Combination therapy in hypertension

Perspectives on improving blood pressure control to reduce the clinical and economic burden of hypertension

The clinical and economic burden of hypertension is high and continues to increase globally. Uncontrolled hypertension has severe but avoidable long-term consequences, including cardiovascular diseases, which are among the most burdensome and most preventable conditions in Europe. Yet, despite clear guidelines on screening, diagnosis and management of hypertension, a large proportion of patients remain undiagnosed or undertreated. Low adherence and persistence are common, exacerbating the issue of poor blood pressure (BP) control. Although current guidelines provide clear direction, implementation is hampered by barriers at the patient-, physician- and healthcare system levels. Underestimation of the impact of uncontrolled hypertension and limited health literacy lead to low adherence and persistence among patients, treatment inertia among physicians and a lack of decisive healthcare system action. Many options to improve BP control are available or under investigation. Patients would benefit from targeted health education, improved BP measurement, individualized treatment or simplified treatment regimens through single-pill combinations. For physicians, increasing awareness of the burden of hypertension, as well as offering training on monitoring and optimal management and provision of the necessary time to collaboratively engage with patients would be useful. Healthcare systems should establish nationwide strategies for hypertension screening and management. Furthermore, there is an unmet need to implement more comprehensive BP measurements to optimize management. In conclusion, an integrative, patient-focused, multimodal multidisciplinary approach to the management of hypertension by clinicians, payers and policymakers, involving patients, is required to achieve long-term improvements in population health and cost-efficiency for healthcare systems.

Hypertension medication from guidelines to practice: A cohort study in western Iran

PURPOSE

Hypertension (HTN) is one of the most common risk factors for non-communicable chronic diseases. The aim of the current study is to evaluate the prescribing patterns of antihypertensive medications in Kermanshah Province, west of Iran.

METHODS

The Ravansar Non-Communicable Diseases (RaNCD) cohort study is the first Kurdish community-based study; subjects' age ranged from 35 to 65 years. In order to examine the use of medications to control blood pressure, participants were asked to bring all prescribed medications to the study center. Treatments were compared with 2013 European Society of Hypertension (ESH)/European Society of Cardiology (ESC) Guidelines for the management of arterial HTN.

RESULTS

From a total of 10 040 participants in RaNCD cohort, 1575 (15.7%) individuals were hypertensive, of whom, 1271 (80.7%) people were aware of their condition. From 1153 (73.20%) people under treatment, 840 (72.8%) had their HTN properly controlled. The most common medications used to treat HTN were losartan (27.5%), metoprolol (14.3%), and captopril (11.9%). Regardless of type of treatment, 49.3% of all patients have received the medication for l 6 ≥ years. The most commonly used drugs were β-blockers and angiotension receptor blockers as 620 (31.0%) and 612 (30.6%), respectively. Multivariable analysis showed that female gender, those receive ≥3 antihypertensive agents, and using preferred combinations were associated with a better blood pressure control. In addition, the probability of hypertension control was less likely with increasing duration of treatment (i.e >6 years) and in obese patients with ≥35 kg/m2 .

CONCLUSIONS

Even though adherence to the international guidelines was acceptable, improvements can be made for better control of HTN. Therefore, it is imperative to educate healthcare professionals on improving their selection of antihypertensive medications and combination therapy for hypertensive patients.

Risk Factors Control After an Acute Coronary Syndrome and Association with Major Adverse Cardiovascular Events: A Single Center Experience in Latin-America

INTRODUCTION

An important challenge in the secondary prevention of cardiovascular diseases is the optimization of risk factors (RFs) after hospital discharge. These have been shown to be insufficiently controlled in clinical practice.

AIM

To evaluate whether secondary prevention goals were met at our institution at 12 months after an acute coronary syndrome (ACS) index event, as well as analyzing if achieving these goals was associated with a lower incidence of major adverse cardiovascular events (MACE).

METHODS

Retrospective cohort of patients with a former diagnosis of ACS over a period of 4 years. To evaluate the proportion of patients who met RF control goals at 12 months after the index event, we used two sets of preestablished goals: stringent and lenient. During follow-up we evaluated the occurrence of MACE, defined by the following: ACS, coronary revascularization, stroke, hospitalization because of acute heart failure and cardiovascular death.

RESULTS

We included 468 patients during the study period. The mean age of the patients was 60 ± 10.76 years, 20.5% were women, and mean follow-up was 41.8 ± 22.0 months. The proportion of patients that met all secondary prevention stringent and lenient goals accounted for 5.5% and 17.2%, respectively, and 8% did not achieve any target. Overall, 9.6% presented the composite of MACE during follow-up. The number of RFs in control at 12 months was associated with a lower rate of MACE, both with stringent and lenient goals.

CONCLUSION

Achieving established goals for modifiable RFs can lower the incidence of MACE during long-term follow-up.

Recent Developments in Drug Targets and Combination Therapy for the Clinical Management of Hypertension

Raised blood pressure is the most common complication worldwide that may lead to atherosclerosis and ischemic heart disease. Unhealthy lifestyles, smoking, alcohol consumption, junk food, and genetic disorders are some of the causes of hypertension. To treat this condition, numerous antihypertensive medications are available, either alone or in combination, that work via various mechanisms of action. Combinational therapy provides a certain advantage over monotherapy in the sense that it acts in multi mechanism mode and minimal drug amount is required to elicit the desired therapeutic effect. Such therapy is given to patients with systolic blood pressure greater than 20 mmHg and/or diastolic blood pressure exceeding 10 mmHg beyond the normal range, as well as those suffering from severe cardiovascular disease. The selection of antihypertensive medications, such as calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and low-dose diuretics, hinges on their ability to manage blood pressure effectively and reduce cardiovascular disease risks. This review provides insights into the diverse monotherapy and combination therapy approaches used for elevated blood pressure management. In addition, it offers an analysis of combination therapy versus monotherapy and discusses the current status of these therapies, from researchbased findings to clinical trials.

Mathematical modeling of antihypertensive therapy

Hypertension is a multifactorial disease arising from complex pathophysiological pathways. Individual characteristics of patients result in different responses to various classes of antihypertensive medications. Therefore, evaluating the efficacy of therapy based on in silico predictions is an important task. This study is a continuation of research on the modular agent-based model of the cardiovascular and renal systems (presented in the previously published article). In the current work, we included in the model equations simulating the response to antihypertensive therapies with different mechanisms of action. For this, we used the pharmacodynamic effects of the angiotensin II receptor blocker losartan, the calcium channel blocker amlodipine, the angiotensin-converting enzyme inhibitor enalapril, the direct renin inhibitor aliskiren, the thiazide diuretic hydrochlorothiazide, and the β-blocker bisoprolol. We fitted therapy parameters based on known clinical trials for all considered medications, and then tested the model's ability to show reasonable dynamics (expected by clinical observations) after treatment with individual drugs and their dual combinations in a group of virtual patients with hypertension. The extended model paves the way for the next step in personalized medicine that is adapting the model parameters to a real patient and predicting his response to antihypertensive therapy. The model is implemented in the BioUML software and is available at https://gitlab.sirius-web.org/virtual-patient/antihypertensive-treatment-modeling.

Development, Validation and Application of a Novel UHPLC-UV Method for the Simultaneous Determination of Valsartan and Nifedipine in the New Formulation of Self-Nanoemulsifying Drug Delivery Systems

Our objective is to develop a robust method to quantify valsartan (VAL) and nifedipine (NIF) in developed a self-nanoemulsifying drug delivery formulation. An in-house ultra-high-performance liquid chromatography (UHPLC UV) method has been developed and validated for the simultaneous determination of VAL and NIF. The UV detection was performed isocratically, with a mobile phase comprised of acetonitrile, methanol and ammonium formate in the ratios of (15:45:40% v/v) and a flow rate of 0.35 mL/min at 236 nm. The correlation coefficients (R2) of this linear regression were 0.9984 for NIF and 0.9997 for VAL, respectively. The limit of detection (LOD) for NIF as 3.78 ppm, whereas the limit of detection (LOD) for VAL was 1.56 ppm. The limit of quantification (LOQ) of NIF and VAL were 11.47 ppm and 4.73 ppm, respectively. This method was effectively utilized to determine the amount of drug entrapped and drug loading efficiency percentage of the NIF and VAL self-nanoemulsifying formulations.

Customised 3D printed multi-drug systems: An effective and efficient approach to polypharmacy

INTRODUCTION

Combination therapies continue to improve therapeutic outcomes as currently achieved by polypharmacy. Since the introduction of the polypill, there has been a significant improvement in adherence and patient outcomes. However, the mass production of polypills presents a number of technical, formulation, and clinical challenges. The current one-size-fits-all approach ignores the unique clinical demands of patients, necessitating the adoption of a more versatile tool. That will be the novel, but not so novel, 3D printing.

AREAS COVERED

: The present review investigates this promising paradigm shift from one medication for all, to customised medicines, providing an overview of the current state of 3D-printed multi-active pharmaceutical forms, techniques applied and printing materials. Details on cost implications, as well as potential limitations and challenges are also elaborated.

EXPERT OPINION

: 3D printing of multi-active systems, is not only beneficial but also essential. With growing interest in this field, a shift in manufacturing, prescribing, and administration patterns is at this point, unavoidable. Addressing limitations and challenges, as well as data presentation on clinical trial results, will aid in the acceleration of this technology's implementation. However, it is clear that 3D printing is not the end of it, as evidenced by the emerging 4D printing technology.

Efficacy of Single-Pill, Triple Antihypertensive Therapy in Patients with Uncontrolled Hypertension: A Systematic Review and Meta-analysis

INTRODUCTION

Systemic arterial hypertension is the most common preventable risk factor for all causes of morbidity and mortality worldwide with a prevalence of 35-40% of the adults. Despite the wide variety of effective antihypertensive medications, most hypertensive patients remain uncontrolled. However, the combination of ACE inhibitor, diuretics, and calcium antagonist for the triple therapy in a single Pill Combination (SPC) is an efficient regimen in hypertension management. It is recommended by the ESH 2018 guideline, which offers better efficacy and compliance to treatment.

AIM

To evaluate the efficacy of perindopril/indapamide/amlodipine single-pill combination in patients with uncontrolled hypertension.

METHODS

We searched PubMed, Scopus, Web of Science, and Cochrane CENTRAL for relevant clinical trials. We conducted the risk of bias assessment using Cochrane's risk of bias tool. We performed the analysis of continuous data using mean difference (MD) and relative 95% confidence interval (CI), while dichotomous data were analyzed using risk ratio (RR) and relative 95% CI. We included the analysis of the following outcomes: systolic blood pressure (SBP), Diastolic blood pressure (DBP), Heart rate (HR), 24 h Ambulatory blood pressure monitoring (ABPM) for SBP, and 24 h ABPM for DBP.

RESULTS

We included six clinical trials. We found that the triple therapy significantly reduces SBP by 24 mmHg (MD = - 24.65 [22.41, 26.89], (P < 0.01)), DBP by 12 mmHg (MD = 12.41 [11.53, 13.29], (P < 0.01)), 24-h ABPM for SBP by 14 mmHg (MD = 14.08 [9.10, 19.05], (P < 0.01)), and ABPM 24 h DBP by 7 mmHg (MD = 7.01 [5.37, 8.65], (P < 0.01)). We noted no significant difference of the single pill on heart rate (MD = 0.81 [- 0.04, 1.67], (P = 0.06).

CONCLUSION

perindopril/indapamide/amlodipine is effective in reducing systolic and diastolic blood pressures by 24 and 12 mmHg respectively. Over 24 h, the combination reduced systolic and diastolic blood pressures by 14 and 7 mmHg respectively.

How Hypertension Guidelines Address Social Determinants of Health: A Systematic Scoping Review

BACKGROUND

Patient-level and community-level social and economic conditions impact hypertension risk and control. We examined adult hypertension management guidelines to explore whether and how existing guidelines refer to social care activities.

OBJECTIVE

The objective of this study was to explore how hypertension guidelines reference social care activities.

RESEARCH DESIGN

A systematic scoping review of clinical guidelines for adult hypertension management. We employed a PubMed search strategy to identify all hypertension guidelines published in the United States between 1977 and 2019. We reviewed all titles to identify the most updated versions focused on nonpregnant adults with hypertension. We extracted instances where guidelines referred to social determinants of health (SDH) or social care activities. The primary outcome was how guidelines covered social care activities, defined using a framework adapted from the National Academies of Sciences, Engineering, and Medicine (NASEM).

RESULTS

Search terms yielded 126 guidelines. Thirty-six guidelines met the inclusion criteria. Of those, 72% (26/36) recommended social care activities as part of hypertension management; 58% recommended clinicians change clinical practice based on social risk information. These recommendations often lacked specific guidance around how to directly address social risk factors or reduce the impact of these risks on hypertension management. When guidelines referred to specific social factors, patient financial security was the most common. Over time, hypertension guidelines have included more references to SDH.

CONCLUSION

Information about SDH is included in many hypertension guidelines, but few guidelines provide clear guidance for clinicians or health systems on how to identify and address social risk factors in the context of care delivery.

3D Printing of Thermo-Sensitive Drugs

Three-dimensional (3D) printing is among the rapidly evolving technologies with applications in many sectors. The pharmaceutical industry is no exception, and the approval of the first 3D-printed tablet (Spiratam^®) marked a revolution in the field. Several studies reported the fabrication of different dosage forms using a range of 3D printing techniques. Thermosensitive drugs compose a considerable segment of available medications in the market requiring strict temperature control during processing to ensure their efficacy and safety. Heating involved in some of the 3D printing technologies raises concerns regarding the feasibility of the techniques for printing thermolabile drugs. Studies reported that semi-solid extrusion (SSE) is the commonly used printing technique to fabricate thermosensitive drugs. Digital light processing (DLP), binder jetting (BJ), and stereolithography (SLA) can also be used for the fabrication of thermosensitive drugs as they do not involve heating elements. Nonetheless, degradation of some drugs by light source used in the techniques was reported. Interestingly, fused deposition modelling (FDM) coupled with filling techniques offered protection against thermal degradation. Concepts such as selection of low melting point polymers, adjustment of printing parameters, and coupling of more than one printing technique were exploited in printing thermosensitive drugs. This systematic review presents challenges, 3DP procedures, and future directions of 3D printing of thermo-sensitive formulations.

Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants

BACKGROUND

Hypertension can be detected at the primary health-care level and low-cost treatments can effectively control hypertension. We aimed to measure the prevalence of hypertension and progress in its detection, treatment, and control from 1990 to 2019 for 200 countries and territories.

METHODS

We used data from 1990 to 2019 on people aged 30-79 years from population-representative studies with measurement of blood pressure and data on blood pressure treatment. We defined hypertension as having systolic blood pressure 140 mm Hg or greater, diastolic blood pressure 90 mm Hg or greater, or taking medication for hypertension. We applied a Bayesian hierarchical model to estimate the prevalence of hypertension and the proportion of people with hypertension who had a previous diagnosis (detection), who were taking medication for hypertension (treatment), and whose hypertension was controlled to below 140/90 mm Hg (control). The model allowed for trends over time to be non-linear and to vary by age.

FINDINGS

The number of people aged 30-79 years with hypertension doubled from 1990 to 2019, from 331 (95% credible interval 306-359) million women and 317 (292-344) million men in 1990 to 626 (584-668) million women and 652 (604-698) million men in 2019, despite stable global age-standardised prevalence. In 2019, age-standardised hypertension prevalence was lowest in Canada and Peru for both men and women; in Taiwan, South Korea, Japan, and some countries in western Europe including Switzerland, Spain, and the UK for women; and in several low-income and middle-income countries such as Eritrea, Bangladesh, Ethiopia, and Solomon Islands for men. Hypertension prevalence surpassed 50% for women in two countries and men in nine countries, in central and eastern Europe, central Asia, Oceania, and Latin America. Globally, 59% (55-62) of women and 49% (46-52) of men with hypertension reported a previous diagnosis of hypertension in 2019, and 47% (43-51) of women and 38% (35-41) of men were treated. Control rates among people with hypertension in 2019 were 23% (20-27) for women and 18% (16-21) for men. In 2019, treatment and control rates were highest in South Korea, Canada, and Iceland (treatment >70%; control >50%), followed by the USA, Costa Rica, Germany, Portugal, and Taiwan. Treatment rates were less than 25% for women and less than 20% for men in Nepal, Indonesia, and some countries in sub-Saharan Africa and Oceania. Control rates were below 10% for women and men in these countries and for men in some countries in north Africa, central and south Asia, and eastern Europe. Treatment and control rates have improved in most countries since 1990, but we found little change in most countries in sub-Saharan Africa and Oceania. Improvements were largest in high-income countries, central Europe, and some upper-middle-income and recently high-income countries including Costa Rica, Taiwan, Kazakhstan, South Africa, Brazil, Chile, Turkey, and Iran.

INTERPRETATION

Improvements in the detection, treatment, and control of hypertension have varied substantially across countries, with some middle-income countries now outperforming most high-income nations. The dual approach of reducing hypertension prevalence through primary prevention and enhancing its treatment and control is achievable not only in high-income countries but also in low-income and middle-income settings.

FUNDING

WHO.

Cardiovascular Benefits of Angiotensin-Converting Enzyme Inhibition Plus Calcium Channel Blockade in Patients Achieving Tight Blood Pressure Control and With Resistant Hypertension

BACKGROUND

The 2017 hypertension guidelines lowered systolic blood pressure (BP) goals to <130 mm Hg and redefined resistant hypertension. We investigated if these changes alter the cardiovascular benefits demonstrated by combining a calcium channel blocker (CCB), rather than hydrochlorothiazide (HCTZ), with an angiotensin-converting enzyme inhibitor (ACEI).

METHODS

In this post hoc analysis of the Avoiding Cardiovascular Events Through Combination Therapy in Patients Living with Systolic Hypertension trial (n = 11,506), we compared the primary composite outcome (cardiovascular death, myocardial infarction, stroke, hospitalization for angina, resuscitation after sudden cardiac death, and coronary revascularization) between the 2 combination-treatment limbs in patients achieving a systolic BP ≤130 mm Hg and those with "apparent resistant hypertension" (prescribed ≥4 antihypertensive medications).

RESULTS

Among study patients, 5,221 (45.4%) achieved a systolic BP ≤130 mm Hg. There were fewer primary endpoints in the amlodipine/benazepril (9.2%) vs. the HCTZ/benazepril (10.9%) limb (adjusted hazard ratio [HR] 0.83, 95% confidence interval [CI], 0.70-0.99). There were also fewer primary endpoints in the amlodipine/benazepril (12.8%) vs. the HCTZ/benazepril (15.2%) limb (n = 4,451, 38.7%) among patients with apparent resistant hypertension (HR 0.81, 95% CI, 0.70-0.95).

CONCLUSIONS

Combination therapy adding a CCB, rather than HCTZ, to an ACEI was more effective in preventing composite cardiovascular events even in hypertensive patients achieving aggressive systolic BP targets as well as in those with apparent resistant hypertension. Our findings add support that most patients, including those following contemporary clinical guidelines, will benefit from this combination.

CLINICAL TRIALS REGISTRATION

Trial Number NCT00170950.

Synthesis, 3D-pharmacophore modelling and 2D-QSAR study of new pyridine-3-carbonitriles as vasorelaxant active agents

A new set of pyridine-3-carbonitriles (3a–v) conjugated with various five-membered ring systems at pyridinyl C-6 were designed and synthesized as vasorelaxant active agents.

Cost-effectiveness analysis of antihypertensive triple combination therapy among patients enrolled in a Medicare advantage plan

OBJECTIVE

To assess the cost-effectiveness of single pill fixed dose triple combination therapy vs. free triple combination therapy for the prevention of cardiovascular events among patients with hypertension.

METHODS

A Markov model with a five year cycle was constructed. Two decision models incorporating strict and more relaxed adherence definitions estimated quality adjusted life years (QALYs) and health-care costs for single pill fixed triple combination therapy vs. free-drug combination therapy.

RESULTS

When the strict adherence measurement criteria were applied, the total QALYs loss and cost/patient were 6.38 QALYs, $486,026.20 for the single pill triple combination therapy and 8.64 QALYs, $406,405.26 for the free combination therapy. ICER for single pill combination therapy compared to free combination therapy was 33,826.46/QALY. When the relaxed adherence measurement criteria were applied, the total QALYs loss and cost/patient were 8.09 QALYs, $493,404.26 for the single pill triple combination therapy and 8.76 QALYs, $436,415.14 for the free combination therapy. ICER for single pill combination compared with free combination therapy was 84,932.26.

CONCLUSION

This study suggested that single pill triple combination therapy was cost-effective in comparison with free combination therapy under a willingness to pay threshold of 50,000 when the strict adherence measurement criteria was applied.

Antihypertensive polytherapy in Australia: prevalence of inappropriate combinations, 2013-2018

OBJECTIVES

To estimate the prevalence of inappropriate antihypertensive polytherapy in Australia.

METHODS

We used a nationally representative 10% sample of Pharmaceutical Benefits Scheme (PBS) eligible Australians and their dispensing history to identify people aged 18+ years exposed to at least one PBS-listed antihypertensive between 2012 and 2018. We measured prevalence of antihypertensive polypharmacy (≥40 days concomitant exposure), inappropriate antihypertensive combinations (against guideline recommendations; within-class polytherapy) and combinations to be used with caution.

RESULTS

Almost half (47.5%) of people using antihypertensives in 2018 experienced polytherapy. Among these, 2.4% had an inappropriate combination (1.5% against guidelines; 1.0% within-class polytherapy). Inappropriate combinations were more prevalent in people experiencing polytherapy with three (3.7%) or four (16.1%) antihypertensive medicines than people on dual therapy (0.7%). Inappropriate combinations occurred at a lower rate in people using fixed-dose rather than free-drug combinations for dual therapy (0 vs. 0.7%) and in those using three antihypertensives (2.4 vs. 7.3%); this was not the case for people using four or more antihypertensives (15.5 vs. 16.1%). Between 2013 and 2018, the prevalence of antihypertensive polytherapy was relatively stable (49-47%); however, the prevalence of inappropriate combinations among these patients halved (from 5.1 to 2.4%).

CONCLUSION

Antihypertensive polytherapy in Australia is common, but the prevalence of inappropriate combinations is low and decreasing over time, suggesting strong awareness of Australian clinical guidelines. However, in 2018, approximately 49 000 Australian adults experienced inappropriate polytherapy; prescribing of fixed-dose combinations in patients on dual or triple therapy may further reduce this inappropriate care, although increased vigilance treating patients with more than 3 antihypertensives is required.

Antihypertensive constituents in Sanoshashinto

It has been reported that Sanoshashinto (SanHuangXieXinTang, 三黃瀉心湯), which is composed of Rhei Rhizoma, Scutellariae Radix, and Coptidis Rhizoma, exhibits vasorelaxant effects in vitro and lowers blood pressure of patients. Based on this discovery, in this study, a mixture containing those three materials and combinations of them were extracted with methanol, and the extracts were fractionated into different parts. Effects of all extracts and fractions on high concentration of potassium chloride (High K⁺)- or noradrenaline (NA)-induced contractions of isolated rat aortic rings or helical strips were examined. Qualitative and quantitative HPLC analyses of the extracts and the fractions revealed that the contents of baicalin and berberine in Sanoshashinto methanol extract (SHXXTM) were higher than those of the other constituents. All pharmacological and HPLC data were analyzed by principal component analysis (PCA) software and the results indicated that baicalin, berberine, palmatine, baicalein, and wogonoside contributed significantly to the pharmacological activity. Furthermore, spontaneously hypertensive rats (SHRs) that were orally given SHXXTM or a baicalin–berberine combination showed significantly reduced increase in the rate of systolic blood pressure (SBP) compared to the control group. These findings suggested that Sanoshashinto has significant vasorelaxant effects in vitro and antihypertensive effects in vivo, and baicalin and berberine, which were the principal constituents of Scutellariae Radix and Coptidis Rhizoma, were the main antihypertensive constituents in Sanoshashinto. It was speculated that baicalin and berberine produced vasorelaxant effects by activating the NO/cGMP pathway and that the BK_Ca channel and the DAG/PKC/CPI-17 pathway were also involved.

Long-term and recent trends in hypertension awareness, treatment, and control in 12 high-income countries: an analysis of 123 nationally representative surveys

BACKGROUND

Antihypertensive medicines are effective in reducing adverse cardiovascular events. Our aim was to compare hypertension awareness, treatment, and control, and how they have changed over time, in high-income countries.

METHODS

We used data from people aged 40-79 years who participated in 123 national health examination surveys from 1976 to 2017 in 12 high-income countries: Australia, Canada, Finland, Germany, Ireland, Italy, Japan, New Zealand, South Korea, Spain, the UK, and the USA. We calculated the proportion of participants with hypertension, which was defined as systolic blood pressure of 140 mm Hg or more, or diastolic blood pressure of 90 mm Hg or more, or being on pharmacological treatment for hypertension, who were aware of their condition, who were treated, and whose hypertension was controlled (ie, lower than 140/90 mm Hg).

FINDINGS

Data from 526 336 participants were used in these analyses. In their most recent surveys, Canada, South Korea, Australia, and the UK had the lowest prevalence of hypertension, and Finland the highest. In the 1980s and early 1990s, treatment rates were at most 40% and control rates were less than 25% in most countries and age and sex groups. Over the time period assessed, hypertension awareness and treatment increased and control rate improved in all 12 countries, with South Korea and Germany experiencing the largest improvements. Most of the observed increase occurred in the 1990s and early-mid 2000s, having plateaued since in most countries. In their most recent surveys, Canada, Germany, South Korea, and the USA had the highest rates of awareness, treatment, and control, whereas Finland, Ireland, Japan, and Spain had the lowest. Even in the best performing countries, treatment coverage was at most 80% and control rates were less than 70%.

INTERPRETATION

Hypertension awareness, treatment, and control have improved substantially in high-income countries since the 1980s and 1990s. However, control rates have plateaued in the past decade, at levels lower than those in high-quality hypertension programmes. There is substantial variation across countries in the rates of hypertension awareness, treatment, and control.

FUNDING

Wellcome Trust and WHO.

Counter-regulatory renin-angiotensin system in cardiovascular disease

The renin-angiotensin system is an important component of the cardiovascular system. Mounting evidence suggests that the metabolic products of angiotensin I and II - initially thought to be biologically inactive - have key roles in cardiovascular physiology and pathophysiology. This non-canonical axis of the renin-angiotensin system consists of angiotensin 1-7, angiotensin 1-9, angiotensin-converting enzyme 2, the type 2 angiotensin II receptor (AT₂R), the proto-oncogene Mas receptor and the Mas-related G protein-coupled receptor member D. Each of these components has been shown to counteract the effects of the classical renin-angiotensin system. This counter-regulatory renin-angiotensin system has a central role in the pathogenesis and development of various cardiovascular diseases and, therefore, represents a potential therapeutic target. In this Review, we provide the latest insights into the complexity and interplay of the components of the non-canonical renin-angiotensin system, and discuss the function and therapeutic potential of targeting this system to treat cardiovascular disease.

3D Printing of a Multi-Layered Polypill Containing Six Drugs Using a Novel Stereolithographic Method

Three-dimensional printing (3DP) has demonstrated great potential for multi-material fabrication because of its capability for printing bespoke and spatially separated material conformations. Such a concept could revolutionise the pharmaceutical industry, enabling the production of personalised, multi-layered drug products on demand. Here, we developed a novel stereolithographic (SLA) 3D printing method that, for the first time, can be used to fabricate multi-layer constructs (polypills) with variable drug content and/or shape. Using this technique, six drugs, including paracetamol, caffeine, naproxen, chloramphenicol, prednisolone and aspirin, were printed with different geometries and material compositions. Drug distribution was visualised using Raman microscopy, which showed that whilst separate layers were successfully printed, several of the drugs diffused across the layers depending on their amorphous or crystalline phase. The printed constructs demonstrated excellent physical properties and the different material inclusions enabled distinct drug release profiles of the six actives within dissolution tests. For the first time, this paper demonstrates the feasibility of SLA printing as an innovative platform for multi-drug therapy production, facilitating a new era of personalised polypills.

Medication Adherence to Antihypertensive Triple-Combination Therapy Among Patients Enrolled in a Medicare Advantage Plan

BACKGROUND

Approximately 32% (75 million) of adults have hypertension in the United States, leading to 1,100 daily deaths and costing more than $48 billion annually in medical expenditures. Approximately 25% of patients with hypertension require triple combination therapy to reach recommended blood pressure. Currently, only 3 single-pill triple-combination therapies are available in the market for the treatment of hypertension. Medication adherence has become a major concern for the health care system, and nonadherence is associated with higher risks of morbidity and mortality.

OBJECTIVE

To compare medication adherence rates among single-pill triple-combination therapy, free triple-combination therapy, and fixed-dose dual-combination therapy plus a third agent in hypertensive patients enrolled in a Medicare Advantage prescription drug plan using 2 adherence definitions.

METHODS

A retrospective cohort study was conducted using Cigna-HealthSpring's medical claims database from January 2014 to December 2016. Antihypertensive combination therapy users were classified into a single-pill triple-combination group, a fixed-dose dual-combination plus a third agent group, and a free triple-combination group. Adherence rates using proportion of days covered (PDC) were calculated for each group within a 1-year follow-up period using 2 definitions: a strict one requiring all antihypertensive agents during follow-up and a more relaxed definition requiring any antihypertensive agent during follow-up. Descriptive statistics were examined, and group differences were assessed using chi-square and analysis of variance. Multivariate logistic regression was conducted to control confounders of adherence using both definitions.

RESULTS

10,836 triple-combination users were identified. In the multivariate model using the first definition, fixed-dose dual-combination plus a third agent was significantly associated with lower adherence compared with single-pill triple therapy (OR = 0.177; 95% CI = 0.119-0.263; P < 0.001). No significant difference was detected between single-pill triple-combination therapy in comparison with free-combination therapy. In the multivariate model using the second definition, fixed-dose dual-combination plus a third agent and free-combination therapy were significantly associated with better adherence in comparison with single-pill triple combination therapy (OR = 3.62, 95% CI = 2.59-5.05; OR = 4.31, 95% CI = 2.15-8.64, respectively). Younger age, female gender, language (Spanish), some comorbidities, and previous hospitalization had a negative effect on adherence.

CONCLUSIONS

Measuring adherence to multiple concurrent regimens is complicated and different adherence definitions can result in significant variations in adherence measures. Future research evaluating clinical outcomes with various definitions is needed.

DISCLOSURES

No outside funding supported this study. Abughosh reports grants from Sanofi, Regeneron, Valeant Pharmaceuticals, BMS/Pfizer, and PhRMA, not related to this study. Serna reports employement with CareAllies, a Cigna company. The other authors have no conflicts of interest to disclose.

Photocurable Bioinks for the 3D Pharming of Combination Therapies

Combination therapies mediate drug synergy to improve treatment efficacy and convenience, leading to higher levels of compliance. However, there are challenges with their manufacturing as well as reduced flexibility in dosing options. This study reports on the design and characterization of a polypill fabricated through the combination of material jetting and binder jetting for the treatment of hypertension. The drugs lisinopril and spironolactone were loaded into hydrophilic hyaluronic acid and hydrophobic poly(ethylene glycol) (PEG) photocurable bioinks, respectively, and dispensed through a piezoelectric nozzle onto a blank preform tablet composed of two attachable compartments fabricated via binder jetting 3D printing. The bioinks were photopolymerized and their mechanical properties were assessed via Instron testing. Scanning electron microscopy (SEM) was performed to indicate morphological analysis. The polypill was ensembled and drug release analysis was performed. Droplet formation of bioinks loaded with hydrophilic and hydrophobic active pharmaceutical ingredients (APIs) was achieved and subsequently polymerized after a controlled dosage was dispensed onto preform tablet compartments. High-performance liquid chromatography (HPLC) analysis showed sustained release profiles for each of the loaded compounds. This study confirms the potential of material jetting in conjunction with binder jetting techniques (powder-bed 3D printing), for the production of combination therapy oral dosage forms involving both hydrophilic and hydrophobic drugs.

Nebivolol/Valsartan: A Novel Antihypertensive Fixed-Dose Combination Tablet

Data Sources: A PubMed (1966 to October 2018) search was conducted using the following keywords: nebivolol, valsartan, and hypertension (HTN). Additional sources were identified by references. Study Selection and Data Extraction: Articles written in English were included if they evaluated the pharmacology, pharmacokinetics, efficacy, safety, or place in therapy of nebivolol/valsartan in human subjects. Data Synthesis: Most patients with HTN require combination therapy; however, β-adrenergic antagonists and AII type 1 receptor blockers have been considered less effective because of overlapping mechanisms of action. A phase III, randomized trial demonstrated that nebivolol/valsartan produced statistically significant blood pressure (BP) lowering as compared with monotherapy with the individual components or placebo. Substudy analyses confirmed this among subgroups and demonstrated that nebivolol/valsartan decreased plasma renin and aldosterone levels. One trial reported continued BP lowering at 52 weeks. Another study showed that nebivolol/valsartan had similar additivity scores as compared with other antihypertensive combinations. Relevance to Patient Care and Clinical Practice: This review discusses drug information, efficacy, and safety of nebivolol/valsartan and discusses its clinical relevance as a novel combination product in managing patients with HTN. Conclusion: Nebivolol/valsartan combination may offer a benefit to patients with an indication for both classes who desire to decrease pill burden. Although BP lowering was statistically significant in comparison to the individual components as monotherapy, the combination does not offer clinically significant benefits that would elevate its place in HTN management.

Insights on β-blockers for the treatment of hypertension: A survey of health care practitioners

A quantitative survey was completed by 103 primary care physicians (PCPs) and 59 cardiologists who regularly prescribed β-blockers to assess knowledge and use of this heterogeneous drug class for hypertension. More cardiologists than PCPs chose β-blockers as initial antihypertensive therapy (30% vs 17%, P < 0.01). Metoprolol and carvedilol were the most commonly prescribed β-blockers. Cardiologists rated "impact on energy" and "arterial vasodilation" as more important than PCPs (P < 0.05/<0.01, respectively). Awareness of vasodilation was greater for carvedilol (52%) than nebivolol (31%). Association between β-blockers and clinical variables included nebivolol with β₁ -selectivity, nebivolol and carvedilol with vasodilation and efficacy in older patients and African Americans, metoprolol with heart rate reduction, and atenolol and metoprolol with weight gain and hyperglycemia. Physicians preferred prescribing β-blockers with lower risk of incident diabetes. Clinical practice guidelines influenced physician prescribing more than formularies or performance metrics. This survey captures physicians' perceptions/use of various β-blockers and clinically relevant knowledge gaps.

Association Trends Between Antihypertensive Drug Therapies and Diastolic Hypotension in Emirati Patients with Type 2 Diabetes: A Single-Center Retrospective Longitudinal Study

INTRODUCTION

Diabetes mellitus (DM) is associated with multiple complications, including cardiovascular diseases. Previously, it was believed that the latter are mainly caused by hypertension and increased systolic blood pressure. However, recent studies have challenged this concept, by showing that diastolic dysfunction may also be involved in the cardiovascular events that are associated with DM. Pharmacologic management of hypertension in patients with type 2 DM appears to adversely influence diastolic function.

METHODS

Four hundred and eight medical records of hypertensive and obese Emirati patients with type 2 DM were included in the present retrospective study. The main objectives of the present study were (1) to determine the prevalence of low diastolic blood pressure (DBP) and diastolic hypotension in this group of patients and (2) to investigate the associations, if any, between the use of various antihypertensive medications and low DBP and diastolic hypotension.

RESULTS

The results of the present study showed that low DBP (< 70 mmHg) was experienced by 40% of the hypertensive type 2 DM patients, whereas diastolic hypotension (< 60 mmHg) was reported to occur in about 10% of the patients. Another important factor that has been significantly correlated with diastolic hypotension is age (p < 0.01). Association trends have been reported between low DBP and diastolic hypotension and several antihypertensive therapies, including (1) monotherapies such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs), (2) dual therapies such as ACE inhibitors in combination with thiazide-like diuretics (THLDs) or beta blockers, and (3) triple therapy combinations of ACE inhibitors with THLDs and potassium-sparing diuretics.

CONCLUSION

The use of antihypertensive medications, in particular ACE inhibitors and ARBs, appears to be a risk factor for the development of low DBP and diastolic hypotension in obese hypertensive Emirati patients with type 2 DM, whereas calcium channel blockers seem to be a safer option for this group of patients.

Chronotherapy for Hypertension

PURPOSE OF REVIEW

Given the emerging knowledge that circadian rhythmicity exists in every cell and all organ systems, there is increasing interest in the possible benefits of chronotherapy for many diseases. There is a well-documented 24-h pattern of blood pressure with a morning surge that may contribute to the observed morning increase in adverse cardiovascular events. Historically, antihypertensive therapy involves morning doses, usually aimed at reducing daytime blood pressure surges, but an absence of nocturnal dipping blood pressure is also associated with increased cardiovascular risk.

RECENT FINDINGS

To more effectively reduce nocturnal blood pressure and still counteract the morning surge in blood pressure, a number of studies have examined moving one or more antihypertensives from morning to bedtime dosing. More recently, such studies of chronotherapy have studied comorbid populations including obstructive sleep apnea, chronic kidney disease, or diabetes. Here, we summarize major findings from recent research in this area (2013-2017). In general, nighttime administration of antihypertensives improved overall 24-h blood pressure profiles regardless of disease comorbidity. However, inconsistencies between studies suggest a need for more prospective randomized controlled trials with sufficient statistical power. In addition, experimental studies to ascertain mechanisms by which chronotherapy is beneficial could aid drug design and guidelines for timed administration.

Risk of Hospitalization for Cardiovascular Events with β-Blockers in Hypertensive Patients: A Retrospective Cohort Study

INTRODUCTION

β-Blockers are a heterogenous class of drugs that are no longer recommended for initial antihypertension monotherapy due to unfavorable long-term cardiovascular events observed with non-vasodilatory β-blockers. However, the comparative cardiovascular event risk between the vasodilatory β₁-selective antagonist/β₃ agonist nebivolol and non-vasodilatory β₁-blockers, atenolol and metoprolol, is unknown.

METHODS

Incident nebivolol, atenolol, or metoprolol monotherapy users with hypertension were identified using US claims data (2007-2014). The first β-blocker claim on/after 1/1/2008 defined the index drug/date. Hypertensive patients without pre-index cardiovascular history were followed until index drug discontinuation (> 90 day supply gap), use of other β-blockers, or end of continuous plan enrollment. Patients were pair-wise propensity score-matched using logistic regression, adjusted for baseline demographics, Charlson Comorbidity Index score, comorbid chronic pulmonary disease, rheumatic disease, renal disease, and diabetes, and use of other antihypertensive drugs during baseline. Time to first hospital claim for a cardiovascular event was assessed via Cox proportional hazards regression, adjusted for the variables above.

RESULTS

Inclusion criteria were met by 81,402 patients (n = 27,134 in each matched treatment cohort), with no between-cohort differences in baseline characteristics, comorbid conditions, or average follow-up duration. Atenolol and metoprolol cohorts had greater risk of hospitalization for a composite event (myocardial infarction, angina, congestive heart failure, stroke) than nebivolol users (adjusted hazard ratios [95% confidence interval] atenolol: 1.68 [1.29, 2.17]; metoprolol: 2.05 [1.59, 2.63]; P < 0.001, both). Risks of most individual cardiovascular events were also lower with nebivolol, including myocardial infarction and angina versus atenolol, and myocardial infarction, congestive heart failure, and angina versus metoprolol (P < 0.05, all).

CONCLUSIONS

Nebivolol was associated with significantly lower risk of hospitalization due to composite cardiovascular events than atenolol or metoprolol in this large retrospective cohort study of monotherapy with three different β₁-selective blockers in hypertensive patients.

FUNDING

Allergan plc, Madison, NJ, USA.

In vitro and in vivo pharmacokinetic and pharmacodynamic study of MBRI-001, a deuterium-substituted plinabulin derivative as a potent anti-cancer agent

MBRI-001 was demonstrated preliminary better pharmacokinetics and antitumor effects than that of plinabulin in vivo. In this approach, we further carried out systematic pharmacokinetic and pharmacodynamic study of MBRI-001 in vitro and in vivo. MBRI-001 was tested stable in rat plasma and more stable in liver microsomes than plinabulin in vitro. In vivo, MBRI-001 could be distributed rapidly and widely in various tissues, especially the concentration of MBRI-001 in lung was remarkably higher than other tissues. Excretion study indicated that MBRI-001 might been decomposed and excreted as metabolites. Additionally, the combination treatment of MBRI-001 and gefitinib revealed better antitumor inhibition rate than monotherapy in vivo. Therefore, we suggest that MBRI-001 could be developed as a promising anti-cancer agent in near future.

TRIPLE ANTIHYPERTENSIVE THERAPY: FOCUS ON EFFICACY AND PROGNOSIS

In the article, with regard to current clinical recommendations, the place of combined antihypertensive therapy, especially triple drugs regimens, is considered in the treatment of patients with arterial hypertension. Special focus is given to the body of evidence for the efficacy of valsartan and amlodipine, as the reference drug of angiotensin II receptor blockers and calcium channel blockers, respectively. Not only their high antihypertensive properties are demonstrated, but also a favorable effect on target-organ protection and prognosis is described. In particular, the possibilities of valsartan in reducing the severity of left ventricular hypertrophy and microalbuminuria are described, and its unique properties in the class of sartans that allow the use of this drug in patients with ischemic heart disease and chronic heart failure are emphasized. Data on the antiatherosclerotic effects of amlodipine and its proven ability to reduce cardiovascular risk are presented. Current data are presented about their use in a fixed-dose combination with hydrochlorothiazide, including real clinical practice settings. The evidence base of high clinical efficacy, safety and metabolic neutrality of the triple combination of antihypertensive drugs valsartan, amlodipine and hydrochorothiazide is presented. The issues of increasing adherence of patients to treatment when prescribing fixed-dose combinations are considered. An algorithm for the selection of antihypertensive drugs in the form of monotherapy and combination therapy of two or three drugs depending on the clinical situation (the presence of certain target-organs damages and associated clinical conditions, primarily ischemic heart disease, atherosclerosis of carotid arteries and chronic heart failure) and the severity of the additional risk of cardiovascular complications.

Polyamidoamine Dendrimers for Enhanced Solubility of Small Molecules and Other Desirable Properties for Site Specific Delivery: Insights from Experimental and Computational Studies

Clinical applications of many small molecules are limited due to poor solubility and lack of controlled release besides lack of other desirable properties. Experimental and computational studies have reported on the therapeutic potential of polyamidoamine (PAMAM) dendrimers as solubility enhancers in pre-clinical and clinical settings. Besides formulation strategies, factors such as pH, PAMAM dendrimer generation, PAMAM dendrimer concentration, nature of the PAMAM core, special ligand and surface modifications of PAMAM dendrimer have an influence on drug solubility and other recommendable pharmacological properties. This review, therefore, compiles the recently reported applications of PAMAM dendrimers in pre-clinical and clinical uses as enhancers of solubility and other desirable properties such as sustained and controlled release, bioavailability, bio-distribution, toxicity reduction or enhancement, and targeted delivery of small molecules with emphasis on cancer treatment.

Rationale for nebivolol/valsartan combination for hypertension: review of preclinical and clinical data

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.

Prior Medications and the Cardiovascular Benefits From Combination Angiotensin-Converting Enzyme Inhibition Plus Calcium Channel Blockade Among High-Risk Hypertensive Patients

Background

The ACCOMPLISH (Avoiding Cardiovascular Events Through Combination Therapy in Patients Living with Systolic Hypertension) trial demonstrated that combination therapy using amlodipine, rather than hydrochlorothiazide, in conjunction with benazepril provided greater cardiovascular risk reduction among high‐risk hypertensive patients. Few trials have evaluated the effect of prior antihypertensive therapy used among participants on the study outcomes.

Methods and Results

In a post hoc observational analysis, we examined the characteristics of the drug regimens taken before trial enrollment in the context of the primary composite outcome (death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, hospitalization for angina, resuscitation after sudden cardiac death, and coronary revascularization). In the “primary subgroup” (n=4475), patients previously taking any renin‐angiotensin system blockade plus either a diuretic or a calcium channel blocker alone or as part of their antihypertensive regimen, there were 206 of 2193 (9.4%) versus 281 of 2282 (12.3%) primary composite events among those randomized to combination therapy involving amlodipine versus hydrochlorothiazide, respectively (adjusted Cox proportional hazard ratio, 0.74; 95% confidence interval, 0.62–0.89; P=0.0015). All other participants (n=6975) previously taking any antihypertensive regimen not included in the primary subgroup also benefited from randomization to amlodipine plus benazepril (adjusted hazard ratio, 0.84; 95% confidence interval, 0.72–0.98; P=0.024). Outcomes among most other subgroups, including patients previously taking lipid‐lowering medications or dichotomized by prior blood pressure control status, showed similar results.

Conclusions

When combined with an angiotensin‐converting enzyme inhibitor, amlodipine provides cardiovascular risk reduction superior to hydrochlorothiazide, largely regardless of prior medication use. These findings add further support for the initial use of this combination regimen among high‐risk hypertensive patients.

Adhering to the principles of clinical pharmacology - the correct fixed combinations of antihypertensive drugs

INTRODUCTION

Hypertension is one of the primary modifiable risk factor for cardiac and renal diseases with the prevalence around 30-45% of the general population, with a steep increase with ageing. The administration of blood pressure-lowering drugs is to reduce the risk of major clinical cardiovascular outcomes. Hypertension guidelines recommend combination therapy in patients with high cardiovascular risk and with subclinical organ damage as well as when monotherapy fails. Areas covered: As the etiology of essential hypertension is multifactorial, combination therapy using different classes of antihypertensive agents have greater effect than each on its own (synergistic effect), may have better tolerability (two components minimizing each other's side effects) and lead to improved patient compliance. Several studies assess the hypotensive efficacy on drug combination; there are also studies on triple drug combination. Expert commentary: At present, dual and triple combination therapy is available to hypertensive patients with good clinical outcomes, compliance and low profile of side effects. It is critical as patients' adherence to the pharmacological therapy significantly decreases the risk of long-term adverse events including mortality. It appears that combinations not only of hypotensive drugs but also with statins (as well as antidiabetics) will be widely used.

Additivity of nebivolol/valsartan single-pill combinations versus other single-pill combinations for hypertension

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.

Multi-kinetics and site-specific release of gabapentin and flurbiprofen from oral fixed-dose combination: in vitro release and in vivo food effect

In this work, a fixed-dose combination of gabapentin and flurbiprofen formulated as multilayer tablets has been designed, developed and studied in vitro and in vivo. The aim was to construct a single dosage form of the two drugs, able to perform a therapeutic program involving three release kinetics and two delivery sites, i.e., immediate release of gabapentin, intra-gastric prolonged release of gabapentin and intestinal (delayed) release of flurbiprofen. An oblong three-layer tablet was manufactured having as top layer a floating hydrophilic polymeric matrix for gastric release of gabapentin, as middle layer a disintegrating formulation for immediate release of a gabapentin loading dose and as bottom layer, an uncoated hydrophilic polymeric matrix, swellable but insoluble in gastric fluids, for delayed and prolonged release of flurbiprofen in intestinal environment. The formulations were studied in vitro and in vivo in healthy volunteers. The in vitro release rate assessment confirmed the programmed delivery design. A significant higher bioavailability of gabapentin administered 30min after meal, compared to fasting conditions or to dose administration 10min before meal, argued in favor of the gastro-retention of gabapentin prolonged release layer. The two drugs were delivered at different anatomical sites, since the food presence prolonged the gastric absorption of gabapentin from the floating layer and delayed the flurbiprofen absorption. The attainment of a successful delayed release of flurbiprofen was realized by a matrix based on a polymers' combination. The combined use of three hydrophilic polymers with different pH sensitivity provided the dosage form layer containing flurbiprofen with gastro-resistant characteristics without the use of film coating.

Macro-Raman spectroscopy for bulk composition and homogeneity analysis of multi-component pharmaceutical powders

A new macro-Raman system equipped with a motorized translational sample stage and low-frequency shift capabilities was developed for bulk composition and homogeneity analysis of multi-component pharmaceutical powders. Different sampling methods including single spot and scanning measurement were compared. It was found that increasing sample volumes significantly improved the precision of quantitative composition analysis, especially for poorly mixed powders. The multi-pass cavity of the macro-Raman system increased effective sample volumes by 20 times from the sample volume defined by the collection optics, i.e., from 0.02μL to about 0.4μL. A stochastic model simulating the random sampling process of polydisperse microparticles was used to predict the sampling errors for a specific sample volume. Comparison of fluticasone propionate mass fractions of the commercial products Flixotide^® 250 and Seretide^® 500 simulated for different sampling volumes with experimentally measured compositions verified that the effective sample volume of a single point macro-Raman measurement in the multi-pass cavity of this instrument was between 0.3μL and 0.5μL. The macro-Raman system was also successfully used for blend uniformity analysis. It was concluded that demixing occurred in the binary mixture of l-leucine and d-mannitol from the observation that the sampling errors indicated by the standard deviations of measured leucine mass fractions increased during mixing, and the standard deviation values were all larger than the theoretical lower limit determined by the simulation. Since sample volume was shown to have a significant impact on measured homogeneity characteristics, it was concluded that powder homogeneity analysis results, i.e., the mean of individual test results and absolute and relative standard deviations, must be presented together with the effective sample volumes of the applied testing techniques for any measurement of powder homogeneity to be fully meaningful.

National patterns in intensity and frequency of outpatient care for apparent treatment-resistant hypertension

BACKGROUND

Apparent treatment-resistant hypertension (aTRH) is associated with an increased risk of adverse cardiovascular outcomes. We studied the frequency and intensity of care for aTRH among participants aged 65 years and older in the US-based REGARDS study linked with Medicare claims.

METHODS

Blood pressure (BP) was measured twice and averaged. aTRH was defined by the use of ≥3 classes of antihypertensive medication and uncontrolled BP (UaTRH, systolic/diastolic BP ≥140/90 mmHg), or ≥4 classes with controlled BP (CaTRH). Participants were categorized as not having aTRH (no aTRH), CaTRH or UaTRH.

RESULTS

Among 4650 participants with hypertension, 468 (10.1%) had UaTRH, 247 (5.3%) had CaTRH, and 3935 (84.6%) had hypertension but did not have aTRH. For hypertension-related visits, those with UaTRH saw primary care physicians and cardiologists more frequently than those without aTRH (mean primary care visits per year: 2.77 vs 2.27, P<.001; cardiologists: 0.50 vs 0.35, P=.014). Among those with UaTRH, CaTRH, and no aTRH, respectively 73.5%, 68.0%, and 67.5% had >1 hypertension-related visit per year. Among those with UaTRH, males vs females (prevalence ratio=0.78; 95% CI 0.69-0.89), whites vs blacks (0.88; 95% CI 0.78-0.99), and current smokers vs non-smokers (0.66; 95% CI 0.48-0.89) were less likely to receive >1 hypertension-related visit per year. Diagnostic intensity, measured by testing for end organ damage and secondary hypertension, was similar between groups.

CONCLUSIONS

Many people with UaTRH are not seen more than once per year for hypertension and may benefit from increased care.

Synthetic approaches towards the multi target drug spironolactone and its potent analogues/derivatives

Spironolactone is a well-known multi-target drug and is specifically used for the treatment of high blood pressure and heart failure. It is also used for the treatment of edema, cirrhosis of the liver, malignant, pediatric, nephrosis and primary hyperaldosteronism. Spironolactone in association with thiazide diuretics treats hypertension and in association with furosemide treats bronchopulmonary dyspepsia. The therapeutic mechanism of action of spironolactone involves binding to intracellular mineralocorticoids receptors (MRs) in kidney epithelial cells, thereby inhibiting the binding of aldosterone. Since its first synthesis in 1957 there are several synthetic approaches have been reported throughout the years, Synthetic community has devoted efforts to improve the synthesis of spironolactone and to synthesize its analogues and derivatives. This review aims to provide comprehensive insight for the synthetic endeavors devoted towards the synthesis of a versatile drug spironolactone and its analogues/derivatives.

The Efficacy of Perindopril/Amlodipine in Reaching Blood Pressure Targets: Results of the CONTROL Study

BACKGROUND

Inadequate blood pressure (BP) control remains a serious concern worldwide. Recent evidence suggests that the combination of a calcium channel blocker (CCB) with an angiotensin-converting enzyme inhibitor (ACEi) in patients with essential hypertension provides effective BP control with decreased adverse cardiac and renal events.

OBJECTIVES

This study was designed to quantitatively evaluate the efficacy and tolerability of a fixed dose combination of perindopril and amlodipine in the Kingdom of Saudi Arabia on a population of patients with essential hypertension, as well as to identify the predictors of BP control in this population.

METHODS

This was an observational, multicenter, open-label cohort study of patients with essential hypertension with or without diabetes mellitus, treated with a fixed dose combination of perindopril and amlodipine. Patients were followed up in four-week intervals for a total of 12 weeks. They were initially started on the lowest dose of the ACEi/CCB combination and up-titrated at each follow-up according to their response to treatment. The primary end-point of the study was the percentage of patients with controlled BP at study termination (week 12).

RESULTS

A total of 1996 patients completed the study. Both systolic blood pressure (SBP) and diastolic blood pressure (DBP) control was observed in 93.3% of patients at week 12. As for the predictors of BP control, it was found that female gender was associated with more BP control [odds ratio (OR) = 1.76, 95% CI: 1.14-2.70, p value = 0.01], whereas older age was associated with less BP control (OR = 0.98, 95% CI: 0.96-1.00, p value = 0.02). Similarly, having type I and type II diabetes mellitus was also associated with less BP control (OR = 0.19, 95% CI: 0.08-0.45, p < 0.0001 and OR = 0.33, 95% CI: 0.22-0.48, p < 0.0001, respectively). In a qualitative assessment, both investigators and patients perceived efficacy and tolerability of perindopril/amlodipine to be excellent.

CONCLUSION

We found that a fixed combination of perindopril/amlodipine is effective in controlling BP in patients with essential hypertension, with older age, male gender, and diabetes mellitus being independent risk factors for less BP control.

Management of Cardiovascular Risk Factors in Type 2 Diabetes Mellitus Patients

People with Type 2 diabetes mellitus (T2DM), compared with non-diabetic individuals, have increased cardiovascular risk. Part of this excess risk is associated with a higher prevalence of other cardiovascular risk factors in these patients, such as obesity, dyslipidaemia, and hypertension. However, the increased cardiovascular risk present in T2DM cannot be attributed entirely to the high prevalence of traditional risk factors and other non-traditional risk factors may also be important for people with T2DM. Evidence suggests that in patients with T2DM, treatment of cardiovascular risk factors is very important in reducing the risk of cardiovascular disease (CVD). The poor control of risk factors observed in the diabetic population supports the need for more aggressive treatment of modifiable cardiovascular risk factors, especially in patients with previous CVD. There is little evidence on the independent association between traditional and non-traditional cardiovascular risk factors, however these risk factors do not appear in isolation and are produced at the same time, exacerbating the risk of a cardiovascular event. Targeting multiple markers of CVD risk offers the best chance of improving CVD outcomes. The objective of this review is to highlight the importance of managing cardiovascular risk factors in patients with T2DM.

Poly (amidoamine) dendrimer-mediated hybrid formulation for combination therapy of ramipril and hydrochlorothiazide

We present a dendrimer-based hybrid formulation strategy to explore the potential of poly (amidoamine) PAMAM dendrimers to be used as drug carriers for combination therapy of an anti-hypertensive drug ramipril (RAPL) and a diuretic hydrochlorothiazide (HCTZ). The drug-dendrimer complexes were prepared by phase-equilibration method. The results showed that the solubility of RAPL and HCTZ was dependent on dendrimer concentration and pH of dendrimer solution. The solubility profile of both RAPL and HCTZ dendrimer complexes illustrated a non-linear relationship with dendrimer concentration. At 0.8% (w/v) dendrimer concentration, solubility of RAPL was increased 4.91 folds with amine-terminated while for HCTZ, solubility enhancement was highest (3.72 folds) with carboxy-terminated. The complexes were characterized by Fourier transform infrared spectroscopy, nuclear magnetic resonance analysis and high performance liquid chromatography. In-vitro drug dissolution performance of pure drugs, individual drug loaded dendrimer formulations and hybrid formulations was studied in USP dissolution medium (pH7.0) and in simulated gastric fluid (pH1.2). Dendrimer mediated formulations showed faster and complete dissolution compared to pure RAPL or HCTZ. Surprisingly, similar pattern of dissolution profile was established with hybrid formulations as compared to individual drug loaded dendrimers. The dendrimer-based hybrid formulations were found to be stable at dark and refrigerated conditions up to 5weeks. Conclusively, the proposed formulation strategy establishes a novel multitasking platform using dendrimer for simultaneous loading and delivery of multiple drugs for pharmaceutical applications.