1
|
Shah SS, Zhang J, Gwini SM, Young MJ, Fuller PJ, Yang J. Efficacy and safety of mineralocorticoid receptor antagonists for the treatment of low-renin hypertension: a systematic review and meta-analysis. J Hum Hypertens 2024; 38:383-392. [PMID: 38200100 PMCID: PMC11076210 DOI: 10.1038/s41371-023-00891-1] [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: 07/18/2023] [Revised: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 01/12/2024]
Abstract
Hypertension is the leading risk factor for premature death. The optimal treatment of low-renin hypertension (LRH), present in 30% of hypertensive individuals, is not known. LRH likely reflects a state of excess salt, expanded volume and/or mineralocorticoid receptor (MR) activation. Therefore, targeted treatment with MR antagonists (MRA) may be beneficial. The objective of this systematic review was to assess the efficacy of MRA therapy in LRH. MEDLINE, Embase and Cochrane databases were searched for randomised controlled trials of adults with LRH that compared the efficacy of MRA to placebo or other antihypertensive treatments. Risk of bias was assessed using the Cochrane risk of bias tool. A meta-analysis was performed using a random-effects model to estimate the difference in blood pressure and the certainty of evidence was assessed using the GRADE approach. The protocol is registered on PROSPERO (CRD42022318763). From the 1612 records identified, 17 studies met the inclusion criteria with a total sample size of 1043 participants. Seven studies (n = 345) were assessed as having a high risk of bias. Meta-analysis indicated that MRA reduced systolic blood pressure by -6.8 mmHg (95% confidence interval -9.6 to -4.1) and -4.8 mmHg (95% confidence interval -11.9 to 2.4) compared to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) and diuretics. The certainty of the evidence was assessed as moderate and very low, respectively. The findings of this systematic review suggest that MRA is effective in lowering blood pressure in LRH and may be better than ACEi/ARB. Translation to clinical practice is limited by the uncertainty of evidence.
Collapse
Affiliation(s)
- Sonali S Shah
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Vic, Australia
- Department of Endocrinology, Monash Health, Clayton, Vic, Australia
- Department of Molecular and Translational Science, Monash University, Clayton, Vic, Australia
| | - Jinghong Zhang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Vic, Australia
| | - Stella May Gwini
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Vic, Australia
| | - Morag J Young
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Vic, Australia
| | - Peter J Fuller
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Vic, Australia
- Department of Endocrinology, Monash Health, Clayton, Vic, Australia
- Department of Molecular and Translational Science, Monash University, Clayton, Vic, Australia
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Vic, Australia.
- Department of Endocrinology, Monash Health, Clayton, Vic, Australia.
- Department of Molecular and Translational Science, Monash University, Clayton, Vic, Australia.
| |
Collapse
|
2
|
Han E, Prausmüller S, Weidenhammer A, Spinka G, Arfsten H, Bartko PE, Goliasch G, Hülsmann M, Pavo N. Renin Trajectories and Outcome in Stable Heart Failure with Reduced Ejection Fraction (HFrEF) on Contemporary Therapy: A Monocentric Study from an Austrian Tertiary Hospital Outpatient Clinic. J Renin Angiotensin Aldosterone Syst 2023; 2023:8883145. [PMID: 37941680 PMCID: PMC10630017 DOI: 10.1155/2023/8883145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/12/2023] [Accepted: 10/14/2023] [Indexed: 11/10/2023] Open
Abstract
Introduction The renin-angiotensin system (RAS) is the main target of neurohumoral therapy in heart failure with reduced ejection fraction (HFrEF) effectively reducing mortality. Reasonably, renin might serve as a biomarker for risk prediction and therapy response. Renin indeed bears some additional value to clinical risk models, albeit the effect is not pronounced. Whether assessing renin trajectories can overcome the weaknesses of single renin measurements has not been reported. Methods A total of 505 patients with stable HFrEF were enrolled prospectively and followed through routine clinical visits. Active plasma renin concentration was documented up to 5 years. Changes in renin were analyzed throughout the disease course, and survival was compared for different renin trajectories within the first year. Results Baseline renin levels were not related to all-cause mortality (crude HR for an increase of 100 μiE/ml: 1.01 (95% CI: 0.99-1.02), p = 0.414) but associated with unplanned HF hospitalizations (crude HR: 1.01 (95% CI: 1.00-1.02), p = 0.015). Renin increased during the disease course from baseline to 1-year and 2-year FUP (122.7 vs. 185.6 μIU/ml, p = 0.039, and 122.7 vs. 258.5 μIU/ml, p = 0.001). Both survival and unplanned HF hospitalization rates were comparable for different renin trajectories at 1-year FUP (p = 0.546, p = 0.357). Conclusions Intriguingly, renin is not a good biomarker to indicate prognosis in HF, while renin trajectories over a 1-year period do not have an additional value. Rapid physiologic plasma renin variations, but also opposing effects of angiotensinogen-derived metabolites under presence of RAS blockade, might obscure the predictive ability of renin.
Collapse
Affiliation(s)
- Emilie Han
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Suriya Prausmüller
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Annika Weidenhammer
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Georg Spinka
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Henrike Arfsten
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Philipp E. Bartko
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| | - Noemi Pavo
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria
| |
Collapse
|
3
|
Clinical effect of nonsteroidal mineralocorticoid receptor (MR) antagonists in the treatment of diabetic kidney disease: expectations as a new therapeutic strategy. Hypertens Res 2022; 45:1310-1321. [PMID: 35726084 DOI: 10.1038/s41440-022-00940-1] [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: 01/30/2022] [Revised: 03/25/2022] [Accepted: 04/11/2022] [Indexed: 11/08/2022]
Abstract
Diabetes mellitus is the main cause of chronic kidney disease (CKD) in Japan and worldwide. Although angiotensin-converting enzyme (ACE) inhibitors and angiotensin II type 1 receptor blockers (ARBs) are basic drugs for the treatment of CKD with diabetes (diabetic kidney disease, DKD) with albuminuria and/or proteinuria, it has also become clear that the use of an ACE inhibitor or ARB alone is not fully sufficient. We have previously reported the clinical effects of mineralocorticoid receptor (MR) antagonists and recommended their use in addition to renin-angiotensin system inhibitors. Recently, new types of nonsteroidal MR antagonists have been developed, and the results of a large-scale study are expected. Nonsteroidal MR antagonists are distributed in the heart, lungs, liver, and kidneys when administered orally and are characterized by their equivalent distribution between the heart (nonepithelial tissue) and kidneys (epithelial tissue). We summarize the latest evidence regarding the use of nonsteroidal MR antagonists in the treatment of DKD. Hyperkalemia and renal dysfunction are frequent during MR antagonist treatment. However, with careful and combined monitoring of these two conditions, the effectiveness of MR antagonists will not be diminished; conversely, it is apparent that patients at such risk will benefit more from the addition of an MR antagonist to the treatment regimen. The most important measure against hyperkalemia is the regular monitoring of serum potassium levels and renal function. The safest and most reliable measure against hyperkalemia is the combined use of a new oral potassium adsorbent that has high potassium selectivity and few side effects. In DKD treatment, it is important to continue using MR antagonists without interruption as much as possible.
Collapse
|
4
|
McNally RJ, Farukh B, Chowienczyk PJ, Faconti L. Effect of diuretics on plasma aldosterone and potassium in primary hypertension: A systematic review and meta-analysis. Br J Clin Pharmacol 2022; 88:1964-1977. [PMID: 34820874 DOI: 10.1111/bcp.15156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 11/01/2021] [Accepted: 11/13/2021] [Indexed: 12/18/2022] Open
Abstract
AIM By contrast with drugs inhibiting the renin-angiotensin-aldosterone system (RAAS), diuretics stimulate renin release by the kidneys. Although plasma aldosterone (PA) is thought to be mainly regulated by RAAS activity, serum potassium has been shown to be an important factor in animal models and humans. Here we perform a systematic review and meta-analysis of randomised controlled trials (RCT) in hypertension investigating the effects of diuretic therapy on PA and the correlation of change in PA with that of potassium and blood pressure (BP). METHODS Three databases were searched: MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). Titles were first screened by title and abstract for relevance before full-text articles were assessed for eligibility according to a predefined inclusion/exclusion criteria. RESULTS A total of 1139 articles were retrieved, of which 42 met the prespecified inclusion/exclusion criteria. The average standardised difference in mean PA was similar for all classes of diuretic: thiazide/thiazide-like 0.299 (95% confidence interval [CI] 0.150, 0.447), loop 0.927 (0.37, 1.49), MRA/potassium-sparing 0.265 (0.173, 0.357) and combination 0.466 (0.137, 0.796), Q = 6.33, P = .097. In subjects untreated with another antihypertensive, there was a significant relationship between change in PA and change in systolic BP but no relationship with the change in potassium. CONCLUSION In RCTs of diuretic therapy in hypertension, there is an increase in PA with all classes of diuretic and no significant between-class heterogeneity. Change in PA is not related with potassium but correlates with the change in BP in subjects untreated with another antihypertensive medication.
Collapse
Affiliation(s)
- Ryan J McNally
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK
| | - Bushra Farukh
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK
| | - Philip J Chowienczyk
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK
| | - Luca Faconti
- Department of Clinical Pharmacology, King's College London British Heart Foundation Centre, London, UK
| |
Collapse
|
5
|
Morimoto S, Ichihara A. Efficacy of esaxerenone-a nonsteroidal mineralocorticoid receptor blocker-on nocturnal hypertension. Hypertens Res 2021; 45:376-377. [PMID: 34837032 DOI: 10.1038/s41440-021-00803-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Satoshi Morimoto
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo, Japan.
| | - Atsuhiro Ichihara
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo, Japan
| |
Collapse
|
6
|
Takahashi M, Ubukata O, Homma T, Asoh Y, Honzumi M, Hayashi N, Saito K, Tsuruoka H, Aoki K, Hanzawa H. Crystal structure of the mineralocorticoid receptor ligand-binding domain in complex with a potent and selective nonsteroidal blocker, esaxerenone (CS-3150). FEBS Lett 2020; 594:1615-1623. [PMID: 31991486 DOI: 10.1002/1873-3468.13746] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/08/2020] [Accepted: 01/15/2020] [Indexed: 12/24/2022]
Abstract
Activation of the mineralocorticoid receptor (MR) has long been considered a risk factor for cardiovascular diseases. It has been reported that the novel MR blocker esaxerenone shows high potency and selectivity for MR in vitro as well as great antihypertensive and renoprotective effects in salt-sensitive hypertensive rats. Here, we determined the cocrystal structure of the MR ligand-binding domain (MR-LBD) with esaxerenone and found that esaxerenone binds to MR-LBD in a unique manner with large side-chain rearrangements, distinct from those of previously published MR antagonists. This structure also displays an antagonist form that has not been observed for MR previously. Such a unique binding mode of esaxerenone provides great insight into the novelty, potency, and selectivity of this novel antihypertensive drug.
Collapse
Affiliation(s)
- Mizuki Takahashi
- Structure-Based Drug Design Group, Organic Synthesis Department, Daiichi Sankyo RD Novare Co., Ltd., Tokyo, Japan
| | - Osamu Ubukata
- Protein Production Research Group, Biological Research Department, Daiichi Sankyo RD Novare Co., Ltd., Tokyo, Japan
| | - Tsuyoshi Homma
- Global Project Management Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Yusuke Asoh
- IT Strategy Department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Masatoshi Honzumi
- Process Technology Research Laboratories, Daiichi Sankyo Co., Ltd., Kanagawa, Japan
| | - Noriyuki Hayashi
- Medicinal Chemistry Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Keiji Saito
- Medicinal Chemistry Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Hiroyuki Tsuruoka
- Intellectual property department, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Kazumasa Aoki
- Medicinal Chemistry Research Laboratories, Daiichi Sankyo Co., Ltd., Tokyo, Japan
| | - Hiroyuki Hanzawa
- Structure-Based Drug Design Group, Organic Synthesis Department, Daiichi Sankyo RD Novare Co., Ltd., Tokyo, Japan
| |
Collapse
|
7
|
Effect of mineralocorticoid antagonists on blood pressure lowering: overview and meta-analysis of randomized controlled trials in hypertension. J Hypertens 2019; 36:987-994. [PMID: 29356711 DOI: 10.1097/hjh.0000000000001671] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Although mineralocorticoid antagonists (MRAs) have been proposed as effective fourth-line blood pressure (BP)-lowering agents in resistant hypertension, this effect in hypertension at-large is unclear. We evaluated whether MRAs-mediated BP lowering is both effective and safe against controls and whether the extent of BP lowering differs between resistant hypertension and nonresistant hypertension . METHODS We searched Medline and the Cochrane Collaboration Library databases from 1991 to mid-September 2017 for randomized controlled trials (RCTs), in which MRAs were compared with placebo or other active drugs. Main outcomes were SBP and DBP lowering and treatment-related discontinuations. Continuous outcome variables were pooled as mean difference and the categorical variables as risk ratios, both with 95% confidence interval (CI). The risk of bias was assessed by using the Cochrane collaboration tool. RESULTS We included 21 RCTs (2736 patients) of MRAs compared either with placebo or with active agents. Whenever all selected trials were analyzed together (MRAs versus controls), the resulting BP reduction was -7.6 (95% CI -10 to -5.3) mmHg for SBP and -2.5 (95% CI -4.2 to -0.8) mmHg for DBP, while limiting our analysis to MRAs versus placebo mean difference was increased by -2.1/-1.3 mmHg. We find no differential BP lowering between resistant hypertension and non-resistant hypertension. Treatment-related discontinuations were not different compared with either placebo or active comparators. CONCLUSION As the extent of BP lowering following treatment with MRAs in patients with and without resistant hypertension was similar and not accompanied by increased rate of treatment-related discontinuations compared with other active comparators, these agents may have a role in BP lowering in already treated hypertensive patients who did not reach target BP values.
Collapse
|
8
|
Adachi H, Kakuma T, Kawaguchi M, Kumagai E, Fukumoto Y. Effects of eplerenone on blood pressure and glucose metabolism in Japanese hypertensives with overweight or obesity. Medicine (Baltimore) 2019; 98:e14994. [PMID: 30985644 PMCID: PMC6485869 DOI: 10.1097/md.0000000000014994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The impact of aldosterone blockade using eplerenone on hypertensives with obesity has not been clarified. We compared the efficacy and safety between eplerenone and trichlormethiazide in hypertensives with overweight or obesity. METHODS A prospective, randomized, open-labeled, blinded-endpoint design, multicenter trial enrolled 204 hypertension-treated outpatients with obesity [body mass index (BMI) ≥25 kg/m] evaluated by ambulatory blood pressure (BP) measurement. Patients were randomly assigned to receive 50 mg of eplerenone (n = 102) or 1 mg of trichlormethiazide (n = 102), each of which were administered once every morning. Primary efficacy endpoints were systolic and diastolic BPs and biomarkers of glucose metabolism after 6 months of treatment. RESULTS At baseline, BPs were comparable between the two groups. Systolic/diastolic blood pressure (SBP/DBP) were reduced from 153.9 ± 12.6/84.6 ± 11.8 to 129.8 ± 14.2/73.7 ± 12.2 mm Hg by eplerenone therapy and from 152.2 ± 12.5/85.2 ± 10.9 to 133.8 ± 12.6/76.1 ± 8.6 mm Hg by trichlormethiazide therapy (all; P < .001). The efficacy of SBP reduction after adjustment for age, sex, and BMI was significantly greater in the eplerenone group than the trichlormethiazide (P = .034), although the efficacy of DBP reduction was marginally significant (P = .072). Especially, the efficacy of BP reduction was more effective for aged over 65 years than less than 65 years. However, biomarkers of glucose metabolism were not significantly different between these 2 groups. CONCLUSION The eplerenone therapy was more effective in BP lowering in hypertensives with overweight or obesity than the trichlormethiazide therapy, especially in the elderly.
Collapse
Affiliation(s)
- Hisashi Adachi
- Department of Community Medicine, Kurume University School of Medicine
- Division of Cardio-Vascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | | | | | - Eita Kumagai
- Division of Cardio-Vascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Yoshihiro Fukumoto
- Division of Cardio-Vascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | | |
Collapse
|
9
|
Yamada M, Mendell J, Takakusa H, Shimizu T, Ando O. Pharmacokinetics, Metabolism, and Excretion of [ 14C]Esaxerenone, a Novel Mineralocorticoid Receptor Blocker in Humans. Drug Metab Dispos 2018; 47:340-349. [PMID: 30541878 DOI: 10.1124/dmd.118.084897] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/05/2018] [Indexed: 11/22/2022] Open
Abstract
Esaxerenone (CS-3150) is a novel, nonsteroidal, selective mineralocorticoid receptor blocker. The absorption, metabolism, distribution, and excretion of esaxerenone were assessed in in vitro studies and in a clinical study, where [14C]esaxerenone (150 μCi/20 mg) was administered orally to six healthy male subjects. The plasma concentrations of esaxerenone and its metabolites (M4, M11, and M1) were measured using liquid chromatography-tandem mass spectrometry. The recovery of radioactivity was 92.5%, with 38.5% and 54.0% excreted in the urine and feces, respectively. The half-life of radioactivity in blood and plasma was approximately 30 hours, similar to that of the unchanged form in plasma. The blood-to-plasma ratio was 0.628, demonstrating low partitioning to blood components. In plasma, esaxerenone was the most abundant moiety (40.8%), followed by O-glucuronide (21.4%; M4), acyl-glucuronide of amide-bond hydrolysate (8.0%; M11), and the deshydroxyethyl form (1.7%; M1). In vitro studies showed that esaxerenone was a substrate of CYP3A and multiple UDP-glucuronosyltransferase isoforms. Oxidation contributed approximately 30% to its clearance, as indicated by the excretion ratio of oxidized metabolites into urine and feces. Caco-2 studies showed that esaxerenone was a substrate of P-glycoprotein and breast cancer resistance protein; however, the excretion ratios of the unchanged form in the feces and urine were 18.7% and 1.6%, respectively, indicating that these transporters were not important for the absorption and elimination of esaxerenone. Low urinary excretion of esaxerenone suggested that the plasma exposure of esaxerenone was not affected by renal dysfunction. Multiple elimination pathways including oxidation, glucuronidation, and hydrolysis, and the low contribution of transporters, indicated limited drug-drug interaction potential.
Collapse
Affiliation(s)
- Makiko Yamada
- Drug Metabolism and Pharmacokinetics Research Laboratories (M.Y., H.T., O.A.) and Clinical Pharmacology Department (T.S.), Daiichi Sankyo Co., Ltd., Tokyo, Japan; and Daiichi Sankyo Pharma Development, Basking Ridge, New Jersey (J.M.)
| | - Jeanne Mendell
- Drug Metabolism and Pharmacokinetics Research Laboratories (M.Y., H.T., O.A.) and Clinical Pharmacology Department (T.S.), Daiichi Sankyo Co., Ltd., Tokyo, Japan; and Daiichi Sankyo Pharma Development, Basking Ridge, New Jersey (J.M.)
| | - Hideo Takakusa
- Drug Metabolism and Pharmacokinetics Research Laboratories (M.Y., H.T., O.A.) and Clinical Pharmacology Department (T.S.), Daiichi Sankyo Co., Ltd., Tokyo, Japan; and Daiichi Sankyo Pharma Development, Basking Ridge, New Jersey (J.M.)
| | - Takako Shimizu
- Drug Metabolism and Pharmacokinetics Research Laboratories (M.Y., H.T., O.A.) and Clinical Pharmacology Department (T.S.), Daiichi Sankyo Co., Ltd., Tokyo, Japan; and Daiichi Sankyo Pharma Development, Basking Ridge, New Jersey (J.M.)
| | - Osamu Ando
- Drug Metabolism and Pharmacokinetics Research Laboratories (M.Y., H.T., O.A.) and Clinical Pharmacology Department (T.S.), Daiichi Sankyo Co., Ltd., Tokyo, Japan; and Daiichi Sankyo Pharma Development, Basking Ridge, New Jersey (J.M.)
| |
Collapse
|
10
|
Fernet M, Beckerman B, Abreu P, Lins K, Vincent J, Burgess E. Antihypertensive effect of the mineralocorticoid receptor antagonist eplerenone: a pooled analysis of patient-level data from comparative trials using regulatory-approved doses. Vasc Health Risk Manag 2018; 14:233-246. [PMID: 30275698 PMCID: PMC6157540 DOI: 10.2147/vhrm.s170141] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose Several options are available for the treatment of hypertension; however, many treated patients are still not below blood pressure (BP) target. Eplerenone, a selective mineralocorticoid receptor antagonist, is an approved treatment option for the management of patients with hypertension in a number of countries. This patient-level pooled analysis was conducted to document the efficacy and safety/tolerability of eplerenone at the dosages approved for use in hypertension in comparison to placebo or other approved antihypertensive agents. Methods Seventeen Phase III studies conducted in patients with mild-to-moderate hypertension in the Eplerenone Hypertension Clinical Program were reviewed; eleven met the selection criteria. The primary endpoint was change from baseline in seated diastolic BP and seated systolic BP measured at the end of the study. Results A total of 2,698 patients were included in this per-protocol analysis. In patients treated for at least 6 weeks with a stable dose of eplerenone, doses of 50 mg daily and 100 mg daily were associated with greater reductions of seated systolic BP and seated diastolic BP compared with placebo (P<0.001) and active-controlled studies (P< 0.033). In the analysis of covariance model testing of the contribution of four factors (age, body mass index [BMI], history of cardiovascular disease, and diabetes) on the BP lowering effects of eplerenone, only BMI and age were associated with small though statistically significant changes in BP (<0.2 mmHg). Eplerenone was well tolerated; headache was the most common adverse event for patients in any group. Severe hyperkalemia (serum potassium level >6.0 mmol/L) occurred in up to 0.4% in the eplerenone groups, 0.4% in the placebo group, and 0.1% in the active-control group. Conclusion This patient-level pooled analysis provides robust evidence that eplerenone, at 50 mg or 100 mg daily, was effective in lowering BP in patients with mild-to-moderate hypertension and was well tolerated.
Collapse
Affiliation(s)
- Mireille Fernet
- Department of Medical Affairs, Pfizer Canada Inc., Kirkland, QC, Canada
| | - Bruce Beckerman
- Department of Clinical Affairs, Pfizer Inc., New York, NY, USA
| | - Paula Abreu
- Department of Clinical Affairs, Pfizer Inc., New York, NY, USA
| | - Katharina Lins
- Department of Medical Affairs, Pfizer Ltd., Tadworth, UK
| | - John Vincent
- Department of Clinical Affairs, Pfizer Inc., New York, NY, USA
| | - Ellen Burgess
- Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada,
| |
Collapse
|
11
|
Tam TSC, Wu MHY, Masson SC, Tsang MP, Stabler SN, Kinkade A, Tung A, Tejani AM. Eplerenone for hypertension. Cochrane Database Syst Rev 2017; 2:CD008996. [PMID: 28245343 PMCID: PMC6464701 DOI: 10.1002/14651858.cd008996.pub2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Eplerenone is an aldosterone receptor blocker that is chemically derived from spironolactone. In Canada, it is indicated for use as adjunctive therapy to reduce mortality for heart failure patients with New York Heart Association (NYHA) class II systolic chronic heart failure and left ventricular systolic dysfunction. It is also used as adjunctive therapy for patients with heart failure following myocardial infarction. Additionally, it is indicated for the treatment of mild and moderate essential hypertension for patients who cannot be treated adequately with other agents. It is important to determine the clinical impact of all antihypertensive medications, including aldosterone antagonists, to support their continued use in essential hypertension. No previous systematic reviews have evaluated the effect of eplerenone on cardiovascular morbidity, mortality, and magnitude of blood pressure lowering in patients with hypertension. OBJECTIVES To assess the effects of eplerenone monotherapy versus placebo for primary hypertension in adults. Outcomes of interest were all-cause mortality, cardiovascular events (fatal or non-fatal myocardial infarction), cerebrovascular events (fatal or non fatal strokes), adverse events or withdrawals due to adverse events, and systolic and diastolic blood pressure. SEARCH METHODS We searched the Cochrane Hypertension Specialised Register, CENTRAL, MEDLINE, Embase, and two trials registers up to 3 March 2016. We handsearched references from retrieved studies to identify any studies missed in the initial search. We also searched for unpublished data by contacting the corresponding authors of the included studies and pharmaceutical companies involved in conducting studies on eplerenone monotherapy in primary hypertension. The search had no language restrictions. SELECTION CRITERIA We selected randomized placebo-controlled trials studying adult patients with primary hypertension. We excluded studies in people with secondary or gestational hypertension and studies where participants were receiving multiple antihypertensives. DATA COLLECTION AND ANALYSIS Three review authors independently reviewed the search results for studies meeting our criteria. Three review authors independently extracted data and assessed trial quality using a standardized data extraction form. A fourth independent review author resolved discrepancies or disagreements. We performed data extraction and synthesis using a standardized format on Covidence. We conducted data analysis using Review Manager 5. MAIN RESULTS A total of 1437 adult patients participated in the five randomized parallel group studies, with treatment durations ranging from 8 to 16 weeks. The daily doses of eplerenone ranged from 25 mg to 400 mg daily. Meta-analysis of these studies showed a reduction in systolic blood pressure of 9.21 mmHg (95% CI -11.08 to -7.34; I2 = 58%) and a reduction of diastolic pressure of 4.18 mmHg (95% CI -5.03 to -3.33; I2 = 0%) (moderate quality evidence).There may be a dose response effect for eplerenone in the reduction in systolic blood pressure at doses of 400 mg/day. However, this finding is uncertain, as it is based on a single included study with low quality evidence. Overall there does not appear to be a clinically important dose response in lowering systolic or diastolic blood pressure at eplerenone doses of 50 mg to 400 mg daily. There did not appear to be any differences in the number of patients who withdrew due to adverse events or the number of patients with at least one adverse event in the eplerenone group compared to placebo. However, only three of the five included studies reported adverse events. Most of the included studies were of moderate quality, as we judged multiple domains as being at unclear risk in the 'Risk of bias' assessment. AUTHORS' CONCLUSIONS Eplerenone 50 to 200 mg/day lowers blood pressure in people with primary hypertension by 9.21 mmHg systolic and 4.18 mmHg diastolic compared to placebo, with no difference of effect between doses of 50 mg/day to 200 mg/day. A dose of 25 mg/day did not produce a statistically significant reduction in systolic or diastolic blood pressure and there is insufficient evidence for doses above 200 mg/day. There is currently no available evidence to determine the effect of eplerenone on clinically meaningful outcomes such as mortality or morbidity in hypertensive patients. The evidence available on side effects is insufficient and of low quality, which makes it impossible to draw conclusions about potential harm associated with eplerenone treatment in hypertensive patients.
Collapse
Affiliation(s)
- Tina SC Tam
- Lower Mainland Pharmacy ServicesPharmacyVancouverBCCanada
| | - May HY Wu
- Lower Mainland Pharmacy ServicesSurrey Memorial Hospital PharmacySurreyBCCanada
| | - Sarah C Masson
- Fraser Health AuthorityPharmacy Services3938 Kincaid StBurnabyBCCanadaV5G 1V7
| | - Matthew P Tsang
- Fraser Health AuthorityPharmacy Services32900 Marshall RoadAbbotsfordBCCanadaV2S 0C2
| | - Sarah N Stabler
- Lower Mainland Pharmacy ServicesCardiac Clinics, Royal Columbian HospitalVancouverBCCanada
| | - Angus Kinkade
- Lower Mainland Pharmacy ServicesPharmacyVancouverBCCanada
| | - Anthony Tung
- Lower Mainland Pharmacy ServicesPharmacyVancouverBCCanada
| | - Aaron M Tejani
- University of British ColumbiaTherapeutics Initiative2176 Health Sciences MallVancouverBCCanadaV6T 1Z3
| | | |
Collapse
|
12
|
Yamada M, Takei M, Suzuki E, Takakusa H, Kotsuma M, Washio T, Murayama N, Inoue SI, Izumi T. Pharmacokinetics, distribution, and disposition of esaxerenone, a novel, highly potent and selective non-steroidal mineralocorticoid receptor antagonist, in rats and monkeys. Xenobiotica 2016; 47:1090-1103. [PMID: 27866463 DOI: 10.1080/00498254.2016.1263766] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
1. Esaxerenone (CS-3150) is a novel non-steroidal mineralocorticoid receptor antagonist. The pharmacokinetics, tissue distribution, excretion, and metabolism of esaxerenone were evaluated in rats and monkeys. 2. Following intravenous dosing of esaxerenone at 0.1-3 mg/kg, the total body clearance and the volume of distribution were 3.53-6.69 mL/min/kg and 1.47-2.49 L/kg, respectively, in rats, and 2.79-3.69 mL/min/kg and 1.34-1.54 L/kg, respectively, in monkeys. The absolute oral bioavailability was 61.0-127% in rats and 63.7-73.8% in monkeys. 3. After oral administration of [14C]esaxerenone, the radioactivity was distributed widely to tissues, with the exception of a low distribution to the central nervous system. Both in rats and in monkeys, following oral administration of [14C]esaxerenone the main excretion route of the radioactivity was feces. 4. Five initial metabolic pathways in rats and monkeys were proposed to be N-dealkylation, carboxylation, hydroxymethylation, O-glucuronidation, and O-sulfation. The oxidized metabolism was predominant in rats, while both oxidation and glucuronidation were predominant in monkeys.
Collapse
Affiliation(s)
- Makiko Yamada
- a Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd. , Tokyo , Japan
| | - Makoto Takei
- a Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd. , Tokyo , Japan
| | - Eiko Suzuki
- a Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd. , Tokyo , Japan
| | - Hideo Takakusa
- a Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd. , Tokyo , Japan
| | - Masakatsu Kotsuma
- a Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd. , Tokyo , Japan
| | - Takuo Washio
- a Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd. , Tokyo , Japan
| | - Nobuyuki Murayama
- a Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd. , Tokyo , Japan
| | - Shin-Ichi Inoue
- a Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd. , Tokyo , Japan
| | - Takashi Izumi
- a Drug Metabolism and Pharmacokinetics Research Laboratories, Daiichi Sankyo Co., Ltd. , Tokyo , Japan
| |
Collapse
|
13
|
De Jager RL, Sanders MF, Bots ML, Lobo MD, Ewen S, Beeftink MMA, Böhm M, Daemen J, Dörr O, Hering D, Mahfoud F, Nef H, Ott C, Saxena M, Schmieder RE, Schlaich MP, Spiering W, Tonino PAL, Verloop WL, Vink EE, Vonken EJ, Voskuil M, Worthley SG, Blankestijn PJ. Renal denervation in hypertensive patients not on blood pressure lowering drugs. Clin Res Cardiol 2016; 105:755-62. [PMID: 27105858 PMCID: PMC4989018 DOI: 10.1007/s00392-016-0984-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/30/2016] [Indexed: 12/11/2022]
Abstract
Introduction Studies on the blood pressure lowering effect of renal denervation (RDN) in resistant hypertensive patients have produced conflicting results. Change in medication usage during the studies may be responsible for this inconsistency. To eliminate the effect of medication usage on blood pressure we focused on unmedicated hypertensive patients who underwent RDN. Methods and results Our study reports on a cohort of patients, who were not on blood pressure lowering drugs at baseline and during follow-up, from eight tertiary centers. Data of patients were used when they were treated with RDN and had a baseline office systolic blood pressure (SBP) ≥140 mmHg and/or 24-h ambulatory SBP ≥130 mmHg. Our primary outcome was defined as change in office and 24-h SBP at 12 months after RDN, compared to baseline. Fifty-three patients were included. There were three different reasons for not using blood pressure lowering drugs: (1) documented intolerance or allergic reaction (57 %); (2) temporary cessation of medication for study purposes (28 %); and (3) reluctance to take antihypertensive drugs (15 %). Mean change in 24-h SBP was −5.7 mmHg [95 % confidence interval (CI) −11.0 to −0.4; p = 0.04]. Mean change in office SBP was −13.1 mmHg (95 % CI −20.4 to −5.7; p = 0.001). No changes were observed in other variables, such as eGFR, body–mass-index and urinary sodium excretion. Conclusion This explorative study in hypertensive patients, who are not on blood pressure lowering drugs, suggests that at least in some patients RDN lowers blood pressure. Electronic supplementary material The online version of this article (doi:10.1007/s00392-016-0984-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Rosa L De Jager
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Room F03.220, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Margreet F Sanders
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Room F03.220, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Michiel L Bots
- The Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Melvin D Lobo
- William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Martine M A Beeftink
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Joost Daemen
- Department of Interventional Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Oliver Dörr
- Department of Cardiology, University of Giessen, Giessen, Germany
| | - Dagmara Hering
- School of Medicine and Pharmacology-Royal Perth Hospital Unit, University of Western Australia, Perth, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Holger Nef
- Department of Cardiology, University of Giessen, Giessen, Germany
| | - Christian Ott
- Department of Nephrology and Hypertension, University Hospital of Erlangen, Erlangen, Germany
| | - Manish Saxena
- William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital of Erlangen, Erlangen, Germany
| | - Markus P Schlaich
- School of Medicine and Pharmacology-Royal Perth Hospital Unit, University of Western Australia, Perth, Australia.,Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pim A L Tonino
- Department of Cardiology, Heartcenter Catharina Hospital, Eindhoven, The Netherlands
| | - Willemien L Verloop
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Eva E Vink
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Room F03.220, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Evert-Jan Vonken
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stephen G Worthley
- Cardiovascular Research Centre, University of Adelaide, Royal Adelaide Hospital, Adelaide, Australia
| | - Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Room F03.220, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| |
Collapse
|
14
|
Safety profile of mineralocorticoid receptor antagonists: Spironolactone and eplerenone. Int J Cardiol 2015; 200:25-9. [DOI: 10.1016/j.ijcard.2015.05.127] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 05/17/2015] [Indexed: 11/19/2022]
|
15
|
|
16
|
Pharmacological profile of CS-3150, a novel, highly potent and selective non-steroidal mineralocorticoid receptor antagonist. Eur J Pharmacol 2015; 761:226-34. [PMID: 26073023 DOI: 10.1016/j.ejphar.2015.06.015] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 06/03/2015] [Accepted: 06/08/2015] [Indexed: 11/22/2022]
Abstract
The present study was designed to characterize the pharmacological profile of CS-3150, a novel non-steroidal mineralocorticoid receptor antagonist. In the radioligand-binding assay, CS-3150 inhibited (3)H-aldosterone binding to mineralocorticoid receptor with an IC50 value of 9.4nM, and its potency was superior to that of spironolactone and eplerenone, whose IC50s were 36 and 713nM, respectively. CS-3150 also showed at least 1000-fold higher selectivity for mineralocorticoid receptor over other steroid hormone receptors, glucocorticoid receptor, androgen receptor and progesterone receptor. In the reporter gene assay, CS-3150 inhibited aldosterone-induced transcriptional activation of human mineralocorticoid receptor with an IC50 value of 3.7nM, and its potency was superior to that of spironolactone and eplerenone, whose IC50s were 66 and 970nM, respectively. CS-3150 had no agonistic effect on mineralocorticoid receptor and did not show any antagonistic or agonistic effect on glucocorticoid receptor, androgen receptor and progesterone receptor even at the high concentration of 5μM. In adrenalectomized rats, single oral administration of CS-3150 suppressed aldosterone-induced decrease in urinary Na(+)/K(+) ratio, an index of in vivo mineralocorticoid receptor activation, and this suppressive effect was more potent and longer-lasting than that of spironolactone and eplerenone. Chronic treatment with CS-3150 inhibited blood pressure elevation induced by deoxycorticosterone acetate (DOCA)/salt-loading to rats, and this antihypertensive effect was more potent than that of spironolactone and eplerenone. These findings indicate that CS-3150 is a selective and highly potent mineralocorticoid receptor antagonist with long-lasting oral activity. This agent could be useful for the treatment of hypertension, cardiovascular and renal disorders.
Collapse
|
17
|
The necessity and effectiveness of mineralocorticoid receptor antagonist in the treatment of diabetic nephropathy. Hypertens Res 2015; 38:367-74. [PMID: 25762415 DOI: 10.1038/hr.2015.19] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 12/06/2014] [Accepted: 12/31/2014] [Indexed: 02/06/2023]
Abstract
Diabetes mellitus is a major cause of chronic kidney disease (CKD), and diabetic nephropathy is the most common primary disease necessitating dialysis treatment in the world including Japan. Major guidelines for treatment of hypertension in Japan, the United States and Europe recommend the use of angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers, which suppress the renin-angiotensin system (RAS), as the antihypertensive drugs of first choice in patients with coexisting diabetes. However, even with the administration of RAS inhibitors, failure to achieve adequate anti-albuminuric, renoprotective effects and a reduction in cardiovascular events has also been reported. Inadequate blockade of aldosterone may be one of the reasons why long-term administration of RAS inhibitors may not be sufficiently effective in patients with diabetic nephropathy. This review focuses on treatment in diabetic nephropathy and discusses the significance of aldosterone blockade. In pre-nephropathy without overt nephropathy, a mineralocorticoid receptor antagonist can be used to enhance the blood pressure-lowering effects of RAS inhibitors, improve insulin resistance and prevent clinical progression of nephropathy. In CKD categories A2 and A3, the addition of a mineralocorticoid receptor antagonist to an RAS inhibitor can help to maintain 'long-term' antiproteinuric and anti-albuminuric effects. However, in category G3a and higher, sufficient attention must be paid to hyperkalemia. Mineralocorticoid receptor antagonists are not currently recommended as standard treatment in diabetic nephropathy. However, many studies have shown promise of better renoprotective effects if mineralocorticoid receptor antagonists are appropriately used.
Collapse
|
18
|
Efficacy and safety of eplerenone in the management of mild to moderate arterial hypertension: Systematic review and meta-analysis. Int J Cardiol 2014; 177:219-28. [DOI: 10.1016/j.ijcard.2014.09.091] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/21/2014] [Indexed: 11/18/2022]
|
19
|
Pelliccia F, Rosano G, Patti G, Volterrani M, Greco C, Gaudio C. Efficacy and safety of mineralocorticoid receptors in mild to moderate arterial hypertension. Int J Cardiol 2014; 200:8-11. [PMID: 25466561 DOI: 10.1016/j.ijcard.2014.10.150] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 10/20/2014] [Indexed: 11/16/2022]
Abstract
The mineralocorticoid receptor antagonists have been shown to have favourable safety and cost-effectiveness profiles across a broad range of clinical indications, including heart failure, primary aldosteronism and resistant hypertension. The clinical biology of the first aldosterone blocker, i.e. spironolactone, and its effects in several organ systems has been well elucidated from multiple studies. The range of adverse effects experienced with spironolactone has led to its modification and the consequent synthesis of eplerenone. Scientific evidence accumulated so far supports the role of eplerenone as first-choice drug in heart failure, with lower prevalence rates of sex-related adverse effects associated with eplerenone as compared to spironolactone. In Europe, eplerenone is currently marketed only in some countries and only with the indication of heart failure, whereas its clinical efficacy and safety in mild to moderate hypertension is said to be uncertain. A review of available scientific evidence, however, discloses that 11 randomized clinical trials assessing eplerenone in >3500 hypertensives have been reported so far. The results of these studies clearly show that eplerenone is an effective antihypertensive agent when used alone or in combination with other medications. In doses ranging from 25 to 100mg daily, eplerenone monotherapy results in a dose-dependent reduction in clinic blood pressure. As compared to placebo, eplerenone reduces significantly blood pressure from baseline. In general, 100mg daily eplerenone has a blood pressure lowering that is 50 to 75% that of spironolactone. Eplerenone results in a greater reduction in blood pressure as compared with losartan, and comparison between eplerenone and amlodipine shows that both treatments decrease systolic blood pressure to a similar extent but eplerenone is better tolerated. In conclusion, there is now evidence that eplerenone can play an important role in the treatment of mild to moderate arterial hypertension and therefore scientific experts and regulatory authorities should support its wider use in clinical practice worldwide.
Collapse
Affiliation(s)
| | - Giuseppe Rosano
- IRCCS San Raffaele Pisana, Rome, Italy; Cardiovascular and Cell Sciences Research Institute, St. George's, University of London, London, UK
| | | | | | - Cesare Greco
- Department 'Attilio Reale', Sapienza University, Rome, Italy
| | - Carlo Gaudio
- Department 'Attilio Reale', Sapienza University, Rome, Italy; Eleonora Lorillard Spencer Cenci Foundation, Rome, Italy
| |
Collapse
|
20
|
Hallow KM, Lo A, Beh J, Rodrigo M, Ermakov S, Friedman S, de Leon H, Sarkar A, Xiong Y, Sarangapani R, Schmidt H, Webb R, Kondic AG. A model-based approach to investigating the pathophysiological mechanisms of hypertension and response to antihypertensive therapies: extending the Guyton model. Am J Physiol Regul Integr Comp Physiol 2014; 306:R647-62. [PMID: 24500431 DOI: 10.1152/ajpregu.00039.2013] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Reproducibly differential responses to different classes of antihypertensive agents are observed among hypertensive patients and may be due to interindividual differences in hypertension pathology. Computational models provide a tool for investigating the impact of underlying disease mechanisms on the response to antihypertensive therapies with different mechanisms of action. We present the development, calibration, validation, and application of an extension of the Guyton/Karaaslan model of blood pressure regulation. The model incorporates a detailed submodel of the renin-angiotensin-aldosterone system (RAAS), allowing therapies that target different parts of this pathway to be distinguished. Literature data on RAAS biomarker and blood pressure responses to different classes of therapies were used to refine the physiological actions of ANG II and aldosterone on renin secretion, renal vascular resistance, and sodium reabsorption. The calibrated model was able to accurately reproduce the RAAS biomarker and blood pressure responses to combinations of dual-RAAS agents, as well as RAAS therapies in combination with diuretics or calcium channel blockers. The final model was used to explore the impact of underlying mechanisms of hypertension on the blood pressure response to different classes of antihypertensive agents. Simulations indicate that the underlying etiology of hypertension can impact the magnitude of response to a given class of therapy, making a patient more sensitive to one class and less sensitive others. Given that hypertension is usually the result of multiple mechanisms, rather than a single factor, these findings yield insight into why combination therapy is often required to adequately control blood pressure.
Collapse
Affiliation(s)
- K Melissa Hallow
- Department of Modeling and Simulation, Primary Care Franchise, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Iqbal J, Parviz Y, Pitt B, Newell-Price J, Al-Mohammad A, Zannad F. Selection of a mineralocorticoid receptor antagonist for patients with hypertension or heart failure. Eur J Heart Fail 2013; 16:143-50. [DOI: 10.1111/ejhf.31] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 07/15/2013] [Accepted: 07/19/2013] [Indexed: 11/28/2022] Open
Affiliation(s)
- Javaid Iqbal
- Department of Cardiovascular Science at the University of Sheffield and Cardiology Department at Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - Yasir Parviz
- Department of Cardiovascular Science at the University of Sheffield and Cardiology Department at Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - Bertram Pitt
- Cardiovascular Centre; University of Michigan; Ann Arbor MI USA
| | - John Newell-Price
- Department of Human Metabolism at the University of Sheffield and Endocrinology Department at Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - Abdallah Al-Mohammad
- Department of Cardiovascular Science at the University of Sheffield and Cardiology Department at Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique and Centre Hospitalier Universitaire, and the Department of Cardiology; Nancy University, Université de Lorraine; Nancy France
| |
Collapse
|
22
|
Spironolactone, eplerenone and the new aldosterone blockers in endocrine and primary hypertension. J Hypertens 2013; 31:3-15. [PMID: 23011526 DOI: 10.1097/hjh.0b013e3283599b6a] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Mineralocorticoid receptor antagonists (MRAs) are commonly used to reduce blood pressure, left-ventricular hypertrophy, and urinary albumin excretion in patients with essential hypertension or primary aldosteronism. Effects of MRAs on hypertensive organ damage seem to occur beyond what is expected from the mere reduction of blood pressure. This suggests that activation of the mineralocorticoid receptor plays a central role in the development of cardiac and renal abnormalities in hypertensive patients. However, broad use of classic MRAs such as spironolactone has been limited by significant incidence of gynecomastia and other sex-related adverse effects. To overcome these problems, new aldosterone blockers have been developed with different strategies that include use of nonsteroidal MRAs and inhibition of aldosterone synthesis. Both strategies have been designed to avoid the steroid receptor cross-reactivity of classic MRAs that accounts for most adverse effects. Moreover, inhibition of aldosterone synthesis could have an additional benefit due to blockade of the mineralocorticoid receptor-independent pathways that might account for some of the untoward effects of aldosterone. The new aldosterone blockers are currently having extensive preclinical evaluation, and one of these compounds has passed phase 2 trials showing promising results in patients with primary hypertension and primary aldosteronism. This narrative review summarizes the knowledge on the use of classic MRAs in hypertension and covers the evidence currently available on new aldosterone blockers.
Collapse
|
23
|
Noguchi R, Yoshiji H, Ikenaka Y, Kaji K, Aihara Y, Shirai Y, Namisaki T, Kitade M, Douhara A, Moriya K, Fukui H. Dual blockade of angiotensin-II and aldosterone suppresses the progression of a non-diabetic rat model of steatohepatitis. Hepatol Res 2013; 43:765-74. [PMID: 23163573 DOI: 10.1111/hepr.12008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 10/15/2012] [Accepted: 10/15/2012] [Indexed: 12/15/2022]
Abstract
AIM Both angiotensin-II (AT-II) and aldosterone (Ald) play pivotal roles in the pathogenesis of diseases in several organs including the liver. We previously reported that suppression of AT-II and Ald with angiotensin-converting enzyme inhibitor (ACE-I) and selective Ald blocker (SAB), respectively, attenuated the rat liver fibrogenesis and hepatocarcinogenesis. The aim of our current study was to elucidate the combined effects of ACE-I and SAB in the progression of a non-diabetic rat model of steatohepatitis, and the possible mechanisms involved. METHODS In the choline-deficient L-amino acid-defined (CDAA) diet-induced model, the effects of ACE-I and SAB on liver fibrosis development and hepatocarcinogenesis were elucidated, especially in conjunction with neovascularization. RESULTS Treatment with both ACE-I and SAB suppressed the development of liver fibrosis and glutathione-S-transferase placental form (GST-P) positive pre-neoplastic lesions. The combined treatment with both agents exerted more inhibitory effects as compared with either a single agent along with suppression of the activated hepatic stellate cells (Ac-HSC) and neovascularization, both of which play important roles in these processes. Our in vitro study showed that AT-II type 1 receptor blocker (ARB) and SAB inhibited Ac-HSC proliferation and in vitro angiogenesis along with suppression of the in vivo studies. CONCLUSION Dual blockade of AT-II and Ald suppresses the progression of a non-diabetic rat model of steatohepatitis. Because both agents are widely and safely used in clinical practice, this combination therapy could be an effective new strategy against steatohepatitis in the future.
Collapse
Affiliation(s)
- Ryuichi Noguchi
- Third Department of Internal Medicine, Nara Medical University, Nara, Japan
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Sato A. Mineralocorticoid receptor antagonists: their use and differentiation in Japan. Hypertens Res 2012; 36:185-90. [DOI: 10.1038/hr.2012.182] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
25
|
Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, Ferdinand KC, Ann Forciea M, Frishman WH, Jaigobin C, Kostis JB, Mancia G, Oparil S, Ortiz E, Reisin E, Rich MW, Schocken DD, Weber MA, Wesley DJ, Harrington RA, Bates ER, Bhatt DL, Bridges CR, Eisenberg MJ, Ferrari VA, Fisher JD, Gardner TJ, Gentile F, Gilson MF, Hlatky MA, Jacobs AK, Kaul S, Moliterno DJ, Mukherjee D, Rosenson RS, Stein JH, Weitz HH, Wesley DJ. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. ACTA ACUST UNITED AC 2011; 5:259-352. [PMID: 21771565 DOI: 10.1016/j.jash.2011.06.001] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
26
|
Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, Ferdinand KC, Forciea MA, Frishman WH, Jaigobin C, Kostis JB, Mancia G, Oparil S, Ortiz E, Reisin E, Rich MW, Schocken DD, Weber MA, Wesley DJ. ACCF/AHA 2011 Expert Consensus Document on Hypertension in the Elderly. Circulation 2011; 123:2434-506. [PMID: 21518977 DOI: 10.1161/cir.0b013e31821daaf6] [Citation(s) in RCA: 216] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | | | - Carl J. Pepine
- American College of Cardiology Foundation Representative
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Deborah J. Wesley
- ACCF Task Force on Clinical Expert Consensus Documents Representative. Authors with no symbol by their name were included to provide additional content expertise apart from organizational representation
| |
Collapse
|
27
|
Aronow WS, Fleg JL, Pepine CJ, Artinian NT, Bakris G, Brown AS, Ferdinand KC, Ann Forciea M, Frishman WH, Jaigobin C, Kostis JB, Mancia G, Oparil S, Ortiz E, Reisin E, Rich MW, Schocken DD, Weber MA, Wesley DJ. ACCF/AHA 2011 expert consensus document on hypertension in the elderly: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus documents developed in collaboration with the American Academy of Neurology, American Geriatrics Society, American Society for Preventive Cardiology, American Society of Hypertension, American Society of Nephrology, Association of Black Cardiologists, and European Society of Hypertension. J Am Coll Cardiol 2011; 57:2037-114. [PMID: 21524875 DOI: 10.1016/j.jacc.2011.01.008] [Citation(s) in RCA: 277] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
28
|
Abstract
In the setting of primary aldosteronism, elevated aldosterone levels are associated with increased blood pressure. Aldosterone concentrations within the normal range, however, can also alter blood pressure. Furthermore, the aldosterone-to-renin ratio, an indicator of aldosterone excess, is associated with hypertension, even in patients without excessive absolute aldosterone levels. In this Review we assess the data on the role of aldosterone in the development and maintenance of hypertension. We provide an overview of the complex crosstalk between genetic and environmental factors, and about aldosterone-mediated arterial hypertension and target organ damage. The discussion is organized according to major targets of aldosterone action: the collecting duct in the kidney, the vasculature and the central nervous system. The antihypertensive efficacy of mineralocorticoid-receptor blockers, even in patients with aldosterone values in the normal range, supports the evidence that aldosterone plays a part in blood pressure elevation in the absence of primary aldosteronism.
Collapse
Affiliation(s)
- Andreas Tomaschitz
- Division of Endocrinology and Nuclear Medicine, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria.
| | | | | | | | | |
Collapse
|
29
|
Clinical effects of eplerenone, a selective aldosterone blocker, in Japanese patients with essential hypertension. J Hum Hypertens 2009; 24:387-94. [PMID: 19865106 DOI: 10.1038/jhh.2009.81] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Eplerenone, a selective aldosterone blocker, has become clinically available in Japan since 2007. It has been reported that eplerenone has a potential antihypertensive effect, with a profile slightly different from that of spironolactone, and has fewer adverse reactions, suggesting that it may become a first-line treatment for hypertension. However, clinical data on hypertensive patients in Japan are lacking for eplerenone. In this study, we explored the clinical efficacy of eplerenone when it is added to an angiotensin-converting enzyme (ACE) inhibitor or a long-acting calcium channel blocker (CCB) in 68 (31 males, 37 females) Japanese patients with essential hypertension. After adding 50 mg of eplerenone to their basal treatment, blood pressure was significantly reduced at 4 weeks, and further reduced after 24 weeks of eplerenone treatment. Urinary albumin excretion decreased significantly after 24 weeks. There were no significant differences in general biochemical test values or electrolytes, but fasting serum triglycerides were significantly decreased after eplerenone treatment. The serum potassium level showed no significant change during treatment. There were no significant correlations between plasma renin activity or plasma aldosterone concentration (PAC) before eplerenone treatment and blood pressure after eplerenone treatment, showing that the antihypertensive effect of eplerenone is not affected by the patient's renin profile or pretreatment PAC values. Eplerenone was also effective in hypertensive patients with metabolic syndrome. In conclusion, eplerenone, when coadministered with an ACE inhibitor or a long-acting CCB, caused an extremely beneficial antihypertensive effect in Japanese patients with essential hypertension, without few clinically important adverse events.
Collapse
|
30
|
Watson RE, Karnchanasorn R, Gossain VV. Hypertension in Asian/Pacific Island Americans. J Clin Hypertens (Greenwich) 2009; 11:148-52. [DOI: 10.1111/j.1751-7176.2009.00088.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|
31
|
Imanishi T, Ikejima H, Tsujioka H, Kuroi A, Kobayashi K, Muragaki Y, Mochizuki S, Goto M, Yoshida K, Akasaka T. Addition of eplerenone to an angiotensin-converting enzyme inhibitor effectively improves nitric oxide bioavailability. Hypertension 2008; 51:734-41. [PMID: 18227404 DOI: 10.1161/hypertensionaha.107.104299] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Angiotensin II and aldosterone both promote endothelial dysfunction and atherosclerosis. We investigated the effect of a combination of eplerenone, a selective aldosterone antagonist, and enalapril, an angiotensin-converting enzyme inhibitor, on NO bioavailability and spontaneous atherosclerotic changes. Twenty-four myocardial infarction-prone Watanabe heritable hyperlipidemic rabbits were treated with vehicle (control), eplerenone (50 mg/kg per day), enalapril (3 mg/kg per day), or eplerenone plus enalapril for 8 weeks (n=6 in each group). After treatment, acetylcholine-induced NO production was measured as a surrogate for endothelium-protective function, and vascular peroxynitrite (a product of superoxide and NO) was measured to assess dysfunctional endothelial NO synthase activity. Plaque area was quantified by histology. Intra-aortic infusion of acetylcholine produced an increase in plasma NO concentration that was significantly higher with all of the drug treatments compared with the control. Eplerenone and enalapril, in combination, increased acetylcholine-induced NO by 7.9 nM, which was significantly higher than with either eplerenone or enalapril alone. Vascular peroxynitrite was significantly higher in the control group (1.3 pmol/mg of protein) and significantly lower with combination treatment (0.4 pmol/mg of protein) compared with the enalapril or eplerenone group. The highest tetrahydrobiopterin levels were observed after cotreatment with eplerenone and enalapril. Histology of the thoracic aorta showed a significantly decreased plaque area with combination therapy compared with monotherapy. Combined treatment with a selective aldosterone antagonist and an angiotensin-converting enzyme inhibitor has additive protective effects on endothelial function and on atherosclerotic changes via decreased nitrosative stress.
Collapse
Affiliation(s)
- Toshio Imanishi
- Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama 641-8510, Japan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
32
|
|
33
|
Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2004). Hypertens Res 2006; 29 Suppl:S1-105. [PMID: 17366911 DOI: 10.1291/hypres.29.s1] [Citation(s) in RCA: 189] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
34
|
Grim CE. Evolution of diagnostic criteria for primary aldosteronism: why is it more common in "drug-resistant" hypertension today? Curr Hypertens Rep 2005; 6:485-92. [PMID: 15527695 DOI: 10.1007/s11906-004-0045-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The recent "epidemic" of primary aldosteronism reported in the literature is most likely related to the widespread acceptance that with easy access to accurate measurements of renin and aldosterone, it is no longer necessary to wait until hypokalemia has become profound before embarking on diagnostic testing to attempt to ferret out this most common cause of "essential" hypertension. This is especially true for those who are now classified as "drug resistant" using today's popular drugs, which are particularly ineffective in lowering blood pressure in primary aldosteronism and its variants. Understanding the physiologic consequences of a slowly increasing aldosterone production by autonomous cells will help both the family practitioner and the specialist understand the role of the aldosterone renin ratio (ARR) in the care of the hypertensive patient. In addition, the increasing number of specific genetic mutations that drive sodium retention and lead to low levels of renin activity and familial hypertension must be incorporated into the routine evaluation and care of hypertensive patients and their families.
Collapse
Affiliation(s)
- Clarence E Grim
- Shared Care Research, Education and Consulting, Inc., 2821 N. 4th Street, Suite 410, Department 71, Milwaukee, WI 53212, USA.
| |
Collapse
|