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Salam A, Sani MU, Ogah OS, Huffman MD, Schutte AE, Pant R, Ghosh A, Dhurjati R, Lakshmi JK, Rodgers A, Ojji DB. deliVERy of optimal blood pressure coNtrol in afrICA (VERONICA)-Nigeria study: Rationale and design of a randomized clinical trial. Am Heart J 2024; 277:66-75. [PMID: 39094841 DOI: 10.1016/j.ahj.2024.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 07/11/2024] [Accepted: 07/11/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Blood pressure (BP) control among treated patients in Africa is very suboptimal, with low levels of combination therapy use and therapeutic inertia being among the major barriers to effective control of hypertension. The VERONICA-Nigeria study aims to evaluate, among Black African adults with hypertension, the effectiveness and safety of a triple pill-based treatment protocol compared to Nigeria hypertension treatment protocol (standard care protocol) for the treatment of hypertension. METHODS This study involves a randomized, parallel-group and open-label trial. Adults with uncontrolled hypertension (n = 300), untreated or receiving monotherapy, with no contraindication to study treatments will be randomly assigned 1:1 to treatment with a triple pill based-treatment protocol or standard care protocol. Follow-up is for 6 months, with interim follow up visits at month 1, 2, and 3. In a noncomparative extension treatment period, participants completing the 6 months randomized period and on ≤3 BP-lowering drugs will receive treatment with the triple pill-based treatment protocol for 12 months. The primary outcome is change in home mean SBP from baseline to month 6, and key secondary efficacy outcome is percentage of participants with clinic BP <140/90 mmHg at month 6. The primary safety outcome is discontinuation of trial treatment due to adverse events from randomization to month 6. Economic evaluation will be conducted to assess the cost-effectiveness of the triple pill-based treatment protocol, and process evaluation will be conducted to understand the context in which the trial was conducted, implementation of the trial and interventions and mechanisms of effect, and potential barriers and facilitators to implementing the intervention in clinical practice. CONCLUSION The VERONICA-Nigeria trial will provide evidence of effectiveness and safety of the triple-based treatment protocol for the pharmacological management of hypertension, in Black African adults. TRIAL REGISTRATION PACTR202107579572114.
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Affiliation(s)
- Abdul Salam
- The George Institute for Global Health, Hyderabad, Telangana, India; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Prasanna School of Public Health, Manipal Academy of Higher Education, India.
| | - Mahmoud U Sani
- Department of Medicine, Bayero University Kano and Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Okechukwu S Ogah
- Department of Internal Medicine, University College Hospital, Ibadan, Nigeria
| | - Mark D Huffman
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Department of Medicine and Global Health Center, Washington University in St. Louis, St. Louis MO
| | - Aletta E Schutte
- Cardiovascular Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; School of Population Health, UNSW Sydney, Sydney, NSW, Australia
| | - Rashmi Pant
- The George Institute for Global Health, Hyderabad, Telangana, India
| | - Arpita Ghosh
- The George Institute for Global Health, Hyderabad, Telangana, India; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Prasanna School of Public Health, Manipal Academy of Higher Education, India
| | - Rupasvi Dhurjati
- The George Institute for Global Health, Hyderabad, Telangana, India
| | - Josyula K Lakshmi
- The George Institute for Global Health, Hyderabad, Telangana, India; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; Prasanna School of Public Health, Manipal Academy of Higher Education, India
| | - Anthony Rodgers
- School of Population Health, UNSW Sydney, Sydney, NSW, Australia
| | - Dike B Ojji
- Department of Internal Medicine, University of Abuja, Abuja, Nigeria; University of Abuja Teaching Hospital, Abuja, Nigeria
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Shah SS, Fuller PJ, Young MJ, Yang J. Update on Low-Renin Hypertension: Current Understanding and Future Direction. Hypertension 2024; 81:2038-2048. [PMID: 39136130 DOI: 10.1161/hypertensionaha.124.23385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2024]
Abstract
Low-renin hypertension is common and affects 1 in 4 people with hypertension. Understanding the different causes and management of low-renin hypertension is becoming increasingly relevant as renin measurements are more widely ordered in clinical practice. Importantly, many people with low-renin hypertension do not fit traditional definitions of known causes, and the approach to management of these people is not unclear. This review provides an overview of our evolving understanding of the causes of low-renin hypertension, the expanding spectrums of pathophysiology, key differentiating characteristics, distinct management strategies, and highlights our knowledge gaps. It is important to distinguish the underlying pathophysiology of an individual with low-renin hypertension to individualize treatment.
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Affiliation(s)
- Sonali S Shah
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia (S.S.S., P.J.F., M.J.Y., J.Y.)
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia (S.S.S., P.J.F., J.Y.)
- Department of Molecular and Translational Science, Monash University, Clayton, Victoria, Australia (S.S.S., P.J.F., J.Y.)
| | - Peter J Fuller
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia (S.S.S., P.J.F., M.J.Y., J.Y.)
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia (S.S.S., P.J.F., J.Y.)
- Department of Molecular and Translational Science, Monash University, Clayton, Victoria, Australia (S.S.S., P.J.F., J.Y.)
| | - Morag J Young
- Baker Heart and Diabetes Institute, Prahran, Victoria, Australia (M.J.Y.)
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia (S.S.S., P.J.F., M.J.Y., J.Y.)
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia (S.S.S., P.J.F., J.Y.)
- Department of Molecular and Translational Science, Monash University, Clayton, Victoria, Australia (S.S.S., P.J.F., J.Y.)
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Ojji DB, Salam A, Sani MU, Ogah OS, Schutte AE, Huffman MD, Pant R, Ghosh A, Dhurjati R, Lakshmi JK, Ripiye NR, Orji IA, Kana SA, Abdussalam T, Olawumi AL, Alfa IM, Orimolade OA, Ajayi MO, Rodgers A. Low-Dose Triple-Pill vs Standard-Care Protocols for Hypertension Treatment in Nigeria: A Randomized Clinical Trial. JAMA 2024; 332:1070-1079. [PMID: 39215620 PMCID: PMC11366076 DOI: 10.1001/jama.2024.18080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024]
Abstract
Importance With the high burden of hypertension in sub-Saharan Africa, there is a need for effective, safe and scalable treatment strategies. Objective To compare, among Black African adults, the effectiveness and safety of a novel low-dose triple-pill protocol compared with a standard-care protocol for blood pressure lowering. Design and Setting Randomized, parallel-group, open-label, multicenter trial conducted in public hospital-based family medicine clinics in Nigeria. Participants Black African adults with uncontrolled hypertension (≥140/90 mm Hg) who were untreated or receiving a single blood pressure-lowering drug. Interventions Participants were randomly allocated to low-dose triple-pill or standard-care protocols. The triple-pill protocol involved a novel combination of telmisartan, amlodipine, and indapamide in triple one-quarter, one-half, and standard doses (ie, 10/1.25/0.625 mg, 20/2.5/1.25 mg, and 40/5/2.5 mg), with accelerated up-titration. The standard-care protocol was the Nigeria hypertension treatment protocol starting with amlodipine (5 mg). Main Outcomes and Measures The primary effectiveness outcome was the reduction in home mean systolic blood pressure, and the primary safety outcome was discontinuation of trial treatment due to adverse events, both from randomization to month 6. Results The first participant was randomized on July 19, 2022, and the last follow-up visit was on July 18, 2024. Among 300 randomized participants (54% female; mean age, 52 years; baseline mean home blood pressure, 151/97 mm Hg; and clinic blood pressure, 156/97 mm Hg), 273 (91%) completed the trial. At month 6, mean home systolic blood pressure was on average 31 mm Hg (95% CI, 28 to 33 mm Hg) lower in the triple-pill protocol group and 26 mm Hg (95% CI, 22 to 28 mm Hg) lower in the standard-care protocol group (adjusted difference, -5.8 mm Hg [95% CI, -8.0 to -3.6]; P < .001]). At month 6, clinic blood pressure control (<140/90 mm Hg) was 82% vs 72% (risk difference, 10% [95% CI, -2% to 20%]) and home blood pressure control (<130/80 mm Hg) was 62% vs 28% (risk difference, 33% [95% CI, 22% to 44%]) in the triple-pill compared with the standard-care protocol group; these were 2 of 21 prespecified secondary effectiveness end points. No participants discontinued trial treatment due to adverse events. Conclusions and Relevance Among Black African adults with uncontrolled hypertension, a low-dose triple-pill protocol achieved better blood pressure lowering and control with good tolerability compared with the standard-care protocol. Trial Registration Pan African Clinical Trials Registry Identifier: PACTR202107579572114.
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Affiliation(s)
- Dike B. Ojji
- Department of Internal Medicine, University of Abuja, Abuja, Nigeria
- University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Abdul Salam
- The George Institute for Global Health, Hyderabad, Telangana, India
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, India
| | - Mahmoud U. Sani
- Department of Medicine, Bayero University Kano and Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Okechukwu S. Ogah
- Department of Internal Medicine, University College Hospital, Ibadan, Nigeria
| | - Aletta E. Schutte
- The George Institute for Global Health, Sydney, New South Wales, Australia
- School of Population Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Mark D. Huffman
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Medicine and Global Health Center, Washington University in St Louis, St Louis, Missouri
| | - Rashmi Pant
- The George Institute for Global Health, Hyderabad, Telangana, India
| | - Arpita Ghosh
- The George Institute for Global Health, Hyderabad, Telangana, India
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Prasanna School of Public Health, Manipal Academy of Higher Education, India
| | - Rupasvi Dhurjati
- The George Institute for Global Health, Hyderabad, Telangana, India
| | - Josyula K. Lakshmi
- Indian Institute of Public Health, Hyderabad
- Now with The George Institute for Global Health, Hyderabad, Telangana, India
- Now with The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Now with Prasanna School of Public Health, Manipal Academy of Higher Education, India
| | - Nanna. R. Ripiye
- Department of Family Medicine, University of Abuja, Abuja, Nigeria
- University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Ikechukwu A. Orji
- University of Abuja Teaching Hospital, Abuja, Nigeria
- Cardiovascular Research Center, University of Abuja, Abuja, Nigeria
| | - Shehu A. Kana
- Department of Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Tijjani Abdussalam
- Department of Medicine, Bayero University Kano and Aminu Kano Teaching Hospital, Kano, Nigeria
| | | | - Isiaka M. Alfa
- Department of Medicine, Bayero University Kano and Aminu Kano Teaching Hospital, Kano, Nigeria
| | | | - Moses O. Ajayi
- Department of Internal Medicine, University College Hospital, Ibadan, Nigeria
| | - Anthony Rodgers
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Imperial College London, London, England
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Zhu Y, Deng T, Ma L, Sun L, Hao Y, Yu H, Yuan F, Tian Y, Wang S. Acid-sensing ion channel 1 in nucleus tractus solitarii neurons contributes to the enhanced CO 2-stimulated cardiorespiratory effect in spontaneously hypertensive rats. Life Sci 2024; 351:122853. [PMID: 38889841 DOI: 10.1016/j.lfs.2024.122853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 06/12/2024] [Accepted: 06/14/2024] [Indexed: 06/20/2024]
Abstract
AIMS Activation of central respiratory chemoreceptors provides excitatory drive to both respiratory and sympathetic outputs. The enhanced respiratory-sympathetic coupling contributes to the onset and development of hypertension. However, the specific central targets and molecular mechanisms involved in this process remain elusive. This study aimed to investigate the role of acid-sensing ion channel 1 (ASIC1) in nucleus tractus solitarii (NTS) neurons in CO2-stimulated cardiorespiratory effects in spontaneously hypertensive rats (SHRs). MAIN METHODS Respiration and blood pressure of conscious rats were recorded by whole-body plethysmography and telemetry, respectively. Western blot was used to detect the expression difference of ASIC1 protein in NTS region between Wistar-Kyoto (WKY) rats and SHRs. Excitability of NTS neurons were assessed by extracellular recordings. KEY FINDINGS Compared to WKY rats, the enhanced CO2-stimulated cardiopulmonary effect and up-regulation of ASIC1 in the NTS were already observed in 4-week-old prehypertensive SHRs. Furthermore, specific blockade of ASIC1 effectively attenuated the CO2-stimulated increase in firing rate of NTS neurons in anesthetized adult SHRs. Intracerebroventricular injections of the ASIC1a blocker PcTx1 or knockdown Asic1 in NTS neurons significantly reduced the heightened CO2-stimulated ventilatory response, and diminished the CO2-stimulated increase in arterial pressure and heart rate in adult SHRs. SIGNIFICANCE These findings showed that dysregulated ASIC1 signaling in the NTS contribute to the exaggerated CO2-stimulated cardiorespiratory effects observed in SHRs.
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Affiliation(s)
- Yufang Zhu
- Department of Neurobiology, Hebei Medical University, Shijiazhuang 050017, China
| | - Tianjiao Deng
- Department of Neurobiology, Hebei Medical University, Shijiazhuang 050017, China
| | - Lan Ma
- Department of Neurobiology, Hebei Medical University, Shijiazhuang 050017, China
| | - Lu Sun
- Department of Neurobiology, Hebei Medical University, Shijiazhuang 050017, China
| | - Yinchao Hao
- Department of Neurobiology, Hebei Medical University, Shijiazhuang 050017, China
| | - Hongxiao Yu
- Department of Neurobiology, Hebei Medical University, Shijiazhuang 050017, China
| | - Fang Yuan
- Department of Neurobiology, Hebei Medical University, Shijiazhuang 050017, China; Hebei Province Key Laboratory of Neurophysiology, Shijiazhuang 050017, China
| | - Yanming Tian
- Department of Neurobiology, Hebei Medical University, Shijiazhuang 050017, China; Hebei Province Key Laboratory of Neurophysiology, Shijiazhuang 050017, China.
| | - Sheng Wang
- Department of Neurobiology, Hebei Medical University, Shijiazhuang 050017, China; Hebei Province Key Laboratory of Neurophysiology, Shijiazhuang 050017, China.
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Durán CE, Bustamante M, Barbosa M, Useche EM, Triviño J, Sandoval L, Moncayo PA, Rivas AM, Zapata JS, Hernández Quintero JD, Meza S, Bolaños JS, Schweineberg J, Mesa L, Posada JG. Evaluation of aldosterone to direct renin ratio, low renin and related Phenotypes in Afro-Colombian patients with apparent treatment resistant hypertension. Sci Rep 2024; 14:18091. [PMID: 39103362 PMCID: PMC11300880 DOI: 10.1038/s41598-024-67261-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 07/09/2024] [Indexed: 08/07/2024] Open
Abstract
Apparent resistant hypertension (aTRH) is a significant public health issue. Once low adherence to antihypertensive treatment has been ruled out and true resistant hypertension is diagnosed, aldosterone-direct-renin-ratio (ADRR) aids in the screening of an aldosterone-producing adenoma (APA) and primary aldosteronism (PA). Once PA and other secondary causes have been ruled out, the values of aldosterone and renin allow patients to be classified into phenotypes such as low renin hypertension (LRH), Liddle's-like (LLph), and primary hyperaldosteronism (PAph). These classifications could aid in the treatment decision-making process. However, optimal cut-off points for these classifications remain uncertain. This study aims to assess the prevalence of these phenotypes and the behavior of different cut-offs of the ADRR in an Afro-Colombian population with apparent resistant hypertension, as well to describe their sodium consumption. Afro-descendant individuals 18 years of age or older, diagnosed with resistant hypertension and attending to a primary care center in Colombia were recruited as volunteers. As part of the study, their plasma renin concentration (PRC) and plasma aldosterone concentration (PAC) were measured. The phenotypes were categorized into three groups based on multiple cut-off points from different authors: low renin and low aldosterone phenotype (LLph), low renin and high aldosterone phenotype (PAph), and high renin and high aldosterone phenotype, referred to as the renal phenotype (Rph). The prevalence of ADRR values exceeding the cut-off and phenotypes were calculated. A linear regression model was derived to assess the effect of sodium consumption with PAC, PRC and ADRR. A total of 88 patients with aTRH were included. Adherence to at least 3 antihypertensive medications was 62.5%. The median age was 56 years (IQR 48-60), 44% were female, and 20% had diabetes. The study found that the prevalence of ADRR values exceeding the cut-off ranged from 4.5 to 23%, while low-renin hypertension (LRH) varied from 15 to 74%, Rph was found in approximately 30 to 34% of patients, PAph in 30 to 51%, and the LLph in 15 to 41%, respectively, depending on the specific cut-off value by different authors. Notably, sodium consumption was associated with lower aldosterone (β - 0.15, 95% CI [- 0.27, - 0.03]) and renin concentrations (β - 0.75, 95% CI [- 1.5, - 0.02]), but ADRR showed no significant association with sodium consumption. There were no significant differences in prevalences between the groups taking < 3 vs ≥ 3 antihypertensive medications. Altered aldosterone-direct-renin-ratio, low renin hypertension, Liddle's-like, and primary hyperaldosteronism are prevalent phenotypes in patients within Afro-Colombian patients with apparent treatment-Resistant hypertension.
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Affiliation(s)
- C E Durán
- Servicio de Nefrología, Fundación Valle del Lili, Carrera 98 No.18-49, 760032, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - M Bustamante
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - M Barbosa
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Carrera 98 No.18-49, Valle del Cauca, 760032, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - E M Useche
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Carrera 98 No.18-49, Valle del Cauca, 760032, Cali, Colombia
| | - J Triviño
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Carrera 98 No.18-49, Valle del Cauca, 760032, Cali, Colombia.
| | - L Sandoval
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Carrera 98 No.18-49, Valle del Cauca, 760032, Cali, Colombia
| | - P A Moncayo
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Carrera 98 No.18-49, Valle del Cauca, 760032, Cali, Colombia
| | - A M Rivas
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Carrera 98 No.18-49, Valle del Cauca, 760032, Cali, Colombia
| | - J S Zapata
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | | | - S Meza
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - J S Bolaños
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - J Schweineberg
- Servicio de Nefrología, Fundación Valle del Lili, Carrera 98 No.18-49, 760032, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - L Mesa
- Servicio de Nefrología, Fundación Valle del Lili, Carrera 98 No.18-49, 760032, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
| | - J G Posada
- Servicio de Nefrología, Fundación Valle del Lili, Carrera 98 No.18-49, 760032, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Calle 18 # 122-135, Cali, Colombia
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Fadl Elmula FEM, Mariampillai JE, Heimark S, Kjeldsen SE, Burnier M. Medical Measures in Hypertensives Considered Resistant. Am J Hypertens 2024; 37:307-317. [PMID: 38124494 PMCID: PMC11016838 DOI: 10.1093/ajh/hpad118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Patients with resistant hypertension are the group of hypertensive patients with the highest cardiovascular risk. METHODS All rules and guidelines for treatment of hypertension should be followed strictly to obtain blood pressure (BP) control in resistant hypertension. The mainstay of treatment of hypertension, also for resistant hypertension, is pharmacological treatment, which should be tailored to each patient's specific phenotype. Therefore, it is pivotal to assess nonadherence to pharmacological treatment as this remains the most challenging problem to investigate and manage in the setting of resistant hypertension. RESULTS Once adherence has been confirmed, patients must be thoroughly worked-up for secondary causes of hypertension. Until such possible specific causes have been clarified, the diagnosis is apparent treatment-resistant hypertension (TRH). Surprisingly few patients remain with true TRH when the various secondary causes and adherence problems have been detected and resolved. Refractory hypertension is a term used to characterize the treatment resistance in hypertensive patients using ≥5 antihypertensive drugs. All pressor mechanisms may then need blockage before their BPs are reasonably controlled. CONCLUSIONS Patients with resistant hypertension need careful and sustained follow-up and review of their medications and dosages at each term since medication adherence is a very dynamic process.
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Affiliation(s)
- Fadl Elmula M Fadl Elmula
- Division of Medicine, Ullevaal University Hospital, Cardiorenal Research Centre, Oslo, Norway
- Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, KSA
| | | | - Sondre Heimark
- Division of Medicine, Ullevaal University Hospital, Cardiorenal Research Centre, Oslo, Norway
- Medical Faculty, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Nephrology, Ullevaal University Hospital, Oslo, Norway
| | - Sverre E Kjeldsen
- Division of Medicine, Ullevaal University Hospital, Cardiorenal Research Centre, Oslo, Norway
- Medical Faculty, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Ullevaal University Hospital, Oslo, Norway
| | - Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Myke-Mbata BK, Basil B, Oloche JJ, Igbom A. Pharmacological Considerations in the Interpretation of Biochemical Results in Diabetic Patients with Cardiovascular Complications. EJIFCC 2023; 34:305-316. [PMID: 38303751 PMCID: PMC10828539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Diabetes mellitus with cardiovascular diseases is often a multi-systemic disease that requires a multi-therapeutic approach which mostly poses a challenge to laboratory result interpretation. The non-availability of information on many patients due to poor referral, documentation and record keeping has resulted in isolated interpretation of laboratory result of diabetic patients with multisystemic complications. This has led to both analytical and post-analytical errors which has a negative impact on total quality of results. Therefore, this review showed the possible therapeutic treatment of a diabetic patient with cardiovascular disease and how their pharmacological role could affect laboratory result.
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Affiliation(s)
| | - Bruno Basil
- Department of Chemical Pathology, Benue State University, Makurdi, Nigeria
| | - Jeremiah John Oloche
- Department of Pharmacology and Therapeutics, Benue State University, Makurdi, Nigeria
| | - Amarachukwu Igbom
- Department of Family Medicine, Lake District Hospital& Health Centre, Burns Lake, BC., Canada
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8
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Lamba R. Redefining primary hyperaldosteronism as "The Syndrome of Inappropriate Aldosterone Secretion (SIALDS)": A common but unrecognized cause of hypertension. J Clin Hypertens (Greenwich) 2023; 25:1045-1052. [PMID: 37877173 PMCID: PMC10710549 DOI: 10.1111/jch.14740] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/26/2023]
Abstract
The current screening and diagnostic recommendations for detecting Primary Hyperaldosteronism (PHA) focus on diagnosing the more severe and overt instances of renin-independent aldosterone production. However, milder forms of autonomous aldosterone secretion have been demonstrated to exist below the diagnostic thresholds of current PHA guidelines, and associate with clinically relevant cardiovascular risk. PHAencompasses a spectrum of renin independent aldosterone production, progressing from a subclinical state in normotensives to a full-blown clinical syndrome representing the resistant hypertension population. The authors propose the Syndrome of Inappropriately Elevated Aldosterone Secretion (SIALDS) concept as a potential new paradigm for understanding and diagnosing PHA and expanded diagnostic approach to improve early detection even in well-controlled hypertension. The authors also delve into the impact of treatments, including mineralocorticoid receptor antagonists and emerging aldosterone synthase inhibitors. Furthermore, The authors outline future research directions, proposing clinical trials to investigate the long-term identification and treatment outcomes of SIALDS.
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Affiliation(s)
- Rajat Lamba
- Department for Continuing EducationKellogg CollegeUniversity of OxfordOxfordshireUK
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9
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Kario K, Ohishi M, Katsuya T, Taguchi T, Tanabe A, Sugimoto K, Shimosawa T. Rationale and design of a multicenter randomized study comparing the efficacy and safety of esaxerenone versus trichlormethiazide in patients with uncontrolled essential hypertension: EXCITE-HT study. J Clin Hypertens (Greenwich) 2023; 25:861-867. [PMID: 37551054 PMCID: PMC10497029 DOI: 10.1111/jch.14705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 08/09/2023]
Abstract
The next-generation mineralocorticoid receptor blocker (MRB) esaxerenone has favorable antihypertensive effects in patients who do not respond to treatment with first-line antihypertensive agents and may be beneficial as a second-line treatment. However, MRBs are currently considered a fourth-line treatment as there is no clinical evidence comparing the efficacy of esaxerenone with other classes of antihypertensive agents. The multicenter, randomized, open-label, parallel-group EXCITE-HT study will evaluate the efficacy and safety of esaxerenone as a second-line agent in the treatment of Japanese patients with uncontrolled essential hypertension. After a 4-week run-in period, patients will receive either esaxerenone or trichlormethiazide for 12 weeks per the package insert and the Japanese Society of Hypertension Guidelines for the Management of Hypertension. At Weeks 4 and 8, the dose of esaxerenone or trichlormethiazide may be increased. Blood pressure (home [morning and bedtime] and office), serum biomarkers, and urinary biomarkers will be measured. The primary efficacy endpoint is the change from baseline in morning home systolic blood pressure/diastolic blood pressure to the end of treatment. The EXCITE-HT study is expected to validate the non-inferiority of esaxerenone to trichlormethiazide and provide the first evidence for the early use of esaxerenone as a second-line agent in the treatment of Japanese patients with uncontrolled essential hypertension instead of its current use as a fourth-line agent.
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Affiliation(s)
- Kazuomi Kario
- Division of Cardiovascular MedicineDepartment of MedicineJichi Medical University School of MedicineTochigiJapan
| | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and HypertensionGraduate School of Medical and Dental SciencesKagoshima UniversityKagoshimaJapan
| | - Tomohiro Katsuya
- Katsuya ClinicHyogoJapan
- Department of Clinical Gene TherapyOsaka University Graduate School of MedicineOsakaJapan
| | - Takashi Taguchi
- Primary Medical Science DepartmentDaiichi Sankyo Co., LtdTokyoJapan
| | - Ayumi Tanabe
- Data Intelligence DepartmentDaiichi Sankyo Co., Ltd.TokyoJapan
| | - Kotaro Sugimoto
- Primary Medical Science DepartmentDaiichi Sankyo Co., LtdTokyoJapan
| | - Tatsuo Shimosawa
- Department of Clinical LaboratorySchool of MedicineInternational University of Health and WelfareChibaJapan
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Luo JQ, Ren H, Chen MY, Zhao Q, Yang N, Liu Q, Gao YC, Zhou HH, Huang WH, Zhang W. Hydrochlorothiazide-induced glucose metabolism disorder is mediated by the gut microbiota via LPS-TLR4-related macrophage polarization. iScience 2023; 26:107130. [PMID: 37456847 PMCID: PMC10338205 DOI: 10.1016/j.isci.2023.107130] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/09/2023] [Accepted: 06/10/2023] [Indexed: 07/18/2023] Open
Abstract
Hydrochlorothiazide (HCTZ) is reported to impair glucose tolerance and may induce new onset of diabetes, but the pharmacomicrobiomics of the adverse effect for HCTZ remains unknown. Mice-fed HCTZ exhibited insulin resistance and impaired glucose tolerance. By using FMT and antibiotic cocktail models, we found that HCTZ-induced metabolic disorder was mediated by commensal microbiota. HCTZ consumption disturbed the structure of the intestinal microbiota, causing abnormal elevation of Gram-negative Enterobacteriaceae and lipopolysaccharide (LPS) then leading to intestinal barrier dysfunction. Additionally, HCTZ activated TLR4 signaling and induced macrophage polarization and inflammation in the liver. Furthermore, HCTZ-induced macrophage polarization and metabolic disorder were abrogated by blocking TLR4 signaling. HCTZ consumption caused a significant increase in Gram-negative Enterobacteriaceae, which elevated the levels of LPS, thereby activating LPS/TLR4 pathway, promoting inflammation and macrophage polarization, and resulting in metabolic disorders. These findings revealed that the gut microbiome is the key medium underlying HCTZ-induced metabolic disorder.
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Affiliation(s)
- Jian-Quan Luo
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, P. R. China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, P. R. China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, P.R. China
- Department of Pharmacy, the Second Xiangya Hospital, Central South University, Changsha, China
| | - Huan Ren
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, P. R. China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, P. R. China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, P.R. China
- Department of Pharmacy, Hunan Provincial People’s Hospital, the First Affiliated Hospital of Hunan Normal University, No.61 Western Jiefang Road, Changsha, Hunan, China
| | - Man-Yun Chen
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, P. R. China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, P. R. China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, P.R. China
| | - Qing Zhao
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, P. R. China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, P. R. China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, P.R. China
| | - Nian Yang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, P. R. China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, P. R. China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, P.R. China
| | - Qian Liu
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, P. R. China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, P. R. China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, P.R. China
| | - Yong-Chao Gao
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, P. R. China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, P. R. China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, P.R. China
| | - Hong-Hao Zhou
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, P. R. China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, P. R. China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, P.R. China
| | - Wei-Hua Huang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, P. R. China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, P. R. China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, P.R. China
| | - Wei Zhang
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, 87 Xiangya Road, Changsha 410008, P. R. China
- Institute of Clinical Pharmacology, Central South University, Hunan Key Laboratory of Pharmacogenetics, 110 Xiangya Road, Changsha 410078, P. R. China
- National Clinical Research Center for Geriatric Disorders, 87 Xiangya Road, Changsha 410008, Hunan, P.R. China
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Martins VM, Ziegelmann PK, Ferrari F, Bottino LG, Lucca MB, Corrêa HLR, Blum GB, Helal L, Fuchs SC, Fuchs FD. Thiazide diuretics alone or combined with potassium-sparing diuretics to treat hypertension: a systematic review and network meta-analysis of randomized controlled trials. J Hypertens 2023; 41:1108-1116. [PMID: 37016911 PMCID: PMC10241430 DOI: 10.1097/hjh.0000000000003436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/03/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND The magnitude of blood pressure (BP)-lowering effects and decrease of the adverse effects of thiazide diuretics provided by potassium-sparing diuretics remain uncertain. The aim of this study was to compare the BP-lowering efficacy and the incidence of adverse effects of high (T+) and low-dose (T-) thiazide diuretics, alone or combined with high (PS+) or low-dose (PS-) potassium-sparing diuretics in patients with primary hypertension. METHODS A systematic literature search was performed in PubMed/MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, Web of Science, Scopus and LILACS. Randomized double-blind placebo or active-controlled trials (RCT) with 3 weeks to 1 year of follow-up were included. Sample size, mean and standard deviation from baseline, follow-up and change from baseline values were extracted by two independent reviewers. Pairwise random effect models and Bayesian network meta-analysis models were used to compare the effects of treatments. The risk of bias in individual studies was assessed using the Rob 1.0 tool. The primary outcome was the mean difference in office SBP. Secondary outcomes were the mean difference in biochemical parameters and the incidence of nonmelanoma skin cancer. RESULTS Two hundred and seventy-six double-blind RCTs involving 58 807 participants (mean age: 55 years; 45% women) were included. All treatment groups were more effective than placebo in lowering BP, with mean differences (MDs) of change from baseline ranging from -7.66 mmHg [95% credible interval (95% CrI), -8.53 to -6.79] for T- to -12.77 mmHg (95% CrI, -15.22 to -10.31) for T+PS-. T+ alone or combined with potassium-sparing was more effective in reducing BP than T-. The surface under the cumulative ranking curve (SUCRA) estimated ranking showed that the best effectiveness in lowering SBP was found for T+PS- (0.69), T+PS+ (0.65) and T+ (0.54). Compared with placebo, all treatments (except T-PS-) were associated with more potassium reduction and T+ compared with all other treatments and T- when compared with T-PS-. Compared with placebo, all active treatments (except T+PS+) showed higher elevations of uric acid. The increase of plasma glucose promoted by thiazides alone was reduced by potassium-sparing agents. CONCLUSION Thiazides with potassium-sparing diuretics are associated with increased BP-lowering efficacy compared with thiazides alone while minimizing hypokalaemia and hyperglycaemia. These findings demonstrate that thiazide and potassium-sparing diuretic combination is preferable to thiazide alone in treating hypertension.
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Affiliation(s)
| | - Patrícia K. Ziegelmann
- Graduate Program in Cardiology and Cardiovascular Sciences
- Graduate Program in Epidemiology, School of Medicine, Universidade Federal do Rio Grande do Sul
| | - Filipe Ferrari
- Graduate Program in Cardiology and Cardiovascular Sciences
| | - Leonardo G. Bottino
- Graduate Program in Cardiology and Cardiovascular Sciences
- INCT PREVER, Clinical Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Marcelo B. Lucca
- Graduate Program in Cardiology and Cardiovascular Sciences
- INCT PREVER, Clinical Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | | | - Gabriela B. Blum
- INCT PREVER, Clinical Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Lucas Helal
- Graduate Program in Cardiology and Cardiovascular Sciences
- Center for Journalology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sandra C. Fuchs
- Graduate Program in Cardiology and Cardiovascular Sciences
- Graduate Program in Epidemiology, School of Medicine, Universidade Federal do Rio Grande do Sul
- INCT PREVER, Clinical Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
| | - Flávio D. Fuchs
- Graduate Program in Cardiology and Cardiovascular Sciences
- INCT PREVER, Clinical Research Center, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS Brazil
- Division of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
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12
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Desbiens L, Khelifi N, Wang Y, Lavigne F, Beaulieu V, Sidibé A, Mac‐Way F. Thiazide Diuretics and Fracture Risk: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. JBMR Plus 2022; 6:e10683. [PMID: 36398110 PMCID: PMC9664541 DOI: 10.1002/jbm4.10683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 11/08/2022] Open
Abstract
Thiazide diuretics are commonly used antihypertensive agents. Until today, whether their use reduces fracture risk remains unclear. Our objective was to conduct a systematic review of thiazide diuretics' effects on fractures and bone mineral density (BMD) in randomized clinical trials (RCT) of adults. MEDLINE, EMBASE, CENTRAL, and the WHO's ICTRP registry were searched from inception to July 31, 2019. Two reviewers assessed studies for eligibility criteria: (i) RCTs; (ii) including adults; (iii) comparing thiazides, alone or in combination; (iv) to placebo or another medication; and (v) reporting fractures or BMD. Conference abstracts and studies comparing thiazides to antiresorptive or anabolic bone therapy were excluded. Bias was assessed using Cochrane Collaboration's Risk of Bias Tool-2. The primary outcome was fracture at any anatomical site. Secondary outcomes were osteoporotic fractures, hip fractures, and BMD at femoral neck, lumbar spine, and/or total hip. Fractures were pooled as risk ratios (RRs) using random-effect models. Prespecified subgroup analyses and post hoc sensitivity analyses were conducted. From 15,712 unique records screened, 32 trials (68,273 patients) met eligibility criteria. Thiazides were associated with decreased fractures at any site (RR = 0.87, 95% confidence interval [CI] 0.77-0.98; I 2 = 0%) and osteoporotic fractures (RR = 0.80; 95% CI 0.69-0.94; I 2 = 0%). Results were consistent in most subgroups and sensitivity analyses. Few studies reported hip fractures, and no association was found between thiazides and this outcome (RR = 0.84; 95% CI 0.67-1.04; I 2 = 0%). Only four studies reported BMD; a meta-analysis was not conducted because BMD reporting was inconsistent. Trials were deemed at low (3 studies, weight = 3%), some concerns (16 studies; 71%), or high (11 studies; 26%) risk of bias for the primary outcome. In conclusion, thiazide diuretics decreases the risk of fractures at any and at osteoporotic sites in a meta-analysis of RCTs. Additional studies are warranted in patients with high fracture risk. © 2022 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Louis‐Charles Desbiens
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
| | - Nada Khelifi
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
| | - Yue‐Pei Wang
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
| | - Felix Lavigne
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
| | - Véronique Beaulieu
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
| | - Aboubacar Sidibé
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
| | - Fabrice Mac‐Way
- CHU de Québec Research CenterL'Hôtel‐Dieu de Québec HospitalQuebecCanada
- Department of Medicine, Faculty of MedicineLaval UniversityQuebecCanada
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13
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Kuzmin OB, Zhezha VV. Refractory Arterial Hypertension: Features of Neurohormonal and Water-salt Imbalanceand Approaches to Antihypertensive Drug Therapy. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-08-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Refractory arterial hypertension is characterized by a lack of control of target blood pressure, despite the prolonged use >5 antihypertensive drugs with different mechanisms of action, including longacting diuretic chlorthalidone and the mineralcorticoid receptor antagonists (spironolactone or eplerenone). The review presents the results of clinical studies devoted the elucidating peculiarities of the neurohormonal status and water-salt balance in such patients and developing new approaches to antihypertensive drug therapy based on them. According to these studies, individuals with refractory hypertension differ from patients with resistant hypertension with the higher of sympathetic nervous system activity and the absence of an increased of intrathoracic fluid volume, which indirectly indicates a significant decrease in the intravascular fluid volume. In this regard, the review focuses on the data obtained in assessing the clinical efficacy of sympatholytics clonidine and reserpine in patients with resistant and refractory hypertension, as well as renal sodium-glucose co-transporter type 2 inhibitors, which suppress the sympathetic nervous system activity and can be used to overcome refractory hypertension in patients with type 2 diabetes.
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14
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Trotman R, McKay G, Llano A. Amiloride. PRACTICAL DIABETES 2022. [DOI: 10.1002/pdi.2389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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Martins VM, Ziegelmann PK, Helal L, Ferrari F, Lucca MB, Fuchs SC, Fuchs FD. Thiazide diuretics alone or in combination with a potassium-sparing diuretic on blood pressure-lowering in patients with primary hypertension: protocol for a systematic review and network meta-analysis. Syst Rev 2022; 11:23. [PMID: 35135630 PMCID: PMC8826711 DOI: 10.1186/s13643-022-01890-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/21/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The use of thiazide (T) diuretics for the treatment of hypertension may be associated with adverse metabolic effects, which can be minimized by combining thiazides with potassium-sparing (PS) diuretics. The additional blood pressure (BP)-lowering effect provided by the addition of a PS diuretic is unclear. Due to a large number of drugs in the T diuretics class, and the possible difference between them, there is a need to identify the best available evidence for health decision-making. This systematic review with network meta-analysis aims to compare the antihypertensive efficacy of T diuretics alone or in combination with a PS diuretic in patients with primary hypertension, as well as the safety of such drugs through the measurement of drug-related adverse events. METHODS A comprehensive electronic search will be conducted in six electronic bibliographic databases (PubMed/MEDLINE, Cochrane Library, Embase, Web of Science, Scopus, Lilacs), a registration database ( ClinicalTrials.gov ), and Educational Resources Information Center (ERIC [ProQuest]), published from inception to the date of the search. The search will be updated towards the end of the review. A hand search of the reference sections of the included studies and cited studies will also be performed. In case of missing data, authors will be contacted by e-mail or academic social networking sites whenever possible. To be included in the review, studies must be double-blind randomized controlled trials evaluating T diuretics alone or in combination with PS diuretics in patients with primary hypertension. The primary outcome measure will be office BP. Ambulatory BP monitoring (ABPM), non-melanoma skin cancer, major adverse cardiovascular events, laboratory parameters, and the number of withdrawals will be included as secondary outcomes. The results will be quantitatively summarized using differences between the mean change from baseline or differences between means for quantitative outcomes and relative risk for dichotomous outcomes. Results will be presented as mean or relative risk with credible intervals through a league table. The treatments will also be ranked using the surface under the cumulative ranking curve method. The risk of bias will be assessed through the RoB 1.0 tool. DISCUSSION To the best of our knowledge, this review will be the first to synthesize currently available evidence on the antihypertensive efficacy of different T diuretics alone or in combination with PS diuretics in adults with hypertension. The goals of hypertension treatment are to control high BP and to reduce associated cardiovascular morbidity and mortality, using the most appropriate therapy. Thiazides are widely used for pharmacological treatment due to their demonstrated effectiveness in reducing BP, favorable safety profile, and low cost. The results of this study will provide evidence regarding the best therapeutic strategies with T and PS diuretics, evidencing interventions with better antihypertensive efficacy and safety profile. TRIAL REGISTRATION This systematic review and network meta-analysis was prospectively registered at the PROSPERO database ( CRD42018118492 ).
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Affiliation(s)
- Vítor M Martins
- Graduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. .,Division of Cardiology, Hospital de Clínicas de Porto Alegre, R. Ramiro Barcellos 2350, Porto Alegre, RS, 90035-903, Brazil.
| | - Patrícia K Ziegelmann
- Graduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Graduate Program in Epidemiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Lucas Helal
- Graduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Center for Journalology, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Filipe Ferrari
- Graduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Marcelo B Lucca
- Graduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,INCT PREVER, Clinical Research Center, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Sandra C Fuchs
- Graduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Graduate Program in Epidemiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,INCT PREVER, Clinical Research Center, Hospital de Clinicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Flávio D Fuchs
- Graduate Program in Cardiology and Cardiovascular Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Division of Cardiology, Hospital de Clínicas de Porto Alegre, R. Ramiro Barcellos 2350, Porto Alegre, RS, 90035-903, Brazil
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16
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Kociánová E. Why take organ damage in hypertension seriously? VNITRNI LEKARSTVI 2022; 68:303-308. [PMID: 36283821 DOI: 10.36290/vnl.2022.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The focus of recent European guidelines has been early initiation of antihypertensive therapy in risk groups, rapid achievement of target blood pressure with fixed combinations of antihypertensive drugs, and the best possible management of an individuals cardiovascular risk. Early intervention in the development of hypertension-mediated organ damage (HMOD) has been shown to have an effect on the subsequent reduction in the risk of cardiovascular events. The point of HMOD origination correlates with the magnitude and duration of blood pressure elevation, and there is no clearly defined boundary from which vascular damage begins to develop. A reduction in blood pressure with pharmacotherapy demonstrably decreases the risk of ischaemic heart disease, stroke, as well as the mortality rate (1). Large clinical trials have consistently shown a significant reduction in the risk of these complications with antihypertensive medications across the entire spectrum from mild to severe hypertension, including hypertension in the elderly as well as isolated systolic hypertension (2). Based on the latest knowledge, a reduction in blood pressure by a mere 5 mm Hg has a cardioprotective effect even in normotensive individuals, which fundamentally changes the view on the diagnosis and definition of hypertension as a disease (3).
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Abstract
Amiloride is a potassium retaining diuretic and natriuretic which acts by reversibly
blocking luminal epithelial sodium channels (ENaCs) in the late distal tubule and
collecting duct. Amiloride is indicated in oedematous states, and for potassium
conservation adjunctive to thiazide or loop diuretics for hypertension, congestive heart
failure and hepatic cirrhosis with ascites. Historical studies on its use in hypertension
were poorly controlled and there is insufficient data on dose-response. It is clearly
highly effective in combination with thiazide diuretics where it counteracts the adverse
metabolic effects of the thiazides and its use in the Medical Research Council Trial of
Older Hypertensive Patients, demonstrated convincing outcome benefits on stroke and
coronary events. Recently it has been shown to be as effective as spironolactone in
resistant hypertension but there is a real need to establish its potential role in the
much larger number of patients with mild to moderate hypertension in whom there is a
paucity of information with amiloride particularly across an extended dose range.
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Affiliation(s)
- Qianhui Sun
- Imperial College London, Faculty of Medicine, Faculty Building, Level 2, London, UK
| | - Peter Sever
- Imperial College London, National Heart and Lung Institute, ICTEM Building, Level 3, London, UK
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18
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Guide de Pratique Clinique. Prise en charge de l’hypertension artérielle chez l’adulte en Tunisie. LA TUNISIE MÉDICALE 2021. [PMCID: PMC9003593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ce document a été réalisé dans le cadre d'une collaboration entre l'Instance Nationale de l’Évaluation et de l'Accréditation en Santé (INEAS), la Société Tunisienne de Cardiologie et de Chirurgie Cardiovasculaire (STCCCV) et la Caisse Nationale d’Assurance Maladie (CNAM).
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19
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Allu AS, Tiriveedhi V. Cancer Salt Nostalgia. Cells 2021; 10:cells10061285. [PMID: 34064273 PMCID: PMC8224381 DOI: 10.3390/cells10061285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 05/18/2021] [Accepted: 05/20/2021] [Indexed: 12/15/2022] Open
Abstract
High-salt (sodium chloride) diets have been strongly associated with disease states and poor health outcomes. Traditionally, the impact of salt intake is primarily studied in cardiovascular diseases, hypertension and renal diseases; however, recently there has been increasing evidence demonstrating the role of salt in autoimmune diseases. Salt has been shown to modulate the inflammatory activation of immune cells leading to chronic inflammation-related ailments. To date, there is minimal evidence showing a direct correlation of salt with cancer incidence and/or cancer-related adverse clinical outcomes. In this review article, we will discuss the recent understanding of the molecular role of salt, and elucidate the apparent double-edged sword nature of the relationship between salt and cancer progression.
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Affiliation(s)
- Aashish S. Allu
- Department of Sciences, Lafayette High School, Wildwood, MO 63011, USA;
| | - Venkataswarup Tiriveedhi
- Department of Biological Sciences, Tennessee State University, 3500 John A Merritt Blvd, Nashville, TN 37209, USA
- Division of Pharmacology, Vanderbilt University, Nashville, TN 37232, USA
- Correspondence: ; Tel.: +1-615-963-5779; Fax: +1-615-963-5747
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Update on Treatment of Hypertension After Renal Transplantation. Curr Hypertens Rep 2021; 23:25. [PMID: 33961145 DOI: 10.1007/s11906-021-01151-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW To incorporate novel findings on pathophysiology and treatment of posttransplant hypertension. RECENT FINDINGS (1) The sodium retaining effects of CNIs are mediated by stimulation of the thiazide-sensitive sodium chloride co-transporter in the distal convoluted tubule and in this regard chlorthalidone was proven to be an effective antihypertensive drug in renal transplantation. (2) Local and not systemic activation of the renin-angiotensin-aldosterone system plays a crucial role in the pathogenesis of posttransplant hypertension. (3) Recent randomized controlled trials failed to prove the presumed superiority of renin-angiotensin blockers in kidney transplantation. (4) Steroid-free and mammalian target of rapamycin-based immunosuppressive drug combinations did not show favorable effects on blood pressure control. (5) In a recent report the risk of non-melanoma skin cancer was higher with thiazide diuretics. But the increased cancer risk in transplant recipients is mainly attributed to comorbidities, such as diabetes and hypertension and of course to the transplantation condition itself or the obligatory application of immunosuppression, and has little to do with the antihypertensive medication Actual recommendations about BP targets in adult renal transplant recipients are coming from a post hoc analysis of a large randomized trial with another primary endpoint. Unless convincing studies on treatment of hypertension after renal transplantation are available, the ESC/ESH Guidelines 2018 should apply for these patients.
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Lin Z, Wong LYF, Cheung BMY. Diuretic-induced hypokalaemia: an updated review. Postgrad Med J 2021; 98:477-482. [PMID: 33688065 DOI: 10.1136/postgradmedj-2020-139701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/29/2021] [Accepted: 01/31/2021] [Indexed: 12/24/2022]
Abstract
Diuretic-induced hypokalaemia is a common and potentially life-threatening adverse drug reaction in clinical practice. Previous studies revealed a prevalence of 7%-56% of hypokalaemia in patients taking thiazide diuretics. The clinical manifestations of hypokalaemia due to diuretics are non-specific, varying from asymptomatic to fatal arrhythmia. Diagnosis of hypokalaemia is based on the level of serum potassium. ECG is useful in identifying the more severe consequences. A high dosage of diuretics and concomitant use of other drugs that increase the risk of potassium depletion or cardiac arrhythmias can increase the risk of cardiovascular events and mortality. Thiazide-induced potassium depletion may cause dysglycaemia. The risk of thiazide-induced hypokalaemia is higher in women and in black people. Reducing diuretic dose and potassium supplementation are the most direct and effective therapies for hypokalaemia. Combining with a potassium-sparing diuretic or blocker of the renin-angiotensin system also reduces the risk of hypokalaemia. Lowering salt intake and increasing intake of vegetables and fruits help to reduce blood pressure as well as prevent hypokalaemia.
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Affiliation(s)
- Ziying Lin
- Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Louisa Y F Wong
- Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Bernard M Y Cheung
- Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong .,State Key Laboratory of Pharmaceutical Biotechnology, University of Hong Kong, Hong Kong, Hong Kong
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Andersen H, Hansen MH, Buhl KB, Stæhr M, Friis UG, Enggaard C, Supramaniyam S, Lund IK, Svenningsen P, Hansen PBL, Jensen BL. Plasminogen Deficiency and Amiloride Mitigate Angiotensin II-Induced Hypertension in Type 1 Diabetic Mice Suggesting Effects Through the Epithelial Sodium Channel. J Am Heart Assoc 2020; 9:e016387. [PMID: 33215566 PMCID: PMC7763785 DOI: 10.1161/jaha.120.016387] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Diabetic nephropathy is a common diabetes mellitus complication associated with hypertension, proteinuria, and excretion of urinary plasmin that activates the epithelial sodium channel, ENaC, in vitro. Here we hypothesized that the deletion of plasminogen and amiloride treatment protect against hypertension in diabetes mellitus. Methods and Results Male plasminogen knockout (plasminogen-deficient [Plg-/-]) and wild-type mice were rendered diabetic with streptozotocin. Arterial blood pressure was recorded continuously by indwelling catheters before and during 10 days of angiotensin II infusion (ANGII; 30-60 ng/kg per minute). The effect of amiloride infusion (2 mg/kg per day, 4 days) was tested in wild-type, diabetic ANGII-treated mice. Streptozotocin increased plasma and urine glucose concentrations and 24-hour urine albumin and plasminogen excretion. Diabetic Plg-/- mice displayed larger baseline albuminuria and absence of urine plasminogen. Baseline mean arterial blood pressure did not differ between groups. Although ANGII elevated blood pressure in wild-type, diabetic wild-type, and Plg-/- control mice, ANGII did not change blood pressure in diabetic Plg-/- mice. Compared with ANGII infusion alone, wild-type ANGII-infused diabetic mice showed blood pressure reduction upon amiloride treatment. There was no difference in plasma renin, ANGII, aldosterone, tissue prorenin receptor, renal inflammation, and fibrosis between groups. Urine from wild-type mice evoked larger amiloride-sensitive current than urine from Plg-/- mice with or without diabetes mellitus. Full-length γ-ENaC and α-ENaC subunit abundances were not changed in kidney homogenates, but the 70 kDa γ-ENaC cleavage product was increased in diabetic versus nondiabetic mice. Conclusions Plasmin promotes hypertension in diabetes mellitus with albuminuria likely through the epithelial sodium channel.
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Affiliation(s)
- Henrik Andersen
- Department of Cardiovascular and Renal Research Institute of Molecular Medicine University of Southern Denmark Odense Denmark
| | - Maria Høj Hansen
- Department of Cardiovascular and Renal Research Institute of Molecular Medicine University of Southern Denmark Odense Denmark
| | - Kristian B Buhl
- Department of Cardiovascular and Renal Research Institute of Molecular Medicine University of Southern Denmark Odense Denmark
| | - Mette Stæhr
- Department of Cardiovascular and Renal Research Institute of Molecular Medicine University of Southern Denmark Odense Denmark
| | - Ulla G Friis
- Department of Cardiovascular and Renal Research Institute of Molecular Medicine University of Southern Denmark Odense Denmark
| | - Camilla Enggaard
- Department of Cardiovascular and Renal Research Institute of Molecular Medicine University of Southern Denmark Odense Denmark
| | - Shanya Supramaniyam
- Department of Cardiovascular and Renal Research Institute of Molecular Medicine University of Southern Denmark Odense Denmark
| | - Ida K Lund
- The Finsen Laboratory Copenhagen University Hospital, and Biotech Research and Innovation Center (BRIC) University of Copenhagen Denmark
| | - Per Svenningsen
- Department of Cardiovascular and Renal Research Institute of Molecular Medicine University of Southern Denmark Odense Denmark
| | - Pernille B L Hansen
- Department of Cardiovascular and Renal Research Institute of Molecular Medicine University of Southern Denmark Odense Denmark.,Research and Early Development Cardiovascular, Renal and Metabolism BioPharmaceuticals R&D AstraZeneca Gothenburg Sweden
| | - Boye L Jensen
- Department of Cardiovascular and Renal Research Institute of Molecular Medicine University of Southern Denmark Odense Denmark
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23
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Bovée DM, Cuevas CA, Zietse R, Danser AHJ, Mirabito Colafella KM, Hoorn EJ. Salt-sensitive hypertension in chronic kidney disease: distal tubular mechanisms. Am J Physiol Renal Physiol 2020; 319:F729-F745. [DOI: 10.1152/ajprenal.00407.2020] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Chronic kidney disease (CKD) causes salt-sensitive hypertension that is often resistant to treatment and contributes to the progression of kidney injury and cardiovascular disease. A better understanding of the mechanisms contributing to salt-sensitive hypertension in CKD is essential to improve these outcomes. This review critically explores these mechanisms by focusing on how CKD affects distal nephron Na+ reabsorption. CKD causes glomerulotubular imbalance with reduced proximal Na+ reabsorption and increased distal Na+ delivery and reabsorption. Aldosterone secretion further contributes to distal Na+ reabsorption in CKD and is not only mediated by renin and K+ but also by metabolic acidosis, endothelin-1, and vasopressin. CKD also activates the intrarenal renin-angiotensin system, generating intratubular angiotensin II to promote distal Na+ reabsorption. High dietary Na+ intake in CKD contributes to Na+ retention by aldosterone-independent activation of the mineralocorticoid receptor mediated through Rac1. High dietary Na+ also produces an inflammatory response mediated by T helper 17 cells and cytokines increasing distal Na+ transport. CKD is often accompanied by proteinuria, which contains plasmin capable of activating the epithelial Na+ channel. Thus, CKD causes both local and systemic changes that together promote distal nephron Na+ reabsorption and salt-sensitive hypertension. Future studies should address remaining knowledge gaps, including the relative contribution of each mechanism, the influence of sex, differences between stages and etiologies of CKD, and the clinical relevance of experimentally identified mechanisms. Several pathways offer opportunities for intervention, including with dietary Na+ reduction, distal diuretics, renin-angiotensin system inhibitors, mineralocorticoid receptor antagonists, and K+ or H+ binders.
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Affiliation(s)
- Dominique M. Bovée
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
- Division of Vascular Medicine, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Catharina A. Cuevas
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Robert Zietse
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - A. H. Jan Danser
- Division of Vascular Medicine, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Katrina M. Mirabito Colafella
- Cardiovascular Disease Program, Monash Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
- Department of Physiology, Monash University, Melbourne, Victoria, Australia
| | - Ewout J. Hoorn
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, Erasmus University Medical Center, Rotterdam, The Netherlands
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24
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Abstract
Diuretics are listed in hypertension guidelines as one of three equally weighted first-line treatment options. In order to differentiate between antihypertensives, a lot of discussion has been directed at side effect profiles and as a result, has created a perhaps disproportionate fear of the metabolic effects that can be associated with diuretics. Data, however, show that the risk of a clinically meaningful change in laboratory parameters is very low, whereas the benefits of volume control and natriuresis are high and the reductions in morbidity and mortality are clinically significant. Moreover, as clinically significant differences in safety and efficacy profiles exist among diuretics, several international guidelines have started making a distinction between thiazides (hydrochlorothiazide) and thiazide-like (chlorthalidone, indapamide) diuretics; and some of them now recommend longer acting thiazide-like diuretics. In time, pending more data, chlorthalidone and indapamide may need to be subdivided further into separate classifications.
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25
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26
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Hall JJ, Eurich DT, Nagy D, Tjosvold L, Gamble JM. Thiazide Diuretic-Induced Change in Fasting Plasma Glucose: a Meta-analysis of Randomized Clinical Trials. J Gen Intern Med 2020; 35:1849-1860. [PMID: 32157653 PMCID: PMC7280437 DOI: 10.1007/s11606-020-05731-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/10/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Prior meta-analyses measuring thiazide-induced glycemic change have demonstrated an increased risk of incident diabetes; however, this measure's definition has changed over time. AIM To determine the magnitude of change in fasting plasma glucose (FPG) for thiazide diuretics. DATA SOURCES A research librarian designed and conducted searches in Medline®, EMBASE, and EBM Reviews-Cochrane Central Register of Controlled Trials (inception through July 2018) and International Pharmaceutical Abstracts (inception to December 2014). STUDY SELECTION Randomized, controlled trials comparing a thiazide or thiazide-like diuretic to any comparator reporting FPG were identified. Trials enrolling < 50 participants, those with a follow-up period of < 4 weeks, and conference abstracts were excluded. DATA EXTRACTION Independent duplicate screening of citations and full-text articles, data extraction, and assessment of risk of bias was conducted. DATA SYNTHESIS Ninety-five studies were included (N = 76,608 participants), with thiazides compared with placebo, beta-blockers, calcium channel blockers, renin-angiotensin-aldosterone-system inhibitors, potassium-sparing diuretic, and others alone or in combination. Thiazide diuretics marginally increased FPG (weighted mean difference 0.20 mmol/L (95% CI 0.15-0.25); I2 = 84%) (1 mmol/L = 18 mg/dL). Results did not change substantially when considering dose or duration, comparing thiazides with placebo or an active comparator, or using thiazides as monotherapy or combination therapy, even when combined with a potassium-correcting agent. CONCLUSION Thiazide diuretics have a small and clinically unimportant impact on FPG.
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Affiliation(s)
- Jill J. Hall
- Faculty of Pharmacy and Pharmaceutical Sciences, 3-236 Edmonton Clinic Health Academy, University of Alberta, Edmonton, AB Canada
| | - Dean T. Eurich
- School of Public Health, University of Alberta, Edmonton, Canada
| | - Danielle Nagy
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Canada
| | - Lisa Tjosvold
- John W. Scott Health Sciences Library, University of Alberta, Edmonton, Canada
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27
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Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, Ramirez A, Schlaich M, Stergiou GS, Tomaszewski M, Wainford RD, Williams B, Schutte AE. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension 2020; 75:1334-1357. [PMID: 32370572 DOI: 10.1161/hypertensionaha.120.15026] [Citation(s) in RCA: 1688] [Impact Index Per Article: 422.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Thomas Unger
- From the CARIM - School for Cardiovascular Diseases, Maastricht University, the Netherlands (T.U.)
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, University of Bologna, Italy (C.B.)
| | - Fadi Charchar
- Federation University Australia, School of Health and Life Sciences, Ballarat, Australia (F.C.).,University of Melbourne, Department of Physiology, Melbourne, Australia (F.C.).,University of Leicester, Department of Cardiovascular Sciences, United Kingdom (F.C.)
| | - Nadia A Khan
- University of British Columbia, Vancouver, Canada (N.A.K.).,Center for Health Evaluation and Outcomes Sciences, Vancouver, Canada (N.A.K.)
| | - Neil R Poulter
- Imperial Clinical Trials Unit, Imperial College London, United Kingdom (N.R.P.)
| | - Dorairaj Prabhakaran
- Public Health Foundation of India, New Delhi, India (D.P.).,Centre for Chronic Disease Control, New Delhi, India (D.P.).,London School of Hygiene and Tropical Medicine, United Kingdom (D.P.)
| | - Agustin Ramirez
- Hypertension and Metabolic Unit, University Hospital, Favaloro Foundation, Buenos Aires, Argentina (A.R.)
| | - Markus Schlaich
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, University of Western Australia, Perth (M.S.).,Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia (M.N.)
| | - George S Stergiou
- Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Greece (G.S.S.)
| | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester, United Kingdom (M.T.).,Division of Medicine and Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust Manchester, United Kingdom (M.T.)
| | - Richard D Wainford
- Department of Pharmacology and Experimental Therapeutics, Boston University School of Medicine, MA (R.D.W.).,The Whitaker Cardiovascular Institute, Boston University, MA (R.D.W.).,Department of Health Sciences, Boston University Sargent College, MA (R.D.W.)
| | - Bryan Williams
- University College London, NIHR University College London, Hospitals Biomedical Research Centre, London, United Kingdom (B.W.)
| | - Aletta E Schutte
- Faculty of Medicine, University of New South Wales, Sydney, Australia (A.E.S.).,The George Institute for Global Health, Sydney, Australia (A.E.S.).,Hypertension in Africa Research Team (A.E.S.), North-West University, Potchefstroom, South Africa.,South African MRC Unit for Hypertension and Cardiovascular Disease (A.E.S.), North-West University, Potchefstroom, South Africa
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28
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Kobalava ZD, Konradi AO, Nedogoda SV, Shlyakhto EV, Arutyunov GP, Baranova EI, Barbarash OL, Boitsov SA, Vavilova TV, Villevalde SV, Galyavich AS, Glezer MG, Grineva EN, Grinstein YI, Drapkina OM, Zhernakova YV, Zvartau NE, Kislyak OA, Koziolova NA, Kosmacheva ED, Kotovskaya YV, Libis RA, Lopatin YM, Nebiridze DV, Nedoshivin AO, Ostroumova OD, Oschepkova EV, Ratova LG, Skibitsky VV, Tkacheva ON, Chazova IE, Chesnikova AI, Chumakova GA, Shalnova SA, Shestakova MV, Yakushin SS, Yanishevsky SN. Arterial hypertension in adults. Clinical guidelines 2020. ACTA ACUST UNITED AC 2020. [DOI: 10.15829/1560-4071-2020-3-3786] [Citation(s) in RCA: 164] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Arterial hypertension in adults. Clinical guidelines 2020
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29
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Nascimento TO, Leite FRF, Mourão HAJL, Malagutti AR. Development of an electroanalytical methodology using differential pulse voltammetry for amiloride determination. J Solid State Electrochem 2020. [DOI: 10.1007/s10008-020-04559-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Sodium-induced inflammation-an invisible player in resistant hypertension. Hypertens Res 2020; 43:629-633. [PMID: 32203452 DOI: 10.1038/s41440-020-0428-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 01/18/2020] [Accepted: 01/18/2020] [Indexed: 12/18/2022]
Abstract
The purpose of this review was to discuss the role of sodium and inflammation in the pathophysiology of hypertension and the observed different hemodynamic effects of drugs. The Pathway-2 study revealed that similar reductions in vascular resistance after spironolactone and doxazosin resulted in opposite effects on sodium balance, water retention, and hemodynamic parameters. These and other clinical findings were bridged to recent experimental and physiological data. Tissue sodium accumulation in salt-sensitive individuals due to endothelial glycocalyx dysfunction causes macrophage infiltration, vascular inflammation, and local changes in angiotensin-2 and aldosterone concentrations. This inflammatory cascade leads to factor XII-related coagulation disorders with neutrophil extracellular trap formation (NETosis). This model of sodium-induced microcirculation impairment was used to explain the differences in central hemodynamic parameters after spironolactone or doxazosin treatment in resistant hypertension. Hypertension treatment by induced sodium removal or reduced sodium intake should reduce endothelial glycocalyx dysfunction, inflammation, NETosis, and coagulation disorders, leading to improved vascular health and cardiac diastolic function.
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31
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Spironolactone use is associated with lower prostate cancer risk: a population-wide case-control study. Prostate Cancer Prostatic Dis 2020; 23:527-533. [PMID: 32123316 DOI: 10.1038/s41391-020-0220-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/14/2020] [Accepted: 02/19/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Spironolactone, a cheap effective diuretic used to manage hypertension and heart failure, also has anti-androgenic effects through its non-selective binding to steroid receptors, and hence may affect prostate cancer (PCa) risk. This study investigated the association between spironolactone use and PCa risk. For comparison, we also examined associations with thiazide diuretics which do not have anti-androgenic properties. METHODS A matched case-control study was undertaken using population-wide data from the Prostate Cancer Data Base Sweden (PCBaSe). All PCa cases diagnosed from 2014 to 2016 were matched by birth year and county with PCa-free controls selected from the general population (1:5). Multivariable conditional logistic regression was used to examine associations between spironolactone use (dose and duration) and PCa risk, and similarly for thiazides. RESULTS Three percent of the 31,591 cases and 4% of the 156,802 controls had been prescribed spironolactone. Multivariable analyses indicated reduced risk of PCa among those ever exposed to spironolactone (odds ratio [OR] 0.83; 95% confidence interval [CI]: 0.76-0.89), with a stronger association for current users (OR: 0.77, 95% CI: 0.69-0.86) than past users (OR: 0.88; 95% CI: 0.79-0.97) and decreasing risk with increasing dose (p-trend < 0.001). No association was observed for thiazide exposure and PCa risk. Biases due to differences in prescribing patterns or frequency of PSA testing may have influenced these findings. CONCLUSION PCa risk was reduced among men exposed to the diuretic spironolactone. Further investigation of spironolactone's potential chemopreventive effects is warranted.
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Bovée DM, Visser WJ, Middel I, De Mik-van Egmond A, Greupink R, Masereeuw R, Russel FGM, Danser AHJ, Zietse R, Hoorn EJ. A Randomized Trial of Distal Diuretics versus Dietary Sodium Restriction for Hypertension in Chronic Kidney Disease. J Am Soc Nephrol 2020; 31:650-662. [PMID: 31996411 DOI: 10.1681/asn.2019090905] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/11/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Distal diuretics are considered less effective than loop diuretics in CKD. However, data to support this perception are limited. METHODS To investigate whether distal diuretics are noninferior to dietary sodium restriction in reducing BP in patients with CKD stage G3 or G4 and hypertension, we conducted a 6-week, randomized, open-label crossover trial comparing amiloride/hydrochlorothiazide (5 mg/50 mg daily) with dietary sodium restriction (60 mmol per day). Antihypertension medication was discontinued for a 2-week period before randomization. We analyzed effects on BP, kidney function, and fluid balance and related this to renal clearance of diuretics. RESULTS A total of 26 patients (with a mean eGFR of 39 ml/min per 1.73 m2) completed both treatments. Dietary sodium restriction reduced sodium excretion from 160 to 64 mmol per day. Diuretics produced a greater reduction in 24-hour systolic BP (SBP; from 138 to 124 mm Hg) compared with sodium restriction (from 134 to 129 mm Hg), as well as a significantly greater effect on extracellular water, eGFR, plasma renin, and aldosterone. Both interventions resulted in a similar decrease in body weight and NT-proBNP. Neither approaches decreased albuminuria significantly, whereas diuretics did significantly reduce urinary angiotensinogen and β2-microglobulin excretion. Although lower eGFR and higher plasma indoxyl sulfate correlated with lower diuretic clearance, the diuretic effects on body weight and BP at lower eGFR were maintained. During diuretic treatment, higher PGE2 excretion correlated with lower free water clearance, and four patients developed mild hyponatremia. CONCLUSIONS Distal diuretics are noninferior to dietary sodium restriction in reducing BP and extracellular volume in CKD. Diuretic sensitivity in CKD is maintained despite lower diuretic clearance. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER DD-study: Diet or Diuretics for Salt-sensitivity in Chronic Kidney Disease (DD), NCT02875886.
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Affiliation(s)
| | | | - Igor Middel
- Division of Pharmacology, Department of Pharmaceutical Sciences, University Utrecht, Utrecht, The Netherlands; and
| | | | - Rick Greupink
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rosalinde Masereeuw
- Division of Pharmacology, Department of Pharmaceutical Sciences, University Utrecht, Utrecht, The Netherlands; and
| | - Frans G M Russel
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A H Jan Danser
- Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands
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34
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Buscemi S, Buscemi C, Borzì AM, Cosentino L, Rosafio G, Randazzo C, Colomba D, Di Raimondo D, Pluchinotta FR, Parrinello G. Metabolic and Cardiovascular Effects of Switching Thiazides to Amlodipine in Hypertensive Patients With and Without Type 2 Diabetes (the Diuretics and Diabetes Control Study). Metab Syndr Relat Disord 2020; 18:110-118. [PMID: 31976814 DOI: 10.1089/met.2019.0099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: Different studies have indicated that thiazide diuretics can increase the risk of developing type 2 diabetes (T2D). Therefore, in this study, we investigated whether switching from hydrochlorothiazide (HCTZ) to amlodipine resulted in ameliorating different cardiovascular and metabolic measures in hypertensive patients with or without T2D. Methods: This study [Diuretics and Diabetes Control (DiaDiC)] was a 6-week, single-blind, single-center randomized controlled trial. The first 20 normal glucose-tolerant, 20 prediabetic, and 20 T2D consecutive patients were randomized to continue the previous antihypertensive treatment with HCTZ (12.5-25 mg/day) or to switch from HCTZ to amlodipine (2.5-10 mg/day). The primary endpoints were the absolute change in 7-day continuous subcutaneous glucose monitoring (CSGM) glycemia, serum uric acid concentrations, and endothelial function [measured as flow-mediated dilation (FMD)]. Other secondary endpoints were investigated, including changes in glycated hemoglobin (HbA1c), glycemic variability from 7-day CSGM, and the estimated glomerular filtration rate (eGFR). Results: Amlodipine treatment was associated with a significant reduction in HbA1c (P = 0.03) for both 7-day CSGM glycemia (P = 0.01) and glycemic variability (coefficient of variability %: HCTZ +3%, amlodipine -2.8%), and a reduction in uric acid concentrations (P < 0.001), especially in participants with T2D or prediabetes. Following amlodipine treatment, a significant increase in both eGFR (P = 0.01) and FMD (P = 0.02) was also observed. Conclusions: This study demonstrates that the replacement of HCTZ with amlodipine has several metabolic and cardiovascular beneficial effects. However, further intervention studies are necessary to confirm the clinical effects of thiazides, especially in diabetic people and in those at risk of diabetes.
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Affiliation(s)
- Silvio Buscemi
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy.,Unit of Endocrinologia, Malattie del Ricambio e della Nutrizione, Policlinico University Hospital, Palermo, Italy
| | - Carola Buscemi
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy.,Unit of Endocrinologia, Malattie del Ricambio e della Nutrizione, Policlinico University Hospital, Palermo, Italy
| | - Antonio Maria Borzì
- Department of Clinical and Experimental Medicine, School in Geriatrics, University of Catania, AOU Policlinico, Catania, Italy
| | - Loretta Cosentino
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy.,Unit of Endocrinologia, Malattie del Ricambio e della Nutrizione, Policlinico University Hospital, Palermo, Italy
| | - Giuseppe Rosafio
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy.,Unit of Endocrinologia, Malattie del Ricambio e della Nutrizione, Policlinico University Hospital, Palermo, Italy
| | - Cristiana Randazzo
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy.,Unit of Endocrinologia, Malattie del Ricambio e della Nutrizione, Policlinico University Hospital, Palermo, Italy
| | - Daniela Colomba
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy.,Unit of Endocrinologia, Malattie del Ricambio e della Nutrizione, Policlinico University Hospital, Palermo, Italy
| | - Domenico Di Raimondo
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy.,Unit of Endocrinologia, Malattie del Ricambio e della Nutrizione, Policlinico University Hospital, Palermo, Italy
| | - Francesca Romana Pluchinotta
- Dipartimento di Cardiochirurgia Pediatrica, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, Milan, Italy
| | - Gaspare Parrinello
- Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza (PROMISE), University of Palermo, Palermo, Italy.,Unit of Endocrinologia, Malattie del Ricambio e della Nutrizione, Policlinico University Hospital, Palermo, Italy
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Abstract
Hypertension is still the number one global killer. No matter what causes are, lowering blood pressure can significantly reduce cardiovascular complications, cardiovascular death, and total death. Unfortunately, some hypertensive individuals simply do not know having hypertension. Some knew it but either not being treated or treated but blood pressure does not achieve goal. The reasons for inadequate control of blood pressure are many. One important reason is that we are not very familiar with antihypertensive agents and less attention has been paid to comorbidities, complications as well as the hypertension-modified target organ damage in patients with hypertension. The right antihypertensive drug was not given to the right hypertensive patients at right time. This reviewer studied comprehensively the literature, hopefully that the review will help improve antihypertensive drug selection and antihypertensive therapy.
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Affiliation(s)
- Rutai Hui
- Chinese Academy of Medical Sciences FUWAI Hospital Hypertension Division, 167 Beilishilu West City District, 100037, Beijing People's Republic of China, China.
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36
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Ala M, Jafari RM, Dehpour AR. Diabetes Mellitus and Osteoporosis Correlation: Challenges and Hopes. Curr Diabetes Rev 2020; 16:984-1001. [PMID: 32208120 DOI: 10.2174/1573399816666200324152517] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/02/2020] [Accepted: 02/24/2020] [Indexed: 01/14/2023]
Abstract
Diabetes and osteoporosis are two common diseases with different complications. Despite different therapeutic strategies, managing these diseases and reducing their burden have not been satisfactory, especially when they appear one after the other. In this review, we aimed to clarify the similarity, common etiology and possible common adjunctive therapies of these two major diseases and designate the known molecular pattern observed in them. Based on different experimental findings, we want to illuminate that interestingly similar pathways lead to diabetes and osteoporosis. Meanwhile, there are a few drugs involved in the treatment of both diseases, which most of the time act in the same line but sometimes with opposing results. Considering the correlation between diabetes and osteoporosis, more efficient management of both diseases, in conditions of concomitant incidence or cause and effect condition, is required.
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Affiliation(s)
- Moein Ala
- Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, 13145-784, Tehran, Iran
| | - Razieh Mohammad Jafari
- Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Reza Dehpour
- Experimental Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Pharmacology, School of Medicine, Tehran University of Medical Sciences, 13145-784, Tehran, Iran
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37
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Kuzmin OB, Buchneva NN, Zhezha VV, Serdyuk SV. Uncontrolled Arterial Hypertension: Kidney, Neurohormonal Imbalance, and Approaches to Antihypertensive Drug Therapy. ACTA ACUST UNITED AC 2019; 59:64-71. [DOI: 10.18087/cardio.2019.12.n547] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 04/29/2019] [Indexed: 11/18/2022]
Abstract
Resistant and refractory arterial hypertensions are two distinct clinical phenotypes of uncontrolled arterial hypertension (AH), which differ in their sensitivity to antihypertensive drug therapy. The review presents data obtained in clinical studies devoted to elucidating the involvement of disorders of neurohormonal status and renal function in the formation of resistant and refractory arterial hypertension, to and the development of new approaches to increasing the effectiveness of antihypertensive therapy in these patient’s populations. The results of these studies have shown that in patients with uncontrolled arterial hypertension, despite prolonged intake ≥ 3 antihypertensive drugs with different mechanisms of action, including a diuretic, excess sodium reabsorption persists in the distal segments of nephron due to increased aldosterone activity and sympathetic nervous system hyperactivity. In this regard, special attention has been paid to the data of PATHWAY-2, PATHWAY-3 and ReHOT trials that in patients with resistant AH tested the clinical efficacy of spironolactone, amiloride, and antiadrenergic drugs bisoprolol, doxazosin and clonidine, suppressing activity of the sympathetic nervous system.
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38
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Martins VM, Helal L, Ferrari F, Bottino LG, Fuchs SC, Fuchs FD. Efficacy of chlorthalidone and hydrochlorothiazide in combination with amiloride in multiple doses on blood pressure in patients with primary hypertension: a protocol for a factorial randomized controlled trial. Trials 2019; 20:736. [PMID: 31843024 PMCID: PMC6916111 DOI: 10.1186/s13063-019-3909-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 11/15/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thiazide diuretics have demonstrated favorable blood pressure lowering efficacy, but the equivalent doses of their more common agents, chlorthalidone and hydrochlorothiazide, are still unclear. Further, concerns exist regarding adverse metabolic effects, which may be attenuated with the concomitant administration of a potassium-sparing diuretic, such as amiloride. This trial aims to investigate the efficacy of chlorthalidone and hydrochlorothiazide, in combination with amiloride at different doses, for initial management of patients with primary hypertension. METHODS/DESIGN This is a factorial (2 × 2) randomized double-blinded clinical trial comparing the association of a thiazide diuretic (chlorthalidone 25 mg/day or hydrochlorothiazide 50 mg/day) with a potassium-sparing diuretic (amiloride 10 mg/day or amiloride 20 mg/day) in patients with primary hypertension. The primary outcome will be the mean change from baseline in 24-h systolic and diastolic blood pressure measured by ambulatory blood pressure monitoring. The secondary outcomes will be the mean change from baseline in daytime and nighttime systolic and diastolic blood pressure measured by ambulatory blood pressure monitoring, mean change from baseline in systolic and diastolic blood pressure measured by office blood pressure, incidence of adverse events, variation of laboratory parameters, and proportion of patients who achieved blood pressure control. The follow-up will last 12 weeks. For a P alpha of 0.05, power of 80%, standard deviation of 9 mmHg, and absolute difference of 6 mmHg on systolic blood pressure on 24-h ambulatory blood pressure monitoring, it will be necessary to study a total of 76 patients. The sample size will be increased by 10% to compensate for losses, resulting in 84 patients being randomized. DISCUSSION Diuretics are pivotal drugs for the treatment of hypertension. Chlorthalidone and hydrochlorothiazide, in combination with amiloride in multiple doses, will be tested in terms of blood pressure lowering efficacy and safety. Since the intensity of blood pressure reduction is the major determinant of reduction in cardiovascular risk in hypertensive patients, this study will help to determine which combination of diuretics represents the most appropriate treatment for this population. TRIAL REGISTRATION ClinicalTrials.gov, NCT03928145. Registered on 25 April 2019. Last update on 29 April 2019.
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Affiliation(s)
- Vítor Magnus Martins
- Graduate Program in Cardiology and Cardiovascular Sciences, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
| | - Lucas Helal
- Graduate Program in Cardiology and Cardiovascular Sciences, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Filipe Ferrari
- Graduate Program in Cardiology and Cardiovascular Sciences, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Leonardo Grabinski Bottino
- Graduate Program in Cardiology and Cardiovascular Sciences, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Sandra Costa Fuchs
- Graduate Program in Cardiology and Cardiovascular Sciences, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Flávio Danni Fuchs
- Graduate Program in Cardiology and Cardiovascular Sciences, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.,Division of Cardiology, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
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39
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Abstract
ZusammenfassungErhöhter Blutdruck bleibt eine Hauptursache von kardiovaskulären Erkrankungen, Behinderung und frühzeitiger Sterblichkeit in Österreich, wobei die Raten an Diagnose, Behandlung und Kontrolle auch in rezenten Studien suboptimal sind. Das Management von Bluthochdruck ist eine häufige Herausforderung für Ärztinnen und Ärzte vieler Fachrichtungen. In einem Versuch, diagnostische und therapeutische Strategien zu standardisieren und letztendlich die Rate an gut kontrollierten Hypertoniker/innen zu erhöhen und dadurch kardiovaskuläre Erkrankungen zu verhindern, haben 13 österreichische medizinische Fachgesellschaften die vorhandene Evidenz zur Prävention, Diagnose, Abklärung, Therapie und Konsequenzen erhöhten Blutdrucks gesichtet. Das hier vorgestellte Ergebnis ist der erste Österreichische Blutdruckkonsens. Die Autoren und die beteiligten Fachgesellschaften sind davon überzeugt, daß es einer gemeinsamen nationalen Anstrengung bedarf, die Blutdruck-assoziierte Morbidität und Mortalität in unserem Land zu verringern.
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40
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McNally RJ, Morselli F, Farukh B, Chowienczyk PJ, Faconti L. A review of the prescribing trend of thiazide-type and thiazide-like diuretics in hypertension: A UK perspective. Br J Clin Pharmacol 2019; 85:2707-2713. [PMID: 31471972 PMCID: PMC6955404 DOI: 10.1111/bcp.14109] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/07/2019] [Accepted: 08/24/2019] [Indexed: 01/02/2023] Open
Abstract
Thiazide diuretics have been the cornerstone of hypertension treatment for >5 decades. Most recent European and American guidelines recommend both thiazide-type and thiazide-like diuretics as first-line drugs for all patients with hypertension. In contrast, diuretics are not regarded as first-line treatment in the UK and in patients who are to be initiated on a diuretic treatment, thiazide-like molecules, such as chlortalidone and indapamide are the preferred option. This review examines the prescribing trend of the 4 most commonly prescribed thiazide diuretics for the treatment of hypertension in the UK. Prescription cost analysis data were obtained for both 2010 and 2016/2017 for each region of the UK to analyse the impact of the 2011 National Institute for Health and Care Excellence hypertension guidelines on the trend in thiazide diuretic prescribing. Overall, the prescriptions of thiazide diuretics declined over the years. Bendroflumethiazide is the most commonly prescribed diuretic in the UK and despite some geographical differences, thiazide-type diuretics are more widely used than thiazide-like. The use of indapamide increased significantly between 2010 and 2016/2017 while chlortalidone was rarely employed. Of the many factors affecting trends in prescriptions, clinical inertia, treatment adherence, availability of the products and the lack of fixed dose combinations may play a role.
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Affiliation(s)
- Ryan J. McNally
- British Heart Foundation CentreKing's College LondonLondonUK
| | - Franca Morselli
- British Heart Foundation CentreKing's College LondonLondonUK
| | - Bushra Farukh
- British Heart Foundation CentreKing's College LondonLondonUK
| | | | - Luca Faconti
- British Heart Foundation CentreKing's College LondonLondonUK
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41
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Cheng F, Kovács IA, Barabási AL. Network-based prediction of drug combinations. Nat Commun 2019; 10:1197. [PMID: 30867426 PMCID: PMC6416394 DOI: 10.1038/s41467-019-09186-x] [Citation(s) in RCA: 345] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 02/20/2019] [Indexed: 12/12/2022] Open
Abstract
Drug combinations, offering increased therapeutic efficacy and reduced toxicity, play an important role in treating multiple complex diseases. Yet, our ability to identify and validate effective combinations is limited by a combinatorial explosion, driven by both the large number of drug pairs as well as dosage combinations. Here we propose a network-based methodology to identify clinically efficacious drug combinations for specific diseases. By quantifying the network-based relationship between drug targets and disease proteins in the human protein-protein interactome, we show the existence of six distinct classes of drug-drug-disease combinations. Relying on approved drug combinations for hypertension and cancer, we find that only one of the six classes correlates with therapeutic effects: if the targets of the drugs both hit disease module, but target separate neighborhoods. This finding allows us to identify and validate antihypertensive combinations, offering a generic, powerful network methodology to identify efficacious combination therapies in drug development.
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Affiliation(s)
- Feixiong Cheng
- Center for Complex Networks Research and Department of Physics, Northeastern University, Boston, MA, 02115, USA.,Center for Cancer Systems Biology and Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA, 02215, USA.,Genomic Medicine Institute, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44106, USA.,Department of Molecular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, 44195, USA.,Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH, 44106, USA
| | - István A Kovács
- Center for Complex Networks Research and Department of Physics, Northeastern University, Boston, MA, 02115, USA.,Center for Cancer Systems Biology and Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA, 02215, USA
| | - Albert-László Barabási
- Center for Complex Networks Research and Department of Physics, Northeastern University, Boston, MA, 02115, USA. .,Center for Cancer Systems Biology and Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA, 02215, USA. .,Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02215, USA. .,Center for Network Science, Central European University, Budapest, 1051, Hungary.
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42
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Latek D, Rutkowska E, Niewieczerzal S, Cielecka-Piontek J. Drug-induced diabetes type 2: In silico study involving class B GPCRs. PLoS One 2019; 14:e0208892. [PMID: 30650080 PMCID: PMC6334951 DOI: 10.1371/journal.pone.0208892] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 11/27/2018] [Indexed: 01/10/2023] Open
Abstract
A disturbance of glucose homeostasis leading to type 2 diabetes mellitus (T2DM) is one of the severe side effects that may occur during a prolonged use of many drugs currently available on the market. In this manuscript we describe the most common cases of drug-induced T2DM, discuss available pharmacotherapies and propose new ones. Among various pharmacotherapies of T2DM, incretin therapies have recently focused attention due to the newly determined crystal structure of incretin hormone receptor GLP1R. Incretin hormone receptors: GLP1R and GIPR together with the glucagon receptor GCGR regulate food intake and insulin and glucose secretion. Our study showed that incretin hormone receptors, named also gut hormone receptors as they are expressed in the gastrointestinal tract, could potentially act as unintended targets (off-targets) for orally administrated drugs. Such off-target interactions, depending on their effect on the receptor (stimulation or inhibition), could be beneficial, like in the case of incretin mimetics, or unwanted if they cause, e.g., decreased insulin secretion. In this in silico study we examined which well-known pharmaceuticals could potentially interact with gut hormone receptors in the off-target way. We observed that drugs with the strongest binding affinity for gut hormone receptors were also reported in the medical information resources as the least disturbing the glucose homeostasis among all drugs in their class. We suggested that those strongly binding molecules could potentially stimulate GIPR and GLP1R and/or inhibit GCGR which could lead to increased insulin secretion and decreased hepatic glucose production. Such positive effect on the glucose homeostasis could compensate for other, adverse effects of pharmacotherapy which lead to drug-induced T2DM. In addition, we also described several top hits as potential substitutes of peptidic incretin mimetics which were discovered in the drug repositioning screen using gut hormone receptors structures against the ZINC15 compounds subset.
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Affiliation(s)
- Dorota Latek
- Faculty of Chemistry, University of Warsaw, Warsaw, Poland
| | | | | | - Judyta Cielecka-Piontek
- Department of Pharmacognosy, Faculty of Pharmacy, Poznan University of Medical Sciences, Poznan, Poland
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43
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Gupta S, Pepper RJ, Ashman N, Walsh SB. Nephrotic Syndrome: Oedema Formation and Its Treatment With Diuretics. Front Physiol 2019; 9:1868. [PMID: 30697163 PMCID: PMC6341062 DOI: 10.3389/fphys.2018.01868] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/11/2018] [Indexed: 01/01/2023] Open
Abstract
Oedema is a defining element of the nephrotic syndrome. Its' management varies considerably between clinicians, with no national or international clinical guidelines, and hence variable outcomes. Oedema may have serious sequelae such as immobility, skin breakdown and local or systemic infection. Treatment of nephrotic oedema is often of limited efficacy, with frequent side-effects and interactions with other pharmacotherapy. Here, we describe the current paradigms of oedema in nephrosis, including insights into emerging mechanisms such as the role of the abnormal activation of the epithelial sodium channel in the collecting duct. We then discuss the physiological basis for traditional and novel therapies for the treatment of nephrotic oedema. Despite being the cardinal symptom of nephrosis, few clinical studies guide clinicians to the rational use of therapy. This is reflected in the scarcity of publications in this field; it is time to undertake new clinical trials to direct clinical practice.
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Affiliation(s)
- Sanjana Gupta
- UCL Centre for Nephrology, University College London, London, United Kingdom.,Renal Unit, The Royal London Hospital, Bart's Health NHS Trust, London, United Kingdom
| | - Ruth J Pepper
- UCL Centre for Nephrology, University College London, London, United Kingdom
| | - Neil Ashman
- Renal Unit, The Royal London Hospital, Bart's Health NHS Trust, London, United Kingdom
| | - Stephen B Walsh
- UCL Centre for Nephrology, University College London, London, United Kingdom
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Khanra D, Duggal B. Pseudo-resistant, resistant, and refractory hypertension: The good, the bad, and the ugly. JOURNAL OF THE PRACTICE OF CARDIOVASCULAR SCIENCES 2019. [DOI: 10.4103/jpcs.jpcs_31_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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45
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2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens 2018; 36:1953-2041. [PMID: 30234752 DOI: 10.1097/hjh.0000000000001940] [Citation(s) in RCA: 1834] [Impact Index Per Article: 305.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
: Document reviewers: Guy De Backer (ESC Review Co-ordinator) (Belgium), Anthony M. Heagerty (ESH Review Co-ordinator) (UK), Stefan Agewall (Norway), Murielle Bochud (Switzerland), Claudio Borghi (Italy), Pierre Boutouyrie (France), Jana Brguljan (Slovenia), Héctor Bueno (Spain), Enrico G. Caiani (Italy), Bo Carlberg (Sweden), Neil Chapman (UK), Renata Cifkova (Czech Republic), John G. F. Cleland (UK), Jean-Philippe Collet (France), Ioan Mircea Coman (Romania), Peter W. de Leeuw (The Netherlands), Victoria Delgado (The Netherlands), Paul Dendale (Belgium), Hans-Christoph Diener (Germany), Maria Dorobantu (Romania), Robert Fagard (Belgium), Csaba Farsang (Hungary), Marc Ferrini (France), Ian M. Graham (Ireland), Guido Grassi (Italy), Hermann Haller (Germany), F. D. Richard Hobbs (UK), Bojan Jelakovic (Croatia), Catriona Jennings (UK), Hugo A. Katus (Germany), Abraham A. Kroon (The Netherlands), Christophe Leclercq (France), Dragan Lovic (Serbia), Empar Lurbe (Spain), Athanasios J. Manolis (Greece), Theresa A. McDonagh (UK), Franz Messerli (Switzerland), Maria Lorenza Muiesan (Italy), Uwe Nixdorff (Germany), Michael Hecht Olsen (Denmark), Gianfranco Parati (Italy), Joep Perk (Sweden), Massimo Francesco Piepoli (Italy), Jorge Polonia (Portugal), Piotr Ponikowski (Poland), Dimitrios J. Richter (Greece), Stefano F. Rimoldi (Switzerland), Marco Roffi (Switzerland), Naveed Sattar (UK), Petar M. Seferovic (Serbia), Iain A. Simpson (UK), Miguel Sousa-Uva (Portugal), Alice V. Stanton (Ireland), Philippe van de Borne (Belgium), Panos Vardas (Greece), Massimo Volpe (Italy), Sven Wassmann (Germany), Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain).The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www.escardio.org/guidelines.
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46
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Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M, Clement DL, Coca A, de Simone G, Dominiczak A, Kahan T, Mahfoud F, Redon J, Ruilope L, Zanchetti A, Kerins M, Kjeldsen SE, Kreutz R, Laurent S, Lip GYH, McManus R, Narkiewicz K, Ruschitzka F, Schmieder RE, Shlyakhto E, Tsioufis C, Aboyans V, Desormais I. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018; 39:3021-3104. [PMID: 30165516 DOI: 10.1093/eurheartj/ehy339] [Citation(s) in RCA: 5747] [Impact Index Per Article: 957.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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47
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Kieboom BCT, Zietse R, Ikram MA, Hoorn EJ, Stricker BH. Thiazide but not loop diuretics is associated with hypomagnesaemia in the general population. Pharmacoepidemiol Drug Saf 2018; 27:1166-1173. [PMID: 30095199 DOI: 10.1002/pds.4636] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 06/22/2018] [Accepted: 07/16/2018] [Indexed: 12/31/2022]
Abstract
PURPOSE Hypomagnesaemia has been associated with various adverse outcomes. Loop and thiazide diuretics promote urinary magnesium excretion. However, it is unknown if this links to hypomagnesaemia. We study if loop or thiazide diuretic use affects serum magnesium levels and if it associates with hypomagnesaemia. In addition, we study the effect of combining a potassium-sparing diuretic with a thiazide diuretic on the presence of hypomagnesaemia. METHODS The study performed a cross-sectional analysis within 9820 participants from the prospective Rotterdam Study. Hypomagnesaemia was defined as a serum magnesium level ≤0.72 mmol/L. Participants were categorized by defined daily dose (DDD), and all analyses were adjusted for age, sex, BMI, eGFR, serum potassium levels, proton pump inhibitor use, and comorbidities. RESULTS Loop diuretic use was associated with higher serum magnesium levels (<1 DDD: 0.004 mmol/L 95% CI: -0.008; 0.017; 1 DDD: 0.023 mmol/L 95% CI: 0.013; 0.032; >1 DDD: 0.043 mmol/L 95% CI: 0.028; 0.057). Thiazide diuretic use was associated with lower serum magnesium levels (<1 DDD: -0.013 mmol/L 95% CI: -0.023; -0.002; ≥1 DDD: -0.018 mmol/L 95% CI: -0.028; -0.010), resulting in an increased odds ratio of hypomagnesaemia of 3.14 (95% CI: 1.67; 5.92) and 2.74 (95% CI: 1.57; 4.77), respectively. These effects were predominantly seen in participants using diuretics for more than 390 days. Combining thiazide diuretics with a potassium-sparing agent was not associated with lower serum magnesium levels or hypomagnesaemia. CONCLUSIONS Thiazide diuretic use is associated with lower serum magnesium levels and an increased risk of hypomagnesaemia. This increased risk is not seen in participants using a combination of thiazide diuretics with a potassium-sparing agent. The use of loop diuretics is not associated with an increased risk of hypomagnesaemia.
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Affiliation(s)
- Brenda C T Kieboom
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Internal Medicine, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands.,Inspectorate for Health Care, Utrecht, the Netherlands
| | - Robert Zietse
- Department of Internal Medicine, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - M Arfan Ikram
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ewout J Hoorn
- Department of Internal Medicine, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Bruno H Stricker
- Department of Epidemiology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Internal Medicine, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands.,Inspectorate for Health Care, Utrecht, the Netherlands
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48
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Williams B, MacDonald TM, Morant SV, Webb DJ, Sever P, McInnes GT, Ford I, Cruickshank JK, Caulfield MJ, Padmanabhan S, Mackenzie IS, Salsbury J, Brown MJ. Endocrine and haemodynamic changes in resistant hypertension, and blood pressure responses to spironolactone or amiloride: the PATHWAY-2 mechanisms substudies. Lancet Diabetes Endocrinol 2018; 6:464-475. [PMID: 29655877 PMCID: PMC5966620 DOI: 10.1016/s2213-8587(18)30071-8] [Citation(s) in RCA: 173] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/19/2018] [Accepted: 02/19/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND In the PATHWAY-2 study of resistant hypertension, spironolactone reduced blood pressure substantially more than conventional antihypertensive drugs. We did three substudies to assess the mechanisms underlying this superiority and the pathogenesis of resistant hypertension. METHODS PATHWAY-2 was a randomised, double-blind crossover trial done at 14 UK primary and secondary care sites in 314 patients with resistant hypertension. Patients were given 12 weeks of once daily treatment with each of placebo, spironolactone 25-50 mg, bisoprolol 5-10 mg, and doxazosin 4-8 mg and the change in home systolic blood pressure was assessed as the primary outcome. In our three substudies, we assessed plasma aldosterone, renin, and aldosterone-to-renin ratio (ARR) as predictors of home systolic blood pressure, and estimated prevalence of primary aldosteronism (substudy 1); assessed the effects of each drug in terms of thoracic fluid index, cardiac index, stroke index, and systemic vascular resistance at seven sites with haemodynamic monitoring facilities (substudy 2); and assessed the effect of amiloride 10-20 mg once daily on clinic systolic blood pressure during an optional 6-12 week open-label runout phase (substudy 3). The PATHWAY-2 trial is registered with EudraCT, number 2008-007149-30, and ClinicalTrials.gov, number NCT02369081. FINDINGS Of the 314 patients in PATHWAY-2, 269 participated in one or more of the three substudies: 126 in substudy 1, 226 in substudy 2, and 146 in substudy 3. Home systolic blood pressure reduction by spironolactone was predicted by ARR (r2=0·13, p<0·0001) and plasma renin (r2=0·11, p=0·00024). 42 patients had low renin concentrations (predefined as the lowest tertile of plasma renin), of which 31 had a plasma aldosterone concentration greater than the mean value for all 126 patients (250 pmol/L). Thus, 31 (25% [95% CI 17-33]) of 126 patients were deemed to have inappropriately high aldosterone concentrations. Thoracic fluid content was reduced by 6·8% from baseline (95% CI 4·0 to 8·8; p<0·0001) with spironolactone, but not other treatments. Amiloride (10 mg once daily) reduced clinic systolic blood pressure by 20·4 mm Hg (95% CI 18·3-22·5), compared with a reduction of 18·3 mm Hg (16·2-20·5) with spironolactone (25 mg once daily). No serious adverse events were recorded, and adverse symptoms were not systematically recorded after the end of the double-blind treatment. Mean plasma potassium concentrations increased from 4·02 mmol/L (95% CI 3·95-4·08) on placebo to 4·50 (4·44-4·57) on amiloride (p<0·0001). INTERPRETATION Our results suggest that resistant hypertension is commonly a salt-retaining state, most likely due to inappropriate aldosterone secretion. Mineralocorticoid receptor blockade by spironolactone overcomes the salt retention and resistance of hypertension to treatment. Amiloride seems to be as effective an antihypertensive as spironolactone, offering a substitute treatment for resistant hypertension. FUNDING British Heart Foundation and UK National Institute for Health Research.
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Affiliation(s)
- Bryan Williams
- UCL Institute of Cardiovascular Sciences, University College London, London, UK; National Institute for Health Research, UCL Hospitals Biomedical Research Centre, London, UK
| | - Thomas M MacDonald
- Medicines Monitoring Unit, Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Steve V Morant
- Medicines Monitoring Unit, Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - David J Webb
- Clinical Pharmacology Unit, Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Peter Sever
- Centre of Circulatory Health, Imperial College London, London, UK
| | - Gordon T McInnes
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | | | - Mark J Caulfield
- William Harvey Research Institute, Queen Mary University of London, London, UK; NIHR Barts Hospital Biomedical Research Centre, London, UK
| | - Sandosh Padmanabhan
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Isla S Mackenzie
- Medicines Monitoring Unit, Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Jackie Salsbury
- William Harvey Research Institute, Queen Mary University of London, London, UK; NIHR Barts Hospital Biomedical Research Centre, London, UK
| | - Morris J Brown
- William Harvey Research Institute, Queen Mary University of London, London, UK; NIHR Barts Hospital Biomedical Research Centre, London, UK.
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Impact of long-term potassium supplementation on thiazide diuretic-induced abnormalities of glucose and uric acid metabolisms. J Hum Hypertens 2018; 32:301-310. [PMID: 29497150 DOI: 10.1038/s41371-018-0036-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 08/05/2017] [Accepted: 08/25/2017] [Indexed: 12/18/2022]
Abstract
Treatment of hypertension with thiazide diuretics may trigger hypokalemia, hyperglycemia, and hyperuricemia. Some studies suggest simultaneous potassium supplementation in hypertensive patients using thiazide diuretics. However, few clinical studies have reported the impact of long-term potassium supplementation on thiazide diuretic-induced abnormalities in blood glucose and uric acid (UA) metabolisms. One hundred hypertensive patients meeting the inclusion criteria were equally randomized to two groups: IND group receiving indapamide (1.25-2.5 mg daily) alone, and IND/KCI group receiving IND (1.25-2.5 mg daily) plus potassium chloride (40 mmol daily), both for 24 weeks. At the end of 24-week follow-up, serum K+ level in IND group decreased from 4.27 ± 0.28 to 3.98 ± 0.46 mmol/L (P < 0.001), and fasting plasma glucose (FPG) and UA increased from 5.11 ± 0.52 to 5.31 ± 0.57 mmol/L (P < 0.05), and from 0.404 ± 0.078 to 0.433 ± 0.072 mmol/L (P < 0.05), respectively. Serum K+ level in IND/KCl group decreased from 4.27 ± 0.36 to 3.89 ± 0.28 mmol/L (P < 0.001), and FPB and UA increased from 5.10 ± 0.41 to 5.35 ± 0.55 mmol/L (P < 0.01), and from 0.391 ± 0.073 to 0.457 ± 0.128 mmol/L (P < 0.001), respectively. The difference value between the serum K+ level and FPG before and after treatment was not statistically significant between the two groups. However, the difference value in UA in IND/KCl group was significantly higher than that in IND group (0.066 (95% confidence interval (CI): 0.041-0.090) mmol/L vs. 0.029 (95% CI: 0.006-0.058) mmol/L, P < 0.05). The results showed that long-term routine potassium supplementation could not prevent or attenuate thiazide diuretic-induced abnormalities of glucose metabolism in hypertensive patients; rather, it may aggravate the UA metabolic abnormality.
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Abstract
PURPOSE OF REVIEW In patients with prediabetes or type 2 diabetes, the use of thiazides as antihypertensive agents has been challenged because associated metabolic adverse events, including new-onset diabetes. RECENT FINDINGS These metabolic disturbances are less marked with low-dose thiazides and, in most but not all studies, with thiazide-like diuretics (chlorthalidone, indapamide) than with thiazide-type diuretics (hydrochlorothiazide). In post hoc analyses of subgroups of patients with hypertension and type 2 diabetes, thiazides resulted in a significant reduction in cardiovascular events, all-cause mortality, and hospitalization for heart failure compared to placebo and generally were shown to be non-inferior to other antihypertensive agents. Benefits attributed to thiazide diuretics in terms of cardiovascular event reduction outweigh the risk of worsening glucose control in type 2 diabetes and of new-onset diabetes in non-diabetic patients. Thiazides still play a key role in the management of patients with type 2 diabetes and hypertension.
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Affiliation(s)
- André J Scheen
- Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Liège, University of Liège, CHU Sart Tilman (B35), B-4000, Liege, Belgium.
- Clinical Pharmacology Unit, CHU Liège, Center for Interdisciplinary Research on Medicines (CIRM), University of Liège, Liège, Belgium.
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