4.1. Therapeutic indications

For the treatment of hypertension.

4.2. Posology and method of administration

Posology

Use in Adults

Initial dosage: Usually 250 mg two or three times a day, for two days.

Adjustment: Usually adjusted at intervals of not less than two days, until an adequate response is obtained. The maximum recommended daily dosage is 3 g.

Many patients experience sedation for two or three days when therapy is started or when the dose is increased. When increasing the dosage, therefore, it may be desirable to increase the evening dose first.

Withdrawal of methyldopa is followed by return of hypertension, usually within 48 hours. This is not complicated generally by an overshoot of blood pressure.

Patients with renal impairment:

Methyldopa is largely excreted by the kidney, and patients with impaired renal function may respond to smaller doses.

Other antihypertensives:

Methyldopa therapy may be initiated in most patients already on treatment with other antihypertensive agents by terminating these other antihypertensive medications gradually if required. Following such previous antihypertensive therapy, methyldopa should be limited to an initial dose of not more than 500 mg daily and increased as required at intervals of not less than two days.

When methyldopa is given to patients on other antihypertensives, the dose of these agents may need to be adjusted to effect a smooth transition.

When 500 mg of methyldopa is added to 50 mg of hydrochlorothiazide, the two agents may be given together once daily.

Paediatric population:

Initial dosage is based on 10 mg/kg body weight daily in 2-4 oral doses. The daily dose is then increased or decreased until an adequate response is obtained. The maximum dosage is 65 mg/kg or 3.0 g daily, whichever is less.

Older people:

The initial dose in elderly patients should be kept as low as possible, not exceeding 250 mg daily; an appropriate starting dose in the elderly would be 125 mg twice daily, increasing slowly as required, but not to exceed a maximum daily dosage of 2 g.

Syncope in older patients may be related to an increased sensitivity and advanced arteriosclerotic vascular disease. This may be avoided by lower doses.

Method of administration

For oral administration.

4.3. Contraindications

Methyldopa is contra-indicated in patients with:

- Depression

- Active hepatic disease such as acute hepatitis and active cirrhosis

- Hypersensitivity (including hepatic disorders associated with previous methyldopa therapy) to methyldopa or to any of the other ingredients listed in section 6.1

- Therapy with monoamine oxidase inhibitors (MAOIs)- with a catecholamine-secreting tumour such as phaeochromocytoma or paraganglioma

- Porphyria.

4.4. Special warnings and precautions for use

Acquired haemolytic anaemia has occurred rarely; should symptoms suggest anaemia, haemoglobin and/or haematocrit determinations should be made. If anaemia is confirmed, tests should be done for haemolysis. If haemolysis anaemia is present, methyldopa should be discontinued. Stopping therapy, with or without giving a corticosteroid, has usually brought prompt remission. Rarely, however, deaths have occurred.

Some patients on continued therapy with methyldopa develop a positive Coombs test. From the reports of different investigators, the incidence averages between 10% and 20%. A positive Coombs test rarely develops in the first six months of therapy, and if it has not developed within 12 months, it is unlikely to do so later on continuing therapy. Development is also dose-related, the lowest incidence occurring in patients receiving 1 g or less of methyldopa per day. The test becomes negative usually within weeks or months of stopping methyldopa.

Prior knowledge of a positive Coombs reaction will aid in evaluating a cross-match for transfusion. If a patient with a positive Coombs reaction shows an incompatible minor cross-match, an indirect Coombs test should be performed. If this is negative, transfusion with blood compatible in the major cross-match may be carried out. If positive, the advisability of transfusion should be determined by a haematologist.

Reversible leukopenia with primary effect on granulocytes has been reported rarely. The granulocyte count returned to normal on discontinuing therapy. Reversible thrombocytopenia has occurred rarely.

Occasionally, fever has occurred within the first three weeks of therapy, sometimes associated with eosinophilia or abnormalities in liver function tests. Jaundice, with or without fever, also may occur. Its onset is usually within the first two or three months of therapy. In some patients the findings are consistent with those of cholestasis. Rare cases of fatal hepatic necrosis have been reported. Liver biopsy, performed in several patients with liver dysfunction, showed a microscopic focal necrosis compatible with drug hypersensitivity. Liver function tests and a total and differential white blood cell count are advisable before therapy and at intervals during the first six weeks to twelve weeks of therapy, or whenever an unexplained fever occurs.

Should fever, abnormality in liver function, or jaundice occur, therapy should be withdrawn. If related to methyldopa, the temperature and abnormalities in liver function will then return to normal. Methyldopa should not be used again in these patients. Methyldopa should be used with caution in patients with a history of previous liver disease or dysfunction.

Patients may require reduced doses of anaesthetics when on methyldopa. If hypotension does occur during anaesthetics, it can usually be controlled by vasopressors. The adrenergic receptors remain sensitive during treatment with methyldopa.

Dialysis removes methyldopa; therefore, hypertension may recur after this procedure.

Rarely, involuntary choreoathetotic movements have been observed during therapy with methyldopa in patients with severe bilateral cerebrovascular disease. Should these movements occur, therapy should be discontinued.

Interference with laboratory tests:

Methyldopa may interfere with the measurement of urinary uric acid by the phosphotungstate method, serum creatinine by the alkaline picrate method, and AST (SGOT) by colorimetric method. Interference with spectrophotometric methods for AST (SGOT) analysis has not been reported.

As methyldopa fluoresces at the same wavelengths as catecholamines, spuriously high amounts of urinary catecholamines may be reported interfering with a diagnosis of catecholamine-secreting tumours such as phaeochromocytoma or paraganglioma.

It is important to recognise this phenomenon before a patient with a possible phaeochromocytoma is subjected to surgery. Methyldopa does not interfere with measurements of VMA (vanillylmandelic acid) by those methods which convert VMA to vanillin. Methyldopa is contraindicated for the treatment of patients with a catecholamine-secreting tumour such as phaeochromocytoma or paraganglioma.

Rarely, when urine is exposed to air after voiding, it may darken because of breakdown of methyldopa or its metabolites.

4.5. Interaction with other medicinal products and other forms of interaction

Alcohol

concomitant use may enhance the hypotensive effect.

Alprostadil

concomitant use may enhance the hypotensive effect.

Analgesics

NSAIDs antagonise the hypotensive effect.

Anxiolytics and hypnotics

Concomitant use may enhance the hypotensive effect.

Beta-blockers

Concomitant use may enhance the hypotensive effect.

Calcium-channel blockers

Concomitant use may enhance the hypotensive effect.

Corticosteroids

Concomitant use may antagonise the hypotensive effect.

Diuretics

Concomitant use may enhance the hypotensive effect.

Dopaminergics

Concomitant use may antagonise the antiparkinsonian effect of this type of medicine. Concomitant use with levodopa or entacapone may enhance the hypotensive effect.

Moxisylyte:

Concomitant use may enhance the hypotensive effect.

Muscle relaxants

Concomitant use with baclofen and tizanidine may enhance the hypotensive effect.

Nitrates

Concomitant use may enhance the hypotensive effect.

Oestrogens and progestogens

Oestrogens and combined oral contraceptives antagonise the hypotensive effect.

Beta2 sympathomimetics

Acute hypotension has been reported with salbutamol infusion.

Lithium:

When methyldopa and lithium are given concomitantly the patient should be monitored carefully for symptoms of lithium toxicity.

Other antihypertensive drugs:

When methyldopa is used with other antihypertensive drugs or alcohol, potentiation of antihypertensive action may occur. The progress of patients should be carefully followed to detect side reactions or manifestations of drug idiosyncrasy.

Other classes of drug:

The antihypertensive effect of methyldopa may be diminished by sympathomimetics, phenothiazines, tricyclic antidepressants and MAOIs (see section 4.3). In addition, phenothiazines may have additive hypotensive effects.

Iron:

Several studies have demonstrated a decrease in the bioavailability of methyldopa when it is ingested with ferrous sulphate or ferrous gluconate. This may adversely affect blood pressure control in patients treated with methyldopa.

4.6. Fertility, pregnancy and lactation

Pregnancy

Methyldopa has been used under close medical supervision for the treatment of hypertension during pregnancy. There was no clinical evidence that methyldopa caused foetal abnormalities or affected the neonate.

Published reports of the use of methyldopa during all trimesters indicate that if this drug is used during pregnancy the possibility of foetal harm appears remote.

Methyldopa crosses the placental barrier and appears in cord blood.

Although no obvious teratogenic effects have been reported, the possibility of foetal injury cannot be excluded and the use of the drug in women who are or may become pregnant, requires that anticipated benefits be weighed against possible risks.

Breast-feeding

Methyldopa appears in breast milk. The use of the drug in breast-feeding mothers requires that anticipated benefits be weighed against possible risks.

4.7. Effects on ability to drive and use machines

Methyldopa may cause sedation, usually transient, during the initial period of therapy or whenever the dose is increased. If affected, patients should not carry out activities where alertness is necessary, such as driving a car or operating machinery.

4.8. Undesirable effects

Sedation, (usually transient), may occur during the initial period of therapy or whenever the dose is increased. If affected, patients should not attempt to drive, or operate machinery. Headache, asthenia or weakness may be noted as early and transient symptoms.

The following convention has been utilised for the classification of frequency: Very common (≥1/10), common (≥1/100 and <1/10), uncommon (≥1/1000 and <1/100), rare (≥1/10,000 and <1/1000), very rare (< 1/10,000) and not known (cannot be estimated from the available data).

System Organ Class

Adverse event term

Frequency

Infections and infestations

Sialoadenitis

Not known

Blood and lymphatic system disorders

Haemolytic anaemia, bone-marrow failure, leukopenia, granulocytopenia, thrombocytopenia, eosinophilia

Not known

Endocrine disorders

Hyperprolactinaemia

Not known

Psychiatric disorders

Psychic disturbances including nightmares, reversible mild psychoses or depression

Not known

Nervous system disorders

Sedation (usually transient), headache, paraesthesia, Bell's Palsy, Parkinsonism, VIIth nerve paralysis, choreoathetosis, mental impairment, carotid sinus syndrome, dizziness, symptoms of cerebrovascular insufficiency (may be due to lowering of blood pressure)

Not known

Cardiac disorders

Bradycardia, angina pectoris, myocarditis, pericarditis, atrioventricular block

Not known

Vascular disorders

Orthostatic hypotension (decrease daily dosage)

Not known

Respiratory, thoracic and mediastinal disorders

Nasal congestion

Not known

Gastrointestinal disorders

Nausea, vomiting, abdominal distension, constipation, flatulence, diarrhoea, colitis, dry mouth, glossodynia, tongue discolouration, pancreatitis

Not known

Hepatobiliary disorders

Liver disorders including hepatitis, jaundice

Not known

Skin and subcutaneous tissue disorders

Rash (eczema, lichenoid eruption), toxic epidermal necrolysis, angioedema, urticaria

Not known

Musculoskeletal and connective tissue disorders

Lupus-like syndrome, mild arthralgia with or without joint swelling, myalgia

Not known

Reproductive system and breast disorders

Breast enlargement, gynaecomastia, amenorrhoea, lactation disorder, erectile dysfunction, ejaculation failure, decreased libido

Not known

General disorder and administration site conditions

Asthenia, oedema (and weigh gain) usually relieved by use of a diuretic. (Discontinue methyldopa if oedema progresses or signs of heart failure appear). Pyrexia

Not known

Investigations

Positive Coombs test, positive tests for antinuclear antibody, LE cells, and rheumatoid factor, abnormal liver-function tests, increased blood urea

Not known

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme; website: www.mhra.gov.uk/yellowcard

4.9. Overdose

Symptoms

Acute overdosage may produce acute hypotension with other responses attributable to brain and gastro-intestinal malfunction (excessive sedation, weakness, bradycardia, dizziness, light-headedness, constipation, distension, flatus, diarrhoea, nausea and vomiting).

Management

If ingestion is recent, emesis may be induced or gastric lavage performed. There is no specific antidote. Methyldopa is dialysable. Treatment is symptomatic. Infusions may be helpful to promote urinary excretion. Special attention should be directed towards cardiac rate and output, blood volume, electrolyte balance, paralytic ileus, urinary function and cerebral activity.

Administration of sympathomimetic agents may be indicated. When chronic overdosage is suspected, methyldopa should be discontinued.