Comparison of the efficacy of candesartan and losartan: a meta-analysis of trials in the treatment of hypertension

Comparative Effectiveness of Angiotensin II Receptor Blockers in Patients With Hypertension in Japan - Systematic Review and Network Meta-Analysis

Background: Angiotensin II receptor blockers (ARBs) are widely used for the management of hypertension in Japan; however, comparative efficacy data within the ARB drug class remain limited. Methods and Results: This systematic literature review identified randomized controlled trials (RCT) indexed in PubMed and Ichushi in Japanese patients with hypertension receiving ARB monotherapy (azilsartan, candesartan cilexetil, irbesartan, losartan potassium, olmesartan medoxomil, telmisartan, valsartan) in at least 1 arm. Of 763 RCTs identified, 77 met the eligibility criteria; of which, 37 reported mean change in systolic blood pressure (SBP) and diastolic blood pressure (DBP) from baseline in the office setting and were used to construct the network. A fixed-effects model (FEM) showed the effect of each drug vs. the reference, azilsartan. Using the FEM, the mean (95% credible interval) change from baseline in SBP/DBP for candesartan cilexetil, irbesartan, losartan potassium, olmesartan medoxomil, telmisartan, and valsartan was 3.8 (2.9-4.8)/2.6 (2.0-3.1), 4.8 (2.0-7.5)/3.7 (1.8-5.6), 3.0 (0.8-5.1)/1.9 (0.5-3.3), 3.2 (1.2-5.1)/2.7 (1.3-4.1), 3.2 (0.8-5.6)/2.0 (0.3-3.6), and 3.1 (1.1-5.1)/2.4 (1.1-3.8) mmHg, respectively. Conclusions: The results of this meta-analysis provide evidence that azilsartan has a more favorable efficacy profile than the other ARBs in reducing SBP and DBP.

Candesartan targeting of angiotensin II type 1 receptor demonstrates benefits for hypertension in pregnancy via the NF‑κB signaling pathway

Hypertensive disorders may be a complication of pregnancy and are characterized by the high blood pressure. Evidence suggests that alterations in the renin-angiotensin-aldosterone system and the sympathetic nervous system are associated with gestational hypertension. Angiotensin II type 1 receptor (Ang-IITR) is a potential target in the progression of gestational hypertension. Candesartan is selective Ang-IITR antagonist that may act against vasoconstriction and reduces peripheral vascular resistance. The aim of the present study was to evaluate the efficacy of Candesartan and the underlying molecular mechanism of the nuclear factor-κB (NF-κB) signaling pathway in the progression of gestational hypertension in a mouse model. Expression and activity of Ang-IITR was evaluated in a mouse model of gestational hypertension prior to and post-treatment of Candesartan both in vitro and in vivo. It was determined whether Candesartan treatment reduces higher blood pressure activated the renal renin-angiotensin system and a prognostic marker, soluble endoglin, and its associated gene in mice with gestational hypertension. Angiotensin-converting enzyme plasma levels and activity were also evaluated in the present study. Cytoplasmic and nuclear immunostaining of NF-κB and associated proteins transforming growth factor β (TGF-β) and endoglin was enhanced in vascular endothelial cells and mice with gestational hypertension. Soluble fms-like tyrosine kinase 1 (sFlt-1), insulin resistance homeostasis model assessment score and associated cardiovascular risk factors also were measured. Results demonstrated that angiotensin and Ang-IITR expression levels were upregulated in mice with gestational hypertension and were downregulated by Candesartan treatment. Renal renin-angiotensin and soluble endoglin were also improved in mice in the Candesartan-treated group. In addition, Candesartan treatment enhanced NF-κB activity, as well as TGF-β and vascular endothelial growth factor expression which led to improved levels of sFlt-1, insulin resistance homeostasis and associated cardiovascular risk factors. Gestational hypertension was markedly improved by treatment of Candesartan compared with the control. In conclusion, the findings of the present study suggested that the NF-κB signaling pathway may be involved in with Candesartan-mediated Ang-IITR for the treatment of gestational hypertension.

Comparative Efficacy of Angiotensin II Antagonists in Essential Hypertension: Systematic Review and Network Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Evidence on the long-term clinical benefits of individual members of angiotensin II receptor blockers is limited given the lack of head-to-head studies. We conducted a network meta-analysis to determine the comparative efficacy of different members within this drug class with respect to outcomes of (i) blood pressure reduction (at 24 and 52 weeks) and (ii) prevention of cardiovascular disease (>104 weeks).

METHODS

A systematic literature review was conducted - Protocol registration: (PROSPERO - CRD42014007067) - to identify relevant literature from the following databases: Cochrane Library, PubMed, Medline and EMBASE; searched from inception to July 2016. Randomised controlled trials (RCTs) were included if they reported long-term effectiveness relating to blood pressure, mortality, myocardial infarction or stroke. Eligible studies included those with placebo or specific active-treatment comparators (either another angiotensin II receptor blockers or hydrochlorothiazide). A Bayesian random-effects network model was used to combine direct within-trial comparisons between treatment groups with indirect evidence from other trials.

RESULTS

Thirty-six studies were identified, representing 28 unique trials. Blood pressure reduction, based on 12 studies (n=807) with fixed dosing regimen, was found to be similar amongst members of the angiotensin receptor blocker drug class at both 24 and 52 weeks. A network meta-analysis of five studies (n=16,716) with a treat-to-target approach found that prevention of all-cause mortality, stroke and myocardial infarction was similar across the angiotensin-receptor blockers therapies initiated.

CONCLUSIONS

Current evidence is insufficient to show differences in any members within the angiotensin II receptor blocker drug class with respect to blood pressuring lowering effects or a reduction in cardiovascular diseases.

Examining the Association of Olmesartan and Other Angiotensin Receptor Blockers With Overall and Cause-Specific Mortality

Concerns about an increased cardiovascular risk with the angiotensin receptor blocker, olmesartan, prompted the current study to examine associations between olmesartan and other angiotensin receptor blockers with overall and cause-specific mortalities. We collected patients who started to use losartan, valsartan, irbesartan, candesartan, telmisartan, and olmesartan between January 1, 2004, and December 31, 2009, from Taiwan’s National Health Insurance claims database. Prescribed drug types, dosage, and other clinical information were collected. Overall mortality and cause-specific mortality were ascertained through linkages with Taiwan’s National Death Registry. Two follow-up analyses, labeled intention-to-treat and as-treated, were conducted. A Cox proportional hazard regression model was used to calculate the hazard ratio (HR) and 95% confidence interval (CI) using losartan as the reference group. A total of 690 463 subjects were included, with a mean follow-up ranging from a low of 2.8 years for olmesartan to a high of 4.1 years for irbesartan. Subjects who began with valsartan had a modest but significantly increased risk of overall mortality (HR, 1.04; 95% CI, 1.02–1.06) compared with losartan. Irbesartan (HR, 0.96; 95% CI, 0.94–0.99), candesartan (HR, 0.95; 95% CI, 0.92–0.99), telmisartan (HR, 0.93; 95% CI, 0.90–0.96), and olmesartan (HR, 0.93; 95% CI, 0.88–0.97) were associated with a slightly lower overall mortality risk than losartan. The analysis indicates that the differences in mortality risk among individual angiotensin receptor blockers were only marginal and thus less likely to be clinically important. Although uncontrolled confounding might still exist, olmesartan does not seem to increase cardiovascular risk compared with losartan.

Comparative assessment of angiotensin II type 1 receptor blockers in the treatment of acute myocardial infarction: surmountable vs. insurmountable antagonist

BACKGROUND

The mechanisms of antagonism vary between the angiotensin II type 1 receptor blockers (ARBs): insurmountable antagonism and surmountable antagonism. Recent retrospective observational studies suggest that ARBs may not have equivalent benefits in various clinical situations. The aim of this study was to compare the effect of two categories of ARBs on the long-term clinical outcomes of patients with acute myocardial infarction (AMI).

METHODS

We analyzed the large-scale, prospective, observational Korea Acute Myocardial Infarction Registry study, which enrolled 2740 AMI patients. They divided by the prescription of surmountable ARBs or insurmountable ARBs at discharge. Primary outcome was major adverse cardiac events (MACEs), defined as a composite of cardiac death, nonfatal MI, and re-percutaneous coronary intervention, coronary artery bypass graft surgery.

RESULTS

In the overall population, the MACEs rate in 1 year was significantly higher in the surmountable ARB group (14.3% vs. 11.2%, p=0.025), which was mainly due to increased cardiac death (3.3% vs. 1.9%, p=0.031). Matching by propensity-score showed consistent results (MACEs rate: 14.9% vs. 11.4%, p=0.037). In subgroup analysis, the insurmountable ARB treatment significantly reduced the incidence of MACEs in patients with left ventricular ejection fraction greater than 40%, with a low killip class, with ST segment elevation MI, and with normal renal function.

CONCLUSIONS

In our study, insurmountable ARBs were more effective on long-term clinical outcomes than surmountable ARBs in patients with AMI.

Candesartan cilexetil/hydrochlorothiazide treatment in high-risk patients with type 2 diabetes mellitus and microalbuminuria: the CHILI T2D study

BACKGROUND

Arterial hypertension complicated by the presence of diabetes mellitus and microalbuminuria is a particularly hazardous risk-factor combination. Blockers of the renin-angiotensin system have been shown to be beneficial with respect to these risk factors in randomized clinical trials.

OBJECTIVES

To provide proof of effectiveness for a fixed-dose combination such as candesartan cilexetil 16 mg/hydrochlorothiazide (HCTZ) 12.5 mg in clinical practice within the context of a variety of concomitant diseases and medications.

METHODS

CHILI T2D was a non-interventional, open-label, non-controlled, multicentre study in clinical practice that evaluated 4110 patients with type 2 diabetes, uncontrolled hypertension and microalbuminuria who were being prescribed a fixed-dose combination of candesartan cilexetil 16 mg/HCTZ 12.5 mg (Blopress). Documented outcomes included blood pressure (BP) reductions, metabolic changes, changes in albuminuria, and adverse events throughout the 12-week treatment period.

RESULTS

Patients had a mean +/- SD age of 64.0 +/- 10.3 years, 54.0% were male and the mean +/- SD body mass index was 29.6 +/- 5.8 kg/m2. Coronary heart disease (34.3%), diabetic neuropathy (23.8%), retinopathy (18.6%) and heart failure (20.2%) were frequent co-morbidities. The use of candesartan cilexetil 16 mg/HCTZ 12.5 mg in patients with a mean +/- SD baseline BP of 158.5 +/- 14.2/92.5 +/- 9.1 mmHg resulted in a substantial further reduction of office BP by a mean +/- SD of -27.1 +/- 14.4/-13.1 +/- 9.5 mmHg (p < 0.001). The reduction was particularly pronounced in patients with severe hypertension (mean reduction of -44.7/-19.9 mmHg). Glucose (glycosylated haemoglobin [HbA(1c)], fasting blood glucose) as well as lipid parameters (total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and triglycerides) were significantly improved (p < 0.001). Microalbuminuria, indicative of renal and cardiovascular risk, was significantly reduced by 28.8% (p < 0.001). Tolerability was excellent with only 16 out of 4110 patients experiencing any adverse event, of which six were considered to be serious.

CONCLUSIONS

The fixed-dose combination of candesartan cilexetil 16 mg/HCTZ 12.5 mg is highly effective in lowering blood pressure in type 2 diabetic patients with all stages of hypertension and microalbuminuria. The data indicate that low-dose HCTZ can safely be added to an existing drug regimen in this patient group to increase the BP-lowering effect, without compromising tolerability and the favourable metabolic profile of candesartan cilexetil monotherapy.