Nifedipine or amlodipine? The choice for hypertension during pregnancy: a systematic review and meta-analysis

Managing diabetic chronic kidney disease in pregnancy: Current clinical practice and uncertainties

BACKGROUND

Pre-gestational diabetes occurs in approximately 1% of pregnancies in the UK and increases the risk of adverse maternal and fetal outcomes. More women with type 2 than type 1 diabetes are now becoming pregnant and tend to have higher rates of obesity and other multi-morbidities. Chronic kidney disease (CKD) affects approximately 5%-10% of pregnant women with type 1 diabetes and about 2%-3% with type 2 diabetes. Diabetic chronic kidney disease (DCKD) increases the risk of preeclampsia, preterm birth, Caesarean section, small for gestational age (SGA) infant and infant admission to neonatal intensive care unit (NICU), and risks are higher compared to those with diabetes without CKD and those with CKD from other causes. Definitions of CKD in pregnancy are not standardised, and studies are generally small, observational, heterogenous, mainly include women with type 1 diabetes and often predate modern diabetes management such as continuous glucose monitoring and insulin pumps. Therefore, there is a lack of robust data to guide practice and clinical guidelines offer conflicting advice, without precise detail.

AIMS

We present our approach to caring for women with diabetes and CKD in pregnancy based on available guidelines and clinical experience.

DISCUSSION AND CONCLUSION

Our practice is to aim for intensive targets for blood pressure and glycaemic control pre and during pregnancy, lower than suggested in many guidelines. The importance of multidisciplinary team work and patient centred care is emphasised. Using standardised prospective data collection to better understand the prevalence and outcomes of diabetes and CKD in contemporary pregnancy populations, is recommended to drive future improvements in care.

Congenital anomalies associated with the use of cardiovascular drugs during pregnancy: a large-scale data analysis from the FAERS database

BACKGROUND

Cardiovascular drugs can cross the placenta during pregnancy, potentially exposing the fetus to teratogenic effects. However, ethical constraints on clinical trials with pregnant women limit safety data and result in inadequate drug labeling.

RESEARCH DESIGN AND METHODS

Using the FAERS database (2004-2023), we conducted a retrospective pharmacovigilance study analyzing adverse event reports involving congenital anomalies in newborns (<28 days). Signal detection methods included Reporting Odds Ratio (ROR), Proportional Reporting Ratio (PRR), Bayesian Confidence Propagation Neural Network (BCPNN), and Multi-item Gamma Poisson Shrinker (MGPS). Our analysis concentrated on the systems or organs involved in the signals, particularly those with higher report counts or signal values, to explore the association between drugs and congenital abnormalities.

RESULTS

Among 6,208 cases of congenital anomalies in newborns, 387 were linked to cardiovascular drugs, generating 97 signals for 16 drugs. Strong signals included sartans (renal failure, skeletal deformity), metoprolol (hypospadias, large-for-dates baby), amlodipine (gastrointestinal malformations), and statins, furosemide, and spironolactone (dysmorphism).

CONCLUSIONS

Enhanced monitoring is recommended for fetal malformations in women exposed to these drugs before or during pregnancy. While our findings suggest associations, they do not establish causality, highlighting the need for further research to ensure medication safety during pregnancy.

Amlodipine versus nifedipine ER for the management of postpartum hypertension: a noninferiority randomized controlled trial

BACKGROUND

Postpartum hypertension is an increasingly prevalent problem and optimizing its treatment is imperative in reducing maternal morbidity and improving long-term health outcomes. Despite this, data on treatment of postpartum hypertension is limited. While most available studies focus on labetalol and nifedipine ER, these medications are not frequently used for hypertension treatment in the non-obstetric setting. As we aim to establish best practices for managing postpartum hypertension, use of more commonly encountered antihypertensives should be evaluated.

OBJECTIVE

To evaluate the use of amlodipine for the treatment of postpartum hypertension, as assessed by postpartum length of stay.

STUDY DESIGN

In a pragmatic, randomized controlled noninferiority trial, patients were assigned to amlodipine or nifedipine ER for treatment of postpartum hypertension. The primary outcome was time from delivery until discharge with a noninferiority limit of 24 hours. A sample size of 132 was needed to achieve 80% power with a 2-tailed alpha of 0.05. Intent-to-Treat and Per Protocol analyses were performed. Prespecified secondary outcomes included the need for additional antihypertensives, side effects, medication discontinuation, breastfeeding satisfaction, and readmission rate. A post-hoc analysis of time from medication initiation until hospital discharge was also performed.

RESULTS

From April 2021 to December 2022, 7618 patients were screened and 175 patients were randomized, with 132 meeting criteria for antihypertensive initiation. Baseline demographics were similar between groups. Amlodipine had a non-inferior length of stay compared to nifedipine ER (Intent-to-Treat Wilcoxon pseudo-median amlodipine=73.5 hours, nifedipine ER=72.0 hours, 95% CI -8.00 to 6.00). The remainder of analyses were performed only on the Per Protocol cohort. Time from medication initiation until hospital discharge was similar between groups (amlodipine=45.0 hours, nifedipine ER=45.5 hours, 95% CI -8.00 to 13.00). There were no differences in use of additional antihypertensives or patient-reported side effects or breastfeeding outcomes, but hypotension and tachycardia were less common with amlodipine use. Amlodipine was significantly less likely to be discontinued due to side effects (amlodipine n=0, nifedipine ER n=7 (10.1%), p=.02). Readmission rates were similar between groups.

CONCLUSION

Amlodipine is noninferior to nifedipine ER for postpartum hypertension treatment, as defined by median length of postpartum stay. Rates of side effects were similar between groups, but there was a statistically significant difference in medication discontinuation rates.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, www.

CLINICALTRIALS

gov, NCT04790279 El resumen está disponible en Español al final del artículo.

Gut microbiome and inflammation in cardiovascular drug response: trends in therapeutic success and commercial focus

The intricate Gut microbiome is evolving as an important system and is hypothesized to be a "metabolic organ" within the host. Alterations in Gut microbiota and inflammation associated with several diseases play a crucial role in drug transformation through microbiota-host co-metabolism, modified pharmacokinetic and pharmacodynamics profiles, and may result in the formation of toxic metabolites with interference in drug response. In recent studies, a large number of drugs are reported that are co-metabolized by the host and the Gut microbial enzymes. we summarize the direct and indirect involvement of Gut microbiome promotion or inhibition of cardiovascular diseases, mechanisms on bioavailability, and therapeutic outcomes of cardiovascular drugs, particularly pharmacokinetics and pharmacodynamics profiles in light of AUC, Tmax, Cmax, and bioavailability and drug transportation via immune cells, inter-individual variations in intestinal microbial taxonomy, influence of drugs on diversity and richness of microflora, high lightening limitations and significance of in personalized medicine. Recent advances in target-drug delivery by nanoparticles with limitations and challenges in application are discussed. The cross-talk between Gut microbiota and cardiovascular drugs signifies a better understanding and rationale for targeting the Gut microbiota to improve the therapeutic outcome for cardiovascular diseases, with present-day limitations.

[Position statement on the use of amlodipine during pregnancy. Working Group on Hypertension in Women, Argentine Society of Hypertension]

Pharmacological management of HDP includes agents supported by extensive evidence ensuring their safety for use. Among those traditionally described in the literature are: alpha-methyldopa, labetalol, and sustained-release nifedipine (NIF-RETARD). These drugs, in addition to being compatible with pregnancy, present additional eligibility criteria. The discontinuation of NIF-RETARD has resulted in the off-label use of other dihydropyridine calcium cannel blockers with lower levels of evidence in pregnancy, such as amlodipine. The Working Group Hypertension in Women of the Argentine Society of Hypertension has proposed to develop a document that precisely and thoroughly addresses the concerns related to the use of amlodipine in pregnancy, providing responses based on the currently available scientific evidence.

Pharmacotherapeutic options for the treatment of hypertension in pregnancy

INTRODUCTION

Hypertensive disorders of pregnancy affect approximately one in 10 pregnancies and are associated with increased risk of adverse fetal, neonatal and maternal outcomes. There is strong evidence that effective treatment of hypertension (blood pressure ≥ 140/90 mmHg), and enhanced monitoring throughout pregnancy reduces these risks.

AREAS COVERED

This article provides a contemporaneous review of treatment of hypertension in pregnancy with antihypertensive agents. We completed a systematic search and review of all meta-analyses and systematic reviews of studies comparing antihypertensives for treatment of pregnancy hypertension in the last five years. We provide a clinically focused summary of when to treat hypertension in pregnancy and which antihypertensive agents can be offered. Special scenarios reviewed include treatment-resistant hypertension and pre-pregnancy antihypertensive optimization.

EXPERT OPINION

Several antihypertensives are considered safe and are known to be effective for treatment of hypertension in pregnancy. Given the current uncertainty as to which antihypertensive(s) are superior for treatment of hypertension in pregnancy, women should be counselled and offered a range of antihypertensive options in keeping with evidence on clinical effectiveness, local context and availability of antihypertensive(s), potential side effect profile, and women's preference. Further research is required to help guide clinical decision making, and move toward personalized treatment.

Considering Adverse Effects of Common Antihypertensive Medications in the ED

PURPOSE OF REVIEW

To evaluate the adverse effects of common antihypertensive agents utilized or encountered in the Emergency Department.

RECENT FINDINGS

All categories of antihypertensive agents may manifest adverse effects, inclusive of adverse drug reactions (ADRs), drug-to-drug interactions, or accidental overdose. Adverse effects, and specifically ADRs, may be stratified into the organ systems affected, might require specific time-sensitive interventions, could pose particular risks to vulnerable populations, and may result in significant morbidity, and potential mortality. Adverse effects of common antihypertensive agents may be encountered in the ED, necessitating that ED systems of care are poised to prevent, recognize, and intervene when adverse effects arise.

Antihypertensives in Pregnancy

Hypertensive disorders of pregnancy (HDP) can result in significant maternal morbidity and even mortality. Available data suggest that many antihypertensives can be safely used in pregnant patients, albeit with close supervision of parameters like fetal growth and amniotic fluid volume. This article summarizes current guidelines on the diagnosis and treatment of hypertension in pregnancy and provides an in-depth guide to the available safety and efficacy data for antihypertensives during pregnancy and postpartum.

Pharmaceutical administration for severe hypertension during pregnancy: Network meta-analysis

Aims: To evaluate the efficacy of different pharmacologic treatment for severe hypertension during pregnancy. Methods: Two reviewers searched Ovid MEDLINE, Ovid EMbase, and the Cochrane Library for randomized clinical trials from the establishment of the database to 15 July 2021 that were eligible for inclusion and analyzed the pharmaceuticals used for severe hypertension in pregnancy. Results: 29 relevant trials with 2,521 participants were involved. Compared with diazoxide in rate of achieving target blood pressure, other pharmaceuticals, including epoprostenol (RR:1.58, 95%CI:1.01-2.47), hydralazine\dihydralazine (RR:1.57, 95%CI:1.07-2.31), ketanserin (RR:1.67, 95%CI:1.09-2.55), labetalol (RR:1.54, 95%CI:1.04-2.28), nifedipine (RR:1.54, 95%CI:1.04-2.29), and urapidil (RR:1.57, 95%CI:1.00-2.47), were statistically significant in the rate of achieving target blood pressure. According to the SUCRA, diazoxide showed the best therapeutic effect, followed by nicardipine, nifedipine, labetalol, and nitroglycerine. The three pharmaceuticals with the worst therapeutic effect were ketanserin, hydralazine, and urapidil. It is worth noting that the high ranking of the top two pharmaceuticals, including diazoxide and nicardipine, comes from extremely low sample sizes. Other outcomes were reported in the main text. Conclusion: This comprehensive network meta-analysis demonstrated that the nifedipine should be recommended as a strategy for blood pressure management in pregnant women with severe hypertension. Moreover, the conventional pharmaceuticals, including labetalol and hydralazine, showed limited efficacy. However, it was important to note that the instability of hydralazine reducing blood pressure and the high benefit of labetalol with high dosages intakes should also be of concern to clinicians.