Side effects of hypotensive agents evaluated by a self-administered questionnaire

A prospective study of the effect of antihypertensive medications on the sexual functions of hypertensive adult male patients

Background:

The potential for antihypertensive medications to produce deleterious adverse effects on sexual functions among hypertensive adult male patients has been widely reported, such adverse effects may limit drug adherence and compliance.

Aim:

The aim of this study was to assess the effect of antihypertensive medication use on sexual functions among hypertensive adult male patients.

Methodology:

The study was carried out at the outpatient clinic of a Nigerian University Teaching Hospital. A total of one hundred and fifty-nine recruited hypertensive adult male patients that were being managed at the center over a 3-month period between January 2017 and April 2017 participated in the study; provided they satisfied the inclusion and exclusion criteria for enrolment.

Results:

The respondents were between 30 and 98 years of age, (mean of 59 ± 11.1 years). Blood pressure recorded was during their initial medical diagnosis for hypertension. Systolic blood pressure recorded was between 128 and 194 mmHg (mean of 162 ± 16.4 mmHg), while their diastolic blood pressure was between 78 and 120 mmHg (mean of 95 ± 10.7 mmHg). The highest occurrence of sexual dysfunctions was associated with calcium-channel blockers in 32 (20.1%) patients, followed by diuretics in 27 (17.0%) and, angiotensin-converting enzyme inhibitors in 20 (12.6%) patients.

Conclusion:

Calcium channel blockers caused the highest occurrence of sexual dysfunctions.

This prospective study assessed the effect of antihypertensive medications on sexual functions among hypertensive adult male patients attending the medical outpatient clinic of a Nigerian University Teaching Hospital. A total of 159 patients who consented to the study and had been attending the clinic regularly for at least 6-month were enrolled. The respondents aged 30–98 years (mean 59 ± 11.1 years). Antihypertensive medication-associated sexual dysfunctions among the patients were observed in descending order as follows: calcium channel blockers in 32 (20.1%), diuretics in 27 (17.0%), Angiotensin converting enzyme inhibitors in 20 (12.6%), centrally acting antihypertensives in 11 (6.9%), beta receptor blockers in 8 (5.0%), vasodilators in 2 (1.3%), combined alpha- and beta-receptor blockers in 2 (1.3%) and alpha receptor blockers in 1 (0.6%). Antihypertensive medical prescriptions should reflect a balance between efficacy and tendency to cause sexual dysfunctions.

A profile of adverse effects of antihypertensive medicines in a tertiary care clinic in Nigeria

Background:

There has been a dearth of comprehensive data on the profile of adverse reactions to antihypertensive medicines in the Nigerian setting despite increased use.

Objective:

This study was aimed to characterize the adverse reactions experienced in the homogenously black African population.

Methods:

The study was carried out at the University of Benin Teaching Hospital, Benin City, Nigeria, in consenting eligible hypertensive patients ≥18 years. Adverse reactions were sought using patient's self-report and a medicine-induced symptom checklist.

Results:

A total of 514 patients (340 females) aged 22–97 years were studied. Thirteen percent, 27.6%, 26.7%, 22.0%, and 10.7% were on 1, 2, 3, 4, and ≥5 medicines, respectively, for control of their blood pressure with the frequency of adverse effects increasing proportionately up to four medicines. Adverse reactions to antihypertensive medicines were reported by a total of 93 (18.1%) patients. Diuretics – 27.9%, calcium channel blockers (CCBs) – 26.8%, and angiotensin-converting enzyme inhibitors (ACEIs) – 26.8% accounted for most of the adverse reactions seen, notably frequent micturition and headaches (CCB); excessive micturition and dizziness (diuretics); dry irritating cough (ACEI). Notable complaints for all patients using the checklist were increased frequency of micturition, reduction in libido, and headaches. The reactions resulted in the discontinuation and substitution of therapy in 49.5% of the patients.

Conclusions:

The characterization of these reactions in Nigerians requires further studies as frequent micturition reported is still a neglected complaint in antihypertensive therapy.

Cardiovascular/Pulmonary Medications and Male Reproduction

Cardiovascular and respiratory medications are used by men of reproductive age although use of the former is most prevalent in advanced age. Many of these drugs have been associated with sexual dysfunction, including erectile and ejaculatory dysfunction, but for most there is insufficient evidence to link their use with testicular dysfunction, reduced semen quality or infertility. Some exceptions are the irreversible α₁-adrenergic antagonist phenoxybenzamine, which carries a high risk of retrograde ejaculation; the specific α_1A-adrenergic antagonists silodosin and tamsulosin, used primarily to treat BPH/lower urinary tract symptoms, which can cause retrograde ejaculation; and the peripheral β₁-adrenergic antagonist atenolol, used to treat hypertension, which may decrease testosterone/free-testosterone levels. In this chapter, we review the evidence available regarding adverse reactions on male reproduction of adrenergic receptor agonists/antagonists, calcium channel blockers, angiotensin converting enzyme (ACE) inhibitors, diuretics, digoxin, and hydralazine. For some of these medications, there is some evidence for male reproductive effects, along with some solid work in experimental and companion animal species suggesting negative effects. In contrast, and of special note, are calcium channel blockers, which have long been included on lists of medications with the potential to cause male infertility. This turns out to be a good example of a substance with profound effects on sperm function in vitro, but with limited evidence for in vivo effects on semen quality or fertility, even in experimental species. We hope that the evidence provided in this chapter will stimulate additional studies for these important classes of medications.

Oxprenolol in Hypertension: A Report on 187 Patients in General Practice Originally Treated with Clonidine

Substitution, in part or totally, of the β- receptor antagonist, oxprenolol, for clonidine in 187 hypertensive patients resulted in significant reduction in blood pressure levels, particularly of systolic pressure.

The incidence of unwanted side-effects was markedly reduced, with an accompanying improvement in the quality of the patient's life.

The Addition of Oxprenolol to Hypertensive Patients Treated with Methyldopa – A General Practice Study

In eighty-seven hypertensive patients in general practice, treated with either methyldopa or the combination of methyldopa and a diuretic, oxprenolol 80 mg was added to the regime with subsequent reduction in methyldopa dosage. In the two groups of patients studied, those whose blood pressure was ‘well controlled’ and another group with a higher blood pressure, the control of blood pressure levels was improved and the incidence of reported tiredness decreased.

Treatment of Moderately Severe Essential Hypertension in General Practice with a Combination of Cyclopenthiazide with Potassium Chloride (Navidrex K) and Oxprenolol (Trasicor 80mg): A Report on 554 Patients

Five hundred and fifty-four patients, with an initial mean diastolic pressure of 130 mm Hg, were treated with a combination of Navidrex K ( 0·5 mg daily) and up to 480 mg (six tablets daily) of Oxprenolol (Trasicor 80 mg).

In 69% of this group, good control of the blood pressure was achieved with a daily dose of four tablets ( 320 mg) of Oxprenolol.

In the remainder of patients significant reductions in blood pressure levels were noted, again with a mean dose of less than 320 mg daily of oxprenolol. There were indications in this group that better control of blood pressure levels might have been reached, had more of the patients been prescribed the maximum dose of 480 mg daily (six tablets) permitted in the study.

Tolerability of this regime was very good. More than 80% of patients reported no side-effects at all, and one patient in four reported ‘feeling better’ after treatment.

A review of the positive and negative effects of cardiovascular drugs on sexual function: a proposed table for use in clinical practice

Several antihypertensive drugs, such as diuretics and β-blockers, can negatively affect sexual function, leading to diminished quality of life and often to noncompliance with the therapy. Other drug classes, however, such as angiotensin II receptor blockers (ARBs) are able to improve patients' sexual function. Sufficient knowledge about the effects of these widely used antihypertensive drugs will make it possible for cardiologists and general practitioners to spare and even improve patients' sexual health by switching to different classes of cardiac medication. Nevertheless, previous data (part I) indicate that most cardiologists lack knowledge about the effects cardiovascular agents can have on sexual function and will thus not be able to provide the necessary holistic patient care with regard to prescribing these drugs. To be able to improve healthcare on this point, we aimed to provide a practical overview, for use by cardiologists as well as other healthcare professionals, dealing with sexual dysfunction in their clinical practices. Therefore, a systematic review of the literature was performed. The eight most widely used classes of antihypertensive drugs have been categorised in a clear table, marking whether they have a positive, negative or no effect on sexual function.

Brain function, cognition, and the blood pressure response to pharmacological treatment

OBJECTIVE

To extend evidence suggesting that essential hypertension influences neuropsychological performance and that brain function before treatment is related to the success of pharmacological lowering of blood pressure (BP).

METHODS

A voxel-based examination of the whole brain was conducted among 43 hypertensive patients treated for 1 year with assessment pre and post treatment, using positron emission tomography and neuropsychological testing.

RESULTS

Neuropsychological performance improved over the year of treatment but was unrelated to change in regional cerebral blood flow (rCBF). Neither mean resting rCBF nor responsivity to a working memory task changed significantly with treatment. However, patients with greater lowering of systolic BP during treatment showed increased rCBF responsivity to a working memory task in medial and orbital frontal areas and decreased rCBF responsivity in mid frontal, parietal, thalamus, and pons (as well as lower thalamic rCBF pretreatment). Improved working memory performance over the treatment period was related to decreased responsivity in medial frontal, medullary, and parietal areas. Patients showing greater lowering of BP with treatment seemed to reduce excitatory and enhance inhibitory coupling between memory processing and BP more than those with less treatment success.

CONCLUSION

Degree of treatment success for both BP and cognitive performance among hypertensives is related to differing patterns of rCBF. Overall, the results emphasize the relevance of brain function to the treatment of hypertension.

The features of reserpine-induced gastric mucosal lesions

AIM

To reinvestigate the characteristics of reserpine-induced gastric mucosal lesions (GMLs).

METHODS

The GML-inducing effect of reserpine and the time-course of recovery from reserpine-induced GMLs were examined in Sprague-Dawley (SD) rats. The GML-inducing and blood pressure-decreasing effects of Compound Hypotensive Tablets (CHTs) were investigated in spontaneously hypertensive rats (SHRs). Intracerebroventricular (icv) injection and vagotomy were performed to verify the central vagal mechanism in reserpine-induced GMLs.

RESULTS

Single intraperitoneal (ip) injections of reserpine (0.25, 0.5, 1, 2, 4, and 6 mg/kg) dose-dependently induced GMLs in SD rats. Both single and repeated (2 weeks) oral administrations of reserpine led to slight GMLs at doses of 24 mg/kg and 10 mg/kg, respectively. Blood pressure was significantly decreased in SHRs after 2 months of CHT administration (0.01 and 0.03 mg/kg; doses were expressed as the amount of reserpine in the CHT). CHT doses of 0.3 mg/kg induced GMLs, but 0.1 mg/kg did not. Examining the time course of recovery from GMLs, severe GMLs occurred 18 h after ip reserpine (4 mg/kg), obviously lessened at 1 week and healed spontaneously at 3 weeks. Intracerebroventricular injections of reserpine caused GMLs at much lower doses (0.08 and 0.4 mg/kg), and reserpine-induced GMLs were greatly inhibited by vagotomy, suggesting the involvement of a central vagal mechanism.

CONCLUSION

Reserpine-induced GMLs were dose-dependent, and the lesions healed spontaneously within 3 weeks. Long-term treatment with CHT at doses adequate to decrease blood pressure will not induce GMLs. A central vagal mechanism was involved in reserpine-induced GMLs.

Serotoninergic and non-serotoninergic effects of two tricyclic antidepressants on visceral nociception in a rat model

OBJECTIVE

Tricyclic antidepressants (TCAs) are well established in the treatment of patients with irritable bowel syndrome (IBS). The effects are believed to be linked to serotoninergic antinociceptive properties, but data on the antinociceptive effects of various TCAs with variable serotoninergic and non-serotoninergic properties have not been investigated. The aim of this study was to compare the antinociceptive effects of different TCAs.

MATERIAL AND METHODS

Colorectal distension (CRD) using a barostat device was carried out in rats and the visceromotor response (VMR) to CRD was quantified by abdominal wall electromyography. Prior to CRD, saline (control), amitriptyline (AM), desipramine (DES), reserpine (RES) or a combination of TCAs and RES (AM + RES or DES + RES) was applied intraperitoneally. Serum 5-HT levels were determined using high-performance liquid chromatography (HPLC). RES was used to antagonize the serotoninergic actions of TCAs in order to discriminate between these effects and others.

RESULTS

Both TCAs decreased the VMR compared to placebo. After RES application without TCAs, the VMR was increased compared to controls (6403 microV+/-1772 microV). Co-administration of AM and RES resulted in a modest decrease in VMR (5774 microV+/-1953 microV), while in rats treated with RES and DES the VMR again was significantly lower (3446 microV (+/-1347 microV; p <0.05)). 5-HT levels were higher in TCA pretreated rats than those in controls and significantly lower 5-HT levels were found in all rats pretreated with RES.

CONCLUSIONS

AM and DES have antinociceptive properties while RES is pro-nociceptive. The antinociceptive effects of DES are not abolished by RES pretreatment, while AM only attenuates the pro-nociceptive effects of RES. The non-serotoninergic properties of TCAs substantially contribute to the differences in the antinococeptive effects of various TCAs.

Effect of the angiotensin II antagonist valsartan on sexual function in hypertensive men

The present open and prospective study was performed to investigate the effect of the angiotensin II receptor blocker (ARB) valsartan on sexual function in hypertensive males. Patients who were either newly treated or who were switched from other treatment regimens received valsartan 80-160 mg/day. Blood pressure decreased from an average of 158/94 mmHg to 136/82 mmHg during the 6 months of treatment (p < 0.001). The patients' sexual function was assessed before valsartan and after 6 months of treatment using the International Index of Erectile Function (IIEF), an internationally validated 15-item questionnaire. The IIEF addresses the relevant domains of male sexual function, i.e. erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction. At baseline, 75.4% of the total group of 3502 patients investigated and 65.0% of the subgroup of patients without previous antihypertensive treatment (n = 952) could be diagnosed as having erectile dysfunction (ED) according to the IIEF. Valsartan therapy markedly reduced ED in these groups to 53% and 45% (p < 0.0001), respectively. Improved ED was associated with highly significant improvements in orgasmic function, intercourse and overall satisfaction both in the total and previously untreated groups. In addition, sexual desire averaged 5.64 +/- 1.99 IIEF units in the total and 5.99 +/- 2.03 in the group without antihypertensive treatment at baseline. Valsartan markedly increased these numbers to 6.82 +/- 1.72 and 7.06 +/- 1.68 (p < 0.0001), respectively. The results of our open study suggest that the ARB valsartan improves sexual function in hypertensive males.

Brain imaging findings predict blood pressure response to pharmacological treatment

Hypertension appears to alter brain morphology, as well as the cerebrovascular support for information processing. Because these effects might reflect progressive effects of essential hypertension on the brain, we asked whether structural and functional brain indices would predict the success of pharmacological treatment of hypertension among 45 previously unmedicated individuals. After initial structural MRI and functional positron emission tomography imaging, subjects were randomly assigned in a double-blind fashion for treatment for 1 year with either lisinopril or atenolol. Systolic and diastolic blood pressure decreases after treatment stabilization were correlated to a pretreatment index of brain aging (combined ratings of ventricle and sulcal size and white matter hyperintensities) and the pretreatment change in regional cerebral blood flow during working memory in the thalamus and posterior parietal regions of interest. In multiple regression analyses, the structural brain index and the blood flow response in the thalamus predicted 20% of the variance in the systolic blood pressure response to treatment controlling for pretreatment blood pressure, age, gender, and type and dose of medication. Alcohol use influenced the thalamic response measure, but covariates did not alter the relation between greater indices of brain aging and less successful blood pressure response to treatment. The state of the brain may be an important factor in the remediation of blood pressure.

Sexual Dysfunction in Male Patients with Hypertension

Evidence suggests that arterial hypertension, in addition to being a cardiovascular and renal risk factor, may also be associated with an impairment of male sexual function. Since other cardiovascular risk factors, especially diabetes mellitus, have also been shown to correlate with impaired sexual function it has been proposed that sexual and especially erectile dysfunction may, at least in part, represent just another manifestation of atherosclerotic vascular disease. In addition to hypertension itself, sexual function in male hypertensive patients may also be affected by antihypertensive drug treatment. Available evidence suggests that centrally acting sympatholytic agents, beta-adrenoceptor antagonists (beta-blockers) and diuretics may have the potential to further impair sexual function. Calcium channel antagonists and ACE inhibitors may be neutral with respect to this endpoint. Preliminary data from several randomised and open studies have suggested that angiotensin II (AT)(1)-receptor antagonists may even be associated with an improvement of sexual function. However, many aspects of the interaction between hypertension, antihypertensive drug treatment and male sexual function remain unclear. Among other factors, the relative contribution of disease labelling both to the higher incidence of sexual dysfunction in hypertensive versus normotensive males and to the negative impact of treatment remains an open question. Furthermore, dose dependence of the observed effects of antihypertensive agents on sexual function, the role of combination therapy and the anticipation of proposed adverse effects of treatment are unresolved issues. Thus, more data from studies of high quality using standardised definitions and procedures are urgently needed to at least partially resolve some of the many open questions.

Sexual activity in hypertensive men

Erectile dysfunction is one of the major obstacles for noncompliance in the antihypertensive treatment. It has been shown that various antihypertensive drugs have a negative influence on sexual activity such as diuretics and beta-blockers. Thus, the purpose of the present study was to evaluate the effect of valsartan, an AT1-receptor antagonist, or its combination with hydrochlorothiazide on sexual activity in hypertensive patients. A total of 2202 patients (mean age 54+/-8 years) with hypertension systolic blood pressure (SBP)> or =140 mmHg, diastolic blood pressure (DBP)> or =95 mmHg), or with pretreated hypertension, were included in the present analysis. Blood pressure was measured at baseline, after 8 and 16 weeks, respectively. Sexual activity was assessed with a questionnaire at each of the three visits. Sexual activity (intercourse per week) was determined in three groups: controls (n=27; conventional therapy); valsartan group (n=1899); valsartan in combination with hydrochlorothiazide (n=276). There were 26 drop outs. SBP (-18.6 mmHg) and DBP (-11.6 mmHg) decreased significantly in all three groups. Sexual activity decreased slightly in controls from 1.3 to 0.9 times per week (NS), whereas it increased in the valsartan group from 1.0 to 1.6 times during follow-up (P<0.0001). Similarly, sexual activity increased in the combination group from 0.9 to 1.3 times per week during follow-up (P<0.0001). No sexual activity was reported by 467 (21%) of the 2202 patients at baseline and 154 (7%) at 16 weeks follow-up (P<0.05). Impaired sexual activity is common in hypertensive patients (app. 20%). Valsartan increases the rate of sexual intercourses per week, whereas conventional therapy affects sexual activity adversely.

Sexual dysfunction in patients with hypertension: implications for therapy

Sexual dysfunction associated with hypertension or antihypertensive therapies may impact the ability of patients to stay on therapy and lead to deterioration in patients' quality of life. Therefore, it is important for practitioners to become familiar with the wide variation in sexual side effects produced by antihypertensive agents and to discuss the potential occurrence of these side effects with their patients. In many cases, a change in the patient's drug regimen may help patients overcome specific sexual side effects experienced with certain treatments. Practitioners should consider selecting an antihypertensive therapy that is highly effective in lowering blood pressure but preserves patients quality of life. The effect of medications on sexual function remains controversial. Some blinded trials report little difference between placebo and specific medications, whereas other studies indicate that antihypertensive medications increase sexual dysfunction, which has an impact on quality of life. Recent evidence suggests that losartan, an angiotensin II antagonist, is not typically associated with development of sexual dysfunction and may actually positively impact several indices of sexual function (erectile function, sexual satisfaction, and frequency of sexual activity) as well as perceived quality of life. Thus, angiotensin II antagonists may offer a therapeutic option to prevent or correct erectile dysfunction in patients with hypertension. The favorable effects of these agents on sexual function may be related, in part, to their ability to block angiotensin II, which has recently become recognized as an important mediator of detumescence and possibly erectile dysfunction.

Quality of life in a sample of hypertensive patients attending primary health care facilities in Al-khobar, saudi arabia

BACKGROUND

Hypertension is one of the most prevalent chronic conditions in Saudi Arabia. It is the leading risk factor for cardiovascular diseases and a major reason for visits to clinic and prescription of medications. Inspite of this, the degree of its control is not to the optimum. This could be due to its impact on patients' quality of life (QOL). Impaired physical and psychological well-being may lead to non-compliance or even the withdrawal of treatment . The aim of this study was to assess QOL of hypertensive patients registered in Al-Khobar.

METHODS

The QOL of hypertensive patients was compared with QOL of a control group. A total of 404 subjects (202 cases and 202 controls) were interviewed. The cases and controls were matched for age and sex. Patients' self-assessment of QOL was measured with an Arabic version of SF-36, a 36-item Short Form Health Survey Questionnaire encompassing two main dimensions, physical and mental.

RESULTS

The QOL of hypertensive patients was substantially impaired in comparison to the control group. The mean scores for the physical component summary scale (PCS) were 39.3 and 50.8 for cases and controls respectively. The mean scores for the mental component summary scale (MCS) were 43.7 and 50.8 for cases and controls respectively. The burden of hypertension was concentrated in the physical dimension of health. Older age, female gender, unmarried patients, patients with hypertension complications, comorbid DM, use of Aldomet and shorter duration of hypertension were independently related to poorer QOL. The variability of the two summary measures explained by selected demographic and clinical characteristics was 24.3% and 10% for the PCS and MCS respectively.

CONCLUSIONS AND RECOMMENDATIONS

The QOL of hypertensive patients was substantially impaired in comparison to the control group. Notably, the total explained variation of QOL by the selected characteristics was small, suggesting that the determinants of QOL are multi-factorial. Further research to explore the determinants and indices of QOL in hypertensive patients is warranted. From a clinical perspective, QOL should be considered in the monitoring of hypertensive patients to estimate the burden of hypertension and monitor their outcome.

Aging and erectile dysfunction: the role of aging and concomitant chronic illness

Erectile dysfunction (ED) can have a strong negative effect on the well-being and quality of life of the sufferer. Many factors may contribute to the development of this disorder; age in particular and also concomitant chronic illnesses including neurological, hormonal, arterial and cavernosal factors. An understanding of the prevalence and characteristics of risk factors for ED is required, in order to establish effective therapeutic strategies. However, the prevalence of ED depends on the definitions used and the use of an internationally established scale for the assessment of male sexual function is necessary to facilitate the comparison of data between different countries. Further epidemiologic research and analysis of individual risk factors is required. Such studies will clarify the interactive effects of organic factors and their probable etiology with the general physical, sociocultural and psychologic status of patients. These efforts will make it possible to design more effective future strategies for the treatment and prevention of ED.

Does hypertension and its pharmacotherapy affect the quality of sexual function in women?

Considerable research has been conducted into the effects of antihypertensive drugs on male sexual functioning. This remains underexplored in women, even though almost half of treated hypertensives are women. An ambulatory medical record-based, case-control study was designed to study sexual function in treated and untreated hypertensive women and healthy controls. We conducted this study at a teaching hospital with satellite clinics in upstate New York. Of 3312 medical records reviewed, 640 premenopausal white women with or without mild hypertension (defined as blood pressure [BP] > or = 140/90 and < 160/110 mmHg), in heterosexual relationships, with no other significant medical history, were eligible. Of these, 241 women agreed to participate, and 224 (35%) completed both a self-administered questionnaire and a telephone interview. Analysis was conducted on 211 women (107 healthy controls, and 104 mild hypertensives, of whom 37 were unmedicated and 67 medicated). Questions on sexuality were classified into seven composite variables and later further divided. There were no demographic differences between participants and nonparticipants. Cases and controls differed only by age (P < .01); therefore, subsequent analysis was age-adjusted. Current smokers reported a significantly lower mean score for orgasm than did nonsmokers (P = .04). Women with unmedicated and medicated hypertension did not differ significantly on sexuality scores and were subsequently combined. Using age-adjusted ANOVA, women with hypertension reported significantly decreased lubrication and orgasm and increased pain compared to nonhypertensive women. There were no significant differences by ANOVA in the quality of sexual functioning between six treatment groups. In conclusion, the quality of female sexual functioning was quantified in an ambulatory outpatient setting. Hypertensive women, regardless of type of treatment, reported age-adjusted decrease in vaginal lubrication, less frequent orgasm, and more frequent pain when compared to nonhypertensive women. Emotional aspects of sexual functioning in hypertensive women do not appear to be impaired. These areas require further investigation. An incidental finding indicated diminished orgasm reported in current smokers, compared to nonsmokers, which was not associated with age or hypertension.

Efferent projections of the nucleus of the solitary tract to peri-locus coeruleus dendrites in rat brain: evidence for a monosynaptic pathway

Locus coeruleus (LC) neurons respond to autonomic influences, are activated by physiological stressors, and discharge in parallel with peripheral sympathetic nerves. The circuitry underlying modulation of LC activity by physiological manipulations (i.e., hemodynamic stress, hypovolumia) remains unclear. Specifically, monosynaptic projections from primary baroreceptor centers to the LC have been suggested by electrophysiological studies but have not been unequivocally established. Light microscopic anterograde tract-tracing studies have previously shown that neurons originating in the nucleus of the solitary tract (NTS) project to a region of the rostrodorsal pontine tegmentum, which contains noradrenergic dendrites of the LC; however, it is not known whether these NTS efferents specifically target LC dendrites. Therefore, we combined peroxidase labeling of biotinylated dextran amine (BDA) or Phaseolus vulgaris-leucoagglutinin (PHA-L) from the NTS with gold-silver labeling for tyrosine hydroxylase (TH) in the rostrolateral peri-LC region. Injections placed into neighboring nuclei (nucleus gracilis, hypoglossal nucleus) served as controls. Only injections centered in the NTS produced anterograde labeling in peri-LC regions containing TH processes. By electron microscopy, BDA- or PHA-L-labeled axon terminals originating from the NTS contained small, clear, and some large dense-core vesicles and formed heterogeneous synaptic contacts characteristic of both excitatory- and inhibitory-type transmitters. Approximately 19% of the BDA and PHA-L axon terminals examined originating from the commissural portion of the NTS formed synaptic specializations with dendrites exhibiting TH immunoreactivity in the peri-LC. These results demonstrate that neurons projecting from the cardiovascular-related portion of the NTS target noradrenergic dendrites, indicating that barosensitive NTS neurons may directly modulate the activity of LC neurons and may serve to integrate autonomic responses in brain by influencing the widespread noradrenergic projections of the LC. In addition, these findings demonstrate that extranuclear dendrites are an important termination site for afferents to the LC.

Effects of angiotensin II on sexual function, blood pressure, and fluid intake are differentially affected by AT-1 receptor blockade

We have previously reported that third ventricular administration of angiotensin II (ANG II) immediately before mating tests suppressed copulatory behavior in male rats. The present studies examine the effects of short- (3 days) and long-term (21 days) intracerebroventricular (i.c.v.) infusion of ANG II (6 microg/h), on parameters of copulatory behavior, fluid intake, and blood pressure in sexually experienced male Long Evans rats. Further, to test the hypothesis that suppression of masculine copulatory behavior by ANG II involves interaction with the angiotensin AT-1 receptor, a highly selective nonpeptide antagonist (L-158,809) was administered in the drinking water (25 mg/liter) to a group of ANG II-infused animals. I.c.v. infusion of ANG II was associated with increases in systolic blood pressure and fluid intake. In copulatory tests after 3, 9 and 15 days of infusion, rats infused with ANG II exhibited increased latencies to the initiation of copulatory behavior and to ejaculation, as well as increased intervals to reinitiate copulatory behavior after the ejaculation. Administration of L-158,809 blocked the effects of i.c.v. infusion of ANG II on systolic blood pressure and fluid intake. Further, L-158,809 attenuated the effects of i.c.v. infusion of ANG II on parameters of copulatory behavior. Data from this study provide support for a modulatory role for ANG II in the regulation of sexual behavior. In addition, this regulation seems to involve the AT-1 receptor.

Inhibition of penile erection in rats by a long-acting somatostatin analogue, octreotide (SMS 201-995)

OBJECTIVE

To assess the effect of a new somatostatin analogue (SMS 201-995, octreotide) on erectile function in rats.

MATERIALS AND METHODS

Animals were fasted and anaesthetized intraperitoneally with pentobarbital. A cannula was placed in the trachea and the femoral vein cannulated for intravenous infusion. The hypogastric and pelvic nerve, major pelvic ganglion, and the nerve fibres to the lower genitourinary tract were identified. In 20 animals, these nerves were stimulated unilaterally using bipolar silver-wire electrodes; the stimulation was repeated every 15 min for 1 h. Twenty animals were divided into two equal groups; after measuring penile erection to obtain basal values, the animals received either saline or 50 micrograms SMS 201-995 over 1 h and 30 min later, the stimulation was repeated.

RESULTS

After administering SMS 201-995 or saline, the levels of penile erection reduced linearly in both groups, but SMS 201-995 caused a greater decrease than in the control group (P < 0.05) and from baseline (P < 0.01) at all times.

CONCLUSION

SMS 201-995 inhibits penile erection in rats and the systems may serve as an in vivo animal model for further investigation.

Risk factors and drugs in the treatment of hypertension

BACKGROUND

A wide range of drug classes, frequently including centrally acting agents, has been used in clinical trials in hypertension which have shown benefit. Although therapy has clearly limited the complications of hypertension, further improvement is needed, especially concerning coronary artery disease.

PERSPECTIVES

Future interest therefore centres on drugs that do not worsen diabetes mellitus, do not cause dyslipidaemia, or induce potassium loss, while not provoking drowsiness, depression, other troublesome side-effects, or being associated with rebound hypertension when stopped. The centrally acting imidazoline agonists merit detailed study in this regard.

Use of pharmacy computer prescription database to access hypertensive patients for mailed survey research

OBJECTIVE

To evaluate the use of a pharmacy computer prescription database (PCPD) to identify and sample hypertensive patients outside of their treatment setting for mailed, self-administered survey research comparing the presence and lack of participation incentives and mailed follow-up reminders.

SETTING

Two independent, privately owned, free-standing community pharmacies.

PARTICIPANTS

A total of 735 individuals identified from a PCPD search who had been prescribed at least 1 of 130 PCPD medications potentially used in hypertensive therapy.

METHODS

PCPD was searched by the pharmacist/owner per protocol; participants were sent an individually addressed cover letter on pharmacy letterhead signed by the pharmacist that requested voluntary anonymous completion of an enclosed self-administered, quality-of-life opinion survey; the first search used no incentive or follow-up; the second search used an incentive and mailed a follow-up reminder. Research protocol followed published ethics guidelines.

RESULTS

There was a mean 84% return with incentive and follow-up strategies compared with a mean 25% return without strategies (p < 0.01) for all drug groups between searches; no statistical difference in response was shown between the same drug groups (alpha 1-blockers, calcium-channel blockers, and centrally acting alpha 2-agonists) within searches.

CONCLUSIONS

Acceptable response rates (74-93% return) can be obtained with traditional follow-up mailed incentives, prescription issuance within 6 months, incentives to both hypertensive and nonhypertensive responders, and sampling strategies within potential drug groups. Methodology can be adapted to other populations by alternative drug sampling strategies.

Men treated with hypolipidaemic drugs complain more frequently of erectile dysfunction

The objective of this study was to assess whether there is an association between impotence and treatment with hypolipidaemic drugs. We asked patients referred to a lipid clinic for primary hyperlipidaemia whether they were complaining of erectile dysfunction. All the patients with a previous cardiovascular history were excluded. The main cardiovascular risk factors and the treatments currently being taken were carefully recorded to analyse their association with erectile dysfunction. The population consisted of two groups (treatment group and control) of 339 age-matched men (mean age: 48 +/- 9.5 years). Our results revealed that there were more impotent men in the group of patients treated with hypolipidaemic drugs (12% vs. 5.6%, P = 0.0029). Multivariate analysis showed that erectile dysfunction was dependent on treatment with fibrate derivatives (odds ratio: 1.46; 1.27-1.68) and statins (odds ratio: 1.51; 1.26-1.80). We conclude that erectile dysfunction is a frequent disorder in hyperlipidaemic men. Our results suggest that this symptom could be a side-effect of hypolipidaemic drugs. If further studies confirm our data, the search for the mechanism and the consequences of this possible side-effect will be useful and important.

Drug-induced depression. Incidence, avoidance and management

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), drug-induced depression may be classified as an Organic Mood Syndrome, Depressed Type. Unfortunately, the DSM-III-R diagnostic criteria are not sufficiently precise for application in research, and studies of drug-induced depression have rarely utilised these criteria. Research concerned with drug-induced depression is characterised by a number of methodological complications. These include differing definitions of depression, including depression defined as a symptom, a syndrome, or by diagnostic criteria for a specific mental disorder. In addition, patients undergoing pharmacological treatments for medical illnesses are typically exposed to considerable psychosocial stress due to the suffering and disability associated with illness. These psychosocial factors may in themselves precipitate episodes of depression. Due to these complicating factors, sophisticated study designs are required to confirm an aetiological role for medications as risk factors for depression. Unfortunately, adequate studies have rarely been conducted, and much of the literature consists of case reports and clinical observations. Consequently, clinicians are frequently required to make clinical judgements about the aetiology of patients' depressive symptoms in the absence of definitive scientific information about the role of drugs. Nevertheless, a knowledge of the relevant literature will assist clinicians in making reasoned judgements about the aetiology, prevention and management of these disorders.

Felodipine, metoprolol and their combination compared with placebo in isolated systolic hypertension in the elderly

This study compared with placebo the efficacy and tolerability of optimised doses of felodipine 5-20 mg daily, metoprolol 50-200 mg daily and their combination in subjects 60 years or over with isolated systolic hypertension. The study employed a randomised double-blind crossover design with allocation of treatment order within subjects by Latin squares. For each subject, after a single-blind run-in placebo phase, there were four randomised treatment phases each of six weeks duration, with a dose titration step at three weeks if necessary. Twenty-eight subjects entered the randomised phases of the study and twenty-one completed all four phases--13 male, 8 female (ages: median 71, range 59-85 years). At the end of both the felodipine and metoprolol phases systolic and diastolic pressure were reduced at 2 hours postdose compared with the placebo phase (p < 0.001), the blood pressure reduction with felodipine (-40/-20 mmHg) being greater than that with metoprolol (-15/-9 mmHg) (p < 0.01). Immediately predose (12 hours postdose) there was a persisting reduction of supine systolic blood pressure (-17 mmHg) with felodipine (p < 0.001), but there was no significant effect of metoprolol. At both measurement times the two drugs when in combination had an additive effect on blood pressure. There was a 20% increase in reported symptoms during each of the active treatment phases. Four subjects withdrew during the randomised phases because of probable drug-related adverse events and six subjects required dosage reductions during the felodipine or combination phases.(ABSTRACT TRUNCATED AT 250 WORDS)

Neuropsychiatric adverse drug reactions: passive reports to Health and Welfare Canada's adverse drug reaction database (1965-present)

OBJECTIVE

Since 1965, Health and Welfare Canada has operated an adverse drug reaction (ADR) program. The program accepts spontaneous reports of adverse drug reactions, and maintains an ADR database. The purpose of this article is to summarize the Psychiatric ADRs reported to this database since 1965. The nature of the information prohibits its use in the evaluation of epidemiological hypotheses about the etiology of drug-induced mental disorders. However, in an exploratory sense, the contents of the database may contribute to the development of epidemiological hypotheses about the etiology of drug-induced mental disorders. Of particular interest are areas of apparent contradiction between the contents of the database and the clinical literature.

METHODS

The database was searched for reports of ADRs to a group of drugs which have been frequently implicated in causing psychiatric toxicity. All reports characterized as "psychiatric disorders" were down-loaded from the database for the analysis (n = 1822). The reports were further classified into nine categories according to the type of psychiatric symptoms described.

RESULTS

There were several reports of hallucinations caused by methyldopa, and also several reports of benzodiazepine-induced hallucinations and encephalopathy. These reactions have not been described in the literature. Also, there were few reports of digoxin-induced organic depression, and an absence of reports of organic mania induced by H-2 blockers, despite descriptions of these sorts of reactions in the clinical literature.

CONCLUSIONS

Further research is needed to define the neuropsychiatric toxicity associated with medical drugs. Clinicians must continue to consider the potential role of medications in the etiology of psychiatric symptoms.

Can drugs cause depression? A review of the evidence

Drug-induced depressive disorders are classified in the DSM-III-R as organic mood syndrome, depressed type. The ability of certain drugs to cause depression is of clinical relevance because organic mood syndrome is a component of the differential diagnosis of depressive symptoms. Consequently, psychiatric textbooks often provide different lists of drugs thought to be capable of causing depression. Strong evidence supporting the existence of causal associations is often lacking. There is no specific drug for which there is definitive evidence of a causal association with depressive symptoms or depressive disorders. Nevertheless, for a number of drugs, the evidence is suggestive, although not conclusively, of a causal association. Despite this, rational decisions about the continuation or discontinuation of drugs can often be made. In this paper, the literature is reviewed and guidelines are suggested for the management of patients with depressive symptoms which may be related to drugs.

Effects of antihypertensive drugs atenolol and nifedipine on sexual function in older men: a placebo-controlled, crossover study

Investigated the adverse sexual effects of two antihypertensive drugs, atenolol and slow-release nifedipine, in a placebo-controlled, randomized, crossover study. Subjects were 16 older men (mean age = 66.6 years, SEM = 1.4) with mild to moderate hypertension. Subjects completed daily self-reports on 13 measures of sexuality: frequency of desire, coitus, noncoital partner sex, masturbation, morning erections, spontaneous erections, orgasms in coitus and masturbation, firmness of morning, masturbatory and coital erections, and subjective pleasure in coitus and masturbation. Except for a significant decrease in masturbatory erectile firmness with nifedipine therapy, variables did not differ between the two drug treatments or between either drug and placebo. Although the sample was relatively small, small differences between treatment means suggest that these antihypertensive agents are fairly benign relative to sexual function in men.

The way towards adverse event monitoring in clinical trials

Different approaches to the monitoring of adverse reactions to drugs have been used over the years, with the aim of preventing catastrophes like the thalidomide episode and to rationalise drug usage. In the 1960s, the use of national and international adverse event monitoring was first suggested by the British statistician, David Finney. According to Finney, the method was well suited for the postmarketing surveillance of drugs. The idea was rejected by the World Health Organization (WHO) but was later taken up by the Prescription Event Monitoring Event System in the UK. Subsequent to problems with practolol in the 1970s it was suggested that adverse event monitoring could also be useful in clinical trials to detect adverse reactions before a drug is launched. The idea of adverse event monitoring has been tested by Astra Hässle in Sweden in clinical trials with felodipine and omeprazole, and is now the standard method within the company. Adverse event monitoring is an expensive and time-consuming method seen from a short term perspective. However, such monitoring offers an opportunity to optimise the use of clinical trials in safety monitoring, and its ability to predict possible adverse drug reactions is superior to other methods.

Novel drug-delivery systems for hypertension

Although novel controlled-release drug-delivery systems have been used in other areas of medicine, their application in the treatment of hypertension has been relatively recent. Biotechnical use of chemical-dispensing systems has been applied to propranolol, clonidine (the transdermal therapeutic system), nifedipine (the gastrointestinal therapeutic system), verapamil (the sodium alginate and spheroidal oral-delivery absorption system), felodipine (the hydrophilic gel principle), metoprolol succinate (the multiple-unit pellet system), and diltiazem (one system comprising sustained-release beads and the other utilizing the patented Geomatrix extended-release system). Oral drug-delivery systems allow antihypertensive agents that previously had to be administered two to four times daily to be administered once each day. Potential disadvantages of the oral controlled-release products include delayed attainment of pharmacodynamic effect, unpredictable or reduced bioavailability, enhanced first-pass hepatic metabolism, dose dumping, sustained toxicity, dosing inflexibility, and increased cost. Potential advantages include reduced dosing frequency, enhanced compliance and convenience, reduced toxicity, stable drug levels, uniform drug effect, and decreased total dose. Although skin reactions are common, the transdermal drug delivery of clonidine provides another innovative approach to supplying transcutaneous, controlled, continuous delivery of drug for 7 days. It is possible that future research will prove that the agents that provide complete 24-hour control may reduce the cardiovascular events associated with the early-morning blood pressure surge. This evolution in antihypertensive therapy to achieve once-daily dosing may prove to be of great value to both physicians and patients in the 1990s.

Pharmacy computer prescription databases: methodologic issues of access and confidentiality

OBJECTIVE

To examine methodologic issues of access and confidentiality regarding the use of pharmacy computer prescription databases (PCPDs) for participant selection to receive mailed, self-administered, hypertensive quality-of-life survey outside a primary-care setting.

DESIGN

Two separate PCPD searches by pharmacist owners for patients prescribed at least one of 130 potential antihypertensive medications. The first PCPD used a nonrandom sample of all patients (n = 635); the second PCPD used a random sample (n = 100) of three specific antihypertensive drug groups. Research protocol was approved by the investigators' institutional review board.

SETTING

Two independent, privately owned PCPDs.

PATIENTS OR OTHER PARTICIPANTS

Individuals prescribed at least 1 of 130 PCPD medications potentially used in antihypertensive treatment.

INTERVENTIONS

Individually addressed cover letter on pharmacy letterhead signed by a pharmacist requesting voluntary completion of the enclosed, self-administered, opinion survey on quality of life.

MAIN OUTCOME MEASURE

Anonymous survey return to off-site post office box in envelope provided.

RESULTS

Favorable or no opposition to PCPD methodology from pharmacist or participants. Ethical opposition was encountered when incorporating PCPD sampling technique into grant proposal.

CONCLUSIONS

The American Pharmaceutical Association Code of Ethics is used as a basis to provide recommendations to examine and justify PCPD investigative use. Increasing availability of PCPD technology encourages more efficient and easier methods of research strategy. PCPD use, however, demands identical stringent guidelines used in traditional research and raises potential issues regarding pharmacist-patient confidentiality as well as the right of PCPD use by others.