Drug treatment in heart failure

Asthma and COPD: A Focus on β-Agonists - Past, Present and Future

Asthma has been recognised as a respiratory disorder for millennia and the focus of targeted drug development for the last 120 years. Asthma is one of the most common chronic non-communicable diseases worldwide. Chronic obstructive pulmonary disease (COPD), a leading cause of morbidity and mortality worldwide, is caused by exposure to tobacco smoke and other noxious particles and exerts a substantial economic and social burden. This chapter reviews the development of the treatments of asthma and COPD particularly focussing on the β-agonists, from the isolation of adrenaline, through the development of generations of short- and long-acting β-agonists. It reviews asthma death epidemics, considers the intrinsic efficacy of clinical compounds, and charts the improvement in selectivity and duration of action that has led to our current medications. Important β2-agonist compounds no longer used are considered, including some with additional properties, and how the different pharmacological properties of current β2-agonists underpin their different places in treatment guidelines. Finally, it concludes with a look forward to future developments that could improve the β-agonists still further, including extending their availability to areas of the world with less readily accessible healthcare.

Effects of chronic application of propranolol on beta-adrenergic signal transduction in heart ventricles from myopathic BIO TO2 and control hamsters

1. In human congestive heart failure beta-adrenoceptor antagonists improve exercise tolerance and cardiac contractility. These beneficial effects are thought to reflect an up-regulation of cardiac beta-adrenoceptors, involving mainly the beta1-subtype. In the present study we evaluated the functional contribution of beta-adrenoceptor subtypes to stimulation of adenylyl cyclase in an animal model of dilated cardiomyopathy, and compared the effects of treatment with propranolol on cardiac beta-adrenergic signal transduction in myopathic and control hamsters. 2. Cardiomyopathic BIO TO2 hamsters and BIO F1B controls aged 270 days were used. In the treatment study, hamsters received drinking water with or without propranolol 40 mg kg(-1) d(-1) for 4 weeks prior to sacrifice. Density and subtype distribution of beta-adrenoceptors were determined in radioligand binding studies. Functional contributions of beta-adrenoceptors were evaluated by subtype-selective stimulation of adenylyl cyclase. Cardiac G-protein content was determined by immunoblotting. 3. Compared to BIO F1B controls, myopathic hamsters showed increases in cardiac total beta- and beta2-adrenoceptor density, G(s alpha) and G(i alpha) content. In BIO TO2 ventricles, beta1-adrenoceptors were almost completely uncoupled from adenylyl cyclase stimulation despite an unchanged density. Treatment of hamsters with propranolol resulted in increased density of beta1-adrenoceptors in both strains, but had no effect on their functional efficacy. Moreover, beta2-adrenergic stimulation of adenylyl cyclase was even reduced in propranolol-treated animals, which could not be explained by changes in cardiac G-protein content. 4. Cardiomyopathic BIO TO2 hamsters showed functional uncoupling of cardiac beta1-adrenoceptors, which could not be normalized by propranolol and, therefore, is unlikely to be solely due to agonist-dependent desensitization. The paradoxical reduction in beta2-adrenergic efficiency in propranolol-treated myopathic and control hamsters deserves further investigation.

Risk of non-fatal cardiac failure and ischaemic heart disease with long acting beta 2 agonists

BACKGROUND

The long term safety of beta agonists, particularly in patients with heart disease, has not been fully established.

METHODS

This study accessed the results of three cohort studies involving: 12,294 patients receiving at least one prescription for nedocromil between November 1986 and September 1988; 15,407 patients prescribed salmeterol between December 1990 and May 1991; and 8098 patients prescribed bambuterol between February 1993 and December 1995. Details of all dispensed prescriptions for these drugs prescribed by general practitioners in England soon after their launch were provided in confidence by the Prescription Pricing Authority. Questionnaires were sent to the prescriber asking for details of events occurring after the first prescription (prescription event monitoring). Rates and relative risks of non-fatal cardiac failure and ischaemic heart disease were calculated, comparing bambuterol and salmeterol with the reference drug nedocromil.

RESULTS

The age and sex adjusted relative risk of non-fatal cardiac failure associated with bambuterol was 3.41 (95% confidence limits (CL) 1.99 to 5.86) when compared with nedocromil. When salmeterol was compared with nedocromil the adjusted relative risk of non-fatal cardiac failure was 1.10 (95% CL 0.63 to 1.91). The adjusted relative risk of non-fatal ischaemic heart disease was 1.23 (95% CL 0.73 to 2.08) and 1.07 (95% CL 0.69 to 1.66) for bambuterol and salmeterol, compared with nedocromil, respectively. However, in the first month of exposure the adjusted relative risk of non-fatal ischaemic heart disease was 3.95 (95% CL 1.38 to 11.31) when bambuterol was compared with nedocromil.

CONCLUSIONS

Caution should be exercised when prescribing long acting oral beta agonists to patients at risk of cardiac failure. More definitive evidence would come from prospective randomised trials.