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Winner G J, Jain S, Gupta D. Unveiling Novel Molecules and Therapeutic Targets in Hypertension - A Narrative Review. Eur J Pharmacol 2024:177053. [PMID: 39393666 DOI: 10.1016/j.ejphar.2024.177053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 09/18/2024] [Accepted: 10/07/2024] [Indexed: 10/13/2024]
Abstract
Hypertension is a prevalent non-communicable disease with serious cardiovascular complications, including heart failure, myocardial infarction, and stroke, often resulting from uncontrolled hypertension. While current treatments primarily target the renin-angiotensin-aldosterone pathway, the therapeutic response remains modest in many patients, with some developing resistant hypertension. Newer therapeutic approaches aim to address hypertension from various aspects beyond conventional drugs, including targeting central nervous system pathways, inflammatory pathways, vascular smooth muscle function, and baroreceptors. Despite these advancements, each therapy faces unique clinical and mechanistic challenges that influence its clinical translatability and long-term viability. This review explores the mechanisms of novel molecules in preclinical and clinical development, highlights potential therapeutic targets, and discusses the challenges and ethical considerations related to hypertension therapeutics and their development.
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Ruan Y, Yu Y, Wu M, Jiang Y, Qiu Y, Ruan S. The renin-angiotensin-aldosterone system: An old tree sprouts new shoots. Cell Signal 2024; 124:111426. [PMID: 39306263 DOI: 10.1016/j.cellsig.2024.111426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 08/25/2024] [Accepted: 09/17/2024] [Indexed: 09/27/2024]
Abstract
The intricate physiological and pathological diversity of the Renin-Angiotensin-Aldosterone System (RAAS) underpins its role in maintaining bodily equilibrium. This paper delves into the classical axis (Renin-ACE-Ang II-AT1R axis), the protective arm (ACE2-Ang (1-7)-MasR axis), the prorenin-PRR-MAP kinases ERK1/2 axis, and the Ang IV-AT4R-IRAP cascade of RAAS, examining their functions in both physiological and pathological states. The dysregulation or hyperactivation of RAAS is intricately linked to numerous diseases, including cardiovascular disease (CVD), renal damage, metabolic disease, eye disease, Gastrointestinal disease, nervous system and reproductive system diseases. This paper explores the pathological mechanisms of RAAS in detail, highlighting its significant role in disease progression. Currently, in addition to traditional drugs like ACEI, ARB, and MRA, several novel therapeutics have emerged, such as angiotensin receptor-enkephalinase inhibitors, nonsteroidal mineralocorticoid receptor antagonists, aldosterone synthase inhibitors, aminopeptidase A inhibitors, and angiotensinogen inhibitors. These have shown potential efficacy and application prospects in various clinical trials for related diseases. Through an in-depth analysis of RAAS, this paper aims to provide crucial insights into its complex physiological and pathological mechanisms and offer valuable guidance for developing new therapeutic approaches. This comprehensive discussion is expected to advance the RAAS research field and provide innovative ideas and directions for future clinical treatment strategies.
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Affiliation(s)
- Yaqing Ruan
- The Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou 350004, China; Fujian University of Traditional Chinese Medicine, Fuzhou 350000, China
| | - Yongxin Yu
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Meiqin Wu
- The Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou 350004, China; Fujian University of Traditional Chinese Medicine, Fuzhou 350000, China
| | - Yulang Jiang
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China; Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Yuliang Qiu
- The Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou 350004, China; Fujian University of Traditional Chinese Medicine, Fuzhou 350000, China.
| | - Shiwei Ruan
- The Affiliated People's Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou 350004, China; Fujian University of Traditional Chinese Medicine, Fuzhou 350000, China.
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Freeman MW, Halvorsen YD, Bond M, Murphy B, Isaacsohn J. Results from a Phase 1 Study Assessing the Pharmacokinetics of the Aldosterone Synthase Inhibitor Baxdrostat in Participants with Varying Degrees of Renal Function. Clin Pharmacol Drug Dev 2024; 13:410-418. [PMID: 38311833 DOI: 10.1002/cpdd.1371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/19/2023] [Indexed: 02/06/2024]
Abstract
Baxdrostat is a selective small-molecule aldosterone synthase inhibitor in development for treatment of hypertension and chronic kidney disease. This phase 1, open-label, parallel-group study assessed the safety and pharmacokinetics (PK) of baxdrostat in participants with varying degrees of renal function. Participants were enrolled into control (estimated glomerular filtration rate [eGFR] ≥60 mL/min), moderate to severe renal impairment (eGFR 15-59 mL/min), or kidney failure (eGFR <15 mL/min) groups and received a single 10-mg baxdrostat dose followed by 7 days of inpatient PK blood and urine sampling. Safety was assessed by adverse events, clinical laboratory evaluations, vital signs, physical examinations, and electrocardiograms (ECGs). Thirty-2 participants completed the study. There were no deaths and only 1 mild drug-related adverse event (diarrhea). No clinically meaningful changes in laboratory values, vital signs, physical examinations, or ECGs occurred. Plasma concentration-time curves of baxdrostat were similar among all groups. Urine PK parameters were similar (approximately 12% excreted) in the moderate to severe renal impairment and control groups. Inadequate urine production in the kidney failure group resulted in minimal urinary baxdrostat excretion. Renal impairment had no significant impact on systemic exposure or clearance of baxdrostat, suggesting that dose adjustment due to PK differences in patients with kidney disease is unnecessary.
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Affiliation(s)
- Mason W Freeman
- Center for Computational and Integrative Biology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- CinCor Pharma, Inc., Waltham, MA, USA
| | | | - Mary Bond
- CinRx Pharma, LLC, Cincinnati, OH, USA
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Nardoianni G, Pala B, Scoccia A, Volpe M, Barbato E, Tocci G. Systematic Review Article: New Drug Strategies for Treating Resistant Hypertension-the Importance of a Mechanistic, Personalized Approach. High Blood Press Cardiovasc Prev 2024; 31:99-112. [PMID: 38616212 PMCID: PMC11043106 DOI: 10.1007/s40292-024-00634-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 03/03/2024] [Indexed: 04/16/2024] Open
Abstract
Resistant hypertension (RHT) is characterized by persistently high blood pressure (BP) levels above the widely recommended therapeutic targets of less than 140/90 mmHg office BP, despite life-style measures and optimal medical therapies, including at least three antihypertensive drug classes at maximum tolerated dose (one should be a diuretic). This condition is strongly related to hypertension-mediated organ damage and, mostly, high risk of hospitalization due to hypertension emergencies or acute cardiovascular events. Hypertension guidelines proposed a triple combination therapy based on renin angiotensin system blocking agent, a thiazide or thiazide-like diuretic, and a dihydropyridinic calcium-channel blocker, to almost all patients with RHT, who should also receive either a beta-blocker or a mineralocorticoid receptor antagonist, or both, depending on concomitant conditions and contraindications. Several other drugs may be attempted, when elevated BP levels persist in these RHT patients, although their added efficacy in lowering BP levels on top of optimal medical therapy is uncertain. Also, renal denervation has demonstrated to be a valid therapeutic alternative in RHT patients. More recently, novel drug classes and molecules have been tested in phase 2 randomised controlled clinical trials in patients with RHT on top of optimal medical therapy with at least 2-3 antihypertensive drugs. These novel drugs, which are orally administered and are able to antagonize different pathophysiological pathways, are represented by non-steroid mineralocorticorticoid receptor antagonists, selective aldosterone synthase inhibitors, and dual endothelin receptor antagonists, all of which have proven to reduce seated office and 24-h ambulatory systolic/diastolic BP levels. The main findings of randomized clinical trials performed with these drugs as well as their potential indications for the clinical management of RHT patients are summarised in this systematic review article.
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Affiliation(s)
- Giulia Nardoianni
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Barbara Pala
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Alessandra Scoccia
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Massimo Volpe
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
- IRCCS San Raffaele Pisana, Roma, Italy
| | - Emanuele Barbato
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Giuliano Tocci
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy.
- Division of Cardiology, Faculty of Medicine and Psychology, Hypertension Unit, University of Rome Sapienza, Sant'Andrea Hospital, Rome, Italy.
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Savarese G, Lindberg F, Filippatos G, Butler J, Anker SD. Mineralocorticoid receptor overactivation: targeting systemic impact with non-steroidal mineralocorticoid receptor antagonists. Diabetologia 2024; 67:246-262. [PMID: 38127122 PMCID: PMC10789668 DOI: 10.1007/s00125-023-06031-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/13/2023] [Indexed: 12/23/2023]
Abstract
The overactivation of the mineralocorticoid receptor (MR) promotes pathophysiological processes related to multiple physiological systems, including the heart, vasculature, adipose tissue and kidneys. The inhibition of the MR with classical MR antagonists (MRA) has successfully improved outcomes most evidently in heart failure. However, real and perceived risk of side effects and limited tolerability associated with classical MRA have represented barriers to implementing MRA in settings where they have been already proven efficacious (heart failure with reduced ejection fraction) and studying their potential role in settings where they might be beneficial but where risk of safety events is perceived to be higher (renal disease). Novel non-steroidal MRA have distinct properties that might translate into favourable clinical effects and better safety profiles as compared with MRA currently used in clinical practice. Randomised trials have shown benefits of non-steroidal MRA in a range of clinical contexts, including diabetic kidney disease, hypertension and heart failure. This review provides an overview of the literature on the systemic impact of MR overactivation across organ systems. Moreover, we summarise the evidence from preclinical studies and clinical trials that have set the stage for a potential new paradigm of MR antagonism.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden.
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Gerasimos Filippatos
- Department of Cardiology, University Hospital Attikon, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Internal Medicine, University of Mississippi, Jackson, MS, USA
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany.
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.
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