New antihypertensive medications and clinical implications

Management of renin-angiotensin-aldosterone inhibitors and other antihypertensives and their clinical effects on pre-anesthesia blood pressure

Background

Blood pressure fluctuations appear more significant in patients with poorly controlled hypertension and are known to be associated with adverse perioperative morbidity. In the present study, we aimed to determine the effects of antihypertensive drug treatment strategies on preanesthetic operating room blood pressure measurements.

Methods

A total of 717 patients participated in our study; 383 patients who were normotensive based on baseline measurements and not under antihypertensive therapy were excluded from the analysis. The remaining 334 patients were divided into six groups according to the antihypertensive drug treatment. These six groups were examined in terms of preoperative baseline and pre-anesthesia blood pressure measurements.

Results

As a result of the study, it was observed that 24% of patients had high blood pressure precluding surgery, and patients using renin-angiotensin-aldosterone system inhibitors (RAASI) had higher pre-anesthesia systolic blood pressure than patients using other antihypertensive drugs. Patients who received beta-blockers were also observed to have the lowest pre-anesthesia systolic blood pressure, diastolic blood pressure, and mean blood pressure, compared to others.

Conclusions

Recently, whether RAASI should be continued preoperatively remains controversial. Our study shows that RAASI cannot provide optimal pre-anesthesia blood pressure and lead to an increase in the number of postponed surgeries, probably due to withdrawal of medication before the operation. Therefore, the preoperative discontinuation of RAASI should be reevaluated in future studies.

Determination of l-(+)-bornesitol, the hypotensive constituent of Hancornia speciosa, in rat plasma by LC-MS/MS and its application on a pharmacokinetic study

Hancornia speciosa is a medicinal plant with proven antihypertensive activity. The cyclitol l-(+)-bornesitol is the main constituent of its leaves and is a potent inhibitor of the angiotensin-converting enzyme. We herein investigated the pharmacokinetic properties of bornesitol administered orally to Wistar rats, as well as bornesitol permeation in Caco-2 cells. Bornesitol was isolated and purified from an ethanol extract of H. speciosa leaves. An ultra-high performance liquid chromatography coupled with electrospray ionization mass spectrometry (UPLC-ESI-MS/MS) method was developed and validated to quantify bornesitol in rat plasma based on Multiple Reaction Monitoring, using pentaerythritol as an internal standard. Pharmacokinetics was evaluated by the administration of single doses via intravenous in bolus (3 mg/kg) and gavage (3, 15 and 25 mg/kg). Bornesitol permeation was assayed in a transwell Caco-2 cells model, tested alone, or combined with rutin, or as a constituent of H. speciosa extract, using a developed and validated UPLC-ESI-MS/MS method. All assayed validation parameters (selectivity, residual effect, matrix effect, linearity, precision, accuracy and stability of analyte in plasma and solution) for the bioanalytical method met the acceptance criteria established by regulatory guidelines. Bornestiol reached peak plasma concentration within approximately 60 min after oral administration with a half-life ranging from 72.15 min to 123.69 min. The peak concentration and area under the concentration-time curve of bornesitol did not rise proportionally with the increasing doses, suggesting a non-linear pharmacokinetics in rats and the oral bioavailability ranged from 28.5%-59.3%. Bornesitol showed low permeability in Caco-2 cells, but the permeability apparently increased when it was administered either combined with rutin or as a constituent of H. speciosa extract. In conclusion, bornesitol was rapidly absorbed after a single oral administration to rats and followed a non-linear pharmacokinetics. The obtained data will be useful to guide further pre-clinical development of bornesitol-containing herbal preparations of H. speciosa as an antihypertensive agent.

Pharmacodynamics and pharmacokinetics in older adults

PURPOSE OF REVIEW

With the growing of the aging population, increased and new methods of anesthesia and surgery allow for surgery and other interventions in older adults.Pharmacokinetics and pharmacodynamics of drugs in older adults differ from those in younger and middle-aged adults. However, the geriatric population is frequently neglected in the context of clinical trials. The present review focuses on the consequences of multimorbidity and pharmacokinetic and pharmacodynamic alterations and their implications on anesthesia.

RECENT FINDINGS

Physiologically based pharmacokinetic and pharmacodynamic modeling may serve as an option to better understand the influence of age on drugs used for anesthesia. However, difficulties to adequately characterize geriatric patients are described.

SUMMARY

Further research of drug effects in the aging population may include physiologically based pharmacokinetic and pharmacodynamic complex models and randomized controlled trials with thoroughly conducted geriatric assessments.

The Cyclitol L-(+)-Bornesitol as an Active Marker for the Cardiovascular Activity of the Brazilian Medicinal Plant Hancornia speciosa

The cyclitol bornesitol is the main constituent of the leaves from the antihypertensive medicinal plant Hancornia speciosa. This study aimed to investigate the ability of bornesitol to reduce blood pressure and its mechanism of action. Normotensive Wistar rats were divided into control group and bornesitol groups treated intravenously with bornesitol (0.1, 1.0 and 3.0 mg/kg). Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were recorded in non-anesthetized awake animals. Nitric oxide (NO) and angiotensin-converting enzyme (ACE) were measured in plasma by using colorimetric methods. Vascular reactivity study was performed in rat aorta rings and the involvement of nitric oxide synthase (NOS), calcium-calmodulin complex and phosphatidylinositol-3-kinase (PI3K)/Akt pathway in the vasodilator effect was investigated. Administration of bornesitol significantly reduced the SBP, increased the plasmatic level of nitrite, and decreased ACE activity in normotensive rats. In the rat aorta, bornesitol induced endothelium-dependent vasodilatation, which was abolished by NOS blockade. While calcium-calmodulin complex inhibition decreased the vasodilator effect of bornesitol, the inhibition of PI3K/Akt pathway did not alter it. Bornesitol reduced the blood pressure by a mechanism involving an increased production or bioavailability of NO, inhibition of ACE, and by an endothelium- and NO-dependent vasodilator effect. The present results support the use of bornesitol as an active marker for the cardiovascular activity of Hancornia speciosa.

Protective effect of Coleus forskohlii leaf-extract compound on progression of cataract against Fructose-Induced experimental cataract in rats

The present study was designed to determine protective effects of Coleus forskohlii hydroalcoholic leaf-extract along with its fractions against fructose-induced cataract rat model. The Coleus forskolii leaf extract was subjected to silica gel column chromatography and fractions were collected. A major high yielding fraction of the leaf extract, designated as fraction B6 was pharmacologically evaluated in Sprague Dawley albino rats at three doses 0.1, 1 and 10 mg/kg respectively. Compound B2; isolated from B6 fraction, identified as 'gallic acid' was also pharmacologically evaluated at three different doses. Cataract was induced by concurrent administration of fructose solution (10% w/v, per oral, dissolved in drinking water) for eight consecutive weeks. Mean arterial pressure, blood glucose level and lenticular opacity were determined. At the end of eight weeks, C. forskohlii leaf extract fraction and gallic acid reduced mean arterial pressure and glucose level in a dose dependent manner. In addition, C. forskohlii led to significant restoration of lens antioxidants enzyme level and reduced cataract formation in rats. These results showed the concentration dependent protective effect by C. forskohlii leaf extract against cataract formation due to restoration of oxidative stress markers.