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Wang SJ, Sander GE. Nebivolol/valsartan combination for the treatment of hypertension: a review. Future Cardiol 2020; 17:573-583. [PMID: 33064027 DOI: 10.2217/fca-2020-0079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Nebivolol (N) is a β1-adrenoreceptor antagonist that is approved for treatment of hypertension in the USA. Effective treatment of hypertension is becoming an increasingly difficult process that often requires multiple drug combinations to meet target guidelines. This has resulted in the increasing introduction of multidrug single-pill combinations (SPCs) to facilitate cost and compliance issues. Some of the SPCs have added valsartan (V), an angiotensin receptor blocker, which is an increasingly advocated antihypertensive class. Pharmacological profiles of N and V, alone and combined, are well characterized. In 2007, the SPC of N and V, 5 and 80 mg, respectively, was approved by the US FDA for treatment of hypertension. This paper will summarize and update key issues in pharmacology, clinical use and benefit.
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Affiliation(s)
- Sarah J Wang
- Department of Medicine, Heart & Vascular Institute, Section of Cardiology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA
| | - Gary E Sander
- Department of Medicine, Heart & Vascular Institute, Section of Cardiology, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112, USA
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Real-world efficacy and safety of nebivolol in Korean patients with hypertension from the BENEFIT KOREA study. J Hypertens 2020; 38:527-535. [DOI: 10.1097/hjh.0000000000002296] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rationale for nebivolol/valsartan combination for hypertension: review of preclinical and clinical data. J Hypertens 2018; 35:1758-1767. [PMID: 28509722 PMCID: PMC5548499 DOI: 10.1097/hjh.0000000000001412] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
To treat hypertension, combining two or more antihypertensive drugs from different classes is often necessary. β-Blockers and renin–angiotensin–aldosterone system inhibitors, when combined, have been deemed ‘less effective’ based on partially overlapping mechanisms of action and limited evidence. Recently, the single-pill combination (SPC) of nebivolol (Neb) 5 mg – a vasodilatory β1-selective antagonist/β3 agonist – and valsartan 80 mg, an angiotensin II receptor blocker, was US Food and Drug Administration-approved for hypertension. Pharmacological profiles of Neb and valsartan, alone and combined, are well characterized. In addition, a large 8-week randomized trial in stages I–II hypertensive patients (N = 4161) demonstrated greater blood pressure-reducing efficacy for Neb/valsartan SPCs than component monotherapies with comparable tolerability. In a biomarkers substudy (N = 805), Neb/valsartan SPCs prevented valsartan-induced increases in plasma renin, and a greater reduction in plasma aldosterone was observed with the highest SPC dose vs. valsartan 320 mg/day. This review summarizes preclinical and clinical evidence supporting Neb/valsartan as an efficacious and well tolerated combination treatment for hypertension.
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Ishak J, Rael M, Punzi H, Gradman A, Anderson LM, Patel M, Ali S, Ferguson W, Neutel J. Additivity of nebivolol/valsartan single-pill combinations versus other single-pill combinations for hypertension. J Clin Hypertens (Greenwich) 2017; 20:143-149. [PMID: 29105958 PMCID: PMC5813198 DOI: 10.1111/jch.13132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 08/09/2017] [Accepted: 08/28/2017] [Indexed: 11/29/2022]
Abstract
The single‐pill combination (SPC) comprising nebivolol (5 mg), a vasodilatory β1‐selective antagonist/β3‐agonist, and valsartan (80 mg), a renin‐angiotensin‐aldosterone system inhibitor, is the only Food and Drug Administration–approved β‐blocker/renin‐angiotensin‐aldosterone system inhibitor SPC for hypertension. Additive effects of four nebivolol/valsartan SPC doses (5 mg/80 mg, 5/160 mg, 10/160 mg, 10/320 mg nebivolol/valsartan) were compared with five Food and Drug Administration–approved non–β‐blocker/renin‐angiotensin‐aldosterone system inhibitor SPCs (aliskiren/hydrochlorothiazide, aliskiren/amlodipine, valsartan/amlodipine, aliskiren/valsartan, and telmisartan/amlodipine). Additivity is the ratio of placebo‐adjusted SPC blood pressure (BP) reduction to the placebo‐adjusted monotherapy component BP reduction sums. A weighted average of comparator scores was calculated and compared vs nebivolol/valsartan. Additivity ratio scores for nebivolol/valsartan SPCs (diastolic BP range: 0.735–0.866; systolic BP range: 0.717–0.822) were similar to the comparator weighted average (diastolic BP: 0.837; systolic BP: 0.825). Among the nebivolol/valsartan SPCs, 5/80 mg had the greatest additivity (diastolic BP: 0.866; systolic BP: 0.822). BP reduction contributions with monotherapy were similar for nebivolol/valsartan 5/80 mg SPC. Additivity scores for nebivolol/valsartan and select non–β‐blocker/renin‐angiotensin‐aldosterone system inhibitor SPCs were comparable.
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Affiliation(s)
| | | | - Henry Punzi
- UT Southwestern Medical Center, Dallas, TX, USA
| | - Alan Gradman
- Temple University School of Medicine, Pittsburgh, PA, USA
| | | | - Mehul Patel
- Allergan plc, Harborside Financial Center, Jersey City, NJ, USA
| | - Sanjida Ali
- Allergan plc, Harborside Financial Center, Jersey City, NJ, USA
| | | | - Joel Neutel
- Orange County Research Center, Tustin, CA, USA
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Abstract
Blood pressure management in hypertensive patients with metabolic abnormalities is challenging, since many of the antihypertensive drugs adversely affect metabolism. Besides effective control of blood pressure in patients with hypertension, third-generation beta-blockers such as nebivolol offer additional benefits for central hemodynamics and neutral or beneficial effects on metabolism. Emerging clinical data suggest that nebivolol also has similar effects on metabolism in obese hypertensive and hypertensive diabetic patients. The present article will provide a systematic analysis of the pathophysiological links among hypertension, insulin resistance, and metabolic syndrome. We will also summarize the available clinical evidence regarding the metabolic effects of beta-blockers in hypertensive patients, with an emphasis on nebivolol. Nebivolol exerts neutral or beneficial effects on insulin sensitivity and lipid metabolism in hypertensive patients, owing to its nitric oxide-mediated vasodilatory and antioxidative properties. Thus, nebivolol could be a favorable therapeutic option for the treatment of hypertension in patients with impaired glucose and lipid metabolism.
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Aladag MA, Turkoz Y, Parlakpinar H, Gul M. Nebivolol attenuates cerebral vasospasm both by increasing endothelial nitric oxide and by decreasing oxidative stress in an experimental subarachnoid haemorrhage. Br J Neurosurg 2017; 31:439-445. [DOI: 10.1080/02688697.2017.1297367] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Mehmet Arif Aladag
- Department of Neurosurgery, Inonu University School of Medicine, Malatya, Turkey
| | - Yusuf Turkoz
- Department of Biochemistry, Inonu University School of Medicine, Malatya, Turkey
| | - Hakan Parlakpinar
- Department of Pharmacology, Inonu University School of Medicine, Malatya, Turkey
| | - Mehmet Gul
- Department of Histology, Inonu University School of Medicine, Malatya, Turkey
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A Single-Center, Open-Label, 3-Way Crossover Trial to Determine the Pharmacokinetic and Pharmacodynamic Interaction Between Nebivolol and Valsartan in Healthy Volunteers at Steady State. Am J Ther 2016; 22:e130-40. [PMID: 25853236 PMCID: PMC4585485 DOI: 10.1097/mjt.0000000000000247] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Combining different classes of antihypertensives is more effective for reducing blood pressure (BP) than increasing the dose of monotherapies. The aims of this phase I study were to investigate pharmacokinetic and pharmacodynamic interactions between nebivolol, a vasodilatory β1-selective blocker, and valsartan, an angiotensin II receptor blocker, and to assess safety and tolerability of the combination. This was a single-center, randomized, open-label, multiple-dose, 3-way crossover trial in 30 healthy adults aged 18-45 years. Participants were randomized into 1 of 6 treatment sequences (1:1:1:1:1:1) consisting of three 7-day treatment periods followed by a 7-day washout. Once-daily oral treatments comprised nebivolol (20 mg), valsartan (320 mg), and nebivolol-valsartan combination (20/320 mg). Outcomes included AUC0-τ,ss, Cmax,ss, Tmax,ss, changes in BP, pulse rate, plasma angiotensin II, plasma renin activity, 24-hour urinary aldosterone, and adverse events. Steady-state pharmacokinetic interactions were observed but deemed not clinically significant. Systolic and diastolic BP reduction was significantly greater with nebivolol-valsartan combination than with either monotherapy. The mean pulse rate associated with nebivolol and nebivolol-valsartan treatments was consistently lower than that associated with valsartan monotherapy. A sharp increase in mean day 7 plasma renin activity and plasma angiotensin II that occurred in valsartan-treated participants was significantly attenuated with concomitant nebivolol administration. Mean 24-hour urine aldosterone at day 7 was substantially decreased after combined treatment, as compared with either monotherapy. All treatments were safe and well tolerated. In conclusion, nebivolol and valsartan coadministration led to greater reductions in BP compared with either monotherapy; nebivolol and valsartan lower BP through complementary mechanisms.
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Abstract
Nebivolol is a highly selective β1-adrenergic receptor antagonist with a pharmacologic profile that differs from those of other drugs in its class. In addition to cardioselectivity mediated via β1 receptor blockade, nebivolol induces nitric oxide-mediated vasodilation by stimulating endothelial nitric oxide synthase via β3 agonism. This vasodilatory mechanism is distinct from those of other vasodilatory β-blockers (carvedilol, labetalol), which are mediated via α-adrenergic receptor blockade. Nebivolol is approved for the treatment of hypertension in the US, and for hypertension and heart failure in Europe. While β-blockers are not recommended within the current US guidelines as first-line therapy for treatment of essential hypertension, nebivolol has shown comparable efficacy to currently recommended therapies in lowering peripheral blood pressure in adults with hypertension with a very low rate of side effects. Nebivolol also has beneficial effects on central blood pressure compared with other β-blockers. Clinical data also suggest that nebivolol may be useful in patients who have experienced erectile dysfunction while on other β-blockers. Here we review the pharmacological profile of nebivolol, the clinical evidence supporting its use in hypertension as monotherapy, add-on, and combination therapy, and the data demonstrating its positive effects on heart failure and endothelial dysfunction.
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Affiliation(s)
- Justin Fongemie
- />Tufts Medical Center, 800 Washington St., Boston, MA 02111 USA
| | - Erika Felix-Getzik
- />MCPHS University, School of Pharmacy-Boston, 179 Longwood Ave, Boston, MA 02115 USA
- />Newton-Wellesley Hospital, 2014 Washington St, Newton, MA 02462 USA
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Chen S, Swallow E, Li N, Faust E, Kelley C, Xie J, Wu E. Economic benefits associated with beta blocker persistence in the treatment of hypertension: a retrospective database analysis. Curr Med Res Opin 2015; 31:615-22. [PMID: 25651483 DOI: 10.1185/03007995.2015.1013624] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To assess the association between medical costs and persistence with beta blockers among hypertensive patients, and to quantify persistence related medical cost differences with nebivolol, which is associated with improved tolerability, versus other beta blockers. METHODS Adults who initiated hypertension treatment with a beta blocker were identified from the MarketScan * claims database (2008-2012). Patients were classified based on their first beta blocker use: nebivolol, atenolol, carvedilol, metoprolol, and other beta blockers. Patients with compelling indications for atenolol, carvedilol or metoprolol (acute coronary syndrome and congestive heart failure) were excluded. Patients enrolled in health maintenance organization or capitated point of service insurance plans were also excluded. Persistence was defined as continuous use of the index drug (<60 day gap). The average effect of persistence on medical costs (2012 USD) was estimated using generalized linear models (GLMs). Regression estimates were used to predict medical cost differences associated with persistence between nebivolol and the other cohorts. RESULTS A total of 587,424 hypertensive patients met the inclusion criteria. Each additional month of persistence with any one beta blocker was associated with $152.51 in all-cause medical cost savings; continuous treatment for 1 year was associated with $1585.98 in all-cause medical cost savings. Patients treated with nebivolol had longer persistence during the 1 year study period (median: 315 days) than all other beta blockers (median: 156-292 days). Longer persistence with nebivolol translated into $305.74 all-cause medical cost savings relative to all other beta blockers. LIMITATIONS The results may not be generalizable to hypertensive patients with acute coronary syndrome or congestive heart failure. CONCLUSIONS Longer persistence with beta blockers for the treatment of hypertension was associated with lower medical costs. There may be greater cost savings due to better persistence with nebivolol than other beta blockers.
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Long-term safety of nebivolol and valsartan combination therapy in patients with hypertension: an open-label, single-arm, multicenter study. ACTA ACUST UNITED AC 2014; 8:915-20. [DOI: 10.1016/j.jash.2014.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 09/15/2014] [Accepted: 09/16/2014] [Indexed: 11/18/2022]
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Varagic J, Punzi H, Ferrario CM. Clinical utility of fixed-dose combinations in hypertension: evidence for the potential of nebivolol/valsartan. Integr Blood Press Control 2014; 7:61-70. [PMID: 25473311 PMCID: PMC4251532 DOI: 10.2147/ibpc.s50954] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Despite significant advances in pharmacologic approaches to treat hypertension during the last decades, hypertension- and hypertension-related organ damage are still a high health and economic burden because a large proportion of patients with hypertension do not achieve optimal blood pressure control. There is now general agreement that combination therapy with two or more antihypertensive drugs is required for targeted blood pressure accomplishment and reduction of global cardiovascular risk. The goals of combination therapies are to reduce long-term cardiovascular events by targeting different mechanism underlying hypertension and target organ disease, to block the counterregulatory pathways activated by monotherapies, to improve tolerability and decrease the adverse effects of up-titrated single agents, and to increase persistence and adherence with antihypertensive therapy. Multiple clinical trials provide evidence that fixed-dose combinations in a single pill offer several advantages when compared with loose-dose combinations. This review discusses the advances in hypertension control and associated cardiovascular disease as they relate to the prospect of combination therapy targeting a third-generation beta (β) 1-adrenergic receptor (nebivolol) and an angiotensin II receptor blocker (valsartan) in fixed-dose single-pill formulations.
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Affiliation(s)
- Jasmina Varagic
- Hypertension and Vascular Research Center, Wake Forest University, Winston-Salem, NC USA ; Division of Surgical Sciences, Wake Forest University, Winston-Salem, NC USA ; Department of Physiology and Pharmacology, Wake Forest University, Winston-Salem, NC USA
| | - Henry Punzi
- Trinity Hypertension and Diagnostic Research Center, Carrollton, TX, USA ; Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Carlos M Ferrario
- Division of Surgical Sciences, Wake Forest University, Winston-Salem, NC USA ; Department of Physiology and Pharmacology, Wake Forest University, Winston-Salem, NC USA ; Department of Internal Medicine and Nephrology, Wake Forest University, Winston-Salem, NC, USA
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Giles TD, Weber MA, Basile J, Gradman AH, Bharucha DB, Chen W, Pattathil M. Efficacy and safety of nebivolol and valsartan as fixed-dose combination in hypertension: a randomised, multicentre study. Lancet 2014; 383:1889-98. [PMID: 24881993 DOI: 10.1016/s0140-6736(14)60614-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The fixed-dose combination of any two antihypertensive drugs from different drug classes is typically more effective in reducing blood pressure than a dose increase of component monotherapy. We assessed the efficacy and safety of a fixed-dose combination of a vasodilating β blocker (nebivolol) and an angiotensin II receptor blocker (valsartan) in adults with hypertension. METHODS We did an 8-week, phase 3, multicentre, randomised, double-blind, placebo-controlled, parallel-group trial at 401 US sites. Participants (age ≥18 years) with hypertension but with blood pressure less than 180/110 mm Hg were randomly assigned (2:2:2:2:2:2:2:1) by a 24-h interactive web response system in blocks of 15 to 4 weeks of double-blind treatment with nebivolol and valsartan fixed-dose combination (5 and 80 mg/day, 5 and 160 mg/day, or 10 and 160 mg/day), nebivolol (5 mg/day or 20 mg/day), valsartan (80 mg/day or 160 mg/day), or placebo. Doses were doubled in weeks 5-8; results are reported according to the final dose. Participants and research staff were masked to treatment allocation. The primary and key secondary endpoints were changes from baseline to week 8 in diastolic and systolic blood pressure, respectively. The primary statistical comparison was between the highest fixed-dose combination dose and the highest monotherapy doses; lower doses were then compared if this comparison was positive (Hochberg method for multiple testing). Efficacy analyses were by intention to treat. Safety assessments included monitoring of adverse events. Continuous efficacy parameters were analysed using an ANCOVA model; binary outcomes were analysed using a logistic regression model. This study is registered with ClinicalTrials.gov, NCT01508026. FINDINGS Between Jan 6, 2012, and March 15, 2013, 4161 patients were randomly assigned (277 to placebo and 554-555 to each active comparator group), 4118 of whom were included in the primary analysis. At week 8, the fixed-dose combination 20 and 320 mg/day group had significantly greater reductions in diastolic blood pressure from baseline than both nebivolol 40 mg/day (least-squares mean difference -1·2 mm Hg, 95% CI -2·3 to -0·1; p=0·030) and valsartan 320 mg/day (-4·4 mm Hg, -5·4 to -3·3; p<0·0001); all other comparisons were also significant, favouring the fixed-dose combinations (all p<0·0001). All systolic blood pressure comparisons were also significant (all p<0·01). At least one treatment-emergent adverse event was experienced by 30-36% of participants in each group. INTERPRETATION Nebivolol and valsartan fixed-dose combination is an effective and well-tolerated treatment option for patients with hypertension. FUNDING Forest Research Institute.
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Affiliation(s)
- Thomas D Giles
- Department of Medicine, Tulane University, New Orleans, LA, USA.
| | - Michael A Weber
- Division of Cardiovascular Medicine, State University of New York, Downstate College of Medicine, Brooklyn, NY, USA
| | - Jan Basile
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Alan H Gradman
- Department of Medicine, Temple University School of Medicine, Pittsburgh, PA, USA
| | - David B Bharucha
- Department of Clinical Development, Forest Research Institute, Jersey City, NJ, USA
| | - Wei Chen
- Department of Biostatistics, Forest Research Institute, Jersey City, NJ, USA
| | - Manoj Pattathil
- Department of Clinical Development, Forest Research Institute, Jersey City, NJ, USA
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Chen S, Macaulay D, Swallow E, Diener M, Farooqui S, Xie J, Wu EQ. Real-world adherence and persistence associated with nebivolol or hydrochlorothiazide as add-on treatment for hypertension. Curr Med Res Opin 2014; 30:637-43. [PMID: 24255986 DOI: 10.1185/03007995.2013.864267] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare adherence and persistence associated with nebivolol and hydrochlorothiazide (HCTZ) as add-on hypertension treatments. RESEARCH DESIGN AND METHODS Adults with ≥1 hypertension diagnosis (ICD-9-CM 401-405) who used nebivolol or HCTZ as their first add-on antihypertensive therapy between 1/1/2008 and 9/30/2010 were identified from a large claims database. Patients had continuous enrollment for ≥1 year preceding (baseline period) and following (study period) the first qualifying prescription fill, and did not use nebivolol or HCTZ during the baseline period. A random sample of HCTZ patients meeting selection criteria were selected in a 3:1 ratio to nebivolol patients. MAIN OUTCOME MEASURES The probability of receiving each drug, adjusted for baseline patient demographics, significantly different comorbidities, and costs was estimated using a logistic model. Inverse propensity score weights were used to balance confounding factors for between-cohort comparisons. Adherence (estimated using the medication possession ratio [MPR]) and persistence (estimated as days from initiation to the first >30 day gap in the index drug supply) at 6, 9, and 12 months were compared using weighted t tests. RESULTS Baseline characteristics of nebivolol (n = 722) and HCTZ (n = 2166) patients were well balanced after weighting. At 12 months, nebivolol patients had a significantly higher MPR than HCTZ patients (0.76 vs. 0.70, P < 0.001), and medication persistence was 28 days longer (273 vs. 245 days, P < 0.001). Between-group differences were also significant at 6 and 9 months. CONCLUSIONS When used as an add-on therapy for hypertension, nebivolol was associated with significantly higher rates of adherence and persistence compared with HCTZ, after adjusting for baseline differences between treatment groups. These results may be impacted by limitations inherent in insurance claims data, such as the lack of clinical information.
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Giles TD, Khan BV, Lato J, Brener L, Ma Y, Lukic T. Nebivolol monotherapy in younger adults (younger than 55 years) with hypertension: a randomized, placebo-controlled trial. J Clin Hypertens (Greenwich) 2013; 15:687-93. [PMID: 24034663 PMCID: PMC8033872 DOI: 10.1111/jch.12169] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 06/18/2013] [Accepted: 06/19/2013] [Indexed: 12/24/2022]
Abstract
Nebivolol, a vasodilatory β1-blocker, may be well suited for the hemodynamics of the younger hypertensive patient. In this 8-week trial, 18- to 54-year-olds with a diastolic blood pressure (DBP) of 95 mm Hg to 109 mm Hg who completed a 4-week placebo-only phase were randomized to receive nebivolol (5 mg/d, titrated to 10-20 mg/d based on achievement of blood pressure <140/90 mm Hg [n=427]) or placebo (n=214). Primary and secondary efficacy parameters were changes in trough seated DBP and systolic blood pressure (SBP), respectively. Safety parameters included adverse events (AEs). The baseline mean age was 45.3 years; SBP/DBP, 154/100 mm Hg; and heart rate, 78 beats per minute. Completion rates were 91.3% (nebivolol) and 88.3% (placebo). At endpoint, there was a significant effect of nebivolol over placebo for DBP (-11.8 mm Hg vs -5.5 mm Hg, P<.001) and SBP (-13.7 mm Hg vs -5.5 mm Hg, P<.001). Total AE rates were 34.7% (nebivolol) and 32.2% (placebo). Nebivolol monotherapy is efficacious and well tolerated in adults younger than 55 years of age with increased DBP.
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Weiss RJ, Stapff M, Lin Y. Placebo effect and efficacy of nebivolol in patients with hypertension not controlled with lisinopril or losartan: a phase IV, randomized, placebo-controlled trial. Am J Cardiovasc Drugs 2013; 13:129-40. [PMID: 23519546 DOI: 10.1007/s40256-013-0010-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Most patients with hypertension require more than one antihypertensive to achieve blood pressure (BP) control. OBJECTIVE The purpose of this trial was to assess the efficacy and tolerability of add-on nebivolol, a vasodilatory β-blocker, in patients with untreated or poorly controlled hypertension, receiving stable therapy with lisinopril (an angiotensin-converting enzyme inhibitor) or losartan (an angiotensin II receptor blocker). STUDY DESIGN This was a phase IV double-blind, placebo-controlled trial conducted from August 2008 to March 2010 (ClinicalTrials.gov identifier: NCT00734630). Patients entered a 2-week, single-blind, placebo-only washout phase, followed by a 3- to 4-week open-label lead-in phase (lisinopril, 10-20 mg/day, or losartan, 50-100 mg/day), and a 12-week randomized, double-blind add-on treatment phase with placebo or nebivolol (5-40 mg/day). SETTING This study was conducted at 76 outpatient centers in the United States. PATIENTS Participants were men and women aged 18-85 years with a diagnosis of primary hypertension and seated trough systolic BP (SBP) at screening in the range of 170-200 mmHg if untreated, 155-180 mmHg if taking 1 antihypertensive medication, or 140-170 mmHg if taking 2 antihypertensive medications. INTERVENTION The intervention was 12 weeks' treatment with nebivolol 5-40 mg/day added to a background therapy of lisinopril 10-20 mg/day or losartan 50-100 mg/day. MAIN OUTCOME MEASURES Primary and secondary efficacy parameters were changes from baseline in seated trough cuff SBP and diastolic BP (DBP) at Week 12, respectively. Tolerability was assessed by monitoring treatment-emergent adverse events (TEAEs). RESULTS A total of 491 patients were randomized to receive nebivolol (n=258) or placebo (n=233). Efficacy analyses were conducted for 256 nebivolol and 232 placebo patients (intent-to-treat population); completion rates were 88.8% and 85.8%, respectively. Mean baseline SBP/DBP values were 163.1/98.2 mmHg (nebivolol) and 162.4/96.8 mmHg (placebo). Nebivolol was associated with a non-significant mean±SD reduction in SBP (-10.1±16.9 mmHg) versus placebo (-7.3±15.9 mmHg, P=0.093) and significant mean DBP reduction (-7.8±10.1 mmHg vs -3.5±10.6 mmHg, P<0.001). Subgroup analysis suggested a significant effect on DBP for patients receiving background losartan treatment (-8.1±9.2 mmHg vs -3.1±9.4 mmHg, P<0.001), but not for those receiving lisinopril (-7.6±10.8 mmHg vs -3.8±11.6 mmHg, P=0.076). A total of 28% nebivolol-treated and 22% placebo-treated patients reported a TEAE, the most frequent being upper respiratory tract infection (4.3% and 2.1%, respectively), bradycardia (2.7% and 0%), headache (2.3% and 2.1%), and nasopharyngitis (2.3% and 0.9%). CONCLUSION These data suggest that nebivolol, when added to lisinopril or losartan, results in an additional BP reduction; however, only the effect on DBP reached statistical significance. A subanalysis suggests that the effect on DBP may be stronger in losartan-treated than lisinopril-treated patients. A relatively strong placebo effect may limit data interpretation. Nebivolol was well tolerated, as there was no difference in TEAEs between nebivolol and placebo. FUNDING This trial (NCT00734630) was funded by Forest Laboratories, Inc.
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Affiliation(s)
- Robert J Weiss
- Maine Research Associates, 2 Great Falls Plaza, Auburn, ME 04210, USA.
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Reiberger T, Payer BA, Schwabl P, Hayden H, Horvatits T, Jäger B, Hummel T, Mitterhauser M, Trauner M, Fuhrmann V, Angermayr B, Peck-Radosavljevic M. Nebivolol treatment increases splanchnic blood flow and portal pressure in cirrhotic rats via modulation of nitric oxide signalling. Liver Int 2013; 33:561-8. [PMID: 23331709 DOI: 10.1111/liv.12101] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 12/17/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND We evaluated the effects of nebivolol, a third generation beta-blocker capable of increasing NO-bioavailability on portal pressure, and on splachnic and systemic haemodynamics in a cirrhotic portal hypertensive rat model. METHODS Male Sprague-Dawley rats underwent sham operation (SO) or bile duct ligation (BDL). When cirrhosis was fully developed, the animals were orally treated with low-dose (5 mg/kg) or high-dose (10 mg/kg) nebivolol (NEBI) or vehicle (VEH) for 7 days. Heart rate (HR), mean arterial pressure (MAP), portal pressure (PP) and superior mesenteric artery blood flow (SMABF) were measured. Portosystemic collateral blood flow (PSCBF) was quantified using radioactive microspheres. Hepatic and splanchnic NOx levels and GSH/GSSG ratios (RedOx state) were determined using commercially available kits. RESULTS BDL-VEH rats showed increased HR, PP and PSCBF, whereas MAP was decreased compared to SO-VEH rats. Nebivolol significantly reduced HR both in SO (P < 0.001) and BDL (P < 0.001) rats. BDL-NEBI animals had significantly higher PP (15.5 vs. 12.6 mmHg; P = 0.006) and SMABF (5.3 vs. 3.7 ml/min/100g; P = 0.016) than BDL-VEH animals. The increase in PP and SMABF was noted both in low-dose and high-dose BDL-NEBI rats. While no beneficial effects on hepatic RedOx state were observed, splanchnic NOx levels were significantly increased by NEBI treatment in a dose-dependent manner. Nebivolol treatment did not affect PSCBF in SO and BDL animals. CONCLUSION Nebivolol increases portal pressure in cirrhotic animals by increasing splanchnic blood flow via modulation of NO signalling. Portosystemic collateral blood flow remained unchanged. These data do not support the use of nebivolol for treatment of cirrhotic patients with portal hypertension.
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Affiliation(s)
- Thomas Reiberger
- Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria
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Lewin A, Punzi H, Luo X, Stapff M. Nebivolol monotherapy for patients with systolic stage II hypertension: results of a randomized, placebo-controlled trial. Clin Ther 2013; 35:142-52. [PMID: 23332366 DOI: 10.1016/j.clinthera.2012.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 11/20/2012] [Accepted: 12/20/2012] [Indexed: 01/13/2023]
Abstract
BACKGROUND Elevated systolic blood pressure (SBP) is an independent risk factor for cardiovascular events and mortality. OBJECTIVE The goal of this study was to assess whether nebivolol (NEB), a vasodilatory β(1)-selective blocker, is a safe and efficacious monotherapy for individuals with systolic stage II hypertension. METHODS In this multicenter trial, 18- to 64-year-olds who had not used antihypertensive treatment for at least 4 weeks and had SBP/diastolic blood pressure (DBP) of 160 to 180/90 to 110 mm Hg were randomized to receive double-blind medication for 6 weeks (NEB, n = 290; placebo [PBO], n = 142). Depending on response, the starting dose (5 mg/d) could be increased directly to 20 mg/d. Primary parameters were baseline-end point changes in trough seated SBP and DBP (intent-to-treat [ITT] population); the Hochberg method was used to control the type I error (α = 0.05). Responder analysis was also performed. Safety and tolerability assessment included monitoring of adverse events (AEs). RESULTS Mean age at baseline (ITT) was 50.7 years, and the mean SBP/DBP values were 167/101 mm Hg; 202 (47.3%) participants were women, 276 (63.9%) had body mass index ≥30 kg/m(2), 152 (35.2%) were black, and 161 (37.3%) were Hispanic. Completion rates were 79.7% (PBO) and 90.3% (NEB). After 2 weeks of treatment, 92% and 95% participants in the NEB and PBO groups, respectively, had SBP in the range of 130 to 180 mm Hg and were titrated to the 20-mg/d NEB dose or its matching PBO tablet. After 6 weeks of treatment, the NEB group experienced significant mean reductions compared with the PBO group for both SBP (-18.2 vs -12.3 mm Hg; P < 0.001) and DBP (-12.3 vs -5.7 mm Hg; P < 0.001), down to mean SBP/DBP values of 149/89 mm Hg and 155/95 mm Hg, respectively, and had a significantly higher percentage of individuals who achieved BP control (SBP/DBP <140/90 mm Hg, 30.6% vs 17.3%; P = 0.004). Post hoc analyses suggest that NEB was not efficacious in reducing SBP in black participants. Mean changes in pulse rate were -12.8 beats/min for the NEB group and -1.6 beats/min for the PBO group (P < 0.001). Rates of discontinuations due to an AE (NEB vs PBO) were 1.4% in both groups, rates of any treatment-emergent AEs were 19.7% versus 19.0%, and rates of serious AEs were 0.3% versus 2.1%. The most common AEs (NEB vs PBO) were headache (2.1% vs 2.8%) and hypertension (0.7% vs 2.1%). CONCLUSIONS NEB monotherapy was an efficacious and well-tolerated treatment option for these study individuals with systolic stage II hypertension, but most of them would need combination therapy to achieve BP control.
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Affiliation(s)
- Andrew Lewin
- National Research Institute, Los Angeles, CA 90057, USA.
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Germino FW, Lin Y, Pejović V, Bowen L. Efficacy and tolerability of nebivolol: does age matter? A retrospective analysis of three randomized, placebo-controlled trials in stage I-II hypertension. Ther Adv Cardiovasc Dis 2012; 6:185-99. [PMID: 23008339 DOI: 10.1177/1753944712459593] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES This retrospective analysis examined the efficacy and tolerability of nebivolol, a ß(1)-selective, vasodilatory β-blocker, in four different age groups of patients with hypertension. METHODS Data were pooled from three 12-week, randomized, placebo-controlled trials (placebo, n = 205; nebivolol [1.25-30/40 mg/day], n = 1811) and stratified into age quartiles (Group 1: 22-46 years; Group 2: 47-53 years; Group 3: 54-62 years; Group 4: 63-84 years). Only patients treated with placebo and the three commonly used nebivolol dosages (5, 10, and 20 mg/day) are presented. Baseline-to-endpoint changes in trough sitting diastolic blood pressure (DBP), systolic blood pressure (SBP), and heart rate (HR) were analyzed for each age quartile using an analysis of covariance (ANCOVA) model. Tolerability was assessed by means of adverse event (AE) rates. RESULTS The analysis comprised 205 placebo-treated patients and 1380 patients treated with nebivolol dosages of 5, 10, or 20 mg/day. Older age was associated with higher SBP values at baseline. In all age groups, each of the three most frequently used nebivolol dosages significantly reduced DBP, compared with placebo (-9.1 to -11.8 mmHg versus -3.4 to -5.9 mmHg; p ≤ 0.008 overall). For SBP, a statistically significant effect versus placebo was observed for all dosages and age groups except for 5 and 10 mg/day in Group 4. Within each group, treatment with nebivolol (all three dosages) and placebo resulted in similar AE rates (nebivolol: 26.1-36.6%; placebo: 36.2-42.6%) and AE-related discontinuation rates (1.8-3.8% versus 0-4.3%). In each age group, there were no significant nebivolol-placebo differences in the rates of patients who experienced clinically significant changes or abnormal endpoint levels of metabolic parameters. CONCLUSIONS This retrospective analysis suggests that nebivolol monotherapy is efficacious and well tolerated across various age groups, with the efficacy in reducing SBP somewhat diminishing in patients over 62 years of age.
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Affiliation(s)
- F Wilford Germino
- Department of Internal Medicine, Orland Primary Care Specialists, 16660 107 Street, Orland Park, IL 60467, USA.
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Black HR, Aguirre P. F, Wright M, Alessi T, Baschiera F. Aliskiren Alone or in Combination With Hydrochlorothiazide in Hispanic/Latino Patients With Systolic Blood Pressure 160 mm Hg to <180 mm Hg (Aliskiren Alone or in Combination With Hydrochlorothiazide in Patients With Stage 2 Hypertension to Provide Quick. J Clin Hypertens (Greenwich) 2012; 14:514-21. [DOI: 10.1111/j.1751-7176.2012.00672.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Current world literature. Curr Opin Cardiol 2012; 27:441-54. [PMID: 22678411 DOI: 10.1097/hco.0b013e3283558773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Signorovitch JE, Samuelson TM, Ramakrishnan K, Marynchenko M, Wu EQ, Blum SI, Ramasamy A, Chen S. Persistence with nebivolol in the treatment of hypertension: a retrospective claims analysis. Curr Med Res Opin 2012; 28:591-9. [PMID: 22352883 DOI: 10.1185/03007995.2012.668495] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Examine drug persistence by evaluating the hazard of discontinuation and of switching to different antihypertensive drugs in patients initiating treatment with a recently approved β-blocker, nebivolol, versus other β-blockers. METHODS This retrospective analysis included all patients diagnosed with hypertension in the MarketScan Database (January 2007 - December 2008) with at least two medical claims and no prior β-blocker prescriptions within 6 months of the initial prescription date. Multivariate Cox proportional hazard models (adjusted for baseline differences in demographics, previous use of other antihypertensive medications, initial doses and supply of medication, and number of distinct prescriptions at baseline) were used to assess the hazard of discontinuation, defined as the first prescription gap of ≥30 days, and to assess the hazard of switching to another antihypertensive drug, defined as a prescription fill for another antihypertensive drug within 15 days before and 30 days after discontinuation of the initial β-blocker. RESULTS Of the 173,200 patients included in the study population, the adjusted hazard of discontinuation for nebivolol-initiated patients was 8-20% lower than that of patients who initiated treatment with atenolol (hazard ratio [HR] 0.82, p < 0.001), metoprolol (HR 0.91, p < 0.001), carvedilol (HR 0.92, p < 0.001), or other β-blockers (HR 0.80, p < 0.001). The adjusted hazard of nebivolol-treated patients switching to a different antihypertensive medication was 12-22% lower than that of the other four β-blocker cohorts (atenolol: HR 0.80, p < 0.001; metoprolol: HR 0.86, p < 0.001; carvedilol: HR 0.88, p < 0.001; other β-blockers: HR 0.78, p < 0.001). Sensitivity analyses defined discontinuation as prescription gaps of ≥45 days and ≥60 days and showed a lower hazard of discontinuation among patients initiating nebivolol than among patients initiating all other drug cohorts (p < 0.001). LIMITATIONS Comparisons of non-randomized treatment groups may be confounded by unobserved differences in patients' baseline characteristics. CONCLUSIONS Initiation with nebivolol was associated with greater persistence than initiation with atenolol, carvedilol, metoprolol, or other β-blockers.
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