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Castañeda TR, Méndez M, Davison I, Elvert R, Schwahn U, Boldina G, Rocher C, Scherer P, Singh K, Bangari DS, Falkenhahn M, Kannt A, Konkar A, Larsen PJ, Arbeeny C, Dhal PK, Hübschle T. The Novel Phosphate and Bile Acid Sequestrant Polymer SAR442357 Delays Disease Progression in a Rat Model of Diabetic Nephropathy. J Pharmacol Exp Ther 2020; 376:190-203. [PMID: 33203659 DOI: 10.1124/jpet.120.000285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/10/2020] [Indexed: 12/11/2022] Open
Abstract
As a gut-restricted, nonabsorbed therapy, polymeric bile acid sequestrants (BAS) play an important role in managing hyperlipidemia and hyperglycemia. Similarly, nonabsorbable sequestrants of dietary phosphate have been used for the management of hyperphosphatemia in end-stage renal disease. To evaluate the potential utility of such polymer sequestrants to treat type 2 diabetes (T2D) and its associated renal and cardiovascular complications, we synthesized a novel polymeric sequestrant, SAR442357, possessing optimized bile acid (BA) and phosphate sequestration characteristics. Long-term treatment of T2D obese cZucker fatty/Spontaneously hypertensive heart failure F1 hybrid (ZSF1) with SAR442357 resulted in enhanced sequestration of BAs and phosphate in the gut, improved glycemic control, lowering of serum cholesterol, and attenuation of diabetic kidney disease (DKD) progression. In comparison, colesevelam, a BAS with poor phosphate binding properties, did not prevent DKD progression, whereas losartan, an angiotensin II receptor blocker that is widely used to treat DKD, showed no effect on hyperglycemia. Analysis of hepatic gene expression levels of the animals treated with SAR442357 revealed upregulation of genes responsible for the biosynthesis of cholesterol and BAs, providing clear evidence of target engagement and mode of action of the new sequestrant. Additional hepatic gene expression pathway changes were indicative of an interruption of the enterohepatic BA cycle. Histopathological analysis of ZSF1 rat kidneys treated with SAR442357 further supported its nephroprotective properties. Collectively, these findings reveal the pharmacological benefit of simultaneous sequestration of BAs and phosphate in treating T2D and its associated comorbidities and cardiovascular complications. SIGNIFICANCE STATEMENT: A new nonabsorbed polymeric sequestrant with optimum phosphate and bile salt sequestration properties was developed as a treatment option for DKD. The new polymeric sequestrant offered combined pharmacological benefits including glucose regulation, lipid lowering, and attenuation of DKD progression in a single therapeutic agent.
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Affiliation(s)
- Tamara R Castañeda
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - María Méndez
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Ian Davison
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Ralf Elvert
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Uwe Schwahn
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Galina Boldina
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Corinne Rocher
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Petra Scherer
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Kuldeep Singh
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Dinesh S Bangari
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Mechthilde Falkenhahn
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Aimo Kannt
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Anish Konkar
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Philip J Larsen
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Cynthia Arbeeny
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Pradeep K Dhal
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
| | - Thomas Hübschle
- R&D Diabetes (T.R.C., R.E., A.Ka., A.Ko., P.J.L., C.A., T.H.), Integrated Drug Discovery (M.M.), Biomarkers and Clinical Bioanalysis (U.S.), Translational In Vivo Models, Global Discovery Pathology (P.S.), and Global Research Project Management (M.F.), Sanofi-Aventis Deutschland GmbH, Industriepark Höchst, Frankfurt, Germany; C&BD Haverhill Operations, Sanofi GB Genzyme Limited, Haverhill, Suffolk, United Kingdom (I.D.); R&D Translational Sciences France, Bioinformatics, Sanofi, Chilly-Mazarin Cedex, France (C.R.); Translational In Vivo Models, Global Discovery Pathology, Framingham, Massachusetts (K.S., D.S.B.); and Pharmaceutical Development Platform, Sanofi Global R&D, Waltham, Massachusetts (P.K.D.)
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Ma W, Sun N, Duan C, Zhao L, Hua Q, Sun Y, Dang A, Gao P, Qu P, Cui W, Zhao L, Dong Y, Cui L, Qi X, Jiang Y, Xie J, Li J, Wu G, Du X, Huo Y, Chen P. Effectiveness of Levoamlodipine Maleate for Hypertension Compared with Amlodipine Besylate: a Pragmatic Comparative Effectiveness Study. Cardiovasc Drugs Ther 2020; 35:41-50. [PMID: 32915349 DOI: 10.1007/s10557-020-07054-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE Antihypertensive treatment is the most important method to reduce the risk of cardiovascular events in hypertensive patients. However, there is scant evidence of the benefits of levoamlodipine maleate for antihypertensive treatment using a head-to-head comparison in the real-world. This study aims to examine the effectiveness of levoamlodipine maleate used to treat outpatients with primary hypertension compared with amlodipine besylate in a real-world setting. METHODS This was a pragmatic comparative effectiveness study carried out at 110 centers across China in outpatients with primary hypertension treated with levoamlodipine maleate or amlodipine besylate, with 24 months of follow-up. The primary outcomes used for evaluating the effectiveness were composite major cardiovascular and cerebrovascular events (MACCE), adverse reactions, and cost-effectiveness. RESULTS Among the included 10,031 patients, there were 482 MACCE, 223 (4.4%) in the levoamlodipine maleate group (n = 5018) and 259 (5.2%) in the amlodipine besylate group (n = 5013) (adjusted hazard ratio = 0.90, 95%CI: 0.75-1.08, P = 0.252). The levoamlodipine maleate group had lower overall incidences of any adverse reactions (6.0% vs. 8.4%, P < 0.001), lower extremity edema (1.1% vs. 3.0%, P < 0.001) and headache (0.7% vs. 1.1%, P = 0.045). There was a nearly 100% chance of the levoamlodipine maleate being cost-effective at a willingness to pay threshold of 150,000 Yuan per quality-adjusted life years (QALYs) gained, resulting in more QALYs (incremental QALYs: 0.00392) and cost savings (saving 2725 Yuan or 28.8% reduction in overall costs) per patient. CONCLUSION In conclusion, levoamlodipine maleate could reduce cost by 29% with a similar MACCE incidence rate and lower occurrence of adverse reactions (especially edema and headache) compared with amlodipine besylate. TRIAL REGISTRATION Clinicaltrials.gov NCT01844570 registered at May 1, 2013.
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Affiliation(s)
- Wei Ma
- Department of Cardiology, Peking University First Hospital, Beijing, 100034, China
| | - Ningling Sun
- Department of Cardiology, Peking University People's Hospital, Beijing, China
| | - Chongyang Duan
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, 510515, China
| | - Lianyou Zhao
- Department of Cardiovascular, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Qi Hua
- Department of Cardiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yingxian Sun
- Department of Cardiology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Aimin Dang
- Department of Special Care Center, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Pingjin Gao
- Department of Hypertension, Research Center for Hypertension Management and Prevention in Community, Shanghai Key Laboratory of Hypertension, Shanghai Institute of Hypertension, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Peng Qu
- Department of Cardiovascular, The Second Hospital of Dalian Medical University, Dalian, China
| | - Wei Cui
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Luosha Zhao
- Department of Cardiovascular, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Lianqun Cui
- Department of Cardiology, Shandong Provence Hospital, Jinan, China
| | - Xiaoyong Qi
- Cardiac Medicine, Hebei General Hospital, Shijiazhuang, China
| | - Yinong Jiang
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jianhong Xie
- Department of Geriatrics, Department of Hypertension, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Jun Li
- Department of Cardiology, Guang'an men Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Gang Wu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xinping Du
- Department of Cardiology, The Fifth Central Hospital of Tianjin, Tianjin, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, 100034, China.
| | - Pingyan Chen
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, 510515, China.
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Chen YJ, Li LJ, Tang WL, Song JY, Qiu R, Li Q, Xue H, Wright JM. First-line drugs inhibiting the renin angiotensin system versus other first-line antihypertensive drug classes for hypertension. Cochrane Database Syst Rev 2018; 11:CD008170. [PMID: 30480768 PMCID: PMC6516995 DOI: 10.1002/14651858.cd008170.pub3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND This is the first update of a Cochrane Review first published in 2015. Renin angiotensin system (RAS) inhibitors include angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and renin inhibitors. They are widely prescribed for treatment of hypertension, especially for people with diabetes because of postulated advantages for reducing diabetic nephropathy and cardiovascular morbidity and mortality. Despite widespread use for hypertension, the efficacy and safety of RAS inhibitors compared to other antihypertensive drug classes remains unclear. OBJECTIVES To evaluate the benefits and harms of first-line RAS inhibitors compared to other first-line antihypertensive drugs in people with hypertension. SEARCH METHODS The Cochrane Hypertension Group Information Specialist searched the following databases for randomized controlled trials up to November 2017: the Cochrane Hypertension Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1946), Embase (from 1974), the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. We also contacted authors of relevant papers regarding further published and unpublished work. The searches had no language restrictions. SELECTION CRITERIA We included randomized, active-controlled, double-blinded studies (RCTs) with at least six months follow-up in people with elevated blood pressure (≥ 130/85 mmHg), which compared first-line RAS inhibitors with other first-line antihypertensive drug classes and reported morbidity and mortality or blood pressure outcomes. We excluded people with proven secondary hypertension. DATA COLLECTION AND ANALYSIS Two authors independently selected the included trials, evaluated the risks of bias and entered the data for analysis. MAIN RESULTS This update includes three new RCTs, totaling 45 in all, involving 66,625 participants, with a mean age of 66 years. Much of the evidence for our key outcomes is dominated by a small number of large RCTs at low risk for most sources of bias. Imbalances in the added second-line antihypertensive drugs in some of the studies were important enough for us to downgrade the quality of the evidence.Primary outcomes were all-cause death, fatal and non-fatal stroke, fatal and non-fatal myocardial infarction (MI), fatal and non-fatal congestive heart failure (CHF) requiring hospitalizations, total cardiovascular (CV) events (fatal and non-fatal stroke, fatal and non-fatal MI and fatal and non-fatal CHF requiring hospitalization), and end-stage renal failure (ESRF). Secondary outcomes were systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR).Compared with first-line calcium channel blockers (CCBs), we found moderate-certainty evidence that first-line RAS inhibitors decreased heart failure (HF) (35,143 participants in 5 RCTs, risk ratio (RR) 0.83, 95% confidence interval (CI) 0.77 to 0.90, absolute risk reduction (ARR) 1.2%), and that they increased stroke (34,673 participants in 4 RCTs, RR 1.19, 95% CI 1.08 to 1.32, absolute risk increase (ARI) 0.7%). Moderate-certainty evidence showed that first-line RAS inhibitors and first-line CCBs did not differ for all-cause death (35,226 participants in 5 RCTs, RR 1.03, 95% CI 0.98 to 1.09); total CV events (35,223 participants in 6 RCTs, RR 0.98, 95% CI 0.93 to 1.02); and total MI (35,043 participants in 5 RCTs, RR 1.01, 95% CI 0.93 to 1.09). Low-certainty evidence suggests they did not differ for ESRF (19,551 participants in 4 RCTs, RR 0.88, 95% CI 0.74 to 1.05).Compared with first-line thiazides, we found moderate-certainty evidence that first-line RAS inhibitors increased HF (24,309 participants in 1 RCT, RR 1.19, 95% CI 1.07 to 1.31, ARI 1.0%), and increased stroke (24,309 participants in 1 RCT, RR 1.14, 95% CI 1.02 to 1.28, ARI 0.6%). Moderate-certainty evidence showed that first-line RAS inhibitors and first-line thiazides did not differ for all-cause death (24,309 participants in 1 RCT, RR 1.00, 95% CI 0.94 to 1.07); total CV events (24,379 participants in 2 RCTs, RR 1.05, 95% CI 1.00 to 1.11); and total MI (24,379 participants in 2 RCTs, RR 0.93, 95% CI 0.86 to 1.01). Low-certainty evidence suggests they did not differ for ESRF (24,309 participants in 1 RCT, RR 1.10, 95% CI 0.88 to 1.37).Compared with first-line beta-blockers, low-certainty evidence suggests that first-line RAS inhibitors decreased total CV events (9239 participants in 2 RCTs, RR 0.88, 95% CI 0.80 to 0.98, ARR 1.7%), and decreased stroke (9193 participants in 1 RCT, RR 0.75, 95% CI 0.63 to 0.88, ARR 1.7% ). Low-certainty evidence suggests that first-line RAS inhibitors and first-line beta-blockers did not differ for all-cause death (9193 participants in 1 RCT, RR 0.89, 95% CI 0.78 to 1.01); HF (9193 participants in 1 RCT, RR 0.95, 95% CI 0.76 to 1.18); and total MI (9239 participants in 2 RCTs, RR 1.05, 95% CI 0.86 to 1.27).Blood pressure comparisons between first-line RAS inhibitors and other first-line classes showed either no differences or small differences that did not necessarily correlate with the differences in the morbidity outcomes.There is no information about non-fatal serious adverse events, as none of the trials reported this outcome. AUTHORS' CONCLUSIONS All-cause death is similar for first-line RAS inhibitors and first-line CCBs, thiazides and beta-blockers. There are, however, differences for some morbidity outcomes. First-line thiazides caused less HF and stroke than first-line RAS inhibitors. First-line CCBs increased HF but decreased stroke compared to first-line RAS inhibitors. The magnitude of the increase in HF exceeded the decrease in stroke. Low-quality evidence suggests that first-line RAS inhibitors reduced stroke and total CV events compared to first-line beta-blockers. The small differences in effect on blood pressure between the different classes of drugs did not correlate with the differences in the morbidity outcomes.
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Affiliation(s)
- Yu Jie Chen
- School of Pharmacy, Fudan UniversityDepartment of PharmacologyRoom 605, Building 18, Lane 280, Cai Lun Road, Pudong New DistrictShanghaiShanghaiChina201203
| | - Liang Jin Li
- School of Pharmacy, Fudan UniversityDepartment of PharmacologyRoom 605, Building 18, Lane 280, Cai Lun Road, Pudong New DistrictShanghaiShanghaiChina201203
| | - Wen Lu Tang
- School of Pharmacy, Fudan UniversityDepartment of PharmacologyRoom 605, Building 18, Lane 280, Cai Lun Road, Pudong New DistrictShanghaiShanghaiChina201203
| | - Jia Yang Song
- School of Pharmacy, Fudan UniversityDepartment of PharmacologyRoom 605, Building 18, Lane 280, Cai Lun Road, Pudong New DistrictShanghaiShanghaiChina201203
| | - Ru Qiu
- School of Pharmacy, Fudan UniversityDepartment of PharmacologyRoom 605, Building 18, Lane 280, Cai Lun Road, Pudong New DistrictShanghaiShanghaiChina201203
| | - Qian Li
- School of Pharmacy, Fudan UniversityDepartment of PharmacologyRoom 605, Building 18, Lane 280, Cai Lun Road, Pudong New DistrictShanghaiShanghaiChina201203
| | - Hao Xue
- School of Pharmacy, Fudan UniversityDepartment of PharmacologyRoom 605, Building 18, Lane 280, Cai Lun Road, Pudong New DistrictShanghaiShanghaiChina201203
| | - James M Wright
- University of British ColumbiaDepartment of Anesthesiology, Pharmacology and Therapeutics2176 Health Sciences MallVancouverBCCanadaV6T 1Z3
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