1
|
Loo G, Puar T, Foo R, Ong TK, Wang TD, Nguyen QN, Chin CT, Chin CWL. Unique characteristics of Asians with hypertension: what is known and what can be done? J Hypertens 2024; 42:1482-1489. [PMID: 38509747 DOI: 10.1097/hjh.0000000000003706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Hypertension remains the leading modifiable risk factor for cardiovascular disease worldwide. Over the past 30 years, the prevalence of hypertension has been increasing in East and Southeast Asia to a greater extent as compared with other Western countries. Asians with hypertension have unique characteristics. This can be attributed to increased impact of obesity on Asians with hypertension, excessive salt intake and increased salt sensitivity, loss of diurnal rhythm in blood pressure and primary aldosteronism. The impact of hypertension on cardiovascular (particularly strokes) and chronic kidney disease is greater in Asians. These unique characteristics underpinned by the diverse socioeconomic backgrounds pose its own challenges in the diagnosis and management of hypertension in Asia.
Collapse
Affiliation(s)
- Germaine Loo
- Department of Cardiology, National Heart Centre Singapore
| | - Troy Puar
- Department of Endocrinology, Changi General Hospital
- Cardiovascular Centre and Divisions of Cardiology and Hospital Medicine, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Medical ACP, Duke-NUS Medical School, Singapore
| | - Roger Foo
- Department of Cardiology, National University Heart Centre, National University Health System
- Cardiovascular Metabolic Disease Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tiong Kiam Ong
- Department of Cardiology, Sarawak Heart Centre, Sarawak, Malaysia
| | - Tzung-Dau Wang
- Cardiovascular Centre and Divisions of Cardiology and Hospital Medicine, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | | | - Chee Tang Chin
- Department of Cardiology, National Heart Centre Singapore
- Cardiovascular ACP, Duke-NUS Medical School, Singapore
| | - Calvin W L Chin
- Department of Cardiology, National Heart Centre Singapore
- Cardiovascular ACP, Duke-NUS Medical School, Singapore
| |
Collapse
|
2
|
Kario K, Ohbayashi H, Hashimoto M, Itabashi N, Kato M, Uchiyama K, Hirano K, Nakamura N, Miyamoto T, Nagashima H, Kajiyama S, Ishida H, Imai E, Ebe Y, Ohishi M, Katsuya T, Taguchi T, Tanabe A, Shimosawa T. Home blood pressure-lowering effect of a non-steroidal mineralocorticoid receptor blocker, esaxerenone, versus trichlormethiazide for uncontrolled hypertension: the EXCITE-HT randomized controlled study. Hypertens Res 2024:10.1038/s41440-024-01762-z. [PMID: 39039285 DOI: 10.1038/s41440-024-01762-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/20/2024] [Accepted: 05/30/2024] [Indexed: 07/24/2024]
Abstract
The EXCITE-HT study aimed to evaluate the efficacy and safety of esaxerenone versus thiazide diuretics (trichlormethiazide) as second-line treatment for Japanese patients with uncontrolled essential hypertension. This was a 12-week, multicenter, randomized, open-label, parallel-group study. The non-inferiority of esaxerenone to trichlormethiazide was confirmed if the upper limit of the two-sided 95% confidence interval (CI) for the difference in systolic blood pressure (SBP)/diastolic blood pressure (DBP) change between groups was below 3.9/2.1 mmHg. A total of 295 and 290 patients were included in the esaxerenone and trichlormethiazide groups, respectively. The non-inferiority of esaxerenone to trichlormethiazide was demonstrated: least squares mean change differences in morning home SBP/DBP at end of treatment (EOT) were -2.2 (95% CI, -3.6, -0.8) mmHg for SBP/-0.6 (-1.4, 0.2) mmHg for DBP. Morning home, bedtime home, and office BP significantly decreased (all p < 0.001) from baseline to EOT in both groups. The urinary albumin-to-creatinine ratio and N-terminal pro-brain natriuretic peptide level decreased from baseline to Week 12 in both groups, with no notable intergroup difference. Serum potassium elevations occurred more frequently with esaxerenone, while serum potassium reductions occurred more with trichlormethiazide. Uric acid elevations were observed in both groups, but more frequently with trichlormethiazide than esaxerenone. No cases of gout occurred in this study. Reductions in estimated glomerular filtration rate were similarly observed in both groups. EXCITE-HT is the first randomized controlled study to demonstrate evidence that esaxerenone is non-inferior to trichlormethiazide as second-line treatment for Japanese patients with uncontrolled essential hypertension, with no new safety concerns. The EXCITE-HT study demonstrated the non-inferiority of esaxerenone to trichlormethiazide in its morning home blood pressure lowering effect and safety profile in Japanese patients with uncontrolled essential hypertension who were previously treated with an angiotensin II receptor blocker or calcium channel blocker.
Collapse
Affiliation(s)
- Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan.
| | | | | | - Naoki Itabashi
- Itabashi Diabetes and Dermatology Medical Clinic, Koga, Ibaraki, Japan
| | - Mitsutoshi Kato
- Kato Clinic of Internal Medicine, Katsushika-ku, Tokyo, Japan
| | | | | | | | | | | | | | | | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Hyogo, Japan
| | | | - Mitsuru Ohishi
- Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Kagoshima, Japan
| | | | - Takashi Taguchi
- Primary Medical Science Department, Medical Affairs Division, Daiichi Sankyo Co., Ltd., Chuo-ku, Tokyo, Japan
| | - Ayumi Tanabe
- Data Intelligence Department, Daiichi Sankyo Co., Ltd., Shinagawa-ku, Tokyo, Japan
| | - Tatsuo Shimosawa
- Department of Clinical Laboratory, School of Medicine, International University of Health and Welfare, Narita, Chiba, Japan
| |
Collapse
|
3
|
Kario K, Shiosakai K, Taguchi T. Antihypertensive effect of esaxerenone and correlation between brachial and wrist home monitoring devices in patients with nocturnal hypertension: A post hoc analysis of the EARLY-NH study. J Clin Hypertens (Greenwich) 2024; 26:842-849. [PMID: 38980252 PMCID: PMC11232449 DOI: 10.1111/jch.14857] [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: 03/07/2024] [Revised: 05/02/2024] [Accepted: 05/21/2024] [Indexed: 07/10/2024]
Abstract
Adequate management of nocturnal hypertension is crucial to reduce the risk of organ damage and cardiovascular events. The EARLY-NH study was a prospective, open-label, multicenter study conducted in Japanese patients with nocturnal hypertension who received esaxerenone treatment for 12 weeks. This post hoc analysis aimed to assess (1) the relationship between changes in morning home systolic blood pressure (SBP), bedtime home SBP, and nighttime home SBP based on changes in SBP and achievement rates of target SBP levels; and (2) the correlation between nighttime home SBP measurements using brachial and wrist home BP monitoring (HBPM) devices. This analysis evaluated 82 patients who completed the 12-week treatment period. Among those who achieved target morning home SBP (<135 mmHg) and target bedtime home SBP (<135 mmHg), the brachial HBPM device showed achievement rates of 63.6% and 56.4%, respectively, for target nighttime home SBP (<120 mmHg). The wrist device showed achievement rates of 66.7% and 63.4%, respectively, for the same targets. Significant correlations were observed between both devices for nighttime home SBP measurements at baseline (r = 0.790), Week 12 (r = 0.641), and change from baseline to Week 12 (r = 0.533) (all, p < .001). In this patient population, approximately 60% of individuals who reached target morning or bedtime home SBP levels <135 mmHg exhibited well-controlled nighttime home SBP. Although nighttime home SBP measurements obtained using both brachial and wrist HBPM devices displayed a significant correlation, the wrist device needs to be examined in more detail for clinical use.
Collapse
Affiliation(s)
- Kazuomi Kario
- Division of Cardiovascular MedicineDepartment of MedicineJichi Medical University School of MedicineShimotsukeJapan
| | | | - Takashi Taguchi
- Primary Medical Science DepartmentDaiichi Sankyo Co., Ltd.TokyoJapan
| |
Collapse
|
4
|
Ikeda S, Shinohara K, Kashihara S, Matsumoto S, Yoshida D, Nakashima R, Ono Y, Matsushima S, Tsutsui H, Kinugawa S. Esaxerenone: blood pressure reduction and cardiorenal protection without reflex sympathetic activation in salt-loaded stroke-prone spontaneously hypertensive rats. Hypertens Res 2024:10.1038/s41440-024-01733-4. [PMID: 38802501 DOI: 10.1038/s41440-024-01733-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 04/18/2024] [Accepted: 05/07/2024] [Indexed: 05/29/2024]
Abstract
Mineralocorticoid receptor (MR) is involved in the mechanisms of blood pressure elevation, organ fibrosis, and inflammation. MR antagonists have been used in patients with hypertension, heart failure, or chronic kidney disease. Esaxerenone, a recently approved MR blocker with a nonsteroidal structure, has demonstrated a strong blood pressure-lowering effect. However, blood pressure reduction may lead to sympathetic activation through the baroreflex. The effect of esaxerenone on the sympathetic nervous system remains unclear. We investigated the effect of esaxerenone on organ damage and the sympathetic nervous system in salt-loaded stroke-prone spontaneously hypertensive rats (SHRSP), a well-established model of essential hypertension with sympathoexcitation and organ damage. Three-week administration of esaxerenone or hydralazine successfully attenuated the blood pressure elevation. Both esaxerenone and hydralazine comparably suppressed left ventricular hypertrophy and urinary albumin excretion. However, renal fibrosis and glomerular sclerosis were suppressed by esaxerenone but not hydralazine. Furthermore, plasma norepinephrine level, a parameter of systemic sympathetic activity, was significantly increased by hydralazine but not by esaxerenone. Consistent with these findings, the activity of the control centers of sympathetic nervous system, the parvocellular region of the paraventricular nucleus in the hypothalamus and the rostral ventrolateral medulla, was enhanced by hydralazine but remained unaffected by esaxerenone. These results suggest that esaxerenone effectively lowers blood pressure without inducing reflex sympathetic nervous system activation. Moreover, the organ-protective effects of esaxerenone appear to be partially independent of its blood pressure-lowering effect. In conclusion, esaxerenone demonstrates a blood pressure-lowering effect without concurrent sympathetic activation and exerts organ-protective effects in salt-loaded SHRSP. Esaxerenone has antihypertensive and cardiorenal protective effects without reflex sympathetic activation in salt-loaded stroke-prone spontaneously hypertensive rats.
Collapse
Affiliation(s)
- Shota Ikeda
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Keisuke Shinohara
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.
- Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Soichiro Kashihara
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Sho Matsumoto
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Yoshida
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryosuke Nakashima
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshiyasu Ono
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shouji Matsushima
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- School of Medicine and Graduate School, International University of Health and Welfare, Fukuoka, Japan
| | - Shintaro Kinugawa
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Cardiovascular Medicine, Research Institute of Angiocardiology, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| |
Collapse
|
5
|
Katsuya T, Inobe Y, Uchiyama K, Nishikawa T, Hirano K, Kato M, Fukui T, Hatta T, Iwasaki A, Ishii H, Sugiura T, Taguchi T, Tanabe A, Sugimoto K, Shimosawa T. Exploratory study on the relationship between urinary sodium/potassium ratio, salt intake, and the antihypertensive effect of esaxerenone: the ENaK Study. Hypertens Res 2024; 47:835-848. [PMID: 38212366 PMCID: PMC10994843 DOI: 10.1038/s41440-023-01519-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/30/2023] [Accepted: 11/05/2023] [Indexed: 01/13/2024]
Abstract
Excessive salt intake is one of the causes of hypertension, and reducing salt intake is important for managing the risk of hypertension and subsequent cardiovascular events. Esaxerenone, a mineralocorticoid receptor blocker, has the potential to exert an antihypertensive effect in hypertensive patients with excessive salt intake, but evidence is still lacking, especially in clinical settings. We aimed to determine if baseline sodium/potassium ratio and baseline estimated 24-h urinary sodium excretion can predict the antihypertensive effect of esaxerenone in patients with essential hypertension inadequately controlled with an angiotensin receptor blocker (ARB) or a calcium channel blocker (CCB). This was an exploratory, open-label, interventional study with a 4-week observation period and a 12-week treatment period. Esaxerenone was orally administered once daily in accordance with the Japanese package insert. In total, 126 patients met the eligibility criteria and were enrolled (ARB subcohort, 67; CCB subcohort, 59); all were included in the full analysis set (FAS) and safety analysis. In the FAS, morning home systolic blood pressure (SBP)/diastolic blood pressure (DBP) significantly decreased from baseline to end of treatment (primary efficacy endpoint) (-11.9 ± 10.9/ - 6.4 ± 6.8 mmHg, both p < 0.001); a similar trend was observed in both subcohorts. Significant reductions were also shown in bedtime home and office SBP/DBP (all p < 0.001). Each BP change was consistent regardless of the urinary sodium/potassium ratio or estimated 24-h urinary sodium excretion at baseline. The urinary albumin-creatinine ratio (UACR) and N-terminal pro-brain natriuretic peptide (NT-proBNP) significantly decreased from baseline to Week 12 in the total population and both subcohorts. No new safety concerns were raised. Esaxerenone significantly decreased morning home, bedtime home, and office BP; UACR; and NT-proBNP in this patient population, regardless of concomitant ARB or CCB use. The antihypertensive effect of esaxerenone was independent of the urinary sodium/potassium ratio and estimated 24-h urinary sodium excretion at baseline.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Toshiyuki Sugiura
- Medical Corporation Association Koukeikai Sugiura Clinic, Kawaguchi, Japan
| | | | | | | | - Tatsuo Shimosawa
- Department of Clinical Laboratory, School of Medicine, International University of Health and Welfare, Narita, Japan
| |
Collapse
|
6
|
Yamamoto E, Usuku H, Sueta D, Suzuki S, Nakamura T, Matsui K, Matsushita K, Iwasaki T, Sakaino N, Sakanashi T, Hirayama K, Kurokawa H, Kikuta K, Yamamoto N, Sato K, Tokitsu T, Taguchi T, Shiosakai K, Sugimoto K, Tsujita K. Efficacy and Safety of Esaxerenone in Hypertensive Patients with Left Ventricular Hypertrophy (ESES-LVH) Study: A Multicenter, Open-Label, Prospective, Interventional Study. Adv Ther 2024; 41:1284-1303. [PMID: 38310194 PMCID: PMC10879332 DOI: 10.1007/s12325-024-02780-6] [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: 09/12/2023] [Accepted: 01/03/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION In contrast to the antihypertensive effect of esaxerenone, there is little evidence of its cardioprotective effect. We investigated the efficacy and safety of esaxerenone in patients with uncontrolled hypertension and left ventricular hypertrophy taking a renin-angiotensin system inhibitor (RASi) or calcium-channel blocker (CCB). METHODS This was a multicenter, open-label, exploratory study with a 24-week treatment period. Esaxerenone was orally administered at an initial dose of 2.5 mg/day (maximum dose: 5 mg/day). The primary endpoints were the change in morning home systolic blood pressure (BP)/diastolic BP and change and percentage change in left ventricular mass index (LVMI) from baseline to end of treatment (EOT). Key secondary endpoints included change from baseline in bedtime home and office BP, achievement rate of target BP, and safety. RESULTS In total, 60 patients were enrolled. Morning home systolic/diastolic BP was significantly decreased from baseline to EOT in the total population (- 11.5/ - 4.7 mmHg, p < 0.001) and in both the RASi and CCB subcohorts (all p < 0.01). Significant reductions in bedtime home and office BP were shown in the total population and both subcohorts. LVMI was also significantly decreased from baseline to EOT in the total population (- 9.9 g/m2, - 8.5%, both p < 0.001) and both subcohorts (all p < 0.05). The incidences of treatment-emergent adverse events (TEAEs) and drug-related TEAEs were 35.0% and 3.3%, respectively; most were mild or moderate. No new safety concerns were identified. CONCLUSION Esaxerenone showed favorable antihypertensive and cardioprotective effects and safety in hypertensive patients with cardiac hypertrophy. TRIAL REGISTRATION Japan Registry of Clinical Trials (jRCTs071190043).
Collapse
Affiliation(s)
- Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
- Center for Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Hiroki Usuku
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
- Center for Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
- Department of Laboratory Medicine, Kumamoto University, Kumamoto, Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
- Center for Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | - Satoru Suzuki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
| | - Taishi Nakamura
- Department of Medical Information Science, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kunihiko Matsui
- Department of General Medicine and Primary Care, Kumamoto University Hospital, Kumamoto, Japan
| | - Kenichi Matsushita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan
- Center for Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan
| | | | | | | | | | - Hirofumi Kurokawa
- Division of Cardiology, Japan Community Health Care Organization, Hitoyoshi Medical Center, Hitoyoshi, Japan
| | - Koichi Kikuta
- Division of Cardiology, Shinbeppu Hospital, Beppu, Japan
| | - Nobuyasu Yamamoto
- Department of Cardiovascular Medicine, Miyazaki Prefectural Nobeoka Hospital, Nobeoka, Japan
| | - Koji Sato
- Department of Cardiology, Kumamoto City Hospital, Kumamoto, Japan
| | - Takanori Tokitsu
- Division of Cardiology, Kumamoto Kenhoku Hospital, Tamana, Japan
| | - Takashi Taguchi
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | | | - Kotaro Sugimoto
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-Ku, Kumamoto, 860-8556, Japan.
- Center for Metabolic Regulation of Healthy Aging, Kumamoto University Faculty of Life Sciences, Kumamoto, Japan.
| |
Collapse
|
7
|
Mullen N, Curneen J, Donlon PT, Prakash P, Bancos I, Gurnell M, Dennedy MC. Treating Primary Aldosteronism-Induced Hypertension: Novel Approaches and Future Outlooks. Endocr Rev 2024; 45:125-170. [PMID: 37556722 PMCID: PMC10765166 DOI: 10.1210/endrev/bnad026] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 07/11/2023] [Accepted: 07/26/2023] [Indexed: 08/11/2023]
Abstract
Primary aldosteronism (PA) is the most common cause of secondary hypertension and is associated with increased morbidity and mortality when compared with blood pressure-matched cases of primary hypertension. Current limitations in patient care stem from delayed recognition of the condition, limited access to key diagnostic procedures, and lack of a definitive therapy option for nonsurgical candidates. However, several recent advances have the potential to address these barriers to optimal care. From a diagnostic perspective, machine-learning algorithms have shown promise in the prediction of PA subtypes, while the development of noninvasive alternatives to adrenal vein sampling (including molecular positron emission tomography imaging) has made accurate localization of functioning adrenal nodules possible. In parallel, more selective approaches to targeting the causative aldosterone-producing adrenal adenoma/nodule (APA/APN) have emerged with the advent of partial adrenalectomy or precision ablation. Additionally, the development of novel pharmacological agents may help to mitigate off-target effects of aldosterone and improve clinical efficacy and outcomes. Here, we consider how each of these innovations might change our approach to the patient with PA, to allow more tailored investigation and treatment plans, with corresponding improvement in clinical outcomes and resource utilization, for this highly prevalent disorder.
Collapse
Affiliation(s)
- Nathan Mullen
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| | - James Curneen
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| | - Padraig T Donlon
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| | - Punit Prakash
- Department of Electrical and Computer Engineering, Kansas State University, Manhattan, KS 66506, USA
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Mark Gurnell
- Wellcome-MRC Institute of Metabolic Science, University of Cambridge and NIHR Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge CB2 0QQ, UK
| | - Michael C Dennedy
- The Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway H91V4AY, Ireland
| |
Collapse
|
8
|
Motoki H, Inobe Y, Fukui T, Iwasaki A, Hiramitsu S, Koyama S, Masuda I, Sekimura N, Yamamoto K, Sato A, Komatsu M, Taguchi T, Shiosakai K, Sugimoto K, Kuwahara K. Efficacy and Safety of Esaxerenone in Hypertensive Patients with Diabetes Mellitus Undergoing Treatment with Sodium-Glucose Cotransporter 2 Inhibitors (EAGLE-DH). Adv Ther 2023; 40:5055-5075. [PMID: 37733211 PMCID: PMC10567833 DOI: 10.1007/s12325-023-02633-8] [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: 12/19/2022] [Accepted: 08/01/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION The EAGLE-DH study assessed the efficacy and safety of esaxerenone in hypertensive patients with diabetes mellitus receiving sodium-glucose cotransporter 2 (SGLT2) inhibitors. METHODS In this multicenter, open-label, prospective, interventional study, esaxerenone was started at 1.25 or 2.5 mg/day and could be gradually increased to 5 mg/day on the basis of blood pressure (BP) and serum potassium levels. Oral hypoglycemic or antihypertensive medications prior to obtaining consent was continued. Data were evaluated in the total population and creatinine-based estimated glomerular filtration rate (eGFR) subcohorts (eGFR ≥ 60 mL/min/1.73 m2 [G1-G2 subcohort] and 30 to < 60 mL/min/1.73 m2 [G3 subcohort]). RESULTS In total, 93 patients were evaluated (G1-G2, n = 49; G3, n = 44). Morning home systolic/diastolic BP values (SBP/DBP) were significantly reduced from baseline to week 12 (- 11.8 ± 10.8/- 5.1 ± 6.3 mmHg, both P < 0.001) and week 24 (- 12.9 ± 10.5/- 5.7 ± 6.3 mmHg, both P < 0.001). Similar results were observed in both eGFR subcohorts. The urinary albumin-to-creatinine ratio significantly decreased from baseline to week 24 in the total population (geometric percentage change, - 49.1%, P < 0.001) and in both eGFR subcohorts. The incidences of treatment-emergent adverse events (TEAEs) and drug-related TEAEs were 45.2% and 12.9%, respectively; most were mild or moderate. Serum potassium levels increased over the first 2 weeks of esaxerenone treatment, gradually decreased by week 12, and remained constant to week 24. One patient in the G1-G2 subcohort had serum potassium levels ≥ 5.5 mEq/L. No patients had serum potassium ≥ 6.0 mEq/L. CONCLUSION Esaxerenone effectively lowered BP, was safe, and showed renoprotective effects in hypertensive patients with diabetes mellitus receiving treatment with SGLT2 inhibitors. Esaxerenone and SGLT2 inhibitors did not interfere with either drug's efficacy and may reduce the frequency of serum potassium elevations, suggesting they are a compatible combination. CLINICAL TRIAL REGISTRATION jRCTs031200273.
Collapse
Affiliation(s)
- Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yoshito Inobe
- Inobe Funai Clinic, 1-3-23 Funaicho, Oita, Oita, 870-0021, Japan
| | - Toshiki Fukui
- Olive Takamatsu Medical Clinic, 649-8 Kankocho, Takamatsu, Kagawa, 760-0076, Japan
| | - Arata Iwasaki
- Asamoto Internal Medicine Clinic, 1 Hottacho, Fukakusa, Fushimi-ku, Kyoto, 612-0026, Japan
| | - Shinya Hiramitsu
- Hiramitsu Heart Clinic, 2-35 Shiroshitacho, Minami-ku, Nagoya, Aichi, 457-0047, Japan
| | - Sekiya Koyama
- Koyama Medical Clinic, 2-3-29 Kitafukashi, Matsumoto, Nagano, 390-0872, Japan
| | - Izuru Masuda
- Koseikai Clinic, 277 Aburanokoji-dori, Shimouonotanasagaru Aburanokoji-cho, Shimogyo-ku, Kyoto, 600-8231, Japan
| | - Noriyuki Sekimura
- Department of Cardiovascular Medicine, National Hospital Organization Matsumoto Medical Center, 2-20-30 Muraimachiminami, Matsumoto, Nagano, 399-8701, Japan
| | - Kazuya Yamamoto
- Department of Cardiology, Iida Municipal Hospital, 438 Yawatamachi, Iida, Nagano, 395-8502, Japan
| | - Ai Sato
- Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine, Shinshu University Hospital, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Mitsuhisa Komatsu
- Division of Diabetes, Endocrinology and Metabolism, Department of Internal Medicine, Shinshu University Hospital, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Takashi Taguchi
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., 3-5-1 Nihonbashi Honcho, Chuo-Ku, Tokyo, 103-8426, Japan
| | - Kazuhito Shiosakai
- Data Intelligence Department, Daiichi Sankyo Co., Ltd., 1-2-58 Hiromachi, Shinagawa-Ku, Tokyo, 140-8710, Japan
| | - Kotaro Sugimoto
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., 3-5-1 Nihonbashi Honcho, Chuo-Ku, Tokyo, 103-8426, Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan.
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Tamura K, Kanaoka T, Fujiwara N, Hirota K. Esaxerenone for nocturnal hypertension and possible future direction for treatment of hypertension-cardiovascular-kidney comorbidity. Hypertens Res 2023; 46:2059-2061. [PMID: 37328695 DOI: 10.1038/s41440-023-01338-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 05/18/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
| | - Tomohiko Kanaoka
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Naoki Fujiwara
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Keigo Hirota
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| |
Collapse
|
11
|
Dogra P, Bancos I, Young WF. Primary Aldosteronism: A Pragmatic Approach to Diagnosis and Management. Mayo Clin Proc 2023; 98:1207-1215. [PMID: 37536806 DOI: 10.1016/j.mayocp.2023.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/17/2023] [Accepted: 04/20/2023] [Indexed: 08/05/2023]
Abstract
Primary aldosteronism is a prevalent but underdiagnosed cause of hypertension, contributing to increased cardiovascular and cerebrovascular events and end-organ damage independent of blood pressure. Prompt diagnosis and treatment with targeted surgical or medical therapy reduce the risk of complications and improve prognosis. This review outlines a practical approach to diagnosis and management of primary aldosteronism for global practitioners.
Collapse
Affiliation(s)
- Prerna Dogra
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN.
| |
Collapse
|
12
|
Kario K, Nishizawa M, Kato M, Ishii H, Uchiyama K, Nagai M, Takahashi N, Asakura T, Shiraiwa T, Yoshida T, Kaneshiro M, Taguchi T, Shiosakai K, Sugimoto K. Nighttime home blood pressure lowering effect of esaxerenone in patients with uncontrolled nocturnal hypertension: the EARLY-NH study. Hypertens Res 2023; 46:1782-1794. [PMID: 37173430 PMCID: PMC10319630 DOI: 10.1038/s41440-023-01292-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 05/15/2023]
Abstract
There is limited evidence on the blood pressure (BP)-lowering effect of esaxerenone on home BP, including nighttime BP. Using two newly developed nocturnal home BP monitoring devices (brachial and wrist), this multicenter, open-label, prospective study investigated the nighttime home BP-lowering effect of esaxerenone in patients with uncontrolled nocturnal hypertension being treated with an angiotensin receptor blocker (ARB) or calcium-channel blocker (CCB). In total, 101 patients were enrolled. During the 12-week study period, change in nighttime home systolic/diastolic BP from baseline to end of treatment measured by the brachial device was -12.9/-5.4 mmHg in the total population and -16.2/-6.6 and -10.0/-4.4 mmHg in the ARB and CCB subcohorts, respectively (all p < 0.001). For the wrist device, the change was -11.7/-5.4 mmHg in the total population and -14.6/-6.2 and -8.3/-4.5 mmHg in each subcohort, respectively (all p < 0.001). Similar significant reductions were shown for morning and bedtime home BP and office BP. Urinary albumin-to-creatinine ratio, N-terminal pro-brain natriuretic peptide, and cardio-ankle vascular index improved in the total population and each subcohort. Incidences of treatment-emergent adverse events (TEAEs) and drug-related TEAEs were 38.6% and 16.8%, respectively; most were mild or moderate. The most frequent drug-related TEAEs were associated with serum potassium elevation (hyperkalemia, 9.9%; blood potassium increased, 3.0%); however, no new safety concerns were raised. Esaxerenone was effective in lowering nighttime home BP as well as morning and bedtime home BP and office BP, safe, and showed organ-protective effects in patients with uncontrolled nocturnal hypertension. Caution is warranted regarding elevated serum potassium levels. This study investigated the effect of esaxerenone on nighttime home BP and organ damage (UACR and NT-proBNP) in patients with uncontrolled nocturnal hypertension despite treatment with an ARB or CCB. Our results show that safe 24-h BP control and organ protection are possible with esaxerenone.
Collapse
Affiliation(s)
- Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan.
| | | | | | | | | | - Michiaki Nagai
- Department of Cardiology, Hiroshima City Asa Hospital, Hiroshima, Japan
| | | | - Taro Asakura
- Tsuruma Kaneshiro Diabetes Clinic, Yamato, Japan
| | | | - Tetsuro Yoshida
- Department of Cardiovascular Medicine, Onga Nakama Medical Association Onga Hospital, Onga, Japan
| | | | - Takashi Taguchi
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | | | - Kotaro Sugimoto
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| |
Collapse
|
13
|
Fujii W, Shibata S. Mineralocorticoid Receptor Antagonists for Preventing Chronic Kidney Disease Progression: Current Evidence and Future Challenges. Int J Mol Sci 2023; 24:ijms24097719. [PMID: 37175424 PMCID: PMC10178637 DOI: 10.3390/ijms24097719] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/05/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
Regulation and action of the mineralocorticoid receptor (MR) have been the focus of intensive research over the past 80 years. Genetic and physiological/biochemical analysis revealed how MR and the steroid hormone aldosterone integrate the responses of distinct tubular cells in the face of environmental perturbations and how their dysregulation compromises fluid homeostasis. In addition to these roles, the accumulation of data also provided unequivocal evidence that MR is involved in the pathophysiology of kidney diseases. Experimental studies delineated the diverse pathological consequences of MR overactivity and uncovered the multiple mechanisms that result in enhanced MR signaling. In parallel, clinical studies consistently demonstrated that MR blockade reduces albuminuria in patients with chronic kidney disease. Moreover, recent large-scale clinical studies using finerenone have provided evidence that the non-steroidal MR antagonist can retard the kidney disease progression in diabetic patients. In this article, we review experimental data demonstrating the critical importance of MR in mediating renal injury as well as clinical studies providing evidence on the renoprotective effects of MR blockade. We also discuss areas of future investigation, which include the benefit of non-steroidal MR antagonists in non-diabetic kidney disease patients, the identification of surrogate markers for MR signaling in the kidney, and the search for key downstream mediators whereby MR blockade confers renoprotection. Insights into these questions would help maximize the benefit of MR blockade in subjects with kidney diseases.
Collapse
Affiliation(s)
- Wataru Fujii
- Division of Nephrology, Department of Internal Medicine, Graduate School of Medicine, Teikyo University, Tokyo 173-8605, Japan
| | - Shigeru Shibata
- Division of Nephrology, Department of Internal Medicine, Graduate School of Medicine, Teikyo University, Tokyo 173-8605, Japan
| |
Collapse
|
14
|
Lerma E, White WB, Bakris G. Effectiveness of nonsteroidal mineralocorticoid receptor antagonists in patients with diabetic kidney disease. Postgrad Med 2023; 135:224-233. [PMID: 35392754 DOI: 10.1080/00325481.2022.2060598] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Nonsteroidal mineralocorticoid receptor antagonists (MRAs) are a new class of drugs developed to address the medical need for effective and safer treatment to protect the kidney and the heart in patients with diabetic kidney disease (DKD). There are several drugs within this class at varying stages of clinical development. Finerenone is the first nonsteroidal MRA approved in the US for treating patients with chronic kidney disease (CKD) associated with type 2 diabetes (T2D). In clinical studies, finerenone slowed CKD progression without inducing marked antihypertensive effects. Esaxerenone is a nonsteroidal MRA with proven blood pressure-lowering efficacy that is currently licensed in Japan for treating hypertension. There are also three other nonsteroidal MRAs in mid-to-late stages of clinical development. Here we overview evidence addressing pharmacological and clinical differences between the nonsteroidal MRAs and the steroidal MRAs spironolactone and eplerenone. First, we describe a framework that highlights the role of aldosterone-mediated pathological overactivation of the mineralocorticoid receptor and inflammation as important drivers of CKD progression. Second, we discuss the benefits and adverse events profile of steroidal MRAs, the latter of which are often a limiting factor to their use in routine clinical practice. Finally, we show that nonsteroidal MRAs differ from steroidal MRAs based on pharmacology and clinical effects, giving the potential to expand the therapeutic options for patients with DKD. In the recently completed DKD outcome program comprising two randomized clinical trials - FIDELIO-DKD and FIGARO-DKD - and the FIDELITY analysis of both trials evaluating more than 13,000 patients, the nonsteroidal MRA finerenone demonstrated beneficial effects on the kidney and the heart across a broad spectrum of patients with CKD and T2D. The long-term efficacy of finerenone on cardiac and renal morbidity and mortality endpoints, along with the anti-hypertensive efficacy of esaxerenone, widens the scope of available therapies for patients with DKD.
Collapse
Affiliation(s)
- Edgar Lerma
- Section of Nephrology, University of Illinois at Chicago/Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - William B White
- Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, USA
| | - George Bakris
- American Heart Association Comprehensive Hypertension Center, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| |
Collapse
|
15
|
Factors Associated with the Antihypertensive Effect of Esaxerenone and Serum Potassium Elevation: A Pooled Analysis of Seven Phase III Studies. Adv Ther 2023; 40:1242-1266. [PMID: 36662393 PMCID: PMC9988784 DOI: 10.1007/s12325-022-02393-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 11/29/2022] [Indexed: 01/21/2023]
Abstract
INTRODUCTION This study investigated factors associated with the antihypertensive effects of esaxerenone and the incidence of serum potassium elevation in patients with hypertension. METHODS Using pooled data from seven phase III studies, the study analyzed factors associated with changes in office systolic (SBP) and diastolic (DBP) blood pressure from baseline to 12 weeks, and factors associated with incidence of serum potassium levels ≥ 5.5 mEq/L in esaxerenone-treated patients. RESULTS Overall, 1466 and 1472 patients were included in the full analysis and safety analysis sets, respectively. Male sex (4.02/2.40 mmHg), weight ≥ 78.4 kg (4.62/2.09 mmHg), hypertension duration ≥ 10 years (2.66/1.71 mmHg), prior antihypertensive treatment (2.38/1.40 mmHg), plasma aldosterone concentration ≥ 120 pg/mL (1.66/1.17 mmHg), urinary albumin-to-creatinine ratio (UACR) ≥ 300 mg/gCr (8.94/4.85 mmHg) or 30-299 mg/gCr (5.17/4.15 mmHg), and smoking (2.62/1.27 mmHg) were associated with mean changes in SBP and DBP. Fasting blood glucose ≥ 126 mg/dL (- 2.73 mmHg) was associated with the mean change in SBP only, and older age (65-74 years, - 2.12 mmHg; and ≥ 75 years, - 3.06 mmHg) with mean change in DBP only. Factors significantly associated with incidence of serum potassium levels ≥ 5.5 mEq/L were higher baseline serum potassium (≥ 4.5 mEq/L, odds ratio [OR] 6.702); lower estimated glomerular filtration rate (≥ 90 mL/min/1.73 m2, OR 0.148; 60-89 mL/min/1.73 m2, OR 0.331 vs 30-59 mL/min/1.73 m2, respectively); higher UACR (30-299 mg/gCr, OR 7.317); higher DBP (≥ 100 mmHg, OR 3.248); and grade I hypertension (OR 2.168). CONCLUSION Esaxerenone is effective in patients with a broad range of backgrounds, though some factors may predict increased benefit. Regarding elevated serum potassium, careful therapeutic management is recommended for patients with higher baseline serum potassium and reduced renal function. CLINICAL TRIAL REGISTRATION UMIN000047026.
Collapse
|
16
|
Hoshide S. Is esaxerenone the ultimate mineralocorticoid receptor antagonist? Hypertens Res 2023; 46:516-517. [PMID: 36289363 DOI: 10.1038/s41440-022-01056-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/01/2022] [Accepted: 09/06/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Satoshi Hoshide
- Division of Cardiovascular Medicine, Jichi Medical University School of Medicine, Shimotsuke, Japan.
| |
Collapse
|
17
|
Liu W, Yu S. Nonsteroidal Mineralocorticoid Receptor Antagonist Eliciting Cardiorenal Protection Is a New Option for Patients with Chronic Kidney Disease. KIDNEY DISEASES (BASEL, SWITZERLAND) 2022; 9:12-25. [PMID: 36756081 PMCID: PMC9900468 DOI: 10.1159/000528066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 10/14/2022] [Indexed: 11/16/2022]
Abstract
Background Mineralocorticoid receptor antagonists (MRAs) protect cardiorenal function by robust anti-inflammatory and antifibrotic functions beyond classical functions of maintaining fluid and electrolyte homeostasis. The application of traditional steroidal MRAs to chronic kidney disease (CKD) has been limited by adverse events, especially when combined with renin-angiotensin system inhibitors, guideline-recommend drugs for CKD patients. Recently, the development of nonsteroidal MRAs gives patients with CKD a promising option. Summary The discovery of nonsteroidal MRAs is based on the molecular structure of the mineralocorticoid receptor (MR) and differs in structure from spironolactone, a progesterone derivative. The structure of nonsteroidal MRAs determines their more effective and selective inhibition of MR providing patients more benefits with fewer adverse effects than MRAs. Recently, two types of nonsteroidal MRAs, finerenone and esaxerenone, have been authorized for clinical use. We elaborate on the physiological and pathophysiological mechanisms of MR, review the history of MRAs, compare two generations of MRAs, and introduce the forward clinical trials of finerenone and esaxerenone. Key Messages Finerenone reduces the cardiovascular and kidney composite outcomes in diabetic patients with CKD eliciting a cardiorenal protection effect. Esaxerenone can effectively reduce blood pressure in hypertensive patients and albuminuria in diabetic patients with CKD. The risk of hyperkalemia is controllable and acceptable through the serum potassium-based dose titrate. Combination therapy with sodium-glucose cotransport-2 inhibition or a new potassium binder may be a safer and more efficient approach.
Collapse
Affiliation(s)
- Wenyu Liu
- Department of Nephrology, Second Affiliated Hospital of Naval Medical University, Shanghai, China,Department of Nephrology, Beidaihe Rehabilitation and Recuperation Center of PLA, Qinhuangdao, China
| | - Shengqiang Yu
- Department of Nephrology, Second Affiliated Hospital of Naval Medical University, Shanghai, China,*Shengqiang Yu,
| |
Collapse
|
18
|
Hattori M, Rahman A, Kidoguchi S, Jahan N, Fujisawa Y, Morisawa N, Ohsaki H, Kobara H, Masaki T, Hossain A, Steeve A, Nishiyama A. Association of Antihypertensive Effects of Esaxerenone with the Internal Sodium Balance in Dahl Salt-Sensitive Hypertensive Rats. Int J Mol Sci 2022; 23:ijms23168915. [PMID: 36012182 PMCID: PMC9408866 DOI: 10.3390/ijms23168915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/05/2022] [Accepted: 08/08/2022] [Indexed: 11/18/2022] Open
Abstract
Background: The nonsteroidal mineralocorticoid receptor blocker esaxerenone is effective in reducing blood pressure (BP). Objective: In this study, we investigated esaxerenone-driven sodium homeostasis and its association with changes in BP in Dahl salt-sensitive (DSS) hypertensive rats. Methods: In the different experimental setups, we evaluated BP by a radiotelemetry system, and sodium homeostasis was determined by an approach of sodium intake (food intake) and excretion (urinary excretion) in DSS rats with a low-salt diet (0.3% NaCl), high-salt diet (HSD, 8% NaCl), HSD plus 0.001% esaxerenone (w/w), and HSD plus 0.05% furosemide. Results: HSD-fed DSS rats showed a dramatic increase in BP with a non-dipper pattern, while esaxerenone treatment, but not furosemide, significantly reduced BP with a dipper pattern. The cumulative sodium excretion in the active period was significantly elevated in esaxerenone- and furosemide-treated rats compared with their HSD-fed counterparts. Sodium content in the skin, skinned carcass, and total body tended to be lower in esaxerenone-treated rats than in their HSD-fed counterparts, while these values were unchanged in furosemide-treated rats. Consistently, sodium balance tended to be reduced in esaxerenone-treated rats during the active period. Histological evaluation showed that esaxerenone, but not furosemide, treatment attenuated glomerulosclerosis, tubulointerstitial fibrosis, and urinary protein excretion induced by high salt loading. Conclusions: Collectively, these findings suggest that an esaxerenone treatment-induced reduction in BP and renoprotection are associated with body sodium homeostasis in salt-loaded DSS rats.
Collapse
Affiliation(s)
- Mai Hattori
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Asadur Rahman
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
- Correspondence: (A.R.); (A.N.); Tel.: +81-87-891-2125 (A.R. & A.N.); Fax: +81-87-891-2126 (A.R. & A.N.)
| | - Satoshi Kidoguchi
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Nourin Jahan
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Yoshihide Fujisawa
- Life Science Research Center, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Norihiko Morisawa
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Hiroyuki Ohsaki
- Department of Medical Biophysics, Kobe University Graduate School of Health Sciences, 7-10-2, Tomogaoka, Suma-ku, Kobe 654-0142, Hyogo, Japan
| | - Hideki Kobara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Akram Hossain
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Akumwami Steeve
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
- Department of Anesthesiology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
| | - Akira Nishiyama
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan
- Correspondence: (A.R.); (A.N.); Tel.: +81-87-891-2125 (A.R. & A.N.); Fax: +81-87-891-2126 (A.R. & A.N.)
| |
Collapse
|
19
|
Höcht C, Allo MA, Polizio AH, Morettón MA, Carranza A, Chiappetta DA, Choi MR. New and developing pharmacotherapies for hypertension. Expert Rev Cardiovasc Ther 2022; 20:647-666. [PMID: 35880547 DOI: 10.1080/14779072.2022.2105204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Despite the significant contribution of hypertension to the global burden of disease, disease control remains poor worldwide. Considering this unmet clinical need, several new antihypertensive drugs with novel mechanisms of action are under development. AREAS COVERED The present review summarizes the recent advances in the development of emerging pharmacological agents for the management of hypertension. The latest technological innovations in the design of optimized formulations of available antihypertensive drugs and the potential role of the modification of intestinal microbiota to improve blood pressure (BP) control are also covered. EXPERT OPINION Significant efforts have been made to develop new antihypertensive agents with novel actions that target the main mechanisms involved in resistant hypertension. Sacubitril/valsartan may emerge as a potential first-line drug due to its superiority over renin angiotensin system inhibitors, and SGLT2 inhibitors can reduce BP in difficult-to-control hypertensive patients with type 2 diabetes. In addition, firibastat and aprocitentan may expand the therapeutic options for resistant hypertension by novel mechanism of actions. Since gut dysbiosis not only leads to hypertension but also causes direct target organ damage, prebiotics and probiotics could represent a potential strategy to prevent or reduce the development of hypertension and to contribute to BP control.
Collapse
Affiliation(s)
- Christian Höcht
- Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Farmacología, Buenos Aires, Argentinaa.,Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Instituto de Tecnología Farmacéutica y Biofarmacia (InTecFyB), Buenos Aires, Argentinab
| | - Miguel A Allo
- Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Farmacología, Buenos Aires, Argentinaa.,Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Instituto de Tecnología Farmacéutica y Biofarmacia (InTecFyB), Buenos Aires, Argentinab
| | - Ariel Héctor Polizio
- Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Farmacología, Buenos Aires, Argentinaa.,Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Instituto de Tecnología Farmacéutica y Biofarmacia (InTecFyB), Buenos Aires, Argentinab
| | - Marcela A Morettón
- Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Instituto de Tecnología Farmacéutica y Biofarmacia (InTecFyB), Buenos Aires, Argentinab.,Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Tecnología Farmacéutica, Buenos Aires, Argentinac.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Argentina
| | - Andrea Carranza
- Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Farmacología, Buenos Aires, Argentinaa.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET) - Universidad de Buenos Aires, Instituto Alberto C. Taquini de Investigaciones en Medicina Traslacional (IATIMET), Buenos Aires, Argentinae
| | - Diego A Chiappetta
- Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Instituto de Tecnología Farmacéutica y Biofarmacia (InTecFyB), Buenos Aires, Argentinab.,Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Tecnología Farmacéutica, Buenos Aires, Argentinac.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Argentina
| | - Marcelo Roberto Choi
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET) - Universidad de Buenos Aires, Instituto Alberto C. Taquini de Investigaciones en Medicina Traslacional (IATIMET), Buenos Aires, Argentinae.,Universidad de Buenos Aires, Facultad de Farmacia y Bioquímica, Departamento de Ciencias Biológicas, Buenos Aires, Argentina f
| |
Collapse
|
20
|
Tezuka Y, Ito S. The Time to Reconsider Mineralocorticoid Receptor Blocking Strategy: Arrival of Nonsteroidal Mineralocorticoid Receptor Blockers. Curr Hypertens Rep 2022; 24:215-224. [PMID: 35488944 PMCID: PMC9300503 DOI: 10.1007/s11906-022-01177-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2022] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW The study aims to verify the advantages of nonsteroidal mineralocorticoid receptor blockers (MRBs) in the management of hypertension and cardiovascular and renal diseases, comparing with conventional MRBs. RECENT FINDINGS Based on the unique structures, the nonsteroidal MRBs have higher selectivity for mineralocorticoid receptors (MRs) and show no agonist activity for major steroid hormone receptors in contrast to steroidal MRBs. Today, there are two nonsteroidal MRBs, esaxerenone and finerenone, which completed phase 3 clinical trials. Series of clinical trials have shown that both agents achieve similar MR blockade with smaller doses as compared with steroidal MRBs, but have no off-target side effect such as gynecomastia. Esaxerenone has persistent blood pressure-lowering effects in various hypertensive populations, including essential hypertension and those with diabetes and/or chronic kidney disease, while finerenone has demonstrated reduction of the cardiovascular risk rather than blood pressure in patients with diabetes and chronic kidney disease. Nonsteroidal MRBs are a more refined agent which contributes to appropriate MR blocking with minimized unpleasant adverse effects.
Collapse
Affiliation(s)
- Yuta Tezuka
- Division of Nephrology, Endocrinology and Vascular Medicine, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-cho, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology and Vascular Medicine, Graduate School of Medicine, Tohoku University, 1-1 Seiryo-cho, Aoba-ku, Sendai, Miyagi, 980-8574, Japan. .,Katta General Hospital, Shiroishi, Miyagi, Japan.
| |
Collapse
|
21
|
Latest hypertension research to inform clinical practice in Asia. Hypertens Res 2022; 45:555-572. [DOI: 10.1038/s41440-022-00874-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 12/16/2022]
|
22
|
Kurata A, Eto T, Tsutsumi J, Igawa Y, Nishikawa Y, Ishizuka H. Bioequivalence of Esaxerenone Conventional Tablet and Orally Disintegrating Tablet: Two Single-Dose Crossover Studies in Healthy Japanese Men. Clin Pharmacol Drug Dev 2022; 11:957-965. [PMID: 35315257 PMCID: PMC9545664 DOI: 10.1002/cpdd.1087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/07/2022] [Indexed: 11/08/2022]
Abstract
We assessed the bioequivalence of a single dose of 5-mg of esaxerenone administered as an orally disintegrating tablet (ODT) with the conventional oral tablet in healthy Japanese men. This single-center, open-label, randomized, two-drug, two-stage crossover, single-dose study was conducted in two parts. In study 1, both formulations were taken with water. In study 2, only the ODT formulation was taken without water. The primary outcome was the evaluation of bioequivalence of the ODT and conventional tablet using the pharmacokinetic (PK) parameters maximum plasma concentration (Cmax ) and area under the plasma concentration-time curve to the last quantifiable time (AUClast ). Plasma concentrations were measured using a validated liquid chromatography/mass spectrometry method and PK parameters were calculated by noncompartmental analysis. The ratios of the geometric least-squares mean (2-sided 90% confidence intervals [90%CIs]) for ODT with (study 1) and without (study 2) water to the conventional tablet were 1.03 (1.00-1.07) and 1.01 (0.96-1.06) for Cmax and 1.03 (1.00-1.07) and 0.96 (0.94-0.98) for AUClast , respectively. The 90%CIs fell within the predefined bioequivalence range of 0.80-1.25. Treatment-emergent adverse events were similar between both formulations. In conclusion, esaxerenone 5-mg ODT taken with or without water was bioequivalent to a single 5-mg conventional oral tablet.
Collapse
Affiliation(s)
- Akifumi Kurata
- Quantitative Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | | | - Junko Tsutsumi
- Data Intelligence Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Yoshiyuki Igawa
- Quantitative Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Yasuhiro Nishikawa
- Development Strategy & Planning Group, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Hitoshi Ishizuka
- Quantitative Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| |
Collapse
|
23
|
Clinical Pharmacokinetics and Pharmacodynamics of Esaxerenone, a Novel Mineralocorticoid Receptor Antagonist: A Review. Eur J Drug Metab Pharmacokinet 2022; 47:291-308. [PMID: 35190999 DOI: 10.1007/s13318-022-00760-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 12/11/2022]
Abstract
Esaxerenone is a selective, nonsteroidal, high-affinity mineralocorticoid receptor antagonist recently approved in Japan for the treatment of hypertension. It has high oral biovailability, a large volume of distribution, and is primarly metabolized in liver and excreted in bile. Esaxerenone is an efficient antihypertensive, whether given alone or as add-on therapy. The antihypertensive effect is accompanied by renoprotective action, which is being further investigated in current clinical trials. Due to its relatively long half-life and high affinity for the mineralocorticoid receptor, esaxerenone is administered once daily and in low absolute doses. The safety of esaxerenone is considerable, since hyperkalemia is not frequent and, when it does appear, not sustained. Endocrine adverse events, which frequently occur with steroidal mineralocorticoid receptor antagonists, are extremely rare with esaxerenone. Although the risk of clinically significant drug-drug interactions is not high, esaxerenone treatment should start with low doses, with subsequent titration to achieve the optimal clinical effect, all while monitoring serum potassium and paying attention to concomitant therapy with drugs that may induce or inhibit esaxerenone metabolism. This review article offers comprehensive information about the pharmacodynamics and pharmacokinetics of esaxerenone in humans, which should help clinicians to more precisely tailor esaxerenone dosing regimens to their patients.
Collapse
|
24
|
Barrera-Chimal J, Bonnard B, Jaisser F. Roles of Mineralocorticoid Receptors in Cardiovascular and Cardiorenal Diseases. Annu Rev Physiol 2022; 84:585-610. [PMID: 35143332 DOI: 10.1146/annurev-physiol-060821-013950] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Mineralocorticoid receptor (MR) activation in the heart and vessels leads to pathological effects, such as excessive extracellular matrix accumulation, oxidative stress, and sustained inflammation. In these organs, the MR is expressed in cardiomyocytes, fibroblasts, endothelial cells, smooth muscle cells, and inflammatory cells. We review the accumulating experimental and clinical evidence that pharmacological MR antagonism has a positive impact on a battery of cardiac and vascular pathological states, including heart failure, myocardial infarction, arrhythmic diseases, atherosclerosis, vascular stiffness, and cardiac and vascular injury linked to metabolic comorbidities and chronic kidney disease. Moreover, we present perspectives on optimization of the use of MR antagonists in patients more likely to respond to such therapy and review the evidence suggesting that novel nonsteroidal MR antagonists offer an improved safety profile while retaining their cardiovascular protective effects. Finally, we highlight future therapeutic applications of MR antagonists in cardiovascular injury.
Collapse
Affiliation(s)
- Jonatan Barrera-Chimal
- Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Mexico City, Mexico.,Laboratorio de Fisiología Cardiovascular y Trasplante Renal, Unidad de Investigación UNAM-INC, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Benjamin Bonnard
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France;
| | - Frederic Jaisser
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France; .,INSERM Centre d'Investigations Cliniques-Plurithématique 1433, UMR 1116, CHRU de Nancy, French-Clinical Research Infrastructure Network (F-CRIN INI-CRCT), Université de Lorraine, Nancy, France
| |
Collapse
|
25
|
Antihypertensive Effect of Long-Term Monotherapy with Esaxerenone in Patients with Essential Hypertension: Relationship Between Baseline Urinary Sodium Excretion and Its Antihypertensive Effect. Adv Ther 2022; 39:4779-4791. [PMID: 35976603 PMCID: PMC9464726 DOI: 10.1007/s12325-022-02282-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/22/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION The blood pressure (BP) control mechanism for mineralocorticoid receptor blockers is unclear, and analysis of their use as a single agent in the clinical setting is required to resolve this uncertainty. There is a paucity of data on esaxerenone monotherapy assessing its long-term antihypertensive effect and urinary biomarkers. METHODS This post hoc exploratory substudy of a long-term phase 3 study evaluated the effect of esaxerenone monotherapy (2.5 or 5 mg/day) in treatment-naïve patients who continued the therapy during the 52-week study period (n = 25). In addition to blood biomarkers, urinary biomarkers were also assessed in 24-h urine collection samples. RESULTS Esaxerenone monotherapy was associated with consistent reductions in systolic/diastolic BP in the substudy population (- 23.5/- 13.1 mmHg at week 52, p < 0.001 vs baseline). Plasma aldosterone concentrations and plasma renin activity significantly increased during esaxerenone monotherapy at all time points. On the basis of the observations that both urine volume and urinary sodium excretion also decreased up to the end of the study, and were significantly lower at 12 weeks, patients were further categorized into higher/lower urinary sodium excretion subgroups according to whether their baseline values were above or below the median. In the group with higher baseline urinary sodium excretion, esaxerenone exhibited a significantly greater decrease in systolic/diastolic BP compared to the lower baseline group. CONCLUSION Esaxerenone exhibited sustained and stable antihypertensive activity even when administered as a single agent for 52 weeks in patients with essential hypertension. The additional urinary biomarker analysis suggests that the BP-lowering effects of esaxerenone may be partly exerted via mechanisms related to salt and water retention, and that the effect is particularly pronounced in patients with hypertension and higher baseline urinary sodium excretion, which may reflect a state of excessive salt intake. TRIAL REGISTRATION NCT02722265.
Collapse
|
26
|
Current and Emerging Classes of Pharmacological Agents for the Management of Hypertension. Am J Cardiovasc Drugs 2022; 22:271-285. [PMID: 34878631 PMCID: PMC8651502 DOI: 10.1007/s40256-021-00510-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease accounts for more than 17 million deaths globally every year, of which complications of hypertension account for 9.4 million deaths worldwide. Early detection and management of hypertension can prevent costly interventions, including dialysis and cardiac surgery. Non-pharmacological approaches for managing hypertension commonly involve lifestyle modification, including exercise and dietary regulations such as reducing salt and fluid intake; however, a majority of patients will eventually require antihypertensive medications. In 2020, the International Society of Hypertension published worldwide guidelines in its efforts to reduce the global prevalence of raised blood pressure (BP) in adults aged 18 years or over. Currently, several classes of medications are used to control hypertension, either as mono- or combination therapy depending on the disease severity. These drug classes include those that target the renin-angiotensin-aldosterone system (RAAS) and adrenergic receptors, calcium channel blockers, diuretics and vasodilators. While some of these classes of medications have shown significant benefits in controlling BP and reducing cardiovascular mortality, the prevalence of hypertension remains high. Significant efforts have been made in developing new classes of drugs that lower BP; these medications exert their therapeutic benefits through different pathways and mechanism of actions. With several of these emerging classes in phase III clinical trials, it is hoped that the discovery of these novel therapeutic avenues will aid in reducing the global burden of hypertension.
Collapse
|
27
|
Kario K, Ito S, Itoh H, Rakugi H, Okuda Y, Yamakawa S. Effect of esaxerenone on nocturnal blood pressure and natriuretic peptide in different dipping phenotypes. Hypertens Res 2022; 45:97-105. [PMID: 34650195 PMCID: PMC8668432 DOI: 10.1038/s41440-021-00756-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/08/2021] [Accepted: 09/08/2021] [Indexed: 02/08/2023]
Abstract
There are limited data on the nighttime blood pressure (BP)-lowering effect of esaxerenone and its effect on N-terminal pro b-type natriuretic peptide (NT-proBNP), a predictor of cardiovascular risk, according to different dipping patterns of nocturnal BP. This was a post hoc analysis of a multicenter, open-label, long-term phase 3 study of esaxerenone, a new highly selective mineralocorticoid receptor blocker, in patients with essential hypertension. Patients were classified by dipping pattern (extreme dippers, dippers, non-dippers, risers). Mean changes in BP, changes in dipping pattern, mean NT-proBNP levels, and percentage of patients with normal NT-proBNP levels (<55 pg/mL) at baseline and Weeks 12 and 28 were evaluated. Nighttime systolic BP decreased in all dipping pattern groups at Week 28, with the riser group showing the greatest change (-25.5 mmHg). A significant shift in dipping pattern and riser/non-dipper pattern changes to dipper/extreme dipper pattern were found from baseline to Week 28 (p < 0.0001). The prevalence of the riser pattern decreased from 14.4% to 9.8%, and that of the non-dipper pattern from 44.7% to 39.2%. The decrease in NT-proBNP from baseline to Week 28 was statistically significant in risers, non-dippers, dippers, and extreme dippers (p < 0.001, respectively). At baseline, the proportion of patients with NT-proBNP <55 pg/mL was lowest in risers versus the other dipping pattern types, but after reductions in NT-proBNP in all groups to Week 28, these differences disappeared. Long-term administration of esaxerenone may be a useful treatment option for nocturnal hypertension, especially in patients with a riser pattern.
Collapse
Affiliation(s)
- Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan.
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine, Tohoku University School of Medicine, Sendai, Japan
- Katta General Hospital, Shiroishi, Japan
| | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and Nephrology, Keio University School of Medicine, Tokyo, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | | | | |
Collapse
|
28
|
Barrera-Chimal J, Lima-Posada I, Bakris GL, Jaisser F. Mineralocorticoid receptor antagonists in diabetic kidney disease - mechanistic and therapeutic effects. Nat Rev Nephrol 2022; 18:56-70. [PMID: 34675379 DOI: 10.1038/s41581-021-00490-8] [Citation(s) in RCA: 84] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 01/19/2023]
Abstract
Chronic kidney disease (CKD) is the leading complication in type 2 diabetes (T2D) and current therapies that limit CKD progression and the development of cardiovascular disease (CVD) include angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and sodium-glucose co-transporter 2 (SGLT2) inhibitors. Despite the introduction of these therapeutics, an important residual risk of CKD progression and cardiovascular death remains in patients with T2D. Mineralocorticoid receptor antagonists (MRAs) are a promising therapeutic option in diabetic kidney disease (DKD) owing to the reported effects of mineralocorticoid receptor activation in inflammatory cells, podocytes, fibroblasts, mesangial cells and vascular cells. In preclinical studies, MRAs consistently reduce albuminuria, CKD progression, and activation of fibrotic and inflammatory pathways. DKD clinical studies have similarly demonstrated that steroidal MRAs lead to albuminuria reduction compared with placebo, although hyperkalaemia is a major secondary effect. Non-steroidal MRAs carry a lower risk of hyperkalaemia than steroidal MRAs, and the large FIDELIO-DKD clinical trial showed that the non-steroidal MRA finerenone also slowed CKD progression and reduced the risk of adverse cardiovascular outcomes compared with placebo in patients with T2D. Encouragingly, other non-steroidal MRAs have anti-albuminuric properties in DKD. Whether or not combining MRAs with other renoprotective drugs such as SGLT2 inhibitors might provide additive protective effects warrants further investigation.
Collapse
Affiliation(s)
- Jonatan Barrera-Chimal
- Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México, Ciudad Universitaria, Mexico City, Mexico.,Laboratorio de Fisiología Cardiovascular y Trasplante Renal, Unidad de Investigación UNAM-INC, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Ixchel Lima-Posada
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France
| | - George L Bakris
- American Heart Association Comprehensive Hypertension Centre, Department of Medicine, University of Chicago Medicine, Chicago, IL, USA
| | - Frederic Jaisser
- INSERM, UMRS 1138, Centre de Recherche des Cordeliers, Sorbonne Université, Université de Paris, Paris, France. .,Université de Lorraine, INSERM Centre d'Investigations Cliniques-Plurithématique 1433, UMR 1116, CHRU de Nancy, French-Clinical Research Infrastructure Network (F-CRIN) INI-CRCT, Nancy, France.
| |
Collapse
|
29
|
Uchida HA, Nakajima H, Hashimoto M, Nakamura A, Nunoue T, Murakami K, Hosoya T, Komoto K, Taguchi T, Akasaka T, Shiosakai K, Sugimoto K, Wada J. Efficacy and Safety of Esaxerenone in Hypertensive Patients with Diabetic Kidney Disease: A Multicenter, Open-Label, Prospective Study. Adv Ther 2022; 39:5158-5175. [PMID: 36070133 PMCID: PMC9449923 DOI: 10.1007/s12325-022-02294-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/03/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Clinical data of esaxerenone in hypertensive patients with diabetic kidney disease (DKD) are lacking. We evaluated the efficacy and safety of esaxerenone in patients with DKD and an inadequate response to blood pressure (BP)-lowering treatment. METHODS In this multicenter, open-label, prospective study, patients were divided into urinary albumin-to-creatinine ratio subcohorts (UACR < 30, 30 to < 300, and 300 to < 1000 mg/gCr). Esaxerenone was initiated at 1.25 mg/day and followed by incremental dose escalation based on BP and serum potassium level monitoring. The treatment period was 12 weeks. The primary endpoint was change in morning home systolic BP/diastolic BP (SBP/DBP) from baseline to end of treatment (EOT). Secondary endpoints included achievement rate of target BP, change in UACR from baseline, and safety. RESULTS In total, 113 patients were enrolled. Morning home SBP/DBP significantly decreased from baseline to EOT in the total population (- 11.6/- 5.2 mmHg, both p < 0.001) and in all UACR subcohorts (all p < 0.001). The target BP achievement rate was 38.5%. Significant reductions in bedtime home and office BPs were also shown in the total population and all UACR subcohorts. UACR significantly improved from baseline to EOT in the total (- 50.9%, p < 0.001) and all UACR subcohorts (all p < 0.001). Incidence of serum potassium elevation as drug-related treatment emergent adverse events was 2.7%. The change from baseline in estimated glomerular filtration rate (eGFR) was - 4.8 mL/min/1.73 m2. CONCLUSION Esaxerenone demonstrated a BP-lowering effect and improved albuminuria. The effects were consistent regardless of the severity of albuminuria without clinically relevant serum potassium elevation and eGFR reduction. CLINICAL TRIAL REGISTRATION jRCTs06119002.
Collapse
Affiliation(s)
- Haruhito A. Uchida
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558 Japan ,Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | | | | | | | | | | | | | - Takashi Taguchi
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Takaaki Akasaka
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | | | - Kotaro Sugimoto
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, 700-8558 Japan
| | | |
Collapse
|
30
|
Iwahana T, Saito Y, Okada S, Kato H, Ono R, Kobayashi Y. Safety and efficacy of esaxerenone in Japanese hypertensive patients with heart failure with reduced ejection fraction: A retrospective study. PLoS One 2021; 16:e0259485. [PMID: 34748605 PMCID: PMC8575262 DOI: 10.1371/journal.pone.0259485] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/21/2021] [Indexed: 11/20/2022] Open
Abstract
Esaxerenone, a mineralocorticoid receptor blocker (MRB), is a new antihypertensive agent. However, esaxerenone-related data with respect to hypertension with heart failure are limited. We investigated the safety and efficacy of esaxerenone in hypertensive patients with heart failure with reduced ejection fraction (HFrEF). Hypertensive patients with HFrEF treated with esaxerenone were retrospectively analyzed at two timepoints (short-term: 35±15 days; mid-term: 167±45 days). Adverse events including hyperkalemia (K+ >5.5 mEq/L), worsening renal function (WRF; estimated glomerular filtration rate (eGFR) reduction by ≥20%), and hypotension (systolic blood pressure <90 mmHg) were evaluated. eGFR and K+, serum creatinine, and brain natriuretic peptide (BNP) levels at baseline, short-term, and mid-term assessments were compared. Patients administered esaxerenone as their first MRB (first-MRB cohort) and those who converted from another MRB (conversion cohort) were separately analyzed. There were 50 (56±10 years old, 26% female) patients. At the short-term assessment, hyperkalemia or hypotension was not observed at a dose of 2.0±0.9 mg/day. Seven patients (14%) showed WRF. K+ was slightly elevated (4.12±0.41 to 4.25±0.39 mmol/L, p = 0.07) and eGFR was significantly reduced (66.9±19.6 mL/min/1.73 m2 to 62.4±19.7 mL/min/1.73 m2, p = 0.006). In the conversion cohort, significant changes in K+ and eGFR from baseline were not observed at the short-term assessment. BNP levels were consistently improved regardless of the cohorts (first-MRB cohort, 310 [110–370] pg/mL to 137 [47–152] pg/mL, p = 0.001; conversion cohort, 181 [30–203] pg/mL to 108 [26–146] pg/mL, p = 0.028). At the mid-term assessment, there were no significant changes in K+ and eGFR compared with the short-term assessment. In conclusion, esaxerenone was safe for hypertensive patients with HFrEF. Hyperkalemia and hypotension were rarely noted, while eGFR was marginally reduced. Moreover, esaxerenone might be beneficial for HFrEF in terms of BNP level reduction.
Collapse
Affiliation(s)
- Togo Iwahana
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
- * E-mail:
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sho Okada
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hirotoshi Kato
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Ryohei Ono
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| |
Collapse
|
31
|
Young MJ, Kanki M, Karthigan N, Konstandopoulos P. The Role of the Mineralocorticoid Receptor and Mineralocorticoid Receptor-Directed Therapies in Heart Failure. Endocrinology 2021; 162:6288445. [PMID: 34050730 DOI: 10.1210/endocr/bqab105] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Mineralocorticoid receptor (MR) antagonists (MRA), also referred to as aldosterone blockers, are now well-recognized for their clinical benefit in patients who have heart failure (HF) with reduced ejection fraction (HFrEF). Recent studies have also shown MRA can improve outcomes in patients with HFpEF, where the ejection fraction is preserved but left ventricular filling is reduced. While the MR is a steroid hormone receptor best known for antinatriuretic actions on electrolyte homeostasis in the distal nephron, it is now established that the MR has many physiological and pathophysiological roles in the heart, vasculature, and other nonepithelial tissue types. It is the impact of MR activation on these tissues that underpins the use of MRA in cardiovascular disease, in particular HF. This mini-review will discuss the origins and the development of MRA and highlight how their use has evolved from the "potassium-sparing diuretics" spironolactone and canrenone over 60 years ago, to the more receptor-selective eplerenone and most recently the emergence of new nonsteroidal receptor antagonists esaxerenone and finerenone.
Collapse
Affiliation(s)
- Morag J Young
- Baker Heart and Diabetes Institute, Cardiovascular Endocrinology Laboratory, Prahran 3181, Australia
| | - Monica Kanki
- Baker Heart and Diabetes Institute, Cardiovascular Endocrinology Laboratory, Prahran 3181, Australia
- Hudson Institute of Medical Research, Victoria 3168, Australia
| | - Nikshay Karthigan
- Baker Heart and Diabetes Institute, Cardiovascular Endocrinology Laboratory, Prahran 3181, Australia
- Hudson Institute of Medical Research, Victoria 3168, Australia
| | - Penny Konstandopoulos
- Baker Heart and Diabetes Institute, Cardiovascular Endocrinology Laboratory, Prahran 3181, Australia
| |
Collapse
|
32
|
Watanabe A, Ishizuka T, Yamada M, Igawa Y, Shimizu T, Ishizuka H. Physiologically based pharmacokinetic modelling to predict the clinical effect of CYP3A inhibitors/inducers on esaxerenone pharmacokinetics in healthy subjects and subjects with hepatic impairment. Eur J Clin Pharmacol 2021; 78:65-73. [PMID: 34415382 PMCID: PMC8724184 DOI: 10.1007/s00228-021-03194-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/26/2021] [Indexed: 11/28/2022]
Abstract
Purpose Esaxerenone is a novel, oral, nonsteroidal treatment for hypertension. Physiologically based pharmacokinetic (PBPK) modelling was performed to predict the drug–drug interaction (DDI) effect of cytochrome P450 (CYP)3A modulators on esaxerenone pharmacokinetics in healthy subjects and subjects with hepatic impairment. Methods In our PBPK model, the fraction of esaxerenone metabolised by CYP3A was estimated from mass-balance data and verified and optimised by clinical DDI study results with strong CYP3A modulators. The model was also verified by the observed pharmacokinetics after multiple oral dosing and by the effect of hepatic impairment on esaxerenone pharmacokinetics. The model was applied to predict the DDI effects on esaxerenone pharmacokinetics with untested CYP3A modulators in healthy subjects and with strong CYP3A modulators in subjects with hepatic impairment. Results The PBPK model well described esaxerenone pharmacokinetics after multiple oral dosing. The predicted fold changes in esaxerenone plasma exposure after coadministration with strong CYP3A modulators were comparable with the observed data (1.53-fold with itraconazole and 0.31-fold with rifampicin). Predicted DDIs with untested moderate CYP3A modulators were less than the observed DDI with strong CYP3A modulators. The PBPK model also described the effect of hepatic impairment on esaxerenone plasma exposure. The predicted DDI results with strong CYP3A modulators in subjects with hepatic impairment indicate that, for concomitant use of CYP3A modulators, caution is advised for subjects with hepatic impairment, as is for healthy subjects. Conclusion The PBPK model developed predicted esaxerenone pharmacokinetics and DDIs and informed concurrent use of esaxerenone with CYP3A modulators. Supplementary information The online version contains supplementary material available at 10.1007/s00228-021-03194-x.
Collapse
Affiliation(s)
- Akiko Watanabe
- Quantitative Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan.
| | - Tomoko Ishizuka
- Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Makiko Yamada
- Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Yoshiyuki Igawa
- Quantitative Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Takako Shimizu
- Quantitative Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Hitoshi Ishizuka
- Quantitative Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| |
Collapse
|
33
|
Mineralocorticoid receptor blockers for moderate kidney dysfunction: more merit than ever? Hypertens Res 2021; 44:1352-1354. [PMID: 34267356 DOI: 10.1038/s41440-021-00690-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 05/31/2021] [Indexed: 11/09/2022]
|
34
|
Watson K, Kukin A, Wasik AK, Shulenberger CE. Nonsteroidal Mineralocorticoid Receptor Antagonists: Exploring Role in Cardiovascular Disease. J Cardiovasc Pharmacol 2021; 77:685-698. [PMID: 34057158 DOI: 10.1097/fjc.0000000000000990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 01/28/2021] [Indexed: 12/20/2022]
Abstract
ABSTRACT Aldosterone, a mineralocorticoid hormone, plays a role in the pathophysiology of many cardiovascular disease states. Mineralocorticoid receptor antagonists (MRAs) have been shown to improve clinical outcomes in select patient populations. However, use of available steroidal receptor antagonists, eplerenone and spironolactone, is often limited by the risk or development of hyperkalemia. Nonsteroidal MRAs have been designed to overcome this limitation. The nonsteroidal MRAs have been studied in patients with heart failure with reduced ejection fraction, hypertension, and to lower the risk of cardiac and renal outcomes in those with type 2 diabetes and renal disease. In this review, the pharmacology of the MRAs is compared, the data evaluating the use of nonsteroidal MRAs are examined, and the place of this new generation of therapy is discussed. At this time, it seems that there could be a future role for nonsteroidal MRAs to reduce the risk of renal outcomes in high-risk individuals.
Collapse
Affiliation(s)
- Kristin Watson
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
- ATRIUM Cardiology Collaborative, Baltimore, MD
| | - Alina Kukin
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Allie K Wasik
- Department of Pharmacy, Northwestern Memorial Hospital Bluhm Cardiovascular Institute, Chicago, IL; and
| | | |
Collapse
|
35
|
Chang WT, Wu SN. Characterization of Direct Perturbations on Voltage-Gated Sodium Current by Esaxerenone, a Nonsteroidal Mineralocorticoid Receptor Blocker. Biomedicines 2021; 9:biomedicines9050549. [PMID: 34068333 PMCID: PMC8153305 DOI: 10.3390/biomedicines9050549] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/07/2021] [Accepted: 05/11/2021] [Indexed: 02/07/2023] Open
Abstract
Esaxerenone (ESAX; CS-3150, Minnebro®) is known to be a newly non-steroidal mineralocorticoid receptor (MR) antagonist. However, its modulatory actions on different types of ionic currents in electrically excitable cells remain largely unanswered. The present investigations were undertaken to explore the possible perturbations of ESAX on the transient, late and persistent components of voltage-gated Na+ current (INa) identified from pituitary GH3 or MMQ cells. GH3-cell exposure to ESAX depressed the transient and late components of INa with varying potencies. The IC50 value of ESAX required for its differential reduction in peak or late INa in GH3 cells was estimated to be 13.2 or 3.2 μM, respectively. The steady-state activation curve of peak INa remained unchanged during exposure to ESAX; however, recovery of peak INa block was prolonged in the presence 3 μM ESAX. In continued presence of aldosterone (10 μM), further addition of 3 μM ESAX remained effective at inhibiting INa. ESAX (3 μM) potently reversed Tef-induced augmentation of INa. By using isosceles-triangular ramp pulse with varying durations, the amplitude of persistent INa measured at high or low threshold was enhanced by the presence of tefluthrin (Tef), in combination with the appearance of the figure-of-eight hysteretic loop; moreover, hysteretic strength of the current was attenuated by subsequent addition of ESAX. Likewise, in MMQ lactotrophs, the addition of ESAX also effectively decreased the peak amplitude of INa along with the increased current inactivation rate. Taken together, the present results provide a noticeable yet unidentified finding disclosing that, apart from its antagonistic effect on MR receptor, ESAX may directly and concertedly modify the amplitude, gating properties and hysteresis of INa in electrically excitable cells.
Collapse
Affiliation(s)
- Wei-Ting Chang
- Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan 71005, Taiwan;
- Division of Cardiovascular Medicine, Chi-Mei Medical Center, Tainan 71004, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
| | - Sheng-Nan Wu
- Department of Physiology, National Cheng Kung University Medical College, Tainan 70101, Taiwan
- Institute of Basic Medical Sciences, National Cheng Kung University Medical College, Tainan 70101, Taiwan
- Correspondence: ; Tel.: +886-6-2353535 (ext. 5334); Fax: +886-6-2362780
| |
Collapse
|
36
|
Rakugi H, Yamakawa S, Sugimoto K. Management of hyperkalemia during treatment with mineralocorticoid receptor blockers: findings from esaxerenone. Hypertens Res 2021; 44:371-385. [PMID: 33214722 PMCID: PMC8019656 DOI: 10.1038/s41440-020-00569-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/29/2020] [Accepted: 09/29/2020] [Indexed: 01/06/2023]
Abstract
The nonsteroidal mineralocorticoid receptor (MR) blocker esaxerenone has demonstrated good antihypertensive activity in a variety of patients, including those with uncomplicated grade I-III hypertension, hypertension with moderate renal dysfunction, hypertension with type 2 diabetes mellitus with albuminuria, and hypertension associated with primary aldosteronism. Hyperkalemia has long been recognized as a potential side effect occurring during treatment with MR blockers, but there is a lack of understanding and guidance about the appropriate management of hyperkalemia during antihypertensive therapy with MR blockers, especially in regard to the newer agent esaxerenone. In this article, we first highlight risk factors for hyperkalemia, including advanced chronic kidney disease, diabetes mellitus, cardiovascular disease, age, and use of renin-angiotensin-aldosterone system inhibitors. Next, we examine approaches to prevention and management, including potassium monitoring, diet, and the use of appropriate therapeutic techniques. Finally, we summarize the currently available data for esaxerenone and hyperkalemia. Proper management of serum potassium is required to ensure safe clinical use of MR blockers, including awareness of at-risk patient groups, choosing appropriate dosages for therapy initiation and dosage titration, and monitoring of serum potassium during therapy. It is critical that physicians take such factors into consideration to optimize MR blocker therapy in patients with hypertension.
Collapse
Affiliation(s)
- Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Satoru Yamakawa
- Clinical Development Department III, R&D Division, Daiichi Sankyo Co., Ltd., 1-2-58, Hiromachi, Shinagawa-ku, Tokyo, 140-8710, Japan
| | - Kotaro Sugimoto
- Medical Science Department, Daiichi Sankyo Co., Ltd., 3-5-1, Nihonbashi Honcho, Chuo-ku, Tokyo, 103-8426, Japan
| |
Collapse
|
37
|
Rahman A, Sawano T, Sen A, Hossain A, Jahan N, Kobara H, Masaki T, Kosaka S, Kitada K, Nakano D, Imamura T, Ohsaki H, Nishiyama A. Cardioprotective Effects of a Nonsteroidal Mineralocorticoid Receptor Blocker, Esaxerenone, in Dahl Salt-Sensitive Hypertensive Rats. Int J Mol Sci 2021; 22:2069. [PMID: 33669786 PMCID: PMC7922950 DOI: 10.3390/ijms22042069] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/09/2021] [Accepted: 02/17/2021] [Indexed: 01/13/2023] Open
Abstract
We investigated the effects of esaxerenone, a novel, nonsteroidal, and selective mineralocorticoid receptor blocker, on cardiac function in Dahl salt-sensitive (DSS) rats. We provided 6-week-old DSS rats a high-salt diet (HSD, 8% NaCl). Following six weeks of HSD feeding (establishment of cardiac hypertrophy), we divided the animals into the following two groups: HSD or HSD + esaxerenone (0.001%, w/w). In survival study, all HSD-fed animals died by 24 weeks of age, whereas the esaxerenone-treated HSD-fed animals showed significantly improved survival. We used the same protocol with a separate set of animals to evaluate the cardiac function by echocardiography after four weeks of treatment. The results showed that HSD-fed animals developed cardiac dysfunction as evidenced by reduced stroke volume, ejection fraction, and cardiac output. Importantly, esaxerenone treatment decreased the worsening of cardiac dysfunction concomitant with a significantly reduced level of systolic blood pressure. In addition, treatment with esaxerenone in HSD-fed DSS rats caused a reduced level of cardiac remodeling as well as fibrosis. Furthermore, inflammation and oxidative stress were significantly reduced. These data indicate that esaxerenone has the potential to mitigate cardiac dysfunction in salt-induced myocardial injury in rats.
Collapse
Affiliation(s)
- Asadur Rahman
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
| | - Tatsuya Sawano
- Division of Pharmacology, Faculty of Medicine, Tottori University, 86 Nishi-cho, Yonago, Tottori 683-8503, Japan; (T.S.); (T.I.)
| | - Anupoma Sen
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
| | - Akram Hossain
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
| | - Nourin Jahan
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
| | - Hideki Kobara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (H.K.); (T.M.)
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (H.K.); (T.M.)
| | - Shinji Kosaka
- Department of Pharmacy, Kagawa University Hospital, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan;
| | - Kento Kitada
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
| | - Daisuke Nakano
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
| | - Takeshi Imamura
- Division of Pharmacology, Faculty of Medicine, Tottori University, 86 Nishi-cho, Yonago, Tottori 683-8503, Japan; (T.S.); (T.I.)
| | - Hiroyuki Ohsaki
- Department of Medical Biophysics, Kobe University Graduate School of Health Sciences, 7-10-2, Tomogaoka, Suma-ku, Kobe, Hyogo 654-0142, Japan;
| | - Akira Nishiyama
- Department of Pharmacology, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan; (A.R.); (A.S.); (A.H.); (N.J.); (K.K.); (D.N.)
| |
Collapse
|
38
|
Efficacy and safety of esaxerenone in patients with hypertension and concomitant heart failure. Hypertens Res 2021; 44:601-603. [PMID: 33420475 DOI: 10.1038/s41440-020-00606-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 11/25/2020] [Accepted: 11/26/2020] [Indexed: 02/07/2023]
|
39
|
Novel therapeutics for the treatment of hypertension and its associated complications: peptide- and nonpeptide-based strategies. Hypertens Res 2021; 44:740-755. [PMID: 33731923 PMCID: PMC7967108 DOI: 10.1038/s41440-021-00643-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/08/2020] [Accepted: 01/20/2021] [Indexed: 01/31/2023]
Abstract
The renin-angiotensin-aldosterone system (RAAS) is responsible for maintaining blood pressure and vascular tone. Modulation of the RAAS, therefore, interferes with essential cellular processes and leads to high blood pressure, oxidative stress, inflammation, fibrosis, and hypertrophy. Consequently, these conditions cause fatal cardiovascular and renal complications. Thus, the primary purpose of hypertension treatment is to diminish or inhibit overactivated RAAS. Currently available RAAS inhibitors have proven effective in reducing blood pressure; however, beyond hypertension, they have failed to treat end-target organ injury. In addition, RAAS inhibitors have some intolerable adverse effects, such as hyperkalemia and hypotension. These gaps in the available treatment for hypertension require further investigation of the development of safe and effective therapies. Current research is focused on the combination of existing and novel treatments that neutralize the angiotensin II type I (AT1) receptor-mediated action of the angiotensin II peptide. Preclinical studies of peptide- and nonpeptide-based therapeutic agents demonstrate their conspicuous impact on the treatment of cardiovascular diseases in animal models. In this review, we will discuss novel therapeutic agents being developed as RAAS inhibitors that show prominent effects in both preclinical and clinical studies. In addition, we will also highlight the need for improvement in the efficacy of existing drugs in the absence of new prominent antihypertensive drugs.
Collapse
|
40
|
Ito S, Itoh H, Rakugi H, Okuda Y, Iijima S. Antihypertensive effects and safety of esaxerenone in patients with moderate kidney dysfunction. Hypertens Res 2020; 44:489-497. [PMID: 33323991 PMCID: PMC8099724 DOI: 10.1038/s41440-020-00585-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/14/2020] [Accepted: 10/02/2020] [Indexed: 12/15/2022]
Abstract
Renin–angiotensin system inhibitors are recommended for treating hypertension with chronic kidney disease. The addition of a mineralocorticoid receptor blocker may be one option to achieve target blood pressure. We investigated the efficacy and safety of esaxerenone, a mineralocorticoid receptor blocker, in Japanese hypertensive patients with moderate kidney dysfunction. Two multicenter, open-label, nonrandomized dose escalation studies were conducted to investigate esaxerenone monotherapy and add-on therapy to renin–angiotensin system inhibitor treatment. Esaxerenone therapy was initiated at 1.25 mg/day and titrated to 2.5 and then 5 mg/day for a treatment duration of 12 weeks. Primary endpoints were changes from baseline in sitting systolic and diastolic blood pressure. Safety, pharmacokinetics, and urinary albumin-to-creatinine ratios were also assessed. Thirty-three patients received monotherapy, and 58 received add-on therapy; the mean baseline estimated glomerular filtration rates were 51.9 and 50.9 mL/min/1.73 m2, respectively. The esaxerenone dosage was increased to ≥2.5 mg/day in 100% (n = 33) and 93.1% (n = 54) of patients receiving monotherapy and add-on therapy, respectively. Reductions in sitting blood pressure from baseline to the end of treatment were similar (monotherapy: −18.5/−8.8 mmHg; add-on therapy: −17.8/−8.1 mmHg; both P < 0.001). The antihypertensive effects of esaxerenone were consistent across patient subgroups. A serum K+ level ≥5.5 mEq/L was observed in seven patients (12.1%) receiving add-on therapy but in none receiving monotherapy. All increases in serum K+ levels were transient, and no patient met predefined serum K+ level criteria for dose reduction or therapy discontinuation. No patient discontinued treatment owing to kidney function decline. Esaxerenone was effective and well tolerated in hypertensive patients with moderate kidney dysfunction.
Collapse
Affiliation(s)
- Sadayoshi Ito
- Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine, Tohoku University School of Medicine, Sendai, Japan. .,Katta General Hospital, Shiroishi, Japan.
| | - Hiroshi Itoh
- Division of Nephrology, Endocrinology and Metabolism, Keio University School of Medicine, Tokyo, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | | | | |
Collapse
|
41
|
Yamakawa S, Homma T, Yamada M, Igawa Y, Yoshimura M. [Pharmacological profile, clinical efficacy, and safety of esaxerenone (Minnebro ® tablets 1.25 mg, 2.5 mg, 5 mg)]. Nihon Yakurigaku Zasshi 2020; 155:340-350. [PMID: 32879177 DOI: 10.1254/fpj.20016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Esaxerenone is a novel non-steroidal mineralocorticoid receptor antagonisit (MR blocker), whose unique binding to the MR-ligand domain yields a stronger MR antagonistic effect and higher selectivity than existing MR antagonisits. Esaxerenone was approved for the treatment of hypertension in Japan in January 2019. Esaxerenone suppresses the reduction of urinary Na+/K+ ratio in adrenalectomized rats and blood pressure increase, proteinuria, and renal tissue lesions in salt-sensitive hypertensive rats-all in a dose-dependent manner. Esaxerenone is rapidly absorbed and reaches intracellular targets because of its high membrane permeability, exhibits high bioavailability with small interindividual exposure variation, and is metabolized via several pathways (e.g., oxidation, glucuronidation, and hydrolysis), which is associated with low drug-drug interaction risk. As esaxerenone is slightly excreted into urine, its exposure is similar between elderly and non-elderly patients, and between patients with normal and moderately deteriorated renal function. Given its 19-hour half-life, once-daily administration would have a sustainable antihypertensive effect. The ESAX-HTN phase 3 study demonstrated the non-inferiority of esaxerenone's antihypertensive effect versus that of eplerenone in essential hypertension. Another study showed a stable antihypertensive effect for 52 weeks as monotherapy or combination therapy. In hypertensive patients with moderate impairment or both type 2 diabetes and albuminuria treated with a renin-angiotensin system inhibitor, esaxerenone elicited a stable antihypertensive effect and manageable hyperkalemia incidence with titration from a low dose and monitoring including serum potassium. Thus, with careful monitoring of serum potassium, esaxerenone can be administered to patients with moderate renal impairment or both diabetes and albuminuria.
Collapse
Affiliation(s)
- Satoru Yamakawa
- Clinical Development Department III, Daiichi Sankyo Co., Ltd
| | - Tsuyoshi Homma
- Global Project Management Department, Daiichi Sankyo Co., Ltd
| | - Makiko Yamada
- Drug Metabolism & Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd
| | - Yoshiyuki Igawa
- Quantitative Clinical Pharmacology Department, Daiichi Sankyo Co., Ltd
| | - Motonobu Yoshimura
- Translational Medicine Function, R & D Division, Daiichi Sankyo Co., Ltd
| |
Collapse
|
42
|
Esaxerenone, a novel nonsteroidal mineralocorticoid receptor blocker (MRB) in hypertension and chronic kidney disease. J Hum Hypertens 2020; 35:148-156. [PMID: 32661269 DOI: 10.1038/s41371-020-0377-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/22/2020] [Accepted: 06/30/2020] [Indexed: 12/14/2022]
Abstract
The steroidal mineralocorticoid receptor (MR) antagonists, spironolactone and eplerenone, decrease blood pressure, and attenuate the progression of chronic kidney disease (CKD). However, their use is limited by the fear of inducing hyperkalemia, gynecomastia, impotence, and amenorrhea. Esaxerenone is a novel nonsteroidal MR blocker (MRB) that has been recently developed. In vitro studies have revealed that esaxerenone has a high potency and selectivity for MR compared with spironolactone and eplerenone. Further studies have shown that esaxerenone elicits a strong blood pressure-lowering effect in hypertensive animals. Following the results from phase III clinical trials that esaxerenone is an effective and well-tolerated MRB in Japanese hypertensive patients, esaxerenone became clinically available in Japan from May 2019 for hypertensive patients. Thus, esaxerenone is a promising treatment option for patients with hypertension. In addition, both preclinical studies and phase II clinical trials have shown that esaxerenone elicits renoprotection independent of its antihypertensive effect. Recently, a phase III clinical trial (ESAX-DN study) has also demonstrated the safety and efficacy of esaxerenone in patients with type 2 diabetes and microalbuminuria. These data support future clinical development of esaxerenone for the treatment of renal disease.
Collapse
|
43
|
Yamada M, Ishizuka T, Inoue SI, Rozehnal V, Fischer T, Sugiyama D. Drug-Drug Interaction Risk Assessment of Esaxerenone as a Perpetrator by In Vitro Studies and Static and Physiologically Based Pharmacokinetic Models. Drug Metab Dispos 2020; 48:769-777. [PMID: 32616542 DOI: 10.1124/dmd.120.090928] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/22/2020] [Indexed: 02/05/2023] Open
Abstract
Esaxerenone (CS-3150) is a novel, oral, nonsteroidal, selective mineralocorticoid receptor blocker approved for the treatment of hypertension in Japan. Here, the drug-drug interaction (DDI) potential of esaxerenone was evaluated in vitro, and its impact in clinical practice was estimated. Esaxerenone exhibited time-dependent inhibition and induction of CYP3A. When the clinical impacts of esaxerenone on the inhibition and induction of CYP3A were estimated separately by using a mechanistic static model, the predicted area under the curve ratios (AUCRs) of midazolam, a typical CYP3A substrate, were 1.80 and 0.31, respectively, suggesting that the DDI potential of esaxerenone cannot be neglected. Because it was suggested that DDIs mainly occur in the intestine, predictions using concentration-time profiles in each segment of the gastrointestinal tract were performed with GastroPlus, a physiologically based pharmacokinetic (PBPK) modeling software. The predicted AUCR of midazolam was approximately 1.2, which is close to that in a clinical study, despite the difficulty of predicting DDIs for compounds with both inhibition and induction effects. When only inhibition or induction was incorporated into a model, the AUCR of midazolam changed depending on the dosing period and dose level of esaxerenone and the timing of midazolam administration. However, the AUCR calculated by incorporating both effects remained almost constant. This study shows the ability of PBPK models to simulate weak DDIs via intestinal CYP3A and that esaxerenone has low DDI potential as a perpetrator because of the offset of inhibition and induction. SIGNIFICANCE STATEMENT: Weak CYP3A inhibition and/or induction sometimes cause DDIs in the intestine but not the liver. Because strong inhibitors maximally inhibit intestinal CYP3A, the predictability of weak DDIs in the intestine should be evaluated further. Here, we simulate the DDIs of esaxerenone as a perpetrator by using physiologically based pharmacokinetic modeling focusing on the intestine and offset of inhibition and induction.
Collapse
Affiliation(s)
- Makiko Yamada
- Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan (M.Y., T.I., S.I., D.S.) and Tissue and Cell Research Center Munich, Daiichi Sankyo Europe GmbH, Martinsried, Germany (V.R., T.F.)
| | - Tomoko Ishizuka
- Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan (M.Y., T.I., S.I., D.S.) and Tissue and Cell Research Center Munich, Daiichi Sankyo Europe GmbH, Martinsried, Germany (V.R., T.F.)
| | - Shin-Ichi Inoue
- Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan (M.Y., T.I., S.I., D.S.) and Tissue and Cell Research Center Munich, Daiichi Sankyo Europe GmbH, Martinsried, Germany (V.R., T.F.)
| | - Veronika Rozehnal
- Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan (M.Y., T.I., S.I., D.S.) and Tissue and Cell Research Center Munich, Daiichi Sankyo Europe GmbH, Martinsried, Germany (V.R., T.F.)
| | - Thomas Fischer
- Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan (M.Y., T.I., S.I., D.S.) and Tissue and Cell Research Center Munich, Daiichi Sankyo Europe GmbH, Martinsried, Germany (V.R., T.F.)
| | - Daisuke Sugiyama
- Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan (M.Y., T.I., S.I., D.S.) and Tissue and Cell Research Center Munich, Daiichi Sankyo Europe GmbH, Martinsried, Germany (V.R., T.F.)
| |
Collapse
|
44
|
Arai K, Morikawa Y, Ubukata N, Sugimoto K. Synergistic reduction in albuminuria in type 2 diabetic mice by esaxerenone (CS-3150), a novel nonsteroidal selective mineralocorticoid receptor blocker, combined with an angiotensin II receptor blocker. Hypertens Res 2020; 43:1204-1213. [PMID: 32616846 PMCID: PMC7685977 DOI: 10.1038/s41440-020-0495-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 12/05/2022]
Abstract
Esaxerenone is a novel selective mineralocorticoid receptor (MR) blocker that was recently approved in Japan to treat hypertension. In phase II and III studies, esaxerenone plus a renin–angiotensin system inhibitor markedly reduced the urinary albumin-to-creatinine ratio (UACR) in hypertensive patients with diabetic nephropathy. To evaluate a direct renoprotective effect by MR blockade independent of an antihypertensive effect in the context of diabetic nephropathy, esaxerenone (3 mg/kg), olmesartan (an angiotensin II receptor blocker; 1 mg/kg), or both were orally administered to KK-Ay mice, a type 2 diabetes model, once daily for 56 days. Urinary albumin (Ualb), UACR, and markers, such as podocalyxin, monocyte chemoattractant protein-1 (MCP-1), and 8-hydroxy-2′-deoxyguanosine (8-OHdG), were measured, along with systolic blood pressure (SBP), fasting blood glucose, and serum K+ levels. Prior to the initiation of drug administration, KK-Ay mice showed higher blood glucose, insulin, Ualb excretion, and UACR levels than C57BL/6 J mice, a nondiabetic control, indicating the development of diabetic renal injury. Combined treatment with esaxerenone and olmesartan significantly reduced the change in UACR from baseline compared with the change associated with vehicle at week 8 (−1.750 vs. 0.339 g/gCre; P < 0.002) and significantly inhibited the change in Ualb from baseline compared with the change associated with vehicle at week 8 (P < 0.002). The combination treatment also reduced urinary excretion of podocalyxin and MCP-1, but did not influence 8-OHdG excretion, SBP, blood glucose, or serum K+ levels. Overall, esaxerenone plus olmesartan treatment ameliorated diabetic nephropathy in KK-Ay mice without affecting SBP, suggesting that the renoprotective effects of esaxerenone could be exerted independently of its antihypertensive effect.
Collapse
Affiliation(s)
- Kiyoshi Arai
- End-Organ Disease Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan. .,Global Project Management Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan.
| | - Yuka Morikawa
- Rare Disease & LCM Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan.,Specialty Medicine Research Laboratories I, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Naoko Ubukata
- End-Organ Disease Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan.,Specialty Medicine Research Laboratories I, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Kotaro Sugimoto
- Medical Science Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| |
Collapse
|
45
|
Abstract
The past nine years have seen major advances in establishing the etiology of unilateral primary aldosteronism, and very possibly that of bilateral hyperaldosteronism, in response to somatic mutations in aldosterone synthase expressing cells. Though there have been important advances in the management of primary aldosteronism, in small but convincing studies, they represent minor changes to current guidelines. What has been totally absent is consideration of the public health issue that primary aldosterone represents, and the public policy issues that would be involved in addressing the disorder. In his introduction to PiPA 6, Martin Reincke calculated that only one in a thousand patients in Germany with primary aldosteronism were treated appropriately, an astounding figure for any disease in the 21st century. Towards remedying this totally unacceptable public health issue, the author proposes a radical simplification and streamlining of screening for primary aldosteronism, and the management of most patients by general practitioners. The second bottle-neck in current management is that of mandatory adrenal venous sampling for all but 1-2% of patients, a costly procedure requiring rare expertise. Ideally, it should be reserved - on the basis of likelihood, enhanced imaging, or peripheral steroid profiles - for a small minority of patients with clear evidence for unilateral disease. Only when costs are minimized and roadblocks removed will primary aldosteronism be properly treated as the public health issue that it is.
Collapse
Affiliation(s)
- John Watson Funder
- Hudson Institute of Medical Research and Monash University, Clayton, Victoria, Australia
| |
Collapse
|
46
|
Al Dhaybi O, Bakris GL. Non-steroidal mineralocorticoid antagonists: Prospects for renoprotection in diabetic kidney disease. Diabetes Obes Metab 2020; 22 Suppl 1:69-76. [PMID: 32267074 DOI: 10.1111/dom.13983] [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: 12/09/2019] [Revised: 01/22/2020] [Accepted: 01/26/2020] [Indexed: 01/26/2023]
Abstract
Diabetic kidney disease (DKD) is the major cause of kidney failure in the world and the combination of DKD and diabetes mellitus contributes to an additive incidence of worsening cardiovascular mortality rates. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) remain the mainstay of therapy and have reduced kidney function decline in DKD from 8 to 10 to ~4 mL/min/y. Sodium-glucose co-transporter-2 (SGLT2) inhibitors, in the presence of ACE inhibitors or ARB agents, further slowdown DKD progression by an additional 58% to 1.8 mL/min/y. Moreover, SGLT2 inhibitors reduce heart failure risk. However, the normal rate of kidney function decline in humans is between 0.7 and 0.9 mL/min/y, hence, there is still room for improvement. Mineralocorticoid receptor antagonists (MRAs) already have a track record of benefit in heart failure risk reduction, and efficacy in reducing albuminuria and treating resistant hypertension; however hyperkalaemia and other adverse effects preclude their routine use in DKD. Novel non-steroidal MRAs offer a reduced risk of hyperkalaemia, and yet have many benefits that they share with their steroidal cousins. This paper reviews the data for both steroidal and non-steroidal MRAs in DKD and presents some data from soon-to-be-completed ongoing renal and cardiovascular outcome trials in DKD.
Collapse
Affiliation(s)
- Omar Al Dhaybi
- Department of Medicine, American Heart Association Comprehensive Hypertension Centre, Section of Endocrinology, Diabetes and Metabolism, University of Chicago Medicine, Chicago, Illinois
| | - George L Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Centre, Section of Endocrinology, Diabetes and Metabolism, University of Chicago Medicine, Chicago, Illinois
| |
Collapse
|
47
|
Maruhashi T, Kihara Y, Higashi Y. Perspectives on the management of hypertension in Japan. Expert Opin Pharmacother 2020; 21:1179-1187. [DOI: 10.1080/14656566.2020.1724958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Tatsuya Maruhashi
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
- Division of Regeneration and Medicine, Hiroshima University Hospital, Hiroshima, Japan
| |
Collapse
|
48
|
Okamura K, Matsushima M, Yamamoto F, Takamiya Y, Okuda T, Shirai K, Okamura K, Urata H. A Patient with Bilateral Primary Aldosteronism Refractory to Oral Eplerenone Who Responded to Esaxerenone with Increased Renin Activity. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e920615. [PMID: 31907345 PMCID: PMC6977600 DOI: 10.12659/ajcr.920615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Patient: Male, 45-year-old Final Diagnosis: Bilateral primary aldosteronism Symptoms: Hypertension Medication: Mineralocorticoid receptor blocker Clinical Procedure: Segmental adrenal venous sampling and medication Specialty: Cardiology
Collapse
Affiliation(s)
- Keisuke Okamura
- Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan.,Internal Medicine, Okamura Clinic, Imari, Saga, Japan
| | - Masatoshi Matsushima
- Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
| | - Fumi Yamamoto
- Department of Cardiology, National Hospital Organization Ureshino Medical Center, Ureshino, Saga, Japan
| | - Yosuke Takamiya
- Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
| | - Tetsu Okuda
- Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
| | - Kazuyuki Shirai
- Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
| | | | - Hidenori Urata
- Department of Cardiovascular Diseases, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
| |
Collapse
|
49
|
Ito S, Itoh H, Rakugi H, Okuda Y, Yoshimura M, Yamakawa S. Double-Blind Randomized Phase 3 Study Comparing Esaxerenone (CS-3150) and Eplerenone in Patients With Essential Hypertension (ESAX-HTN Study). Hypertension 2019; 75:51-58. [PMID: 31786983 DOI: 10.1161/hypertensionaha.119.13569] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Mineralocorticoid receptors (MRs) are implicated in the pathology of hypertension. MR blockers are recommended for the treatment of salt-sensitive or resistant hypertension. However, use of currently available MR blockers is limited by adverse events. This phase 3 multicenter, randomized, double-blind study compared the efficacy and safety of esaxerenone, a new selective nonsteroidal MR blocker, at 2.5 and 5 mg/day and eplerenone 50 mg/day in Japanese patients with essential hypertension. After a 4-week washout period, 1001 eligible adults with hypertension were randomized evenly to esaxerenone 2.5 or 5 mg/day or eplerenone 50 mg/day treatments, taken orally once daily for 12 weeks. Primary end points were changes in sitting systolic or diastolic blood pressure (BP) from baseline at the end of treatment. Esaxerenone 2.5 mg/day was noninferior to eplerenone for reductions in sitting and 24-hour BP. Reductions in BP with esaxerenone 5 mg/day were significantly greater than those with esaxerenone 2.5 mg/day. Changes in diurnal BP showed persistent 24-hour antihypertensive effects in all treatment groups. The proportions of patients achieving target sitting BP (<140/90 mm Hg) were 31.5%, 41.2%, and 27.5% with esaxerenone 2.5 and 5 mg/day and eplerenone 50 mg/day, respectively. Incidences of adverse events (all mild or moderate) were similar across treatment groups. These results indicate that esaxerenone is an effective and well-tolerated MR blocker in Japanese patients with essential hypertension, with BP-lowering activity at least equivalent to eplerenone. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT02890173.
Collapse
Affiliation(s)
- Sadayoshi Ito
- From the Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine, Tohoku University School of Medicine, Sendai, Japan (S.I.)
| | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and Nephrology, Keio University, School of Medicine, Tokyo, Japan (H.I.)
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Japan (H.R.)
| | - Yasuyuki Okuda
- Daiichi Sankyo Co., Ltd., Tokyo, Japan (Y.O., M.Y., S.Y.)
| | | | | |
Collapse
|