MicardisPlus (Telmisartan / Hydrochlorothiazide)
Combination treatment for high blood pressure (hypertension)
MicardisPlus is a prescription combination medicine containing telmisartan (an angiotensin II receptor blocker, or ARB) and hydrochlorothiazide (a thiazide diuretic). It is used to treat high blood pressure (hypertension) in adults when telmisartan alone does not provide adequate blood pressure control. By working through two complementary mechanisms, MicardisPlus helps reduce the risk of serious cardiovascular events including stroke, heart attack, and kidney disease.
Quick Facts
Key Takeaways
- MicardisPlus combines two blood-pressure-lowering medicines (telmisartan and hydrochlorothiazide) in a single tablet for convenient once-daily dosing.
- It is prescribed when telmisartan alone is insufficient to control blood pressure, or as initial combination therapy in patients requiring significant blood pressure reduction.
- MicardisPlus must never be used during pregnancy as it can cause serious harm to the unborn baby.
- Common side effects include dizziness, electrolyte changes (especially low potassium), and increased uric acid levels.
- Regular monitoring of kidney function, electrolytes, and blood pressure is important while taking this medicine.
What Is MicardisPlus and What Is It Used For?
MicardisPlus belongs to a class of medicines known as combination antihypertensives. It contains two well-established active ingredients that have been used individually for decades to treat high blood pressure. Telmisartan is an angiotensin II receptor blocker (ARB) that works by blocking the hormone angiotensin II from binding to its receptors in blood vessel walls. This prevents the blood vessels from constricting, allowing them to relax and widen, which in turn lowers blood pressure. Hydrochlorothiazide (HCTZ) is a thiazide diuretic that acts on the kidneys, promoting the excretion of excess sodium and water from the body. By reducing the volume of fluid in the circulatory system, HCTZ further contributes to lowering blood pressure.
The rationale for combining these two agents in a single tablet is well supported by clinical evidence. The European Society of Cardiology (ESC) and European Society of Hypertension (ESH) 2023 guidelines recommend initial combination therapy with two antihypertensive agents for most patients with hypertension, as monotherapy achieves adequate blood pressure control in fewer than 50% of patients. The combination of an ARB with a thiazide diuretic is one of the preferred first-line combinations recommended by international guidelines.
High blood pressure, or hypertension, is one of the most important modifiable risk factors for cardiovascular disease worldwide. According to the World Health Organization (WHO), hypertension affects an estimated 1.28 billion adults aged 30 to 79 years globally, and is a leading cause of premature death. Despite the availability of effective treatments, only about one in five adults with hypertension has the condition under control. Fixed-dose combinations like MicardisPlus aim to simplify treatment regimens and improve adherence, which is essential for long-term blood pressure control and cardiovascular risk reduction.
MicardisPlus is specifically indicated for the treatment of essential hypertension in adults. It is used either as a step-up therapy when telmisartan alone does not provide sufficient blood pressure reduction, or as initial combination therapy in patients who are likely to need two antihypertensive medicines to reach their target blood pressure. By addressing blood pressure through two distinct and complementary pathways, MicardisPlus typically provides a greater reduction in systolic and diastolic blood pressure than either component alone.
What Should You Know Before Taking MicardisPlus?
Contraindications
MicardisPlus must not be used in the following situations. If any of these apply to you, inform your doctor immediately so that an alternative treatment can be selected:
- Allergy to telmisartan, hydrochlorothiazide, or any sulfonamide-derived medicines (hydrochlorothiazide is chemically related to sulfonamides)
- Pregnancy at any stage, particularly during the second and third trimesters (see Pregnancy and Breastfeeding section below)
- Severe hepatic impairment including biliary obstruction or cholestasis
- Severe renal impairment (creatinine clearance below 30 mL/min) or anuria (no urine production)
- Refractory hypokalemia (persistently low potassium levels that do not respond to supplementation) or hypercalcemia
- Concomitant use with aliskiren in patients with diabetes mellitus or moderate-to-severe renal impairment
Warnings and Precautions
Before starting MicardisPlus, your doctor will need to know about all your medical conditions. Special caution is required in the following situations:
Kidney function: Both telmisartan and hydrochlorothiazide are partly eliminated through the kidneys. In patients with impaired renal function, more frequent monitoring of serum creatinine, potassium, and other electrolytes is recommended. Hydrochlorothiazide may reduce kidney function in vulnerable patients, and this risk is increased in combination with NSAIDs or in the setting of dehydration.
Liver function: Telmisartan is predominantly eliminated via bile. Patients with mild-to-moderate hepatic impairment should use MicardisPlus with caution, and the maximum dose of telmisartan in these patients should not exceed 40 mg daily. The medicine is contraindicated in severe liver disease.
Electrolyte imbalances: Hydrochlorothiazide can cause significant changes in serum electrolytes, including hypokalemia (low potassium), hyponatremia (low sodium), and hypomagnesemia (low magnesium). Although telmisartan may partially offset the potassium-lowering effect of hydrochlorothiazide through its action on aldosterone, regular blood tests to monitor electrolyte levels are important, especially in the first weeks of treatment and after dose changes.
Diabetes: Hydrochlorothiazide can impair glucose tolerance and may increase blood sugar levels. Patients with diabetes mellitus may require adjustment of their antidiabetic medicines. Regular monitoring of blood glucose is advisable. Additionally, the concurrent use of MicardisPlus with aliskiren is contraindicated in patients with diabetes.
Gout: Hydrochlorothiazide reduces the excretion of uric acid by the kidneys, which can lead to elevated serum uric acid levels (hyperuricemia). In patients with a history of gout, this may precipitate acute gout attacks. Your doctor should monitor uric acid levels if you have a predisposition to gout.
In patients who are volume-depleted or salt-depleted (for example, those receiving high-dose diuretic therapy, those on a salt-restricted diet, or those with prolonged vomiting or diarrhoea), symptomatic hypotension (dangerously low blood pressure) may occur after the first dose. Volume depletion should be corrected before starting MicardisPlus, or treatment should be initiated under close medical supervision.
Pregnancy and Breastfeeding
Pregnancy: MicardisPlus is strictly contraindicated during pregnancy. Medicines that act directly on the renin-angiotensin-aldosterone system (RAAS), such as telmisartan, can cause serious fetal toxicity including renal failure, oligohydramnios (reduced amniotic fluid), skull ossification defects, and fetal or neonatal death when used during the second and third trimesters. Even first-trimester exposure cannot be considered completely safe. If pregnancy is detected while taking MicardisPlus, the medicine should be discontinued immediately and an alternative antihypertensive started. Women of childbearing potential should use effective contraception while taking this medicine.
Breastfeeding: It is not known whether telmisartan is excreted in human breast milk. Hydrochlorothiazide is excreted into breast milk in small amounts and may suppress lactation. Because of the potential for adverse effects in the nursing infant, MicardisPlus is not recommended during breastfeeding. Your doctor will help you decide whether to discontinue breastfeeding or to discontinue the medicine, taking into account the importance of the treatment for the mother.
How Does MicardisPlus Interact with Other Drugs?
Drug interactions are an important consideration for any patient taking MicardisPlus. Both telmisartan and hydrochlorothiazide have the potential to interact with other medicines, sometimes with clinically significant consequences. The table below summarizes the most important interactions. This is not exhaustive; always tell your prescriber about every medicine, over-the-counter product, supplement, or herbal remedy you take.
Major Interactions
| Interacting Drug | Effect | Clinical Recommendation |
|---|---|---|
| Lithium | Increased lithium blood levels with risk of toxicity. Both telmisartan and HCTZ reduce renal lithium clearance. | Combination not recommended. If unavoidable, monitor lithium levels closely. |
| ACE inhibitors (e.g. ramipril, enalapril) | Dual RAAS blockade increases risk of hyperkalemia, hypotension, and renal impairment. | Avoid combination. Contraindicated in patients with diabetic nephropathy. |
| Aliskiren | Triple RAAS blockade with increased risk of serious adverse effects. | Contraindicated in patients with diabetes or renal impairment. Avoid in all other patients. |
| NSAIDs (e.g. ibuprofen, naproxen, diclofenac) | May reduce antihypertensive effect and increase risk of acute kidney injury. | Use with caution. Monitor renal function and blood pressure. Use lowest NSAID dose for shortest duration. |
| Potassium supplements / potassium-sparing diuretics | Risk of hyperkalemia (especially with telmisartan component). | Monitor serum potassium regularly if combination is necessary. |
Other Notable Interactions
| Interacting Drug | Effect | Clinical Recommendation |
|---|---|---|
| Digoxin | Telmisartan may increase digoxin levels. HCTZ-induced hypokalemia increases digoxin toxicity risk. | Monitor digoxin levels and serum potassium. |
| Other antihypertensives | Additive blood-pressure-lowering effect; increased risk of hypotension. | Dose adjustments may be needed. Monitor blood pressure closely. |
| Corticosteroids | May reduce the antihypertensive effect of HCTZ and worsen electrolyte depletion. | Monitor blood pressure and electrolytes. |
| Insulin and oral antidiabetics | HCTZ may impair glucose tolerance, potentially requiring dose adjustment of antidiabetic medicines. | Monitor blood glucose more frequently when starting or changing dose. |
| Alcohol | May potentiate the blood-pressure-lowering effect and increase risk of orthostatic hypotension. | Limit alcohol consumption. Rise slowly from sitting or lying positions. |
What Is the Correct Dosage of MicardisPlus?
MicardisPlus is available in several strengths to allow dose individualization. The choice of strength depends on your current blood pressure level, previous antihypertensive therapy, and the degree of blood pressure reduction needed. Your doctor will select the most appropriate strength for you.
Adults
Standard Dosing
The recommended dose is one tablet once daily, taken at the same time each day, with or without food. The tablet should be swallowed whole with a glass of water.
- 40/12.5 mg: Typically used as the starting dose for patients inadequately controlled on telmisartan 40 mg alone, or as initial combination therapy in patients needing moderate blood pressure reduction.
- 80/12.5 mg: For patients requiring greater blood pressure reduction, or those not adequately controlled on the 40/12.5 mg strength.
- 80/25 mg: The highest available strength, reserved for patients who require additional blood pressure lowering despite treatment with the 80/12.5 mg tablet.
The maximum recommended dose is 80 mg telmisartan / 25 mg hydrochlorothiazide once daily. The full antihypertensive effect is generally reached within 4 to 8 weeks of treatment initiation.
Children and Adolescents
Paediatric Use
MicardisPlus is not recommended for use in children and adolescents under 18 years of age. The safety and efficacy of this combination has not been established in this age group. If blood pressure treatment is needed in children, alternative medicines with established paediatric dosing should be used.
Elderly Patients
Dose Adjustment in the Elderly
No specific dose adjustment is routinely required in elderly patients. However, elderly individuals are more susceptible to electrolyte imbalances, dehydration, and orthostatic hypotension (a sudden drop in blood pressure upon standing). Treatment should therefore be initiated at the lowest available dose, and blood pressure should be monitored carefully during dose titration. Regular monitoring of renal function and electrolytes is particularly important in this age group.
Missed Dose
If you forget to take a dose of MicardisPlus, take it as soon as you remember on the same day. If it is close to the time of your next dose, skip the missed dose and take your next dose at the usual time. Do not take a double dose to make up for a missed one. If you frequently forget doses, consider setting a daily reminder or using a pill organizer to help maintain a consistent dosing schedule.
Overdose
If you suspect an overdose, seek emergency medical attention immediately. Overdose with telmisartan may manifest primarily as low blood pressure (hypotension) and rapid heartbeat (tachycardia); bradycardia may also occur. Overdose with hydrochlorothiazide can cause severe electrolyte depletion (hypokalemia, hyponatremia, hypochloremia) and dehydration, with symptoms including nausea, drowsiness, muscle cramps, and cardiac arrhythmias. Treatment is supportive and symptomatic. Telmisartan is not removed by haemodialysis.
What Are the Side Effects of MicardisPlus?
The side effect profile of MicardisPlus reflects the combined effects of its two components. Clinical trials involving thousands of patients have provided a comprehensive picture of the adverse reactions associated with this medicine. The frequency categories below are based on data from clinical studies and post-marketing surveillance reports as assessed by the European Medicines Agency (EMA).
It is important to note that many of the biochemical changes (such as electrolyte shifts) may not cause noticeable symptoms but can have clinical significance. This is why regular blood monitoring is recommended while taking MicardisPlus.
Common Side Effects
May affect up to 1 in 10 people
- Dizziness or lightheadedness
- Hypokalemia (low potassium levels in the blood)
- Hyperuricemia (elevated uric acid levels)
- Increased blood triglycerides
- Increased blood cholesterol
- Elevated blood glucose (hyperglycemia)
Uncommon Side Effects
May affect up to 1 in 100 people
- Hypotension (low blood pressure), especially when standing
- Hyponatremia (low sodium levels)
- Upper respiratory tract infections
- Urinary tract infections
- Back pain, muscle spasms, or myalgia (muscle pain)
- Diarrhoea, nausea, or dyspepsia
- Fatigue or asthenia (weakness)
- Increased serum creatinine or blood urea nitrogen
- Skin rash or eczema
- Anxiety or depression
Rare Side Effects
May affect up to 1 in 1,000 people
- Angioedema (swelling of face, lips, tongue, or throat)
- Hepatic function abnormal or liver enzyme elevations
- Hyperkalemia (high potassium levels)
- Thrombocytopenia (low platelet count)
- Anaphylactic reactions
- Photosensitivity (increased sensitivity to sunlight)
- Interstitial nephritis
- Visual disturbances
Very Rare / Post-Marketing Reports
May affect fewer than 1 in 10,000 people
- Acute angle-closure glaucoma
- Aplastic anaemia or agranulocytosis
- Systemic lupus erythematosus exacerbation
- Acute pancreatitis
- Severe cutaneous adverse reactions (Stevens-Johnson syndrome, toxic epidermal necrolysis)
Contact your doctor or seek medical attention if you experience: swelling of the face, lips or throat (possible angioedema); severe dizziness or fainting; signs of an allergic reaction such as widespread rash, difficulty breathing; unusual bleeding or bruising; severe muscle pain or weakness; or a significant change in urination pattern. These symptoms may indicate a serious side effect that requires prompt medical evaluation.
How Should You Store MicardisPlus?
Proper storage of MicardisPlus is essential to ensure the medicine remains effective throughout its shelf life. Telmisartan/hydrochlorothiazide tablets are sensitive to moisture and should always be kept in their original blister packaging or container until the time of use. Below are the detailed storage recommendations:
- Temperature: Store below 25°C (77°F). Do not freeze. Brief excursions up to 30°C (86°F) are generally acceptable, but prolonged exposure to heat should be avoided.
- Moisture protection: Keep the tablets in the original blister pack or tightly closed container. Hydrochlorothiazide is hygroscopic and can absorb moisture, which may affect the tablet integrity.
- Light: Store in the original packaging to protect from direct sunlight.
- Children: Keep out of the sight and reach of children.
- Expiry date: Do not use MicardisPlus after the expiry date printed on the packaging. The expiry date refers to the last day of that month.
- Disposal: Do not throw unused medicines in household waste or wastewater. Ask your pharmacist how to dispose of medicines you no longer use. This helps to protect the environment.
What Does MicardisPlus Contain?
Active Ingredients
Each MicardisPlus tablet contains:
- Telmisartan: Either 40 mg or 80 mg, depending on the strength prescribed. Telmisartan is a selective angiotensin II type 1 (AT1) receptor antagonist with high affinity for the AT1 receptor. It has the longest half-life among the ARB class (approximately 24 hours), which supports effective once-daily dosing.
- Hydrochlorothiazide (HCTZ): Either 12.5 mg or 25 mg, depending on the strength prescribed. Hydrochlorothiazide is a benzothiadiazide (thiazide) diuretic that inhibits the sodium-chloride cotransporter in the distal convoluted tubule of the kidney.
Inactive Ingredients (Excipients)
The following excipients are typically present in MicardisPlus tablets, though the exact composition may vary slightly between manufacturers:
- Sodium hydroxide
- Povidone (K25)
- Meglumine
- Sorbitol (E420)
- Magnesium stearate
- Lactose monohydrate
- Maize starch
- Microcrystalline cellulose
- Iron oxide red (E172) (colouring agent)
MicardisPlus contains lactose and sorbitol. If you have been told by your doctor that you have an intolerance to some sugars, contact your doctor before taking this medicine. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency, or glucose-galactose malabsorption should not take MicardisPlus.
Frequently Asked Questions About MicardisPlus
Medical References
- European Society of Cardiology / European Society of Hypertension (2023). "2023 ESH Guidelines for the management of arterial hypertension." Journal of Hypertension. 41(12):1874-2071. Comprehensive European guidelines for hypertension management including combination therapy recommendations. Evidence level: 1A
- World Health Organization (2021). "Guideline for the pharmacological treatment of hypertension in adults." WHO Publication WHO evidence-based guideline for pharmacological treatment of hypertension in adults.
- European Medicines Agency (EMA). "MicardisPlus - Summary of Product Characteristics." Official European regulatory product information for MicardisPlus (telmisartan/hydrochlorothiazide).
- Sharpe M, et al. (2001). "Telmisartan: a review of its use in hypertension." Drugs. 61(10):1501-1529. Comprehensive review of telmisartan pharmacology, clinical efficacy, and tolerability.
- Yusuf S, et al. (2008). "Telmisartan, ramipril, or both in patients at high risk for vascular events." New England Journal of Medicine. 358(15):1547-1559. ONTARGET trial Landmark ONTARGET trial demonstrating telmisartan non-inferiority to ramipril in cardiovascular protection. Evidence level: 1A
- NICE (2022). "Hypertension in adults: diagnosis and management." NICE guideline [NG136]. UK clinical guideline for diagnosis and management of hypertension including combination therapy.
- British National Formulary (BNF). "Telmisartan with hydrochlorothiazide." Authoritative UK drug reference with dosing, interactions, and prescribing information.
Evidence grading: This article uses the GRADE framework (Grading of Recommendations Assessment, Development and Evaluation) for evidence-based medicine. Evidence level 1A represents the highest quality of evidence, based on systematic reviews of randomized controlled trials.
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