodic monitoring of the potassium content and serum creatinine concentration is recommended.Clinical experience of the drug Telmisartan In patients who have recently undergone kidney transplantation, there is no.

Reduction of the volume of circulating blood (BCC)

In patients with reduced BCC and / or sodium content due to previous diuretic therapy, restriction of salt intake, diarrhea, or vomiting, symptomatic arterial hypotension may occur, especially after the first intake of the drug Telmisartan. The deficiency of fluid and / or sodium should be eliminated before the drug is taken Telmisartan.

Double blockade of the renin-angiotensin-aldosterone system (RAAS)

As the effects of inhibition of RAAS were observed: the occurrence of arterial hypotension, syncope, hyperkalemia and impaired renal function (including acute renal failure) in predisposing patients, especially when used in combination with drugs also acting on this system. Double blocking of RAAS, for example, with the addition of an ACE inhibitor to APA II, is not recommended for patients with already controlled blood pressure and should be limited to individual cases with enhanced monitoring of renal function (including periodic monitoring of potassium and plasma creatinine concentrations).

Other diseases characterized by activation of RAAS

Patients with renal vascular tone and function of which depend primarily on the activity of the RAAS (e.g., patients with chronic heart failure or renal disease, including renal artery stenosis), the use of drugs acting on the system, such as telmisartan, was associated with the emergence of acute arterial hypotension, hyperaemia, oliguria, or rarely - with acute renal failure (see section "Side effect").

Primary hyperaldosteronism

Patients with primary hyperaldosteronism, as a rule, do not respond to treatment hypotensive drugs, the effect of which is manifested by inhibition of RAAS. In connection with this, the use of the drug Telmisartan in these cases is not recommended.

Stenosis of the aortic and mitral valve, hypertrophic obstructive cardiomyopathy (GOKMP)

As with other vasodilators, for patients with aortic and mitral stenosis or GOKMP observance of special precautions is shown.

Hyperkalemia

The use of drugs acting on RAAS can cause hyperkalemia.

For elderly patients, patients with renal insufficiency, patients with diabetes mellitus and also with arterial hypertension and coronary heart disease (CHD), patients receiving concomitant medication therapy that can cause an increase in potassium content and / or patients with concomitant disease, Hyperkalemia can be fatal. Before considering the possibility of concomitant use of drugs acting on RAAS, it is necessary to evaluate the benefit-risk relationship.

The main risk factors that should be considered are:

- Diabetes mellitus, renal failure, age (patients older than 70 years).

- Combination with one or more drugs acting on RAAS and / or an increase in serum potassium. Drugs or therapeutic classes of drugs that can cause hyperkalemia include salt substitutes containing potassium, potassium-sparing diuretics, ACE inhibitors, ARA II, NSAIDs, including selective inhibitors of COX-2, heparin, immunosuppressants (ciclosporin or tacrolimus) and trimethoprim.

- Intercurrent diseases, especially dehydration, acute heart failure, metabolic acidosis, impaired renal function, severe deterioration of the kidneys (eg, infectious diseases), cytolysis syndrome (eg, acute limb ischemia, rhabdomyolysis, severe trauma).

For patients at risk, regular monitoring of serum potassium content is recommended (see section "Interaction with other drugs").

In patients with diabetes mellitus and an additional cardiovascular risk, for example, in patients with diabetes mellitus and IHD in the case of antihypertensive drugs such as ARA II or ACE inhibitors, the risk of fatal myocardial infarction and sudden cardiovascular death may increase.

In patients with diabetes mellitus, IHD can be asymptomatic, and therefore may not be diagnosed. In patients with diabetes before the use of the drug Telmisartan To identify and treat coronary artery disease, appropriate diagnostic tests should be carried out, including a physical load.

As an alternative, the drug Telmisartan can be used in combination with thiazide diuretics, such as hydrochlorothiazide, which additionally have an antihypertensive effect.

Racial differences

As noted for ACE inhibitors, telmisartan and other ARA II seem to be less effective in lowering blood pressure in patients of the Negroid race than in representatives of other races, possibly due to a greater predisposition to reduced renin activity in the Negroid race, patients with diabetes mellitus and also with arterial hypertension and ischemic heart disease .

Other

As with the use of other antihypertensive drugs, excessive reduction in blood pressure in patients with ischemic cardiomyopathy or coronary heart disease can lead to the development of myocardial infarction or stroke.

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

Special studies of the effect of the drug on the ability to drive vehicles and work with machinery were not conducted. Care must be taken when driving vehicles, as well as when working with machinery (risk of dizziness and drowsiness).

Form release / dosage:

Tablets of 40 mg and 80 mg.

Packaging:

By 5, 7, 10 or 20 tablets in a contour cell pack of film polyvinylchloride and aluminum foil printed lacquered.

For 10, 20, 28, 30, 40, 50 or 100 tablets in cans of polyethylene terephthalate for medicines, sealed with caps screwed on with the control of the first opening or "push-turn" system of polypropylene or polyethylene or cans of polypropylene for medicines, sealed with lids pulled with the control of the first opening of polyethylene or jars polypropylene for drugs, sealed with lids pulled with the control of the first opening of high pressure polyethylene.

One jar or 1, 2, 3, 4, 5, 8 or 10 contour squares, together with instructions for use, are placed in a cardboard box (bundle).

Storage conditions:

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:LP-004442

Date of registration:01.09.2017

Expiration Date:01.09.2022

The owner of the registration certificate:ATOLL, LLC ATOLL, LLC Russia

Manufacturer: & nbsp

OZONE, LLC Russia

Information update date: & nbsp02.10.2017

Illustrated instructions

Instructions

Telmisartan (Telmesteine)