Efficacy and safety of a lercanidipine/enalapril fixed-dose combination in hypertensive patients in Portugal

Combination therapy with lercanidipine and enalapril in the management of the hypertensive patient: an update of the evidence

Hypertension is an important risk factor for premature death as it increases the probability of stroke, myocardial infarction, and heart failure. Antihypertensive drugs can decrease cardiovascular (CV) morbidity and mortality. The majority of hypertensive patients need more than one antihypertensive agent to attain blood pressure (BP) targets. Monotherapy can effectively reduce BP only in 20%–40% of patients. Multiple mechanisms including increased peripheral vascular resistance, increased cardiac work, and hypervolemia are involved in the pathogenesis of hypertension. Targeting multiple pathways may more potently reduce BP. Increasing the dose of a single agent in many cases does not provide the expected BP-lowering effect because the underlying mechanism of the BP increase is either different or already corrected with the lower dose. Moreover, drugs acting on different pathways may have synergistic effects and thus better control hypertension. It is well known that diuretics enhance the actions of renin–angiotensin aldosterone system and activate it as a feedback to the reduced circulated blood volume. The addition of a renin–angiotensin aldosterone system blocker to a diuretic may more effectively reduce BP because the system is upregulated. Reducing the maximal dose of an agent may also reduce possible side effects if they are dose dependent. The increased prevalence of peripheral edema with higher doses of calcium channel blockers (CCBs) is reduced when renin–angiotensin aldosterone system blockers are added to CCBs through vein dilation. The effectiveness of the combination of enalapril with lercanidipine in reducing BP, the safety profile, and the use of the combination of angiotensin-converting enzyme inhibitors with CCBs in clinical trials with excellent CV hard end point outcomes make this combination a promising therapy in the treatment of hypertension.

Dose-response effect of the lercanidipine/enalapril combination: a pooled analysis

OBJECTIVE

The dose-effect relationship of fixed-dose combinations of anti-hypertensive drugs has been only poorly explored. This pooled analysis investigates the dose-response relationship of fixed-dose lercanidipine + enalapril in patients with mild-to-moderate hypertension.

RESEARCH DESIGN AND METHODS

This was an individual patient data analysis of four randomized studies (n = 2340).

MAIN OUTCOME MEASURES

The primary efficacy variable was the change from baseline in sitting diastolic blood pressure (SDBP). Secondary variables were change from baseline in sitting systolic BP (SSBP), proportion of responder patients, and safety.

RESULTS

All fixed-dose combinations were superior to placebo in the reduction of SDBP. The greatest effect was observed with the market-available combination lercanidipine 20 mg/enalapril 20 mg (-15.3 mmHg vs. baseline; p < 0.05). The reduction in SDBP associated with the other two marketed fixed combinations of lercanidipine/enalapril were -10.7 mmHg for the 10 mg/20 mg combination and -9.8 mmHg for the 10 mg/10 mg combination (p < .05 for both comparisons). Similar findings were reported for SSBP reduction: the greatest effect was observed with lercanidipine 20 mg/enalapril 20 mg (-19.2 mmHg). The reduction in SSBP was -12.5 mmHg for the 10 mg/20 mg combination and -11.1 mmHg for the 10 mg/10 mg combination (p < .05 for all comparisons). The highest responder rate was reported with lercanidipine 20 mg/enalapril 20 mg (75.0%); this figure was 56.1% with the 10 mg/20 mg and 53.0% with the 10/10 mg combination. No safety concerns were reported.

CONCLUSION

This pooled analysis of four randomized studies shows evidence of a dose-response effect in BP reduction with different fixed combinations of lercanidipine + enalapril. To our knowledge, this is the first analysis investigating the dose-response effect of a specific fixed-dose combination of anti-hypertensive agents. Further studies on this intriguing topic are however necessary.

Fixed-dose lercanidipine and enalapril in field practice: a meta-analysis

OBJECTIVE

This meta-analysis evaluates the efficacy and safety of lercanidipine/enalapril fixed-dose combination in patients with mild to moderate essential hypertension.

METHODS

Four observational studies on patients with sitting diastolic blood pressure (SDBP) between 95 and 109 mmHg, treated with lercanidipine/enalapril fixed-dose combination, were analyzed. The Random-Effect Model was used to limit heterogeneity across the studies. Weights were applied to determine the influence of each study on the combined results. The efficacy outcome measure was the reduction from baseline to endpoint in systolic and diastolic blood pressure (SBP and DBP, respectively). The incidence of treatment-emergent adverse events (TEAEs) was also investigated.

RESULTS

The total number of patients analyzed for efficacy and safety was 9565. No differences between study groups in demographics characteristics were observed. Mean blood pressure in the pooled population of the four studies was 162/94 mmHg at baseline. Overall, the lercanidipine/enalapril fixed-dose combination reduced SBP by 26 mmHg (95% CI, 23-29), and DBP by 13 mmHg (12-15), p < 0.05 for both. No safety concerns were reported.

CONCLUSION

This meta-analysis supports the use of the lercanidipine/enalapril fixed-dose combination for the treatment of mild-to-moderate hypertension.

Differential effects of lercanidipine/enalapril versus amlodipine/enalapril and hydrochlorothiazide/enalapril on target organ damage and sympathetic activation in non-obese essential hypertensive subjects

OBJECTIVE

The aim of the present study was to compare the effects of the combination of lercanidipine/enalapril versus amlodipine/enalapril and hydrochlorothiazide/enalapril on blood pressure, target organ damage and sympathetic activation in patients with grade 2 essential hypertension.

RESEARCH DESIGN AND METHODS

This was a 3 month, randomized, blinded-endpoint study in essential hypertensive patients.

MAIN OUTCOME MEASURES

Office and ambulatory blood pressure, arterial stiffness, urinary albumin to creatinine ratio, renal arterial resistive index, and muscle sympathetic nerve activity were evaluated at baseline, after a 2 week run-in placebo period, at 1 month and at 3 months.

RESULTS

In total, 56 patients were assigned to lercanidipine/enalapril (n = 19), enalapril/amlodipine (n = 18) and hydrochlorothiazide/enalapril (n = 19). Each pharmacological combination tested was effective in reducing office blood pressure at 1 month and 3 months, and 24 h ambulatory blood pressure at 3 months. Renal arterial resistive index (RI) significantly improved at 1 month and 3 months compared with baseline in all groups. However in the lercanidipine/enalapril and hydrochlorothiazide/enalapril groups, RI was favorably reduced (0.53 ± 0.03 and 0.54 ± 0.04 respectively, p < 0.05) in comparison with the enalapril/amlodipine RI value (0.57 ± 0.03) at 3 months. Moreover, after 3 months of treatment, a significant decrease (by -5.47 bursts/min) (p < 0.05) in muscle sympathetic nerve activity was observed in the lercanidipine/enalapril group (50.79 ± 6.49) compared with baseline (56.26 ± 6.05), while no differences were detected in the amlodipine/enalapril and hydrochlorothiazide/enalapril groups.

CONCLUSIONS

Our study provides evidence of the efficacy of the lercanidipine/enalapril combination in ameliorating hypertension-related target organ damage and in reducing sympathetic overdrive.

Efficacy and safety of lercanidipine/enalapril fixed combination in Lebanon: a prospective observational study

OBJECTIVE

The DUAL study evaluated the effectiveness and safety of the fixed-dose combination of lercanidipine and enalapril in a real-practice scenario; the effects of this combination on a number of markers of cardiovascular risk have been also investigated.

RESEARCH DESIGN AND METHODS

This was a 2 month, phase IV, open-label, single-group, prospective observational study. Adult patients with untreated or uncontrolled hypertension (blood pressure [BP] >140/90 mmHg) were eligible for this study. All patients received lercanidipine/enalapril, in a once-daily fixed combination (10 mg/10 mg).

MAIN OUTCOME MEASURES

The patients were evaluated at baseline, at 1 month and at 2 months. The following parameters were evaluated at all time points: systolic BP (SBP) and diastolic BP (DBP); heart rate (HR). A number of laboratory parameters were measured at baseline and at 2 months. Safety considerations were performed.

RESULTS

In total, 188 patients were enrolled (104 males; mean age 58 ± 12 years). At baseline, mean SBP was 159 ± 10 mmHg and mean DBP was 94 ± 7 mmHg. Treatment with lercanidipine/enalapril in fixed combination was associated with a reduction in both SBP and DBP already at 1 month; this reduction was sustained until month 2 (SBP: 131 ± 7 mmHg; DBP: 79 ± 5 mmHg; p < 0.05 vs baseline). At baseline HR was 78 ± 10 bpm; a significant reduction in this parameter was observed at month 2 (75 ± 7 bpm; p < 0.05 vs baseline). A significant decrease in total cholesterol, low-density lipoprotein cholesterol, triglycerides, and fasting glucose, and a significant increase in K(+), and Ca(2+) was observed at month 2 compared with baseline values. In total, two patients (1%) experienced dry cough. No other adverse effects were reported.

CONCLUSIONS

Even with all the limitations of any observational study, these data show that a 2 month treatment with a fixed dose of lercanidipine/enalapril is associated with significant reductions in SBP and DBP, HR, and improvement in a number of laboratory parameters.