Efficacy, tolerability, and quality of life of losartan, alone or with hydrochlorothiazide, versus nifedipine GITS in patients with essential hypertension

Blockade of the angiotensin system improves mental health domain of quality of life: A meta-analysis of randomized clinical trials

OBJECTIVE

It is unclear whether blockade of the angiotensin system has effects on mental health. Our objective was to determine the impact of angiotensin converting enzyme inhibitors and angiotensin II type 1 receptor (AT1R) blockers on mental health domain of quality of life.

STUDY DESIGN

Meta-analysis of published literature.

DATA SOURCES

PubMed and clinicaltrials.gov databases. The last search was conducted in January 2017.

STUDY SELECTION

Randomized controlled trials comparing any angiotensin converting enzyme inhibitor or AT1R blocker versus placebo or non-angiotensin converting enzyme inhibitor or non-AT1R blocker were selected. Study participants were adults without any major physical symptoms. We adhered to meta-analysis reporting methods as per PRISMA and the Cochrane Collaboration.

DATA SYNTHESIS

Eleven studies were included in the analysis. When compared with placebo or other antihypertensive medications, AT1R blockers and angiotensin converting enzyme inhibitors were associated with improved overall quality of life (standard mean difference = 0.11, 95% confidence interval = [0.08, 0.14], p < 0.0001), positive wellbeing (standard mean difference = 0.11, 95% confidence interval = [0.05, 0.17], p < 0.0001), mental (standard mean difference = 0.15, 95% confidence interval = [0.06, 0.25], p < 0.0001), and anxiety (standard mean difference = 0.08, 95% confidence interval = [0.01, 0.16], p < 0.0001) domains of QoL. No significant difference was found for the depression domain (standard mean difference = 0.05, 95% confidence interval = [0.02, 0.12], p = 0.15).

CONCLUSIONS

Use of angiotensin blockers and inhibitors for the treatment of hypertension in otherwise healthy adults is associated with improved mental health domains of quality of life. Mental health quality of life was a secondary outcome in the included studies. Research specifically designed to analyse the usefulness of drugs that block the angiotensin system is necessary to properly evaluate this novel psychiatric target.

The renin-angiotensin system: a possible new target for depression

Depression remains a debilitating condition with an uncertain aetiology. Recently, attention has been given to the renin-angiotensin system. In the central nervous system, angiotensin II may be important in multiple pathways related to neurodevelopment and regulation of the stress response. Studies of drugs targeting the renin-angiotensin system have yielded promising results. Here, we review the potential beneficial effects of angiotensin blockers in depression and their mechanisms of action. Drugs blocking the angiotensin system have efficacy in several animal models of depression. While no randomised clinical trials were found, case reports and observational studies showed that angiotensin-converting enzyme inhibitors or angiotensin receptor blockers had positive effects on depression, whereas other antihypertensive agents did not. Drugs targeting the renin-angiotensin system act on inflammatory pathways implicated in depression. Both preclinical and clinical data suggest that these drugs possess antidepressant properties. In light of these results, angiotensin system-blocking agents offer new horizons in mood disorder treatment.

Comprehensive overview: efficacy, tolerability, and cost-effectiveness of irbesartan

Background

Hypertension represents a major health problem, affecting more than one billion adults worldwide. Irbesartan, an angiotensin II receptor blocker, is considered to be a highly effective treatment in the management of hypertension. The purpose of this review is to evaluate the efficacy, safety and tolerability profile , and cost-effectiveness of treatment with irbesartan in hypertension.

Methods

A review of the literature was conducted using the electronic PubMed and Cochrane Library databases and the Health Economic Evaluations Database of search terms relating to irbesartan efficacy, tolerability, and cost-effectiveness, and the results were utilized.

Results

Findings from the present analysis show that irbesartan either as monotherapy or in combination with other antihypertensive agents can achieve significant reductions in blood pressure, both systolic and diastolic, compared with alternative treatment options. Irbesartan was also found to have a renoprotective effect independent of its blood pressure-lowering in patients with type 2 diabetes and nephropathy. Furthermore, irbesartan demonstrated an excellent safety and tolerability profile , with either lower or equal adverse events compared with placebo and other alternative treatments. In terms of economic analyses, compared with other antihypertensive therapy alternatives, irbesartan was found to be a preferred option, that is less costly and more effective.

Conclusion

The evidence indicates that treating patients with hypertension alone or with type 2 diabetes and nephropathy using irbesartan can control hypertension, prolong life, and reduce costs in relation to existing alternatives.

Peripheral edema associated with calcium channel blockers: incidence and withdrawal rate--a meta-analysis of randomized trials

OBJECTIVE

Peripheral edema is considered to be a common and annoying adverse effect of calcium channel blockers (CCBs). It has been thought to occur secondary to arteriolar dilatation causing intracapillary hypertension and fluid extravasation. We aimed to evaluate the incidence and withdrawal rate of peripheral edema with CCBs.

METHODS

A systematic search was made in PubMed, EMBASE and CENTRAL from 1980 to January 2011 for randomized clinical trials reporting peripheral edema with CCBs in patients with hypertension. Trials enrolling at least 100 patients in the CCB arm and lasting at least 4 weeks were included in the analysis. Both the incidence and withdrawal rate due to edema were pooled by weighing each trial by the inverse of the variance. Head-to-head comparison was done to evaluate the risk of edema between newer lipophilic dihydropyridine (DHP) CCBs and older DHPs.

RESULTS

One hundred and six studies with 99 469 participants, mean age 56 ± 6 years, satisfied our inclusion criteria and were included in this analysis. The weighted incidence of peripheral edema was significantly higher in the CCBs group when compared with controls/placebo (10.7 vs. 3.2%, P < 0.0001). Similarly, the withdrawal rate due to edema was higher in patients on CCBs compared with control/placebo (2.1 vs. 0.5%, P < 0.0001). Both the incidence of edema and patient withdrawal rate due to edema increased with the duration of therapy with CCBs reaching 24 and 5%, respectively, after 6 months. The risk of peripheral edema with lipophilic DHPs was 57% lower than with traditional DHPs (relative risk 0.43; 95% confidence interval 0.34-0.53; P < 0.0001). Incidence of peripheral edema in patients on DHPs was 12.3% compared with 3.1% with non-DHPs (P < 0.0001). Edema with high-dose CCBs (defined as more than half the usual maximal dose) was 2.8 times higher than that with low-dose CCBs (16.1 vs. 5.7%, P < 0.0001).

CONCLUSION

The incidence of peripheral edema progressively increased with duration of CCB therapy up to 6 months. Over the long term, more than 5% of patients discontinued CCBs because of this adverse effect. Edema rates were lower with both non-DHPs and lipophilic DHPs.

Mechanism underlying the efficacy of combination therapy with losartan and hydrochlorothiazide in rats with salt-sensitive hypertension

Although thiazide diuretics are commonly used to supplement angiotensin receptor blockers for treatment of hypertension, the mechanism underlying the therapeutic effects of this drug combination remains unclear. We investigated the antihypertensive and cardioprotective effects of combination therapy with losartan (LOS) and hydrochlorothiazide (HCTZ), in comparison with those of either drug alone, in Dahl salt-sensitive hypertensive rats. Rats fed a high-salt diet from 6 weeks of age were treated with LOS, HCTZ, both drugs (COMB) and vehicle from 6 to 11 weeks. The salt-induced increase in systolic blood pressure was attenuated moderately by LOS and to a greater extent by HCTZ and COMB. Left ventricular (LV) hypertrophy and fibrosis, diastolic dysfunction, as well as angiotensin-converting enzyme and angiotensin II type 1A (AT(1A)) receptor gene expression were attenuated similarly by LOS and HCTZ and more so by COMB. LOS downregulated expression of the AT(1A) receptor gene, without affecting that of the AT(2) receptor gene, in the aorta. In contrast, neither HCTZ nor COMB affected aortic expression of the AT(1A) receptor gene, but both markedly upregulated that of the AT(2) receptor gene. The salt-induced decrease in the plasma concentration of nitric oxide metabolites was attenuated substantially by LOS and abolished by both HCTZ and COMB. In conclusion, the combination of LOS and HCTZ attenuated hypertension, as well as LV remodeling and diastolic dysfunction, more effectively than did LOS or HCTZ alone in rats with salt-sensitive hypertension. Modulation of the cardiac and vascular renin-angiotensin system may have contributed to these beneficial effects of the drug combination.

Clinical experience in treating hypertension with fixed-dose combination therapy: angiotensin II receptor blocker losartan plus hydrochlorothiazide

The goal of antihypertensive treatment is to reduce cardiovascular and cerebrovascular events associated with high blood pressure. A combination therapy with different antihypertensive agents is more successful than monotherapy in most hypertensive patients, with the added advantage of a better safety profile. Therefore, treatment of hypertensive patients with fixed-dose combination therapy consisting of the angiotensin II receptor blocker losartan along with hydrochlorothiazide (HCTZ) has several potential benefits over monotherapy with each individual component. It provides more effective blood pressure control, a reduction in the likelihood of adverse effects and facilitation of patient compliance due to a simple once-daily regimen. One of the advantages of the combination of losartan with HCTZ is the potential reduction in HCTZ-induced metabolic disorders; in particular, this combination can have attractive benefits for patients of hyperuricemia. Losartan plus HCTZ fixed-dose combination therapy is frequently recommended for the treatment of hypertension and lowers blood pressure in mild-to-moderate and even severe hypertensive patients to a level comparable with other classes of antihypertensive agents in combination with HCTZ. Fixed-dose combination therapy with losartan plus HCTZ is a logical choice as antihypertensive therapy for patients in whom combination therapy is necessary to achieve additional blood pressure reduction.

Identifying health-related quality of life (HRQL) domains for multiple chronic conditions (diabetes, hypertension and dyslipidemia): patient and provider perspectives

OBJECTIVE

To examine patient and provider perspectives about the impact of having diabetes, hypertension and/or dyslipidemia (DHD) on health-related quality of life (HRQL) in order to identify domains for an HRQL instrument focusing on specific chronic diseases (DHD).

STUDY DESIGN

Exploratory qualitative design was used to elicit patient and provider responses. Patient survey contained 11 demographic and nine content questions inquiring how the disease(s) affected patient HRQL. Provider survey examined how the disease(s) affected their patient's HRQL and crucial factors for improvement. Patients were included if they had DHD and spoke English. Providers working with DHD patients were identified among university faculty and community practitioners.

RESULTS

Thirty-eight patients (24.7%) completed the interviews. Three judges content analysed patient responses and proposed seven categories (patients ranked physical functioning first followed by diet, emotional well-being (E), general well-being, social functioning (S), 'no change in HRQL' and medications). One question about medications had four categories (medication inconvenience, medication side effects, forgetfulness and general well-being). Index for reliability was greater than 80% for all categories. Providers ranked lifestyle modification (LM), first followed by complications, medication, self-care, E, education, S, physical activity and resources (ability to pay) as components that impact HRQL.

CONCLUSIONS

Patient and provider perspectives were similar in four areas (E, S, medication and diet); however, the differences were in how these impacted HRQL - patients focused on activities relevant to daily life that were affected, while providers based it on processes of therapy management and self-care (education and implementation of LM).

Long-acting nifedipine in the management of the hypertensive patient

Hypertension is a global condition affecting billions worldwide. It is a significant contributor to cardiovascular events, cardiac death and kidney disease. A number of medication classes exist to aid healthcare providers and their patients in controlling hypertension. Nifedipine, a dihydropyridine calcium channel blocker, was once one of the most widely used medications for hypertension, but safety and tolerability concerns along with the introduction of new classes of antihypertensive medications and an increasing pool of data showing mortality benefit of other classes caused nifedipine to fall out of favor. More recently, long-acting formulations were developed and made available to clinicians. These newer formulations were designed to address many of the concerns raised by earlier formulations of nifedipine. Numerous clinical trials have been conducted comparing long-acting nifedipine to many of the more commonly prescribed antihypertensive medications. This review will address the pharmacology, pharmacokinetics and the available clinical trial data on long-acting nifedipine and summarize its role in the management of hypertension.

Antihypertensive efficacy and safety of fixed-dose combination therapy with losartan plus hydrochlorothiazide in Japanese patients with essential hypertension

A randomized, double-blind, placebo-controlled, parallel-group multicenter study was conducted to evaluate the antihypertensive efficacy and safety of 8-week treatment with one of three fixed-dose combinations-losartan 50 mg plus hydrochlorothiazide 12.5 mg, losartan 50 mg plus hydrochlorothiazide 6.25 mg, or losartan 25 mg plus hydrochlorothiazide 6.25 mg-in comparison with those of hydrochlorothiazide 12.5 mg alone, losartan 50 mg alone, or placebo in Japanese patients with essential hypertension. Significant reductions in sitting diastolic blood pressure (DBP) and systolic blood pressure (SBP) were seen in all three combination groups compared with the placebo group (each p<0.001). The greatest reductions in DBP and SBP were observed in the losartan 50 mg plus hydrochlorothiazide 12.5 mg group (12.7 and 18.0 mmHg, respectively). The reductions in the losartan 50 mg plus hydrochlorothiazide 12.5 mg group were significantly greater (each p<0.001) than those in the placebo group and each of the monotherapy groups. There were no significant differences in the incidences of clinical and laboratory drug-related adverse events between any of the combination groups and the placebo group. All combination groups showed improved hypokalemia and hyperuricemia compared to the hydrochlorothiazide 12.5 mg group. These results demonstrated that once-daily, fixed-dose combination therapy with losartan 50 mg plus hydrochlorothiazide 12.5 mg is well tolerated and more efficacious in lowering DBP and SBP than monotherapy in Japanese hypertensive patients.

Modified-release nifedipine: a review of the use of modified-release formulations in the treatment of hypertension and angina pectoris

Nifedipine is a dihydropyridine calcium channel antagonist with predominantly vasodilatory activity. Modified-release formulations of nifedipine are effective antihypertensive and antianginal therapies and are generally well tolerated. Among the available formulations, those that produce a gradual increase in plasma nifedipine concentration, which is then sustained over a 24-hour period, are preferred, as they cause a gradual onset of vasodilatation and avoid baroreflex sympathetic activation (for example, nifedipine gastrointestinal therapeutic system [GITS] and a Japanese controlled-release formulation). Modified-release nifedipine had beneficial effects on a number of markers of vascular function, and nifedipine GITS reduced the need for coronary procedures in patients with coronary artery disease. In patients with hypertension, nifedipine GITS and nifedipine retard had beneficial effects on the overall incidence of major cardiovascular events, as did nifedipine retard in patients with concurrent hypertension and coronary artery disease.

Renin angiotensin aldosterone system blockade and renal disease in patients with type 2 diabetes: a subanalysis of Japanese patients from the RENAAL study

BACKGROUND

The Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) study has previously shown losartan to confer significant benefits to patients with type 2 diabetes and nephropathy. The original study of 1513 patients included 96 Japanese patients; the present study is a post-hoc analysis of the effects of losartan in this Japanese subpopulation.

METHODS

This double-blind, randomized study compared losartan (50 to 100 mg once daily) with placebo. The study medication was taken in addition to conventional antihypertensive treatment, and the mean follow-up period for the Japanese patients was 2.8 years. The primary endpoint was the composite of doubling of serum creatinine, endstage renal disease, or death. Secondary endpoints included changes in proteinuria levels. Safety was also evaluated.

RESULTS

The primary composite endpoint was reached in fewer Japanese patients receiving losartan than placebo (50.0% versus 65.4%, respectively). The treatment effects of losartan were more robust when data were corrected for differences in proteinuria at baseline--a significant relative risk reduction of 45% with losartan (P=0.0397) was apparent. Treatment benefit exceeded that attributable to blood pressure changes alone. Levels of proteinuria were reduced with losartan compared with placebo, with an overall losartan treatment effect of 37.8% (P<0.001). Overall, losartan was similarly well tolerated in both the Japanese patients and the total population.

CONCLUSIONS

In Japanese patients with type 2 diabetes and nephropathy, losartan offers renal protection and is generally well tolerated.

Treatment of systolic hypertension: spotlight on recent studies with angiotensin II antagonists

Systolic blood pressure has a continuous, graded, strong, independent, and aetiologically significant relationship to mortality from coronary heart disease, stroke, and all cardiovascular diseases, as well as to all-cause mortality and life expectancy. Angiotensin II (AII) may be intimately involved in the pathogenesis of systolic hypertension through multiple mechanisms, including decreasing the elastin content and increasing the collagen content of the arterial wall, thickening and fibrotic remodelling of the vascular intima, and proliferating smooth muscle cells in the arterial wall, resulting in increased thickness, stiffening, and partial loss of contractility. AII antagonists may therefore offer hitherto unrecognized benefits (independent of blood pressure) on age-related vascular damage and provide particular benefits in patients with systolic hypertension. Recent evidence has demonstrated that losartan offers cardiovascular outcomes benefits in isolated systolic hypertension (ISH) associated with an excellent tolerability profile. This, in patients with ISH, AII antagonists more facilitate systolic BP control, providing cardiovascular protection and offering an excellent risk-benefit profile.

The effect of a losartan-based treatment regimen on isolated systolic hypertension

This study was conducted to compare the antihypertensive efficacy and tolerability, over 12 weeks, of a losartan-based treatment regimen and placebo in patients with isolated systolic hypertension. Three hundred eight patients > or =35 years of age with isolated systolic hypertension, defined as trough sitting blood pressure between 140 and 200 mm Hg systolic and between 70 and 89 mm Hg diastolic, were randomized to losartan 50 mg (n=157) or placebo (n=151) once daily, with titration as necessary to achieve a goal trough sitting systolic blood pressure (SBP) <140 mm Hg. At baseline, mean trough sitting SBP was 140-159 mm Hg in 20.5% of patients, 160-179 mm Hg in 62.7%, and 180-200 mm Hg in 16.9%, and was similar in the two groups (losartan, 165.3 mm Hg; placebo, 166.1 mm Hg). At 12 weeks, mean trough sitting SBP decreased significantly (p<0.001) in both the losartan-based treatment group (by 19.2 mm Hg) and in the placebo group (by 7.6 mm Hg). The reduction in sitting SBP was significantly greater for losartan than placebo (-11.6 mm Hg; 95% confidence interval, -14.8 to -8.4). In patients with isolated systolic hypertension, a once-daily losartan-based treatment regimen significantly lowered SBP. The losartan-based regimen exhibited antihypertensive efficacy that was superior to that of placebo, with a similar tolerability profile.

Improving the managed care of hypertension with angiotensin II antagonists

Among the modifiable risk factors for cardiovascular disease, hypertension is the most powerful and treatable. For an asymptomatic patient to remain on a lifetime of antihypertensive treatment that might cause adverse effects is difficult for most patients. Managed care plans should treat hypertensive patients in ways that the patient can remain on therapy to prevent complications and thereby reduce the long-term costs associated with untreated hypertension. The recent disappointing outcomes achieved with antihypertensive drugs suggest there is room for improvement in the management of hypertension. Since the introduction of the first orally active angiotensin II receptor blocking drug, losartan, attention has been focused on the central role of angiotensin II in hypertension and cardiovascular disease. Studies of angiotensin II antagonists (AIIAs), which block the tissue receptor for angiotensin II, show that these agents effectively control hypertension when given once daily and cause no significant adverse effects or laboratory abnormalities. Losartan is unique among the AIIAs in that it offers 1-step titration dosing and has a uricosuric effect. Losartan, candesartan, and valsartan have been shown to improve the symptoms of congestive heart failure; losartan has been similar to an angiotensin-converting enzyme inhibitor in reducing systolic dysfunction congestive heart failure mortality. At 1 year, the refill rate for losartan in a managed care setting has been more than that for any other class of antihypertensive agents. Although there is not yet a clinical trial determining the long term mortality of AIIA treatment in hypertension compared with other antihypertensive agents, the use of AIIAs in conjunction with lifestyle modification and patient education can provide more efficient hypertension control and a provide a treatment with which patients can live.

Comparison of quality of life and cough on eprosartan and enalapril in people with moderate hypertension

The objective of this study was to compare quality of life and incidence of dry persistent cough among patients treated with eprosartan and enalapril for mild-moderate hypertension. This was a randomised 26-week double-blind controlled trial carried out in clinics in nine countries of North America, Europe and South Africa. A total of 529 patients aged 18 and over with diastolic blood pressure between 95 mm Hg and 114 mm Hg were studied. Treatment comprised of eprosartan or enalapril monotherapy for 12 weeks with the option of hydrochlorothiazide addition for the remaining 14 weeks. The primary outcome measures were cough and the Psychological General Wellbeing Index (PGWB) total and subscales (anxiety, self-control, depression, general health, positive wellbeing and vitality). The results were that 17.8% of enalapril patients and 13.2% of eprosartan patients withdrew from randomised treatment. Those on enalapril were twice as likely to have gained a definite or possible cough by study end point as those on eprosartan (7.6% vs 3.2%) P = 0.099. At monotherapy end point the differences were greater (9.9% vs 2.1%) and of statistical significance, P = 0.001. Patients treated with enalapril, however, had small but significant improvements in measures of self-control and total PGWB compared with those on eprosartan. The effect sizes of 0.2 or less indicated that there were small differences. In conclusion eprosartan was associated with fewer coughs than enalapril but it performed less well on some aspects of quality of life.

Efficacy, tolerability, and impact on quality of life of long-term treatment with manidipine or amlodipine in patients with essential hypertension

This double-blind, multicenter trial compared antihypertensive efficacy, tolerability, and impact on quality of life of manidipine and amlodipine in patients with mild-to-moderate essential hypertension. Patients were randomly assigned to 48 weeks of once-daily manidipine, 10-20 mg, or amlodipine, 5-10 mg. Patients who did not respond to treatment after 12 weeks were also given enalapril, 10-20 mg, for the study's duration. The main efficacy end point was equivalence in sitting systolic (SiSBP) and diastolic (SiDBP) blood pressure reduction between the two drugs after 8 weeks (per protocol analysis). An intention-to-treat (ITT) analysis was performed in all patients with at least one efficacy determination during treatment. Quality of life was assessed by the "Subjective Symptoms Assessment Profile" (SSA-P) and "General Well-being Schedule" (GWBS), after 12 weeks of treatment. SiSBP reduction after 8 weeks was equivalent for manidipine (15.2 mm Hg, n = 227) and amlodipine (17.0 mm Hg, n = 219). The corresponding figure for SiDBP was 11.3 mm Hg for manidipine and 12.3 mm Hg for amlodipine. In the larger ITT population SiDBP was similarly and significantly reduced by manidipine (from 102 +/- 5 to 88 +/- 9 mm Hg, n = 241) and amlodipine (from 101 +/- 5 to 87 +/- 8 mm Hg, n = 240). Similar results were observed for SiSBP and standing SBP and DBP. Neither drug changed sitting or standing heart rate compared with baseline. SSA-P scores improved with manidipine but not amlodipine. GWBS total and partial scores increased more with manidipine than with amlodipine. Safety profile favored manidipine, which was associated with significantly less ankle edema than was amlodipine. This study shows for the first time that long-term treatment with the long-acting calcium channel blocker manidipine is as effective as treatment with amlodipine, has a better tolerability profile, and induces greater improvement in quality of life than amlodipine.

Losartan versus valsartan in the treatment of patients with mild to moderate essential hypertension: data from a multicenter, randomized, double-blind, 12-week trial

BACKGROUND

Losartan, the first of the angiotensin II receptor blockers (ARBs) to be introduced, has been studied extensively in comparison with other classes of antihypertensive agents. Less research has been conducted on the efficacy and tolerability of losartan compared with that of other ARBs.

OBJECTIVE

This randomized, multicenter, double-blind, parallel-group equivalence study was conducted to compare the antihypertensive efficacy and tolerability of a once-daily regimen of losartan with that of valsartan.

METHODS

Patients > or = 21 years of age with mild to moderate hypertension, defined as a trough sitting diastolic blood pressure (SiDBP) between 95 and 115 mm Hg, were randomized to receive once-daily losartan (50 mg) or valsartan (80 mg) for 12 weeks. At the end of the sixth treatment week, patients in both groups with trough SiDBP > or = 90 mm Hg had their dose doubled for the remainder of the treatment period. Analysis of variance was used to compare treatment groups with respect to change in mean trough SiDBP from baseline to week 12. Within-treatment changes were analyzed using the paired t test. With at least 220 patients per treatment group, the study had 90% power to place a 90% CI on the difference between losartan and valsartan in SiDBP within the equivalence interval of +/- 2.5 mm Hg.

RESULTS

A total of 495 patients were randomized, 247 to the losartan group and 248 to the valsartan group: 456 patients completed the study. Adjusted mean change from baseline values for trough SiDBP atthe end of 12 weeks of treatment were significantly different (P < 0.001) from zero in both the losartan group (-9.9 mm Hg) and the valsartan group (-10.1 mm Hg). At week 12, losartan was as effective as valsartan in lowering SiDBP, with a between-group difference of 0.2 mm Hg (90% CI, -1.3 to 1.7; P = 0.827). At week 6, the difference in SiDBP between groups was -1.3 mm Hg (90% CI, -2.7 to 0.0; P = 0.106). A similar pattern of results was obtained at weeks 6 and 12 for sitting systolic blood pressure. The percentage of patients reaching the SiDBP goal at week 6 (46% [112/2411 losartan; 42% [103/245] valsartan) and week 12 (57% [139/243] losartan; 59% [145/245] valsartan) was not significantly different between the treatment groups. Both losartan and valsartan were similarly well tolerated. Over the 12 weeks, the laboratory profiles of the 2 drugs were similar except for serum uric acid levels, which decreased from 6.0 to 5.7 mg/dL in the losartan group and increased from 5.9 to 6.0 mg/dL in the valsartan group (P = 0.001 for between-treatment difference).

CONCLUSIONS

At starting and titrated doses, losartan and valsartan are similarly effective in reducing blood pressure in patients with mild to moderate hypertension. Losartan, but not valsartan, was associated with a decrease in serum uric acid levels.

Sexual Dysfunction in Hypertensive Patients Treated with Losartan

BACKGROUND

Impaired erectile function in men is a component of the dysmetabolic syndrome of high blood pressure as well as a sequela of antihypertensive therapy. This prospective interventional study in men with uncontrolled hypertension (blood pressure > or =140/90 mm Hg) used a survey instrument to assay sexual dysfunction before and after therapy with losartan.

METHODS

We evaluated the influence of a 12-week therapy with losartan in 82 hypertensive subjects with (n = 82) and without (n = 82) a diagnosis of erectile dysfunction using a self-administered questionnaire validated in another 60 subjects with hypertension.

RESULTS

From an initial sample of 323 hypertensive men and women, 82 men, aged 30 to 65 years, with sexual dysfunction underwent a 12-week regimen of losartan therapy (50-100 mg/day). Losartan treatment improved sexual satisfaction from an initial 7.3 to 58.5% (chi2; P = 0.001). Subjects reporting a high frequency of sexual activity improved from 40.5% initially to 62.3% after drug treatment, whereas the number of patients with low or very low frequency of sexual activity decreased significantly (chi2; P = 0.001). At the completion of the 12-week losartan regimen, only 11.8% of the treated subjects reported in improvement in sexual function. Improvement on quality of life was demonstrated in 73.7% of subjects medicated with losartan, 25.5% reported no changes, and only 0.8% felt worse. In the group without sexual dysfunction, losartan had a nonsignificant effect on sexual function.

CONCLUSIONS

Our data suggest that losartan improved erectile function and both satisfaction and frequency of sexual activity. Because side effects are one of the most influential factors in the management of hypertension, an added benefit of losartan therapy may be its positive impact on quality of life.

The losartan renal protection study--rationale, study design and baseline characteristics of RENAAL (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan)

The RENAAL Study is a double-blind, placebo-controlled trial to evaluate the renal protective effects of losartan in Type 2 diabetic patients with nephropathy. The study has enrolled 1513 patients and is expected to continue for 3.5 years after the last patient has been entered. Eligible patients must have a urinary albumin:creatinine ratio of at least 300 mg/g and serum creatinine between 1.3 to 3.0 mg/dL. Eligible hypertensive or normotensive patients are randomised to receive either losartan or placebo, in addition to their existing antihypertensive therapy. Medications that block angiotensin production or action, are excluded. The primary endpoint is a composite of the time to first event of doubling of serum creatinine, end-stage renal disease, or death; secondary endpoints include cardiovascular events, progression of renal disease, and changes in proteinuria; tertiary endpoints include quality of life, healthcare resource utilisation, and amputations. Patients include Caucasians (48.6%), Blacks (15.2%), Asians (16.7%), and Hispanics (18.2%). Baseline urinary albumin:creatinine ratio and serum creatinine levels average 1867 mg/g and 1.9 mg/dL, respectively. Mean systolic and diastolic blood pressures are 153 and 82 mmHg, respectively. RENAAL will document whether blockade of the AII receptor with losartan produces clinical benefits in patients with Type 2 diabetes and nephropathy.

Health-related quality-of-life measurement in hypertension. A review of randomised controlled drug trials

In hypertension, tolerability of drug treatment is important because individuals may see the use of antihypertensive medications as more troubling than their seemingly symptomless disease. This may result in noncompliance and ineffectual long term treatment. In the past 15 years, new antihypertensive medications have been marketed on the basis of the advantages they offer with regard to adverse effects and the unavoidable impact of such adverse effects on a person's quality of life. When related to health, quality of life refers to the physical, psychological and social dimensions of health that are influenced by a person's experiences, beliefs, expectations and perceptions. To measure this concept, many instruments, either generic or specific, may be used. The purpose of this study is to describe, by way of a critical review of the literature, the instruments that are most often used in the measurement of health-related quality of life (HR-QOL) in people using antihypertensive drug treatments. We carried out a search of the literature published in English in the period January 1966 to July 2000, looking for randomised controlled trials of antihypertensive drugs. Using the Medline database, we included 77 papers in our review. Our main finding suggests that HR-QOL changes associated with antihypertensive treatment are measured with many different instruments. In almost all studies, at least 1 instrument specific to a health dimension was used, whereas not many used a generic instrument only. The most commonly measured HR-QOL dimensions were cognitive function, symptomatic well-being, sexual function, psychological well-being, sleep dysfunction, social participation and general health perception. Since the choice of dimensions to measure depends not only on the disease but also on the drug, this review adds further evidence that a generic instrument as well as a preference measurement should be added to a specific instrument.

The efficacy and tolerability of losartan versus atenolol in patients with isolated systolic hypertension. Losartan ISH Investigators Group

OBJECTIVE

To compare the efficacy and tolerability of angiotensin II (Ang II) antagonist losartan and the beta-blocker atenolol in the treatment of patients with isolated systolic hypertension (ISH) after 16 weeks of treatment.

METHODS

A double-blind, randomized, multi-country study was carried out in 273 patients with ISH. Patients with a sitting systolic blood pressure (SiSBP) of 160-205 mmHg, and a sitting diastolic blood pressure (SiDBP) < 90 mmHg at screening and at placebo baseline were subjected to a 4-week placebo period and then randomly grouped to receive 50 mg losartan or 50 mg atenolol once daily for 16 weeks. At 8 and 12 weeks, patients not controlled (SiDBP > or = 160 mmHg) were given additional treatment of 12.5 mg hydrochlorothiazide (HCTZ) once daily.

RESULTS

Similar significant reductions in SiSBPs (mean +/- SD) were obtained with 50 mg losartan and 50 mg atenolol, from 173.7 +/- 10.3 and 173.5 +/- 10.7 mmHg at baseline to 149.0 +/- 15.5 and 148.2 +/- 15.3 mmHg after 16 weeks of losartan or atenolol treatment respectively. Sixty-seven percent of the losartan-treated and 64% of the atenolol-treated patients remained on monotherapy throughout the study. Only 1.5% of the losartan-treated patients withdrew because of a clinical adverse event (CAE) compared with 7.2% in the atenolol-treatment group (P= 0.035). Drug-related CAEs were observed significantly more frequently with atenolol than with losartan treatment (20.3 versus 10.4%; P = 0.029).

CONCLUSION

It is concluded that 50 mg losartan and 50 mg atenolol produced comparable reductions in SiSBP in patients with ISH but losartan was better tolerated. This is the first demonstration of the therapeutic value of selective Ang II receptor blockade with losartan in the treatment of ISH.

Quality-of-life questionnaire for patients taking antihypertensive medication

This study was undertaken to construct a health-related quality-of-life (QOL) questionnaire for hypertensive patients from preexisting instruments and to validate its use in full form and in a shortened version. Two hundred seventy hypertensive patients who were stable while taking antihypertensive medication (control group), changing medication because of side effects, or newly treated for hypertension were enrolled in a prospective, observational, longitudinal study. At baseline and at months 1, 2, and 3, patients completed a questionnaire covering 7 domains of QOL. The criteria for evaluating the scales were internal consistency, test-retest reliability, construct validity, and responsiveness to change. Data were analyzed for the full questionnaire and the shortened version. Internal consistency and test-retest correlation values were 0.69 to 0.95 for scales in the full questionnaire and 0.57 to 0.92 in the shortened version. Construct validity was supported by statistically significant, positive correlations with a global QOL item for all but 1 scale in both versions. Responsiveness to change was supported by increases in scores between baseline and month 3 for all scales in patients changing their medication because of side effects; scores remained unchanged (on all but 1 scale) in the stable (control) group. By uniformly applying standard validation criteria to a set of preexisting instruments, we created a new QOL questionnaire. Results were similar in both the full form and shortened version.

Spectrum of use for the angiotensin-receptor blocking drugs

The renin-angiotensin system (RAS) plays an important role in regulating blood pressure, and maintaining fluid and electrolyte balance. Angiotensin II is the principal mediator of the RAS and has been implicated in the development of hypertension as well as other forms of cardiovascular and renal disease. Angiotensin II-receptor antagonists are a new class of drugs that inhibit the RAS by selectively blocking the AT(1) receptor. These compounds therefore provide more specific and thorough blockade of the RAS by inhibiting the deleterious actions of angiotensin II at the receptor level, irrespective of how this peptide is formed. The increased specificity of action of angiotensin II-receptor antagonists may also circumvent unwanted side-effects normally associated with angiotensin-converting enzyme (ACE) inhibitors (eg, cough and angioedema) as these agents do not interfere with the metabolism of other peptides (eg, bradykinin, substance P, etc.). There is still some concern with angiotensin II-receptor antagonists and the long-term effects of hyper-stimulation of the unopposed AT(2) receptor that is caused by elevated levels of angiotensin II. However, it appears that stimulation of the AT(2) receptor may actually contribute to the beneficial effects of angiotensin II-receptor antagonists by counteracting the effects mediated by the AT(1) receptor. Angiotensin II-receptor antagonists display great therapeutic promise in the field of cardiovascular medicine and are currently being exploited as new antihypertensive agents. These drugs have demonstrated safety, efficacy, and tolerability; however, morbidity and mortality data are still lacking. Nonetheless, it is likely that angiotensin II-receptor antagonists will become part of the medical arsenal against cardiovascular and renal disease, thus consideration should be given to their future use as first-line antihypertensive agents.

Safety and efficacy of eprosartan, a new angiotensin II receptor blocker

Angiotensin-converting enzyme inhibitors have been used extensively in the management of hypertension and related cardiovascular conditions. However, this treatment approach is limited by lack of specificity and continued production of angiotensin II by other routes. Antagonism of the angiotensin II receptor offers the possibility of improved control of hypertension by providing a more complete blockade of the renin-angiotensin system than angiotensin-converting enzyme inhibition without bradykinin-related effects. Eprosartan is the only nonbiphenyl, nontetrazole competitive angiotensin II receptor antagonist clinically available and is highly selective for the AT1 receptor subtype. In clinical trials, eprosartan has been shown to lower blood pressure effectively in a once-daily regimen in hypertensive patients. In the recommended dose range of 600 to 1200 mg once daily, eprosartan is effective in patients with all grades of hypertension irrespective of age, sex, or race. Furthermore, the tolerability profile of eprosartan is comparable to that of placebo, and there are no known clinically relevant drug-drug interactions. A number of large-scale clinical studies are currently underway or planned to determine which of the increasing number of AT1 receptor antagonists may reduce cardiovascular morbidity and mortality rates in different groups of hypertensive patients. Meanwhile, current evidence suggests that the AT1 receptor antagonists represent a significant new approach to cardiovascular therapy and merit a fuller assessment in hypertension and other cardiovascular diseases.

The effects of dietary patterns on quality of life: a substudy of the Dietary Approaches to Stop Hypertension trial

Few studies have examined the effects of dietary changes, particularly modifications of whole dietary patterns, on quality of life. The Dietary Approaches to Stop Hypertension (DASH) trial compared the effects of 3 dietary patterns on blood pressure. In this substudy, we examined the effect of these diets on health-related quality of life. All DASH participants ate a control diet for 3 weeks and then were randomly assigned to continue the control diet, to a fruits and vegetables diet or to a combination diet for 8 weeks. The combination diet emphasized fruits, vegetables, and low-fat dairy products. It included whole grains, poultry, fish, and nuts, and was reduced in fats, red meat, sweets, and sugar-containing beverages. The control diet was similar to typical American intake; the fruits and vegetables diet was rich in fruits and vegetables but was otherwise similar to the control diet. Both the fruits and vegetables diet (P < .001) and the combination diet (P < .001) significantly lowered blood pressure. At the Duke University Medical Center, Durham, NC, site, participants completed the Medical Outcomes Study Short Form-36 questionnaire to assess their health-related quality of life at baseline and at the end of the dietary intervention. Eighty-three participants completed the questionnaires at both time points. In general, health-related quality of life improved in all treatment groups except for the control group in perceptions of change in health, which diminished. In the combination diet group all the subscales were improved or unchanged compared with baseline values. However, only the change in health score improved significantly (P < .05) as compared with that of the control diet group. When all the subscales were summed into a total score, the control diet was associated with mean improvement of 4.0%, the fruits and vegetables diet with 5.0%, and the combination diet with 5.9% from baseline. These data suggest that the fruits and vegetables diet and particularly the combination diet cannot only lower blood pressure, but may also improve the perception of health-related quality of life.

Nifedipine increases microvascular permeability via a direct local effect on postcapillary venules

Calcium-channel antagonist drugs are prescribed widely for angina and hypertension. A limiting side effect is edema, which can make heart failure worse. We show that nifedipine, a dihydropyridine-type calcium-channel antagonist, can increase vascular permeability in rat skeletal muscle and skin when injected locally. In nifedipine-injected cremaster muscle, the copper content, used to quantify Monastral blue dye accumulation, was 15.0 +/- 2.4 microgram/g compared with 5.3 +/- 0.7 microgram/g in control preparations (P < 0. 05). The injection of nifedipine in rat skin in vivo increased local plasma leakage in injected sites from 5.5 +/- 1.1 microliter in control sites to 9.9 +/- 2.5, 17.0 +/- 2.4, 24.3 +/- 5.9, and 23.3 +/- 5.4 microliter in sites injected with 10(-10), 10(-9), 10(-8), or 10(-7.2) mol/site, respectively (P < 0.05 in each case compared with control). Vascular labeling techniques using light microscopy, electron microscopy, and microanalysis show that the microvascular site of leakage is not from capillaries but from postcapillary venules of 12-36 micrometer in diameter, the same site that controls the edema response in inflammation. Nifedipine can act within the microcirculation to increase the permeability of the postcapillary venule.

Continuation of initial antihypertensive medication after 1 year of therapy

This paper describes use of the prescription records of a large pharmaceutical benefits management organization to retrospectively analyze the refill behavior of patients who have recently started antihypertensive therapy in the outpatient setting. Using logistic regression analysis, the author identified class of antihypertensive medication, patient age, and dosing frequency as clinically important independent covariates that are predictive of persistence (defined as continuing therapy with the original antihypertensive drug as originally prescribed) at 12 months. At 12 months' follow-up, the percentage of patients continuing initial angiotensin II (A-II) antagonist therapy was substantially higher than the percentage continuing therapy with angiotensin-converting enzyme inhibitors, calcium antagonists, beta-blockers, or thiazide diuretics (64% vs 58%, 50%, 43%, and 38%, respectively). Additional studies are needed to explain why more patients continued with the same A-II antagonist therapy at 12 months compared with the other classes of antihypertensive drugs; whether these findings are explained by drug tolerability, financial incentives, newness of the product, selection bias, or other factors; whether these differences will be maintained in the following years; and whether the differences are associated with better health outcomes.

Cardiac inotropes inhibit the oedema caused by nifedipine in rabbit skin

1. We have shown previously that exposing the rat or rabbit microcirculation to nifedipine increases the permeability of the post-capillary venule, the segment of microcirculation that is known to control inflammatory oedema. 2. In the present study modulation by the inotropes isoprenaline, dopexamine and dobutamine of nifedipine-induced oedema was examined in the rabbit skin microcirculation by measuring the localised leakage of 125I-radiolabelled albumin after the i.d. injection of agents. 3. Coinjection of isoprenaline (10(-11) moles per site), dopexamine (10(-10) moles per site) or dobutamine (10(-10) moles per site) suppressed significantly (P < 0.05) the oedema response to nifedipine (10(-7.2) moles per site) in the rabbit dorsal skin microcirculation. 4. To confirm the oedema suppresser effect of the inotropes, dopexamine or dobutamine were also coinjected with histamine 10(-8) + PGE2 10(-10) moles per site, or bradykinin 10(-10) + PGE2 10(-10) moles per site. Both inotropes at 10(-10) moles per site reduced significantly (P < 0.05) the leakage of albumin caused by bradykinin + PGE2 and histamine + PGE2. 5. When measured by laser Doppler, basal local skin blood flow increased at 30 min by 57 +/- 14% with nifedipine 10(-7.2) moles per site and 15 +/- 11% with isoprenaline 10(-11) moles per site. Isoprenaline did not suppress the blood flow response to nifedipine, the response to coinjection being 68 +/- 11%. 6. Oedema caused by nifedipine can be suppressed by low concentrations of beta-adrenergic agonists that do not suppress the blood flow response to nifedipine. This suggests that cardiac inotropes can influence non-inflammatory changes in microvascular permeability.

Main results of the losartan versus amlodipine (LOA) study on drug tolerability and psychological general well-being. LOA Study Group

OBJECTIVE

To compare two losartan regimens (with and without hydrochlorothiazide) and amlodipine in treating mild-to-moderate hypertension regarding their blood-pressure-lowering effect, drug tolerability and quality of life.

DESIGN

A 12-week, randomized, double-blind, parallel-group, multi-centre study. After 4 weeks of placebo, patients with a diastolic blood pressure (DBP) in the range 95-115 mmHg were allocated randomly to be administered 50 mg losartan (increased to 100 mg if the DBP was 90 mmHg or more after 6 weeks), 50 mg losartan (plus 12.5 mg hydrochlorothiazide under the above conditions), or 5 mg amlodipine (increased to 10 mg under the above condition). The tolerability of the treatment and the quality of life were evaluated by spontaneous reporting, active questioning and the Psychological General Well-Being (PGWB) index.

STUDY POPULATION

In total 898 hypertensives, mainly referred from primary health care (mean age 57.8 years) of whom 52% were men.

RESULTS

Administration of 50 mg losartan (plus 12.5 hydrochlorothiazide if necessary) and of 5 mg amlodipine (or 10 mg if necessary) lowered the blood pressure as well as or better than did 50 mg losartan (or 100 mg if necessary). The incidence of 'any discomfort' and 'swollen ankles' increased with amlodipine but not with losartan treatment. The opposite was found for 'dizziness upon standing'. The incidence of drug-related adverse events and the number of patients withdrawn from therapy were higher with amlodipine than they were with losartan treatment. The PGWB index at week 12 indicated that improvements from baseline had occurred in some domains for the losartan groups whereas it remained unchanged for the amlodipine group.

CONCLUSION

Both losartan and amlodipine were effective in lowering the blood pressure and were tolerated well. Administration of 50 mg losartan (plus 12.5 mg hydrochlorothiazide if necessary) and of 5 mg amlodipine (or 10 mg if necessary) lowered the blood pressure equally well or better than did 50 mg losartan (or 100 mg if necessary). Drug-related adverse effects and withdrawal from the study were more common for the amlodipine group. The clinical significance of the improvements in the PGWB index with losartan needs to be studied further.

Clinical safety and tolerability of losartan

Losartan is a novel orally active nonpeptidal antihypertensive agent that specifically blocks the angiotensin II type 1 receptor. This paper compares the short- and long-term safety and tolerability of losartan with those of placebo. Approximately 3800 patients with mild-to-severe essential hypertension were enrolled in 16 double-masked and 4 open clinical trials worldwide. Of these, approximately 2900 were treated with losartan either alone or in combination with other antihypertensive drugs. These trials included patients with diabetes mellitus (n = 133). An additional 5 trials enrolled hypertensive patients with compromised renal function (n = 115) or heart failure (n = 220). Losartan dosages primarily ranged from 10 to 150 mg once daily, with most patients receiving 50 to 100 mg per day. Hypertension trials generally lasted 12 weeks. The most frequently reported adverse events were headache, upper respiratory tract infection, dizziness, and asthenia/fatigue, but only dizziness occurred more frequently (> or = 1%) in the losartan-treated groups. Cough occurred in 3.1% of patients treated with losartan and 2.6% of patients treated with placebo. The overall incidence of clinical and laboratory adverse events in the losartan- and placebo-treated groups was similar among patients with hypertension and either diabetes mellitus, renal impairment, or heart failure. The data suggest that losartan can be safely administered in hypertensive patients with concomitant illnesses. It can be considered for first-line therapy and is suitable as an alternative therapy in patients already experiencing side effects with other agents.

Angiotensin II receptor antagonists. Potential in elderly patients with cardiovascular disease

Raised blood pressure in the elderly is not a normal consequences of aging, but is a major risk factor for cardiovascular disease. Cardiac and cerebrovascular disease account for > 50% of deaths among people aged > 65 years. Because the percentage of elderly people in most populations is rising, blood pressure control in this group is becoming increasingly important. Several large intervention studies in the elderly have demonstrated that antihypertensive medication reduces cardiovascular morbidity and mortality. In addition, the absolute benefits of blood pressure reduction are higher in elderly compared with younger patients. ACE inhibitors are effective and well tolerated in the treatment of hypertension in the elderly. Their success led to interest in alternative ways of blocking the renin angiotensin system, and the subsequent development of angiotensin II (AII) receptor antagonists. Losartan was the first drug in this class to become commercially available. Since then, valsartan has been launched in some markets and others are likely to be launched in the near future. Losartan is effective in the treatment of essential hypertension and has a low incidence of adverse effects. First-dose hypotension is very uncommon and, at the present time, cough does not appear to be an adverse effect of these drugs, although long term tolerability studies are needed to confirm this. Angioedema, a rare but life-threatening adverse effect of ACE inhibitors, has also been associated with losartan. Current data suggest that All receptor antagonists are effective in elderly hypertensive patients, although further data are needed to confirm these findings. At present, All receptor antagonists are likely to be used in hypertensive patients who are intolerant of ACE inhibitors, although this may change with the availability of long term tolerability and clinical outcomes data.

Angiotensin-converting enzyme inhibitors, angiotensin II receptor antagonists and calcium channel blocking agents: a review of potential benefits and possible adverse reactions

A review of recent studies suggests that the use of angiotensin-converting enzyme (ACE) inhibitors may be preferred (usually along with a diuretic drug) as initial therapy in several subsets of hypertensive patients (i.e., those with diabetes and nephropathy or with diminished left ventricular function with or without symptoms of heart failure). Limited long-term data are available for the angiotensin II receptor antagonists. The use of nondihydropyridine calcium channel blocking agents (CCBs) appears to reduce reinfarction in patients with ischemic heart disease (however, mortality is not reduced). Long-acting formulas of CCBs appear to decrease congestive heart failure in patients with dilated, but not ischemic, cardiomyopathy and to decrease strokes and arrhythmias in hypertensive subjects. Short-acting agents (primarily those that increase heart rate) may increase coronary heart disease events in hypertensive patients. There is little evidence at present that CCBs offer a major advantage over other antihypertensive agents or that they should be recommended as initial therapy, except in special situations.

Efficacy, tolerability, and effects on quality of life of losartan, alone or with hydrochlorothiazide, versus amlodipine, alone or with hydrochlorothiazide, in patients with essential hypertension

A randomized, double-masked, parallel-group, multicenter clinical trial was conducted to compare the efficacy, tolerability, and effects on quality of life associated with treatment regimens including the angiotensin II receptor antagonist losartan, with hydrochlorothiazide (HCTZ) added as needed, with regimens including the dihydropyridine calcium channel blocker amlodipine with HCTZ added as needed. The trial included patients whose sitting diastolic blood pressure (SiDBP) measurements were between 95 and 114 mm Hg, inclusive, at placebo baseline. Patients were randomized to receive either losartan or amlodipine in a double-masked, double-dummy fashion. A 4-week placebo washout period was followed by a 12-week active treatment period. Patients in the losartan arm (n = 97) were initially given 50 mg of oral (PO) losartan once a day (QD); the medication could be titrated to 50-mg losartan/ 12.5-mg HCTZ PO QD after 4 weeks, followed by 50-mg losartan plus 25-mg HCTZ PO QD after 8 weeks as necessary. Patients in the amlodipine group (n = 93) received 5-mg amlodipine PO QD, which could be titrated to 10 mg PO QD after 4 weeks, followed by 10 mg plus 25-mg HCTZ PO QD after 8 weeks. Medication was titrated upward as necessary to achieve trough SiDBP < 90 mm Hg. Efficacy, tolerability, and quality-of-life scores were assessed after 12 weeks of therapy with each regimen. Trough SiDBP reductions after 4, 8, and 12 weeks of therapy were clinically comparable (losartan group: 7.3, 10.4, and 11.1 mm Hg, respectively; amlodipine group: 7.9, 11.2, and 11.8 mm Hg, respectively). Similar reductions in systolic blood pressure were also seen for both treatment groups. The percentage of patients reaching goal SiDBP (defined as trough SiDBP < 90 mm Hg or SiDBP > or = 90 mm Hg with a > or = 10 mm Hg drop from placebo baseline) was comparable for the two groups, with 68% of patients in the losartan group and 71% of patients in the amlodipine group reaching goal. Significantly more patients in the amlodipine group had drug-related adverse experiences (27% vs 13%). In particular, drug-related edema was more common in patients receiving the amlodipine regimen than in those receiving the losartan regimen (11% vs 1%). Patients in the amlodipine arm reported significantly more bother due to edema, regardless of whether edema was present at baseline, than did patients in the losartan arm (12% vs 2%), although overall quality of life was not different in the two treatment groups. This study demonstrates that a regimen of losartan with HCTZ added as needed, when compared with a regimen of amlodipine with HCTZ added as needed, provides comparable efficacy and superior tolerability and less bother to patients with respect to edema.