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Bransetter JW, Anderson M, Zaki H, Gleason ME, Beshish AG. Captopril to Lisinopril Conversion in Pediatric Cardiothoracic Surgery Patients Less Than 7 Years of Age (RISE-7). Pediatr Cardiol 2024; 45:394-400. [PMID: 38153545 DOI: 10.1007/s00246-023-03373-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 12/03/2023] [Indexed: 12/29/2023]
Abstract
Hypertension after cardiothoracic surgery is common, often requiring pharmacologic management. The recommended first-line antihypertensives in pediatrics are angiotensin converting enzyme inhibitors. Captopril and enalapril are approved for infants and children; however, lisinopril is only approved for > 7 years of age. This study evaluated safety and efficacy of converting from captopril to lisinopril in patients utilizing a pre-defined conversion of 3 mg captopril to 1 mg lisinopril. This was a single center, retrospective study including patients less than 7 years of age admitted for cardiothoracic surgery who received both captopril and lisinopril from 01/01/2017 to 06/01/2022.The primary outcome was mean change in systolic blood pressure (SBP) from baseline for 72 h after conversion of captopril to lisinopril. A total of 99 patients were enrolled. There was a significant decrease in mean SBP (99.12 mmHg vs 94.86 mmHg; p = 0.007) with no difference in DBP (59.23 mmHg vs 61.95 mmHg; p = 0.07) after conversion to lisinopril. Of the 99 patients who were transitioned to lisinopril, 79 (80%) had controlled SBP, 20 (20%) remained hypertensive, 13 (13%) received an increase in their lisinopril dose, and 2 (2%) required an additional antihypertensive agent. There was a low overall rate of AKI (3%) and hyperkalemia (4%) respectively. This study demonstrates that utilizing lisinopril with a conversion rate of 3 mg of captopril to 1 mg of lisinopril was safe and effective for controlling hypertension in pediatric patients following cardiothoracic surgery.
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Affiliation(s)
- Joshua W Bransetter
- Department of Pharmacy, Children's Healthcare of Atlanta, 1405 East Clifton Rd. Northeast, Atlanta, GA, 30322, USA.
| | - McKenzie Anderson
- Department of Pharmacy, University of Tennessee Health Science, Knoxville, TN, USA
| | - Hania Zaki
- Department of Pharmacy, Children's Healthcare of Atlanta, 1405 East Clifton Rd. Northeast, Atlanta, GA, 30322, USA
| | | | - Asaad G Beshish
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
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2
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Hu Y, Liang L, Liu S, Kung JY, Banh HL. Angiotensin-converting enzyme inhibitor induced cough compared with placebo, and other antihypertensives: A systematic review, and network meta-analysis. J Clin Hypertens (Greenwich) 2023; 25:661-688. [PMID: 37417783 PMCID: PMC10423763 DOI: 10.1111/jch.14695] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023]
Abstract
Studies have shown that angiotensin converting enzyme inhibitors (ACEIs) are superior in primary and secondary prevention for cardiac mortality and morbidity to angiotensin receptor blocker (ARBs). One of the common side effects from ACEI is dry cough. The aims of this systematic review, and network meta-analysis are to rank the risk of cough induced by different ACEIs and between ACEI and placebo, ARB or calcium channel blockers (CCB). We performed a systematic review, and network meta-analysis of randomized controlled trials to rank the risk of cough induced by each ACEI and between ACEI and placebo, ARB or CCB. A total of 135 RCTs with 45,420 patients treated with eleven ACEIs were included in the analyses. The pooled estimated relative risk (RR) between ACEI and placebo was 2.21 (95% CI: 2.05-2.39). ACEI had more incidences of cough than ARB (RR 3.2; 95% CI: 2.91, 3.51), and pooled estimated of RR between ACEI and CCB was 5.30 (95% CI: 4.32-6.50) Moexipril ranked as number one for inducing cough (SUCRA 80.4%) and spirapril ranked the least (SUCRA 12.3%). The order for the rest of the ACEIs are as follows: ramipril (SUCRA 76.4%), fosinopril (SUCRA 72.5%), lisinopril (SUCRA 64.7%), benazepril (SUCRA 58.6%), quinapril (SUCRA 56.5%), perindopril (SUCRA 54.1%), enalapril (SUCRA 49.7%), trandolapril (SUCRA 44.6%) and, captopril (SUCRA 13.7%). All ACEI has the similar risk of developing a cough. ACEI should be avoided in patients who have risk of developing cough, and an ARB or CCB is an alternative based on the patient's comorbidity.
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Affiliation(s)
- Yiyun Hu
- Department of PharmacySecond Xiangya Hospital of Central South UniversityChangshaChina
| | - Ling Liang
- Department of CardiologyThe Third Clinical Medical College, Fujian Medical UniversityFuzhouChina
- Department of CardiologyThe First Affiliated Hospital of Xiamen UniversityXiamenChina
| | - Shuang Liu
- Medical Affairs Management DepartmentSecond Xiangya Hospital of Central South UniversityChangshaChina
| | - Janice Y. Kung
- University of Alberta, John W. Scott Health Sciences LibraryEdmontonCanada
| | - Hoan Linh Banh
- Faculty of Medicine and DentistryDepartment of Family MedicineUniversity of AlbertaEdmontonCanada
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3
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Wühl E, Calpe J, Drożdż D, Erdine S, Fernandez-Aranda F, Hadjipanayis A, Hoyer PF, Jankauskiene A, Jiménez-Murcia S, Litwin M, Mancia G, Mazur A, Pall D, Seeman T, Sinha MD, Simonetti G, Stabouli S, Lurbe E. Joint statement for assessing and managing high blood pressure in children and adolescents: Chapter 2. How to manage high blood pressure in children and adolescents. Front Pediatr 2023; 11:1140617. [PMID: 37124176 PMCID: PMC10130632 DOI: 10.3389/fped.2023.1140617] [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] [Received: 01/09/2023] [Accepted: 03/20/2023] [Indexed: 05/02/2023] Open
Abstract
The joint statement is a synergistic action between HyperChildNET and the European Academy of Pediatrics about the diagnosis and management of hypertension in youth, based on the European Society of Hypertension Guidelines published in 2016 with the aim to improve its implementation. Arterial hypertension is not only the most important risk factor for cardiovascular morbidity and mortality, but also the most important modifiable risk factor. Early hypertension-mediated organ damage may already occur in childhood. The duration of existing hypertension plays an important role in risk assessment, and structural and functional organ changes may still be reversible or postponed with timely treatment. Therefore, appropriate therapy should be initiated in children as soon as the diagnosis of arterial hypertension has been confirmed and the risk factors for hypertension-mediated organ damage have been thoroughly evaluated. Lifestyle measures should be recommended in all hypertensive children and adolescents, including a healthy diet, regular exercise, and weight loss, if appropriate. If lifestyle changes in patients with primary hypertension do not result in normalization of blood pressure within six to twelve months or if secondary or symptomatic hypertension or hypertension-mediated organ damage is already present, pharmacologic therapy is required. Regular follow-up to assess blood pressure control and hypertension-mediated organ damage and to evaluate adherence and side effects of pharmacologic treatment is required. Timely multidisciplinary evaluation is recommended after the first suspicion of hypertension. A grading system of the clinical evidence is included.
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Affiliation(s)
- Elke Wühl
- Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
- Correspondence: Elke Wühl Empar Lurbe Adamos Hadjipanayis
| | | | - Dorota Drożdż
- Department of Pediatric Nephrology and Hypertension, Pediatric Institute, Jagiellonian University Medical College, Cracow, Poland
| | - Serap Erdine
- Istanbul University-Cerrahpaşa, Cerrahpaşa Faculty of Medicine, Istanbul, Turkey
| | - Fernando Fernandez-Aranda
- University Hospital of Bellvitge-IDIBELL and Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
- CIBER Fisiopatología de Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Adamos Hadjipanayis
- School of Medicine, European University Cyprus, Nicosia, Cyprus
- Department of Paediatrics, Larnaca General Hospital, Larnaca, Cyprus
- Correspondence: Elke Wühl Empar Lurbe Adamos Hadjipanayis
| | - Peter F. Hoyer
- Klinik für Kinderheilkunde II, Zentrum für Kinder und Jugendmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Germany
| | - Augustina Jankauskiene
- Pediatric Center, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Susana Jiménez-Murcia
- University Hospital of Bellvitge-IDIBELL and Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
- CIBER Fisiopatología de Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Artur Mazur
- Institute of Medical Sciences, Medical College, Rzeszów University, Rzeszow, Poland
| | - Denes Pall
- Department of Medical Clinical Pharmacology and Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tomas Seeman
- Division of Pediatric Nephrology, UniversityChildren's Hospital, Charles University, Prague, Czech Republic
- Department of Pediatrics, University Hospital Ostrava, Ostrava, Czech Republic
| | - Manish D. Sinha
- Department of Pediatric Nephrology, Evelina London Children's Hospital, Guys and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Giacomo Simonetti
- Institute of Pediatrics of Southern Switzerland, Ente Ospedaliero Cantonale (EOC), Bellinzona, Switzerland
| | - Stella Stabouli
- 1st Department of Pediatrics, Aristotle University of Thessaloniki, Hippokratio General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Empar Lurbe
- CIBER Fisiopatología de Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- Department of Pediatric, Consorcio Hospital General, University of Valencia, Valencia, Spain
- Correspondence: Elke Wühl Empar Lurbe Adamos Hadjipanayis
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Redon J, Seeman T, Pall D, Suurorg L, Kamperis K, Erdine S, Wühl E, Mancia G. Narrative update of clinical trials with antihypertensive drugs in children and adolescents. Front Cardiovasc Med 2022; 9:1042190. [PMID: 36479567 PMCID: PMC9721463 DOI: 10.3389/fcvm.2022.1042190] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/04/2022] [Indexed: 08/27/2023] Open
Abstract
INTRODUCTION To date, our knowledge on antihypertensive pharmacological treatment in children and adolescents is still limited because there are few randomized clinical trials (CTs), hampering appropriate management. The objective was to perform a narrative review of the most relevant aspects of clinical trials carried out in primary and secondary hypertension. METHODS Studies published in PubMed with the following descriptors: clinical trial, antihypertensive drug, children, adolescents were selected. A previous Cochrane review of 21 randomized CTs pointed out the difficulty that statistical analysis could not assess heterogeneity because there were not enough data. A more recent meta-analysis, that applied more stringent inclusion criteria and selected 13 CTs, also concluded that heterogeneity, small sample size, and short follow-up time, as well as the absence of studies comparing drugs of different classes, limit the utility. RESULTS In the presented narrative review, including 30 studies, there is a paucity of CTs focusing only on children with primary or secondary, mainly renoparenchymal, hypertension. In trials on angiotensin converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs) and diuretics, a significant reduction of both SBP and DBP in mixed cohorts of children with primary and secondary hypertension was achieved. However, few studies assessed the effect of antihypertensive drugs on hypertensive organ damage. CONCLUSIONS Given the increasing prevalence and undertreatment of hypertension in this age group, innovative solutions including new design, such as 'n-of-1', and optimizing the use of digital health technologies could provide more precise and faster information about the efficacy of each antihypertensive drug class and the potential benefits according to patient characteristics.
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Affiliation(s)
- Josep Redon
- INCLIVA Research Institute, CIBERObn Institute of Health Charles III, University of Valencia, Madrid, Spain
| | - Tomas Seeman
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University Prague, Prague, Czechia
| | - Dénes Pall
- Department of Medical Clinical Pharmacology, University of Debrecen, Debrecen, Hungary
| | | | - Konstantinos Kamperis
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Serap Erdine
- Hypertension and Atherosclerosis Center, Marmara University School of Medicine, Istanbul, Turkey
| | - Elke Wühl
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
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Jankauskiene A, Drozdz D, Wasilewska A, de Paula-Bernardes R, Glazer R, Valentin M, Tan M, Chiang Y, Bapatla K. Efficacy and safety of valsartan in children aged 1-5 years with hypertension, with or without chronic kidney disease: a randomized, double-blind study followed by open-label phase. Curr Med Res Opin 2021; 37:2113-2122. [PMID: 34543161 DOI: 10.1080/03007995.2021.1982681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess the dose-response relationship for reduction in mean systolic blood pressure (MSBP) with valsartan solution, in young children with hypertension with or without chronic kidney disease (CKD). METHODS In this multicenter, randomized, double-blind, double-dummy study, 127 young children aged 1-5 years with hypertension (MSBP ≥95th percentile) were randomized (1:1) to receive valsartan 0.25 or 4 mg/kg/day for 6 weeks, followed by a 20 week open-label phase, where patients received valsartan 1 mg/kg/day for 4 weeks, and then optionally titrated to 2 mg/kg/day or up to 4 mg/kg/day. The primary endpoint was the change in MSBP from baseline at Week 6 during the double-blind phase. RESULTS Overall, 120 patients (94.5%) completed the study; 63 had CKD. A clinically and statistically significant reduction in MSBP from baseline to Week 6 was observed with the valsartan 4 mg/kg group compared with the valsartan 0.25 mg/kg group (8.5 vs 4.1 mmHg; p = .0157). A positive dose-response relationship for MSBP reduction was observed between the 0.25 mg/kg and 4 mg/kg groups (p = .0012). In the CKD subgroup, a significant reduction in MSBP was observed with 4 mg/kg (9.2 mmHg) versus 0.25 mg/kg (1.2 mmHg; p = .0096). In the non-CKD subgroup, a numerically greater decrease in MSBP was observed with 4 mg/kg (7.8 mmHg) versus 0.25 mg/kg (6.9 mmHg; p = .6531). Incidence of adverse events was lower with valsartan 4 mg/kg than 0.25 mg/kg (41.9% vs 51.6%) and similar between CKD and non-CKD subgroups (48.4% vs 45.3%) irrespective of dose. Increase in serum potassium (>20% compared to baseline) was observed more frequently in patients with CKD compared to non-CKD patients. CONCLUSION Valsartan was efficacious and well tolerated in children 1 to 5 years of age with hypertension, with or without CKD. Clinical trial registration: The study has been registered at ClinicalTrials.gov (Identifier: NCT01617681).
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Affiliation(s)
| | - Dorota Drozdz
- Department of Pediatric Nephrology and Hypertension, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Wasilewska
- Department of Pediatrics and Nephrology, Medical University of Białystok, Waszyngtona, Poland
| | | | - Robert Glazer
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Monique Tan
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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6
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Bouhanick B, Sosner P, Brochard K, Mounier-Véhier C, Plu-Bureau G, Hascoet S, Ranchin B, Pietrement C, Martinerie L, Boivin JM, Fauvel JP, Bacchetta J. Hypertension in Children and Adolescents: A Position Statement From a Panel of Multidisciplinary Experts Coordinated by the French Society of Hypertension. Front Pediatr 2021; 9:680803. [PMID: 34307254 PMCID: PMC8292722 DOI: 10.3389/fped.2021.680803] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/09/2021] [Indexed: 11/23/2022] Open
Abstract
Hypertension is much less common in children than in adults. The group of experts decided to perform a review of the literature to draw up a position statement that could be used in everyday practice. The group rated recommendations using the GRADE approach. All children over the age of 3 years should have their blood pressure measured annually. Due to the lack of data on cardiovascular morbidity and mortality associated with blood pressure values, the definition of hypertension in children is a statistical value based on the normal distribution of blood pressure in the paediatric population, and children and adolescents are considered as having hypertension when their blood pressure is greater than or equal to the 95th percentile. Nevertheless, it is recommended to use normative blood pressure tables developed according to age, height and gender, to define hypertension. Measuring blood pressure in children can be technically challenging and several measurement methods are listed here. Regardless of the age of the child, it is recommended to carefully check for a secondary cause of hypertension as in 2/3 of cases it has a renal or cardiac origin. The care pathway and principles of the therapeutic strategy are described here.
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Affiliation(s)
- Béatrice Bouhanick
- Service d'Hypertension Artérielle et Thérapeutique, CHU Rangueil, CERPOP, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Philippe Sosner
- Centre Médico-Sportif MON STADE, Paris, France.,Hôpital Hôtel-Dieu, APHP, Centre de Diagnostic et de Thérapeutique, Paris, France.,Laboratoire MOVE (EA 6314), Université de Poitiers, Faculté des Sciences du Sport, Poitiers, France
| | - Karine Brochard
- Service de Néphrologie Médecine Interne Pédiatrique, Hôpital des Enfants, CHU Toulouse, Toulouse, France
| | - Claire Mounier-Véhier
- Institut Cœur-Poumon, Médecine Vasculaire et HTA, CHU, Université Lille, EA 2694 - Santé Publique: Epidémiologie et Qualité des Soins Lille, Lille, France
| | - Geneviève Plu-Bureau
- Unité de Gynécologie Médicale, AP-HP, Hôpital Port-Royal, Université de Paris, Paris, France
| | - Sébastien Hascoet
- Pôle des Cardiopathies Congénitales du Nouveau-Né à L'adulte - Centre Constitutif Cardiopathies Congénitales Complexes M3C, Groupe Hospitalier Paris Saint-Joseph, Hôpital Marie-Lannelongue, Inserm U999, Université Paris-Saclay, Le Plessis-Robinson, France
| | - Bruno Ranchin
- Centre de Référence des Maladies Rénales Rares, Service de Néphrologie Rhumatologie et Dermatologie Pédiatriques, Filières Maladies Rares ORKID et ERK-Net, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France.,Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
| | | | - Laetitia Martinerie
- Centre de Reference des Maladies Rares de la Croissance et du Développement, Université de Paris, Endocrinologie et Diabétologie Pédiatrique, AP-HP, Hôpital Robert-Debré, Paris, France
| | - Jean Marc Boivin
- Département de Médecine Générale, Université de Lorraine, Inserm CIC-P Pierre Drouin Vandœuvre-Lès-Nancy, Vandœuvre-lès-Nancy, France
| | - Jean Pierre Fauvel
- Service de Néphrologie Hospices Civils, Hôpital Edouard Herriot, Lyon, France.,UMR CNRS 5558, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Justine Bacchetta
- Centre de Référence des Maladies Rénales Rares, Service de Néphrologie Rhumatologie et Dermatologie Pédiatriques, Filières Maladies Rares ORKID et ERK-Net, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France.,Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
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7
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Safety of Enalapril in Infants: Data from the Pediatric Heart Network Infant Single Ventricle Trial. J Pediatr 2020; 227:218-223. [PMID: 32768465 DOI: 10.1016/j.jpeds.2020.07.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the safety profile of angiotensin-converting enzyme inhibitor therapy in infants with single ventricle. STUDY DESIGN The Pediatric Heart Network conducted a double-blind trial involving infants with single ventricle physiology randomized to receive enalapril or placebo and followed to 14 months of age. Data including demographics, drug administration, hemodynamic monitoring, laboratory measurements, adverse events, and survival were extracted from the public use data set and compared between the placebo and enalapril-treated groups. RESULTS The Infant Single Ventricle trial randomized 230 patients, with 115 patients in each group. Initial enalapril dose was 0.10 mg/kg/d and median maximal dose was 0.38 mg/kg/d. There was no significant difference in change in blood pressure at study drug initiation or when resuming study drug after Glenn surgery. The incidence of hyperkalemia and neutropenia did not differ between groups. Renal dysfunction occurred in 3% of the enalapril group and none of the placebo patients, which was not statistically significant. There was a high frequency of serious adverse events in both groups. There was no difference in the frequency of heart transplant or death between groups. CONCLUSIONS Enalapril did not have sustained hemodynamic effects at initiation or up-titration of drug. Creatinine and potassium were not different between groups, although renal dysfunction occurred more often in the patients on enalapril. Although efficacy of enalapril in neonates with single ventricle has not been demonstrated, the safety profile of angiotensin-converting enzyme inhibitors appears to be low risk in infants and children with significant heart disease.
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8
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Smeets NJL, Schreuder MF, Dalinghaus M, Male C, Lagler FB, Walsh J, Laer S, de Wildt SN. Pharmacology of enalapril in children: a review. Drug Discov Today 2020; 25:S1359-6446(20)30336-6. [PMID: 32835726 DOI: 10.1016/j.drudis.2020.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/06/2020] [Accepted: 08/13/2020] [Indexed: 12/28/2022]
Abstract
Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that is used for the treatment of (paediatric) hypertension, heart failure and chronic kidney diseases. Because its disposition, efficacy and safety differs across the paediatric continuum, data from adults cannot be automatically extrapolated to children. This review highlights paediatric enalapril pharmacokinetic data and demonstrates that these are inadequate to support with certainty an age-related effect on enalapril/enalaprilat pharmacokinetics. In addition, our review shows that evidence to support effective and safe prescribing of enalapril in children is limited, especially in young children and heart failure patients; studies in these groups are either absent or show conflicting results. We provide explanations for observed differences between age groups and indications, and describe areas for future research.
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Affiliation(s)
- Nori J L Smeets
- Department of Pharmacology and Toxicology, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboud Institute of Molecular Sciences, Radboudumc Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Michiel Dalinghaus
- Department of Pediatric Cardiology, Erasmus MC - Sophia, Rotterdam, the Netherlands
| | - Christoph Male
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | | | | | - Stephanie Laer
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud Institute of Health Sciences, Radboudumc, Nijmegen, the Netherlands; Department of Intensive Care and Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, the Netherlands.
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9
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Siddiqi N, Shatat IF. Antihypertensive agents: a long way to safe drug prescribing in children. Pediatr Nephrol 2020; 35:2049-2065. [PMID: 31676933 PMCID: PMC7515858 DOI: 10.1007/s00467-019-04314-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/12/2019] [Accepted: 07/23/2019] [Indexed: 01/07/2023]
Abstract
Recently updated clinical guidelines have highlighted the gaps in our understanding and management of pediatric hypertension. With increased recognition and diagnosis of pediatric hypertension, the use of antihypertensive agents is also likely to increase. Drug selection to treat hypertension in the pediatric patient population remains challenging. This is primarily due to a lack of large, well-designed pediatric safety and efficacy trials, limited understanding of pharmacokinetics in children, and unknown risk of prolonged exposure to antihypertensive therapies. With newer legislation providing financial incentives for conducting clinical trials in children, along with publication of pediatric-focused guidelines, literature available for antihypertensive agents in pediatrics has increased over the last 20 years. The objective of this article is to review the literature for safety and efficacy of commonly prescribed antihypertensive agents in pediatrics. Thus far, the most data to support use in children was found for angiotensin-converting enzyme inhibitors (ACE-I), angiotensin receptor blockers (ARB), and calcium channel blockers (CCB). Several gaps were noted in the literature, particularly for beta blockers, vasodilators, and the long-term safety profile of antihypertensive agents in children. Further clinical trials are needed to guide safe and effective prescribing in the pediatric population.
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Affiliation(s)
- Nida Siddiqi
- Department of Pharmacy, Sidra Medicine, Doha, Qatar
| | - Ibrahim F. Shatat
- Pediatric Nephrology and Hypertension, Sidra Medicine, HB. 7A. 106A, PO Box 26999, Doha, Qatar ,Weill Cornell College of Medicine-Qatar, Ar-Rayyan, Qatar ,grid.259828.c0000 0001 2189 3475Medical University of South Carolina, Charleston, SC USA
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10
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Taylor-Zapata P, Baker-Smith CM, Burckart G, Daniels SR, Flynn JT, Giacoia G, Green D, Kelly AS, Khurana M, Li JS, Pratt C, Urbina EM, Zajicek A. Research Gaps in Primary Pediatric Hypertension. Pediatrics 2019; 143:peds.2018-3517. [PMID: 31023830 PMCID: PMC6564054 DOI: 10.1542/peds.2018-3517] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2019] [Indexed: 11/24/2022] Open
Abstract
Hypertension affects >40% of the US population and is a major contributor to cardiovascular-related morbidity and mortality. Although less common among children and adolescents, hypertension affects 1% to 5% of all youth. The 2017 Clinical Practice Guideline for the Diagnosis and Management of High Blood Pressure in Children and Adolescents provided updates and strategies regarding the diagnosis and management of hypertension in youth. Despite this important information, many gaps in knowledge remain, such as the etiology, prevalence, and trends of hypertension; the utility and practicality of ambulatory blood pressure monitoring; practical goals for lifestyle modification that are generalizable; the long-term end-organ impacts of hypertension in youth; and the long-term safety and efficacy of antihypertensive therapy in youth. The Eunice Kennedy Shriver National Institute of Child Health and Human Development, in collaboration with the National Heart, Lung, and Blood Institute and the US Food and Drug Administration, sponsored a workshop of experts to discuss the current state of childhood primary hypertension. We highlight the results of that workshop and aim to (1) provide an overview of current practices related to the diagnosis, management, and treatment of primary pediatric hypertension; (2) identify related research gaps; and (3) propose ways to address existing research gaps.
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Affiliation(s)
- Perdita Taylor-Zapata
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development,
| | | | - Gilbert Burckart
- Office of Clinical Pharmacology, Immediate Office of the Commissioner, and
| | - Stephen R. Daniels
- Department of Pediatrics, Section of Cardiology, School of Medicine, University of Colorado, Aurora, Colorado
| | - Joseph T. Flynn
- School of Medicine, University of Washington, Seattle, Washington
| | - George Giacoia
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | - Dionna Green
- Office of Clinical Pharmacology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Aaron S. Kelly
- Department of Pediatrics, Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Mona Khurana
- Division of Pediatric and Maternal Health, Office of New Drugs
| | - Jennifer S. Li
- Department of Pediatrics, Duke University, Durham, North Carolina; and
| | - Charlotte Pratt
- Clinical Applications and Prevention Branch, National Heart, Lung, and Blood Institute, and
| | - Elaine M. Urbina
- Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Anne Zajicek
- Office of Clinical Research Training and Medical Education, National Institutes of Health, Bethesda, Maryland
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Affiliation(s)
- I. V. Leontyeva
- Veltischev Research and Clinical Institute for Pediatrics of the Pirogov Russian National Research Medical University
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Fornari E, Maffeis C. Treatment of Metabolic Syndrome in Children. Front Endocrinol (Lausanne) 2019; 10:702. [PMID: 31681173 PMCID: PMC6803446 DOI: 10.3389/fendo.2019.00702] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 09/27/2019] [Indexed: 02/06/2023] Open
Abstract
The Metabolic Syndrome may be tentatively defined as the clustering of several metabolic risk factors in the same individual. A progressively higher number of children and adolescents is affected by this syndrome worldwide, mainly as a consequence of the constant increase of the prevalence of obesity and sedentary habits. As obesity, the chance that the metabolic syndrome traks into adulthood is high. Moreover, the evidence of an association between the duration of the exposition to metabolic risk factors and morbidity and mortality justifies early treatment and prevention of the metabolic syndrome in both children and adolescents. Treatment includes behavioral interventions, adequate nutrition and physical activity, and, if necessary, pharmacological treatments aimed at reducing excessive weight, dyslipidemia, hypertension, and glucose impairments. A multidisciplinary and staged approach to treatment, which includes pediatrician, mental health practitioner, dietician, and nurses, is crucial. Usually, the reduction of fat mass promotes an overall improvement of all the components of the metabolic syndrome. Nevertheless, every single component of the metabolic syndrome should be treated as quickly as possible, by using the best current practice. Drugs may be necessary for treating hypertension, type 2 diabetes mellitus and dyslipidemia. In selected cases of gross obesity resistant to treatment, surgical therapy may be also performed.
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Lou-Meda R, Stiller B, Antonio ZL, Zielinska E, Yap HK, Kang HG, Tan M, Glazer RD, Valentin MA, Wang L. Long-term safety and tolerability of valsartan in children aged 6 to 17 years with hypertension. Pediatr Nephrol 2019; 34:495-506. [PMID: 30397789 PMCID: PMC6349801 DOI: 10.1007/s00467-018-4114-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 09/28/2018] [Accepted: 10/05/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The present study aimed to assess the long-term safety and tolerability of valsartan in hypertensive children aged 6-17 years, with or without chronic kidney disease (CKD). METHODS This was an 18-month, open-label, multicentre, prospective study conducted in 150 patients with history of hypertension with or without CKD. The primary endpoint was long-term safety and tolerability of valsartan and valsartan-based treatments, assessed in terms of adverse events (AEs), serious AEs, laboratory measurements, estimated glomerular filtration rate (eGFR), urinalysis and electrocardiogram. RESULTS Of 150 enrolled patients, 117 (78%) completed the study. At week 78, a clinically and statistically significant reduction in mean sitting systolic and diastolic blood pressures was observed in all patients (- 14.9 mmHg and - 10.6 mmHg, respectively). Within the first 3 months of treatment, mean urine albumin creatinine ratio decreased in CKD population, which was sustained. A higher percentage of CKD patients had at least one AE compared to non-CKD patients (85.3% vs. 73.3%, respectively). The majority of AEs were mild (50.7%) or moderate (18.7%) in severity. As expected, in patients with underlying CKD, increases in serum potassium, creatinine and blood urea nitrogen were more commonly reported compared to non-CKD patients. A > 25% decrease in Schwartz eGFR was observed in 28.4% of CKD patients and 13.5% of non-CKD patients. CONCLUSIONS Valsartan was generally well tolerated, with an AE profile consistent with angiotensin receptor blockers in the overall population and in patients with underlying CKD. Long-term efficacy was maintained and a beneficial effect on proteinuria was observed.
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Affiliation(s)
- Randall Lou-Meda
- Fundación para el Niño Enfermo Renal/H. Roosevelt, 6 Avenida 9-18 zona 10 Edificio Sixtino II, Ala I, Oficina 804, Guatemala City, Guatemala.
| | - Brigitte Stiller
- University Heart Center Freiburg, Bad Krozingen, Department of Congenital Heart Fundación para el Niño Enfermo Renal Disease and Pediatric Cardiology, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Zenaida L Antonio
- Department of Pediatric Nephrology, National Kidney and Transplant Institute, Quezon City, Philippines
| | - Ewa Zielinska
- Niepubliczny Zakład Opieki Zdrowotnej, Ezmed, Warsaw, Poland
| | - Hui-Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Monique Tan
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | | | - Linda Wang
- Shanghai Novartis Trading Ltd, Shanghai, China
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Abstract
The prevalence of elevated blood pressure and hypertension in children and adolescents has increased over the past decade. This trend is most likely related to increases in primary hypertension associated with increasing obesity rates in children. Lifestyle as well as genetics play a significant role in the development of primary hypertension. Hypertension in children and adolescents is under-recognized and undertreated. The 2017 Revised Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents aimed to create new normative blood pressure tables using data from healthy weight children, meaning between the 5th and 85th percentile per the Centers for Disease Control and Prevention. Another important objective was to simplify normative data to ease screening and detection of elevated blood pressures. The consequences of chronic hypertension are significant, with its major affect being in poor cardiovascular health outcomes both in childhood and early adulthood. Challenges to detection and adequate treatment should be overcome with continued education and awareness to prevent the long-term effects of uncontrolled hypertension that starts in childhood. [Pediatr Ann. 2018;47(12):e499-e503.].
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2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens 2017; 34:1887-920. [PMID: 27467768 DOI: 10.1097/hjh.0000000000001039] [Citation(s) in RCA: 696] [Impact Index Per Article: 99.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.
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Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140:peds.2017-1904. [PMID: 28827377 DOI: 10.1542/peds.2017-1904] [Citation(s) in RCA: 1865] [Impact Index Per Article: 266.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.
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Affiliation(s)
- Joseph T Flynn
- Dr. Robert O. Hickman Endowed Chair in Pediatric Nephrology, Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - David C Kaelber
- Departments of Pediatrics, Internal Medicine, Population and Quantitative Health Sciences, Center for Clinical Informatics Research and Education, Case Western Reserve University and MetroHealth System, Cleveland, Ohio
| | - Carissa M Baker-Smith
- Division of Pediatric Cardiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Douglas Blowey
- Children's Mercy Hospital, University of Missouri-Kansas City and Children's Mercy Integrated Care Solutions, Kansas City, Missouri
| | - Aaron E Carroll
- Department of Pediatrics, School of Medicine, Indiana University, Bloomington, Indiana
| | - Stephen R Daniels
- Department of Pediatrics, School of Medicine, University of Colorado-Denver and Pediatrician in Chief, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah D de Ferranti
- Director, Preventive Cardiology Clinic, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Bonita Falkner
- Departments of Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan K Flinn
- Consultant, American Academy of Pediatrics, Washington, District of Columbia
| | - Samuel S Gidding
- Cardiology Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Celeste Goodwin
- National Pediatric Blood Pressure Awareness Foundation, Prairieville, Louisiana
| | - Michael G Leu
- Departments of Pediatrics and Biomedical Informatics and Medical Education, University of Washington, University of Washington Medicine and Information Technology Services, and Seattle Children's Hospital, Seattle, Washington
| | - Makia E Powers
- Department of Pediatrics, School of Medicine, Morehouse College, Atlanta, Georgia
| | - Corinna Rea
- Associate Director, General Academic Pediatric Fellowship, Staff Physician, Boston's Children's Hospital Primary Care at Longwood, Instructor, Harvard Medical School, Boston, Massachusetts
| | - Joshua Samuels
- Departments of Pediatrics and Internal Medicine, McGovern Medical School, University of Texas, Houston, Texas
| | - Madeline Simasek
- Pediatric Education, University of Pittsburgh Medical Center Shadyside Family Medicine Residency, Clinical Associate Professor of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vidhu V Thaker
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York; and
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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Hypertension Canada's 2017 Guidelines for the Diagnosis, Assessment, Prevention, and Treatment of Pediatric Hypertension. Can J Cardiol 2017; 33:577-585. [DOI: 10.1016/j.cjca.2017.03.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 03/08/2017] [Accepted: 03/08/2017] [Indexed: 12/18/2022] Open
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Snauwaert E, Vande Walle J, De Bruyne P. Therapeutic efficacy and safety of ACE inhibitors in the hypertensive paediatric population: a review. Arch Dis Child 2017; 102:63-71. [PMID: 27682140 DOI: 10.1136/archdischild-2016-310582] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 07/08/2016] [Accepted: 09/04/2016] [Indexed: 11/03/2022]
Abstract
PURPOSE Since 1997, strong incentives have been introduced worldwide to improve access to safe and effective medicines addressing the therapeutic needs of children. ACE inhibitors, the most prescribed antihypertensive drugs in the paediatric population, are one of the prototype drugs targeted by the legislation initiatives. Our purpose in assembling this review is to evaluate and describe the current evidence for the efficacy and safety profile of ACE inhibitors in the paediatric population. METHODS The authors made a descriptive review of the literature from 1980 to 2015 using the following search terms: hypertension, child, paediatric, ACE (inhibitors), renin-angiotensin aldosterone system, captopril, lisinopril, enalapril, ramipril and fosinopril. RESULTS A total of 16 studies evaluating efficacy and safety of ACE inhibitors were included in this review. The included studies demonstrate that ACE inhibitors have the potency to decrease the systolic and/or diastolic blood pressure with an overall favourable safety profile in a short-term period. More importantly, the incentives resulted in an improvement of the overall availability of paediatric labelling, dosing and safety information for ACE inhibitors. However, they failed to fulfil several of paediatric needs: absence of long-term safety data on growth and maturation, absence of commercially available child-friendly formulations and incomplete evaluation of the entire paediatric hypertension population. CONCLUSION Additional efforts are needed to close the gap between the availability of drugs that are labelled and indicated for paediatric use and the actual drug usage in children, especially in young children, neonates and children with severe hypertension, renal transplantation or severe renal impairment.
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Affiliation(s)
- Evelien Snauwaert
- Department of Paediatrics and Medical Genetics, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
| | | | - Pauline De Bruyne
- Department of Paediatrics and Medical Genetics, Faculty of Medicine and Health Science, Ghent University, Ghent, Belgium
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Ku LC, Zimmerman K, Benjamin DK, Clark RH, Hornik CP, Smith PB. Safety of Enalapril in Infants Admitted to the Neonatal Intensive Care Unit. Pediatr Cardiol 2017; 38:155-161. [PMID: 27826711 PMCID: PMC5288129 DOI: 10.1007/s00246-016-1496-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
Abstract
Enalapril is used to treat hypertension and congestive heart failure in infants. However, enalapril is not labeled for neonates, and safety data in infants are sparse. To evaluate the safety of enalapril in young infants, we conducted a retrospective cohort study of infants who were exposed to enalapril in the first 120 days of life and were cared for in 348 neonatal intensive care units from 1997 to 2012. We determined the proportion of exposed infants who developed adverse events, including death, hypotension requiring pressors, hyperkalemia, and elevated serum creatinine. Using multivariable logistic regression, we examined risk factors for adverse events, including postnatal age at first exposure, exposure duration, gestational age group, small for gestational age status, race, sex, 5-min Apgar score, and inborn status. Of a cohort of 887,910 infants, 662 infants (0.07%) were exposed to enalapril. Among exposed infants, 142 infants (21%) suffered an adverse event. The most common adverse event was hyperkalemia (13%), followed by elevated serum creatinine (5%), hypotension (4%), and death (0.5%). Significant risk factors for adverse events included postnatal age <30 days at first exposure and longer exposure duration. This study is the largest to date examining the safety of enalapril in young term and preterm infants without significant structural cardiac disease.
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Affiliation(s)
- Lawrence C Ku
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Box 17969, Durham, NC, 27715, USA
| | - Kanecia Zimmerman
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Box 17969, Durham, NC, 27715, USA
| | | | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL, USA
| | - Christoph P Hornik
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Box 17969, Durham, NC, 27715, USA
| | - P Brian Smith
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University School of Medicine, Box 17969, Durham, NC, 27715, USA.
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Tabatabaei-Malazy O, Nikfar S, Larijani B, Abdollahi M. Drugs for the treatment of pediatric type 2 diabetes mellitus and related co-morbidities. Expert Opin Pharmacother 2016; 17:2449-2460. [PMID: 27819155 DOI: 10.1080/14656566.2016.1258057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Malachias MVB, Koch V, Colombo C, Silva S, Guimarães ICB, Nogueira PK. 7th Brazilian Guideline of Arterial Hypertension: Chapter 10 - Hypertension in Children and Adolescents. Arq Bras Cardiol 2016; 107:53-63. [PMID: 27819389 PMCID: PMC5319464 DOI: 10.5935/abc.20160160] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Fischer K, Li C, Wang H, Song Y, Furth S, Tasian GE. Renal Parenchymal Area Growth Curves for Children 0 to 10 Months Old. J Urol 2016; 195:1203-8. [PMID: 26926532 DOI: 10.1016/j.juro.2015.08.097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2015] [Indexed: 12/17/2022]
Abstract
PURPOSE Low renal parenchymal area, which is the gross area of the kidney in maximal longitudinal length minus the area of the collecting system, has been associated with increased risk of end stage renal disease during childhood in boys with posterior urethral valves. To our knowledge normal values do not exist. We aimed to increase the clinical usefulness of this measure by defining normal renal parenchymal area during infancy. MATERIALS AND METHODS In a cross-sectional study of children with prenatally detected mild unilateral hydronephrosis who were evaluated between 2000 and 2012 we measured the renal parenchymal area of normal kidney(s) opposite the kidney with mild hydronephrosis. Measurement was done with ultrasound from birth to post-gestational age 10 months. We used the LMS method to construct unilateral, bilateral, side and gender stratified normalized centile curves. We determined the z-score and the centile of a total renal parenchymal area of 12.4 cm(2) at post-gestational age 1 to 2 weeks, which has been associated with an increased risk of kidney failure before age 18 years in boys with posterior urethral valves. RESULTS A total of 975 normal kidneys of children 0 to 10 months old were used to create renal parenchymal area centile curves. At the 97th centile for unilateral and single stratified curves the estimated margin of error was 4.4% to 8.8%. For bilateral and double stratified curves the estimated margin of error at the 97th centile was 6.6% to 13.2%. Total renal parenchymal area less than 12.4 cm(2) at post-gestational age 1 to 2 weeks had a z-score of -1.96 and fell at the 3rd percentile. CONCLUSIONS These normal renal parenchymal area curves may be used to track kidney growth in infants and identify those at risk for chronic kidney disease progression.
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Affiliation(s)
- Katherine Fischer
- Division of Urological Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chunming Li
- Center for Biomedical Image Analysis, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Huixuan Wang
- Center for Biomedical Image Analysis, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yihua Song
- Center for Biomedical Image Analysis, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan Furth
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gregory E Tasian
- Division of Urological Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Pediatric Urology, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
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Chaturvedi S, Lipszyc DH, Licht C, Craig JC, Parekh R. Pharmacological interventions for hypertension in children. ACTA ACUST UNITED AC 2015; 9:498-580. [PMID: 25236305 DOI: 10.1002/ebch.1974] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hypertension is a major risk factor for stroke, coronary artery disease and kidney damage in adults. There is a paucity of data on the long-term sequelae of persistent hypertension in children, but it is known that children with hypertension have evidence of end organ damage and are at risk of hypertension into adulthood. The prevalence of hypertension in children is rising, most likely due to a concurrent rise in obesity rates. In children with hypertension, non-pharmacological measures are often recommended as first-line therapy, but a significant proportion of children will eventually require pharmacological treatment to reduce blood pressure, especially those with evidence of end organ damage at presentation or during follow-up. A systematic review of the effects of antihypertensive agents in children has not previously been conducted. OBJECTIVES To determine the dose-related effects of different classes of antihypertensive medications, as monotherapy compared to placebo; as combination therapy compared to placebo or a single medication; or in comparisons of various doses within the same class, on systolic or diastolic blood pressure (or both) in children with hypertension. SEARCH METHODS We searched the Cochrane Hypertension Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 9), Ovid MEDLINE (1946 to October 2013), Ovid EMBASE (1974 to October 2013) and bibliographic citations. SELECTION CRITERIA The selection criteria were deliberately broad due to there being few clinical trials in children. We included randomised controlled trials (RCTs) of at least two weeks duration comparing antihypertensive agents either as monotherapy or combination therapy with either placebo or another medication, or comparing different doses of the same medication, in children with hypertension. Hypertension was defined as an average (over a minimum of three readings) systolic or diastolic blood pressure (or both) on the 95(th) percentile or above for age, height and gender. DATA COLLECTION AND ANALYSIS Two authors independently selected relevant studies, extracted data and assessed risk of bias. We summarised data, where possible, using a random-effects model. Formal assessment of heterogeneity was not possible because of insufficient data. MAIN RESULTS A total of 21 trials evaluated antihypertensive medications of various drug classes in 3454 hypertensive children with periods of follow-up ranging from three to 24 weeks. There were five RCTs comparing an antihypertensive drug directly with placebo, 12 dose-finding trials, two trials comparing calcium channel blockers with angiotensin receptor blockers, one trial comparing a centrally acting alpha blocker with a diuretic and one trial comparing an angiotensin-converting enzyme inhibitor with an angiotensin receptor blocker. No randomised trial was identified that evaluated the effectiveness of antihypertensive medications on target end organ damage. The trials were of variable quality and most were funded by pharmaceutical companies. Among the angiotensin receptor blockers, candesartan (one trial, n = 240), when compared to placebo, reduced systolic blood pressure by 6.50 mmHg (95% confidence interval (CI) -9.44 to -3.56) and diastolic blood pressure by 5.50 mmHg (95% CI -9.62 to -1.38) (low-quality evidence). High dose telmisartan (one trial, n = 76), when compared to placebo, reduced systolic blood pressure by -8.50 (95% CI -13.79 to -3.21) but not diastolic blood pressure (-4.80, 95% CI -9.50 to 0.10) (low-quality evidence). Beta blocker (metoprolol, one trial, n = 140), when compared with placebo , significantly reduced systolic blood pressure by 4.20 mmHg (95% CI -8.12 to -0.28) but not diastolic blood pressure (-3.20 mmHg 95% CI -7.12 to 0.72) (low-quality evidence). Beta blocker/diuretic combination (Bisoprolol/hydrochlorothiazide, one trial, n = 94)when compared with placebo , did not result in a significant reduction in systolic blood pressure (-4.0 mmHg, 95% CI -8.99 to -0.19) but did have an effect on diastolic blood pressure (-4.50 mmHg, 95% CI -8.26 to -0.74) (low-quality evidence). Calcium channel blocker (extended-release felodipine,one trial, n = 133) was not effective in reducing systolic blood pressure (-0.62 mmHg, 95% CI -2.97 to 1.73) or diastolic blood pressure (-1.86 mmHg, 95% CI -5.23 to 1.51) when compared with placebo. Further, there was no consistent dose response observed among any of the drug classes. The adverse events associated with the antihypertensive agents were mostly minor and included headaches, dizziness and upper respiratory infections. AUTHORS' CONCLUSIONS Overall, there are sparse data informing the use of antihypertensive agents in children, with outcomes reported limited to blood pressure and not end organ damage. The most data are available for candesartan, for which there is low-quality evidence of a modest lowering effect on blood pressure. We did not find evidence of a consistent dose response relationship for escalating doses of angiotensin receptor blockers, calcium channel blockers or angiotensin-converting enzyme inhibitors. All agents appear safe, at least in the short term.
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Affiliation(s)
- Swasti Chaturvedi
- Department of Paediatrics, Christian Medical College, Vellore, India.
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Maltz LA, Klugman D, Spaeder MC, Wessel DL. Off-label drug use in a single-center pediatric cardiac intensive care unit. World J Pediatr Congenit Heart Surg 2014; 4:262-6. [PMID: 24327493 DOI: 10.1177/2150135113481042] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The frequency of off-label drug use and its association with morbidity and mortality in the cardiac intensive care unit (CICU) has not been previously studied. METHODS Patients less than 18 years of age admitted to the CICU from June to August 2008 were retrospectively identified. Patient demographics were collected for 30 days or until CICU discharge. Off-label drug use was defined as the prescription of a medication that lacked a labeled indication based on patient's age as reported in the Micromedex drug database and electronic Physician's Desk Reference. RESULTS Eighty-two patients were admitted to the CICU during the study period. In all, 40 (46%) patients were male; the median age was 10.6 months. Common diagnoses were left-to-right shunt lesions (20.7%) and single-ventricle lesions (20.7%), with an overall mortality of 2.4%. Of all drugs prescribed, 36% were off-label. In all, 94% of the patients received ≥1 drug off-label. The median number of drugs prescribed off-label was four. Patients receiving more than four off-label medications were younger, had longer CICU lengths of stay (median 9.5 vs 2 days, P < .001), and increased ventilator days (median two vs one day, P < .001). CONCLUSIONS Off-label drug use in the CICU is common. Frequency of use is likely higher in patients with a higher severity of illness. Further safety, efficacy, and pharmaceutical trials are warranted to optimize the use of these drugs to improve outcomes.
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Affiliation(s)
- Lily A Maltz
- Department of Cardiology, Children's National Medical Center, Washington, DC, USA
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Moffett BS, DiSanto AR, Espinosa O, Hou J, Colabuono P. Bioequivalence of enalapril oral solution for treatment of pediatric hypertension and enalapril tablets. Clin Pharmacol Drug Dev 2014; 3:493-8. [DOI: 10.1002/cpdd.129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 04/30/2014] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Orlando Espinosa
- Bioanalytical Sciences; Worldwide Clinical Trials; Austin TX USA
| | - Jingguo Hou
- Bioanalytical Sciences; Worldwide Clinical Trials; Austin TX USA
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Rational use of antihypertensive medications in children. Pediatr Nephrol 2014; 29:979-88. [PMID: 23715784 DOI: 10.1007/s00467-013-2510-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 04/09/2013] [Accepted: 05/07/2013] [Indexed: 12/13/2022]
Abstract
Hypertension has traditionally been regarded as an uncommon diagnosis in childhood and adolescence; however, there is compelling evidence to suggest that its prevalence is on the rise, particularly in those with obesity. As a result, pediatricians increasingly are asked to evaluate and manage patients with elevated blood pressure. An increased emphasis on conducting drug trials in children over the last 15 years has yielded important advances with respect to evidence-based data regarding the efficacy and safety of antihypertensive medications in children and adolescents. Unfortunately, data to definitively guide selection of initial agents is lacking. This article will present guidelines for the appropriate use of antihypertensive medications in the pediatric population, including the rational approach to selecting an appropriate medication with respect to pathophysiology, putative benefit, and likelihood for side effects.
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Chaturvedi S, Lipszyc DH, Licht C, Craig JC, Parekh R. Pharmacological interventions for hypertension in children. Cochrane Database Syst Rev 2014; 2014:CD008117. [PMID: 24488616 PMCID: PMC11056235 DOI: 10.1002/14651858.cd008117.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hypertension is a major risk factor for stroke, coronary artery disease and kidney damage in adults. There is a paucity of data on the long-term sequelae of persistent hypertension in children, but it is known that children with hypertension have evidence of end organ damage and are at risk of hypertension into adulthood. The prevalence of hypertension in children is rising, most likely due to a concurrent rise in obesity rates. In children with hypertension, non-pharmacological measures are often recommended as first-line therapy, but a significant proportion of children will eventually require pharmacological treatment to reduce blood pressure, especially those with evidence of end organ damage at presentation or during follow-up. A systematic review of the effects of antihypertensive agents in children has not previously been conducted. OBJECTIVES To determine the dose-related effects of different classes of antihypertensive medications, as monotherapy compared to placebo; as combination therapy compared to placebo or a single medication; or in comparisons of various doses within the same class, on systolic or diastolic blood pressure (or both) in children with hypertension. SEARCH METHODS We searched the Cochrane Hypertension Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 9), Ovid MEDLINE (1946 to October 2013), Ovid EMBASE (1974 to October 2013) and bibliographic citations. SELECTION CRITERIA The selection criteria were deliberately broad due to there being few clinical trials in children. We included randomised controlled trials (RCTs) of at least two weeks duration comparing antihypertensive agents either as monotherapy or combination therapy with either placebo or another medication, or comparing different doses of the same medication, in children with hypertension. Hypertension was defined as an average (over a minimum of three readings) systolic or diastolic blood pressure (or both) on the 95(th) percentile or above for age, height and gender. DATA COLLECTION AND ANALYSIS Two authors independently selected relevant studies, extracted data and assessed risk of bias. We summarised data, where possible, using a random-effects model. Formal assessment of heterogeneity was not possible because of insufficient data. MAIN RESULTS A total of 21 trials evaluated antihypertensive medications of various drug classes in 3454 hypertensive children with periods of follow-up ranging from three to 24 weeks. There were five RCTs comparing an antihypertensive drug directly with placebo, 12 dose-finding trials, two trials comparing calcium channel blockers with angiotensin receptor blockers, one trial comparing a centrally acting alpha blocker with a diuretic and one trial comparing an angiotensin-converting enzyme inhibitor with an angiotensin receptor blocker. No randomised trial was identified that evaluated the effectiveness of antihypertensive medications on target end organ damage. The trials were of variable quality and most were funded by pharmaceutical companies.Among the angiotensin receptor blockers, candesartan (one trial, n = 240), when compared to placebo, reduced systolic blood pressure by 6.50 mmHg (95% confidence interval (CI) -9.44 to -3.56) and diastolic blood pressure by 5.50 mmHg (95% CI -9.62 to -1.38) (low-quality evidence). High dose telmisartan (one trial, n = 76), when compared to placebo, reduced systolic blood pressure by -8.50 (95% CI -13.79 to -3.21) but not diastolic blood pressure (-4.80, 95% CI -9.50 to 0.10) (low-quality evidence). Beta blocker (metoprolol, one trial, n = 140), when compared with placebo , significantly reduced systolic blood pressure by 4.20 mmHg (95% CI -8.12 to -0.28) but not diastolic blood pressure (-3.20 mmHg 95% CI -7.12 to 0.72) (low-quality evidence). Beta blocker/diuretic combination (Bisoprolol/hydrochlorothiazide, one trial, n = 94)when compared with placebo , did not result in a significant reduction in systolic blood pressure (-4.0 mmHg, 95% CI -8.99 to -0.19) but did have an effect on diastolic blood pressure (-4.50 mmHg, 95% CI -8.26 to -0.74) (low-quality evidence). Calcium channel blocker (extended-release felodipine,one trial, n = 133) was not effective in reducing systolic blood pressure (-0.62 mmHg, 95% CI -2.97 to 1.73) or diastolic blood pressure (-1.86 mmHg, 95% CI -5.23 to 1.51) when compared with placebo. Further, there was no consistent dose response observed among any of the drug classes. The adverse events associated with the antihypertensive agents were mostly minor and included headaches, dizziness and upper respiratory infections. AUTHORS' CONCLUSIONS Overall, there are sparse data informing the use of antihypertensive agents in children, with outcomes reported limited to blood pressure and not end organ damage. The most data are available for candesartan, for which there is low-quality evidence of a modest lowering effect on blood pressure. We did not find evidence of a consistent dose response relationship for escalating doses of angiotensin receptor blockers, calcium channel blockers or angiotensin-converting enzyme inhibitors. All agents appear safe, at least in the short term.
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Affiliation(s)
- Swasti Chaturvedi
- Christian Medical CollegeDepartment of PaediatricsIda Scudder RoadVelloreTamil NaduIndia632004
| | - Deborah H Lipszyc
- Hospital for Sick ChildrenInstitute of Medical ScienceUniversity of Toronto555 University AvenueTorontoONCanadaM5G 1X8
| | - Christoph Licht
- Hospital for Sick ChildrenDepartment of Nephrology555 University AvenueTorontoONCanadaM5G 1X8
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
| | - Rulan Parekh
- Hospital for Sick ChildrenDepartment of PaediatricsTorontoONCanada
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Sunkara G, Bende G, Mendonza AE, Solar-Yohay S, Biswal S, Neelakantham S, Wagner R, Flarakos J, Zhang Y, Jarugula V. Bioavailability of valsartan oral dosage forms. Clin Pharmacol Drug Dev 2013; 3:132-8. [DOI: 10.1002/cpdd.56] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 07/15/2013] [Indexed: 11/06/2022]
Affiliation(s)
| | - Girish Bende
- Novartis Institutes for Biomedical Research; Hyderabad India
| | | | | | - Shibadas Biswal
- Novartis Institutes for Biomedical Research; Hyderabad India
| | | | - Robert Wagner
- Novartis Pharmaceuticals Corporation; East Hanover NJ USA
| | - Jimmy Flarakos
- Novartis Institutes for Biomedical Research; East Hanover NJ USA
| | - Yiming Zhang
- Novartis Pharmaceuticals Corporation; East Hanover NJ USA
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Treatment of Pediatric Hypertension: Lessons Learned from Recent Studies. CURRENT CARDIOVASCULAR RISK REPORTS 2013. [DOI: 10.1007/s12170-013-0336-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Litwin M, Michałkiewicz J, Gackowska L. Primary hypertension in children and adolescents is an immuno-metabolic disease with hemodynamic consequences. Curr Hypertens Rep 2013; 15:331-9. [PMID: 23737217 PMCID: PMC3712132 DOI: 10.1007/s11906-013-0360-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
With the rise in obesity epidemic primary hypertension (PH) is now one of the most common chronic diseases in adolescence. In contrast to hypertensive adults, hypertensive children usually are not exposed to other comorbidities such as diabetes, chronic kidney disease and atherosclerosis. Thus, PH in children and adolescents can be treated as the early stage of development of cardiovascular disease. There is increasing amount of data indicating that PH is not only hemodynamic phenomenon but a complex syndrome involving disturbed activity of sympathetic nervous system, metabolic abnormalities and activation of innate and adaptive immune system. We discuss results of the studies on clinical, metabolic and immunological phenotype of hypertensive children, associations between metabolic and immunological abnormalities with target organ damage and results of antihypertensive treatment.
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Affiliation(s)
- Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children's Memorial Health Institute, Warsaw, Poland.
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Efficacy and safety of valsartan in hypertensive children 6 months to 5 years of age. J Hypertens 2013; 31:993-1000. [DOI: 10.1097/hjh.0b013e32835f5721] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Batisky DL. What is the optimal first-line agent in children requiring antihypertensive medication? Curr Hypertens Rep 2013; 14:603-7. [PMID: 22986908 DOI: 10.1007/s11906-012-0302-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
There has been an evolution in the understanding of the treatment of hypertension in children and adolescents over the past decade. This has been fueled in part by the increased attention paid to the clinical problem, given the increasing numbers of children and adolescents being diagnosed with this condition. There has also been a growing number of clinical trials performed and completed that demonstrate the blood pressure (BP)-lowering effects of antihypertensives and the side effect profiles of these medications, and that has led to FDA-labeling of many antihypertensive medications for use in children and adolescents. However, none of these trials has provided definitive data on the optimal first line agent for this patient population. Clinical experience and other approaches discussed in this review are still necessary to guide treatment of hypertension in the young. The quest for the optimal antihypertensive agent is just beginning, and it is going to take some extraordinary effort to reach that goal.
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Affiliation(s)
- Donald L Batisky
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Abstract
PURPOSE OF REVIEW This review summarizes recent insights into the epidemiology of primary hypertension in children, with emphasis on the most important risk factors for the development of hypertension, and also updates current options for treating primary hypertension in children. RECENT FINDINGS There is growing evidence that the prevalence of hypertension has increased over the past decade and that the epidemic of obesity has played a key role in the increase of blood pressure (BP) in the USA and abroad. Recent studies have shown that in addition to obesity, environmental factors such as second-hand smoking and sedentary lifestyle are important in development of hypertension even in preschool age children. Studies also have confirmed the effect of vegetables and fruits on lowering BP. Recent clinical trials of valsartan and olmesartan have provided efficacy and safety information for use in children. SUMMARY The increased prevalence of hypertension in children in recent years emphasizes the need for a more aggressive approach to screen and diagnose elevated BP even in early childhood. Early initiation of treatment is important to decrease the risk of cardiovascular morbidity in adulthood.
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Abstract
Valsartan is an oral angiotensin II subtype 1 receptor antagonist with well established antihypertensive efficacy in adults. It is now approved in the EU and the US for the treatment of hypertension in children and adolescents. In two, randomized, double-blind trials, a once-daily regimen of valsartan reduced the blood pressure (BP) of children and adolescents with hypertension. In one trial in hypertensive children and adolescents aged 6-16 years, significant dose-dependent reductions from baseline in mean sitting systolic BP (msSBP) were observed for recipients of valsartan following 2 weeks' treatment (primary endpoint). There were corresponding dose-dependent and significant reductions in mean sitting diastolic BP. Following 2 further weeks of treatment, the reduction in msSBP was maintained in patients who were re-randomized to continue receiving the same dosage of valsartan but not in those re-randomized to placebo. In the other trial in hypertensive children and adolescents aged 6-17 years, valsartan was no less effective than enalapril in reducing BP. Following 12 weeks' treatment, the least square mean reduction from baseline in msSBP (primary endpoint) in recipients of valsartan was noninferior to that in recipients of enalapril. In addition, the proportion of patients achieving an msSBP <95th percentile for age, sex, and height at week 12 was not significantly different between recipients of valsartan and enalapril (67% vs 70%). Treatment with valsartan for up to 52 weeks was well tolerated in children and adolescents with hypertension.
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