1
|
Soleman SI, Maya J, Levesque P, Mohammad A, Christopher L, Schumacher J, Nanduri A, Sivakumar P, Kozinn M, Costet P, Wang C, Richter J, Hawthorne D, Bui A, Rao VS, Dickerson D, Testani J, Ramírez-Valle F, Baribaud F, Murthy B, Merali S. First-in-Human Study to Assess the Safety, Pharmacokinetics, and Pharmacodynamics of BMS-986308: A Renal Outer Medullary Potassium Channel Inhibitor. Clin Pharmacol Ther 2024. [PMID: 39219444 DOI: 10.1002/cpt.3430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 08/03/2024] [Indexed: 09/04/2024]
Abstract
In patients with heart failure (HF) who respond inadequately to loop diuretic therapy, BMS-986308, an oral, selective, reversible renal outer medullary potassium channel (ROMK) inhibitor may represent an effective diuretic with a novel mechanism of action. We present data from the first-in-human study aimed to assess the safety, tolerability, pharmacokinetics (PK) and pharmacodynamics (PD) following single ascending doses of BMS-986308 in healthy adult participants. Forty healthy participants, aged from 20 to 55 years, and body mass index (BMI) from 19.8 to 31.6 kg/m2 were assigned to 1 of 5 dose cohorts (1, 3, 10, 30, and 100 mg) and randomized (6:2) to receive BMS-986308 oral solution or matching placebo. Following administration, BMS-986308 was rapidly absorbed with a median time to maximum concentration (Tmax) of 1.00 to 1.75 h and exhibiting a mean terminal half-life (t1/2) of approximately 13 h. Dose proportionality was evident in BMS-986308 area under the concentration-time curve (AUC), while maximum concentration (Cmax) was slightly greater than dose-proportional. We observed that urine output (or diuresis; mL) and urinary sodium excretion (or natriuresis; mmol) increased in a dose-dependent manner, starting at a minimum pharmacologically active dose of 30 mg. The largest mean changes from baseline in diuresis and natriuresis occurred in both the 6- and -24 h post-dose period following administration of 100 mg (1683.0 mL and 2055.3 mL, and 231.7 mmol and 213.7 mmol, respectively; ***P < 0.001). Overall, single-dose BMS-986308 was found to be safe, well-tolerated, with an excellent PK profile, and substantial diuretic and natriuretic activity.
Collapse
Affiliation(s)
- Sharif I Soleman
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Juan Maya
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Paul Levesque
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Atif Mohammad
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Lisa Christopher
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Justin Schumacher
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Aparna Nanduri
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | | | - Marc Kozinn
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Philippe Costet
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Chang Wang
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Jeremy Richter
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Dara Hawthorne
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Anh Bui
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Veena S Rao
- Department of Cardiovascular Medicine, Yale Medical Center, New Haven, Connecticut, USA
| | | | - Jeffrey Testani
- Department of Cardiovascular Medicine, Yale Medical Center, New Haven, Connecticut, USA
| | | | - Frédéric Baribaud
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Bindu Murthy
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| | - Samira Merali
- Bristol Myers Squibb Research & Early Development, Princeton, New Jersey, USA
| |
Collapse
|
2
|
Rao VS, Cox ZL, Ivey-Miranda JB, Neville D, Balkcom N, Moreno-Villagomez J, Ramos-Mastache D, Maulion C, Bellumkonda L, Tang WHW, Collins SP, Velazquez EJ, Mentz RJ, Wilson FP, Turner JM, Wilcox CS, Ellison DH, Fang JC, Testani JM. Mechanistic Differences between Torsemide and Furosemide. J Am Soc Nephrol 2024:00001751-990000000-00409. [PMID: 39196651 DOI: 10.1681/asn.0000000000000481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 08/23/2024] [Indexed: 08/30/2024] Open
Abstract
Background:
Torsemide is proposed to have clinically important pharmacokinetic and pharmacodynamic advantages over furosemide. However, clinical outcomes did not differ in the Torsemide Comparison with Furosemide for Management of Heart Failure (TRANSFORM-HF) randomized trial.
Methods:
We conducted a multicenter mechanistic substudy of patients with heart failure randomized to oral furosemide or torsemide (TRANSFORM-Mechanism). At baseline and 30 days, participants underwent detailed assessments of pharmacokinetic and pharmacodynamic parameters.
Results:
TRANSFORM-Mechanism enrolled 88 participants. Kidney bioavailability, or the proportion of dose delivered to the tubular site of action, was significantly less with torsemide compared to furosemide [median 17.1%, (IQR 12.3, 23.5%) vs. 24.8% (16.6, 34.1%), p < 0.001]. Furosemide had a longer duration of kidney drug delivery and duration of natriuresis (p≤0.004 for both). Prescribed doses of furosemide and torsemide in TRANSFORM-Mechanism were similar to TRANSFORM-HF, with providers on average using a 2:1 dose equivalence conversion between drugs. However, these doses resulted in a substantially greater natriuresis with torsemide (p<0.001). A dose equivalence of ∼4:1 resulted in similar natriuresis. Higher diuretic doses in the torsemide group resulted in mild perturbations in kidney function and significant increases in renin, aldosterone, and norepinephrine (p<0.05 for all). Plasma volume (p=0.52) and body weight (p=0.89) did not improve with torsemide vs. furosemide.
Conclusions:
We observed no meaningful pharmacokinetic/pharmacodynamic advantages for torsemide vs. furosemide. The greater natriuresis from higher diuretic doses in the torsemide group was offset by greater neurohormonal activation and kidney dysfunction.
Collapse
Affiliation(s)
- Veena S Rao
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Juan B Ivey-Miranda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Daniel Neville
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Natasha Balkcom
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Julieta Moreno-Villagomez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Facultad de Estudios Superiores Iztacala, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Daniela Ramos-Mastache
- Facultad de Estudios Superiores Iztacala, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Christopher Maulion
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Lavanya Bellumkonda
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center (GRECC), Nashville, Tennessee
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Robert J Mentz
- Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | - F Perry Wilson
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey M Turner
- Division of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher S Wilcox
- Division of Nephrology and Hypertension Center, Georgetown University, Washington, DC
| | - David H Ellison
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University, Portland, Oregon
| | - James C Fang
- Department of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jeffrey M Testani
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
3
|
Sherazi AW, Zamir A, Rehman AU, Ashraf W, Imran I, Saeed H, Majeed A, Saleem Z, Aziz M, Alqahtani F, Rasool MF. A Systematic Critical Review of Clinical Pharmacokinetics of Torasemide. Ther Drug Monit 2024; 46:309-320. [PMID: 38176856 DOI: 10.1097/ftd.0000000000001141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 08/10/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE Torasemide is a potassium-sparing loop diuretic used to treat fluid retention associated with congestive heart failure and kidney and hepatic diseases. This systematic review was conducted to combine all accessible data on the pharmacokinetics (PK) of torasemide in healthy and diseased populations, which may help clinicians avert adverse drug reactions and determine the correct dosage regimen. METHODS Four databases were systematically searched to screen for studies associated with the PK of torasemide, and 21 studies met the eligibility criteria. The review protocol was registered in the PROSPERO database (CRD42023390178). RESULTS A decrease in maximum plasma concentration (C max ) was observed for torasemide after administration of the prolonged-release formulation in comparison to that after administration of the immediate-release formulation, that is, 1.12 ± 0.17 versus 1.6 ± 0.2 mcg/mL. After administering an oral dose of torasemide, a 2-fold increase in the area under the concentration-time curve (AUC) was reported in patients with congestive heart failure compared with the healthy population. Moreover, the patients with renal failure (clearance < 30 mL/min) showed an increase in value of AUC 0-∞ that is, 42.9 versus 8.091 mcg.h -1 .mL -1 compared with healthy subjects. In addition, some studies have reported interactions with different drugs, in which irbesartan showed a slight increase in the AUC 0-∞ of torasemide, whereas losartan and empagliflozin did not. CONCLUSIONS The current review summarizes all available PK parameters of torasemide that may be beneficial for avoiding drug-drug interactions in subjects with renal and hepatic dysfunction and for predicting doses in patients with different diseases.
Collapse
Affiliation(s)
- Abdul Wasay Sherazi
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | - Ammara Zamir
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | - Anees Ur Rehman
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | - Waseem Ashraf
- Department of Pharmacology, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | - Imran Imran
- Department of Pharmacology, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | - Hamid Saeed
- University College of Pharmacy, University of the Punjab, Lahore, Pakistan
| | - Abdul Majeed
- Department of Pharmaceutics, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan; and
| | - Zikria Saleem
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| | - Majid Aziz
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
- Department of Pharmacology, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
- University College of Pharmacy, University of the Punjab, Lahore, Pakistan
- Department of Pharmaceutics, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan; and
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Faleh Alqahtani
- Department of Pharmacology and Toxicology, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Muhammad Fawad Rasool
- Department of Pharmacy Practice, Faculty of Pharmacy, Bahauddin Zakariya University, Multan, Pakistan
| |
Collapse
|
4
|
Martens P, Greene SJ, Mentz RJ, Li S, Wojdyla D, Kapelios CJ, Mullens W, Hall ME, Ketema F, Kim DY, Eisenstein EL, Anstrom K, Fang JC, Pitt B, Velazquez EJ, Tang WHW. Impact of baseline kidney dysfunction on oral diuretic efficacy following hospitalization for heart failure - insights from TRANSFORM-HF. Eur J Heart Fail 2024; 26:1242-1250. [PMID: 38558520 DOI: 10.1002/ejhf.3207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024] Open
Abstract
AIM Among patients discharged after hospitalization for heart failure (HF), a strategy of torsemide versus furosemide showed no difference in all-cause mortality or hospitalization. Clinicians have traditionally favoured torsemide in the setting of kidney dysfunction due to better oral bioavailability and longer half-life, but direct supportive evidence is lacking. METHODS AND RESULTS The TRANSFORM-HF trial randomized patients hospitalized for HF to a long-term strategy of torsemide versus furosemide, and enrolled patients across the spectrum of renal function (without dialysis). In this post-hoc analysis, baseline renal function during the index hospitalization was assessed as categories of estimated glomerular filtration rate (eGFR; <30, 30-<60, ≥60 ml/min/1.73 m2). The interaction between baseline renal function and treatment effect of torsemide versus furosemide was assessed with respect to mortality and hospitalization outcomes, and the change in Kansas City Cardiomyopathy Questionnaire clinical summary score (KCCQ-CSS). Of 2859 patients randomized, 336 (11.8%) had eGFR <30 ml/min/1.73 m2, 1138 (39.8%) had eGFR 30-<60 ml/min/1.73 m2, and 1385 (48.4%) had eGFR ≥60 ml/min/1.73 m2. Baseline eGFR did not modify treatment effects of torsemide versus furosemide on all adverse clinical outcomes including individual components or composites of all-cause mortality and all-cause (re)-hospitalizations, both when assessing eGFR categorically or continuously (p-value for interaction all >0.108). Similarly, no treatment effect modification by eGFR was found for the change in KCCQ-CSS (p-value for interaction all >0.052) when assessing eGFR categorically or continuously. CONCLUSION Among patients discharged after hospitalization for HF, there was no significant difference in clinical and patient-reported outcomes between torsemide and furosemide, irrespective of renal function.
Collapse
Affiliation(s)
- Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Genk, Belgium
- Kaufman Center for Heart Failure Treatment and Recovery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Shuang Li
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Chris J Kapelios
- Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Genk, Belgium
| | - Michael E Hall
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Fassil Ketema
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Dong-Yun Kim
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | | | | | - James C Fang
- Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Bertram Pitt
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - W H Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
5
|
Koirala A, Pourafshar N, Daneshmand A, Wilcox CS, Mannemuddhu SS, Arora N. Etiology and Management of Edema: A Review. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:110-123. [PMID: 36868727 DOI: 10.1053/j.akdh.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 04/18/2023]
Abstract
The development of peripheral edema can often pose a significant diagnostic and therapeutic challenge for practitioners due to its association with a wide variety of underlying disorders ranging in severity. Updates to the original Starling's principle have provided new mechanistic insights into edema formation. Additionally, contemporary data highlighting the role of hypochloremia in the development of diuretic resistance provide a possible new therapeutic target. This article reviews the pathophysiology of edema formation and discusses implications for treatment.
Collapse
Affiliation(s)
- Abbal Koirala
- Division of Nephrology, University of Washington, Seattle, WA
| | - Negiin Pourafshar
- Division of Nephrology, MedStar Georgetown University Hospital, Washington DC
| | - Arvin Daneshmand
- Division of Nephrology, MedStar Georgetown University Hospital, Washington DC
| | | | | | - Nayan Arora
- Division of Nephrology, University of Washington, Seattle, WA.
| |
Collapse
|
6
|
Guo L, Fu B, Liu Y, Hao N, Ji Y, Yang H. Diuretic resistance in patients with kidney disease: Challenges and opportunities. Biomed Pharmacother 2023; 157:114058. [PMID: 36473405 DOI: 10.1016/j.biopha.2022.114058] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/15/2022] [Accepted: 11/27/2022] [Indexed: 12/10/2022] Open
Abstract
Edema caused by kidney disease is called renal edema. Edema is a common symptom of many human kidney diseases. Patients with renal edema often need to take diuretics.However, After taking diuretics, patients with kidney diseases are prone to kidney congestion, decreased renal perfusion, decreased diuretics secreted by renal tubules, neuroendocrine system abnormalities, abnormal ion transporter transport, drug interaction, electrolyte disorder, and hypoproteinemia, which lead to ineffective or weakened diuretic use and increase readmission rate and mortality. The main causes and coping strategies of diuretic resistance in patients with kidney diseases were described in detail in this report. The common causes of DR included poor diet (electrolyte disturbance and hypoproteinemia due to patients' failure to limit diet according to correct sodium, chlorine, potassium, and protein level) and poor drug compliance (the patient did not take adequate doses of diuretics. true resistance occurs only if the patient takes adequate doses of diuretics, but they are not effective), changes in pharmacokinetics and pharmacodynamics, electrolyte disorders, changes in renal adaptation, functional nephron reduction, and decreased renal blood flow. Common treatment measures include increasing in the diuretic dose and/or frequency, sequential nephron blockade,using new diuretics, ultrafiltration treatment, etc. In clinical work, measures should be taken to prevent or delay the occurrence and development of DR in patients with kidney diseases according to the actual situation of patients and the mechanism of various causes. Currently, there are many studies on DR in patients with heart diseases. Although the phenomenon of DR in patients with kidney diseases is common, there is a relatively little overview of the mechanism and treatment strategy of DR in patients with kidney diseases. Therefore, this paper hopes to show the information on DR in patients with kidney diseases to clinicians and researchers and broaden the research direction and ideas to a certain extent.
Collapse
Affiliation(s)
- Luxuan Guo
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Baohui Fu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Yang Liu
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Na Hao
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Yue Ji
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China
| | - Hongtao Yang
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin 300193, China; National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin 300193, China; Tianjin University of Traditional Chinese Medicine, Tianjin 301617, China.
| |
Collapse
|
7
|
Torsemide Pharmacometrics in Healthy Adult Populations Including CYP2C9 Genetic Polymorphisms and Various Patient Groups through Physiologically Based Pharmacokinetic-Pharmacodynamic Modeling. Pharmaceutics 2022; 14:pharmaceutics14122720. [PMID: 36559213 PMCID: PMC9784843 DOI: 10.3390/pharmaceutics14122720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/28/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Torsemide is a widely used diuretic in clinical practice. In this study, pharmacokinetic (PK) and pharmacodynamic (PD) simulations of torsemide for various population groups and exposure scenarios were performed through human-scale physiologically-based PK-PD (PBPK-PD) modeling of torsemide. For PBPK-PD modeling of torsemide, invitro and clinical data of torsemide reported previously were used. After exposure to clinical doses of torsemide, observed plasma (or serum) concentration and urine torsemide excretion profiles were used as PK-data, and observed urinary sodium excretion rate was used as PD-data. The model was then extended to take into account physiological and biochemical factors according to different CYP2C9 phenotypes or patient populations. The established model captured various torsemide clinical results well. Differences in torsemide PKs and PDs between patient groups or CYP2C9 genetic polymorphisms were modelologically identified. It was confirmed that degrees of differences in torsemide PKs and PDs by disease groups were greater than those according to different CYP2C9 phenotypes. According to torsemide administration frequency or dose change, it was confirmed that although the difference in plasma PKs between groups (healthy adult and patient groups) could increase to 14.80 times, the difference in PDs was reduced to 1.01 times. Results of this study suggested that it is very important to consider disease groups in the setting of torsemide clinical therapy and that it is difficult to predict PD proportionally with only differences in PKs of torsemide between population groups. The PBPK-PD model established in this study is expected to be utilized for various clinical cases involving torsemide application in the future, enabling optimal drug therapy.
Collapse
|
8
|
Tang J, Ye L, Yan Q, Zhang X, Wang L. Effects of Sodium-Glucose Cotransporter 2 Inhibitors on Water and Sodium Metabolism. Front Pharmacol 2022; 13:800490. [PMID: 35281930 PMCID: PMC8905496 DOI: 10.3389/fphar.2022.800490] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 01/24/2022] [Indexed: 12/19/2022] Open
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors exert hypoglycemic and diuretic effects by inhibiting the absorption of sodium and glucose from the proximal tubule. Currently available data indicate that SGLT2 inhibitors transiently enhance urinary sodium excretion and urinary volume. When combined with loop diuretics, SGLT2 inhibitors exert a synergistic natriuretic effect. The favorable diuretic profile of SGLT2 inhibitors may confer benefits to volume management in patients with heart failure but this natriuretic effect may not be the dominant mechanism for the superior long-term outcomes observed with these agents in patients with heart failure. The first part of this review explores the causes of transient natriuresis and the diuretic mechanisms of SGLT2 inhibitors. The second part provides an overview of the synergistic effects of combining SGLT2 inhibitors with loop diuretics, and the third part summarizes the mechanisms of cardiovascular protection associated with the diuretic effects of SGLT2 inhibitors.
Collapse
Affiliation(s)
- Jun Tang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China.,Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Lifang Ye
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China.,Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Qiqi Yan
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China.,Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Xin Zhang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China.,Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Lihong Wang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China.,Department of Cardiovascular Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| |
Collapse
|
9
|
Cox ZL, Rao VS, Testani JM. Classic and Novel Mechanisms of Diuretic Resistance in Cardiorenal Syndrome. KIDNEY360 2022; 3:954-967. [PMID: 36128483 PMCID: PMC9438407 DOI: 10.34067/kid.0006372021] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/23/2022] [Indexed: 01/10/2023]
Abstract
Despite the incompletely understood multiple etiologies and underlying mechanisms, cardiorenal syndrome is characterized by decreased glomerular filtration and sodium avidity. The underlying level of renal sodium avidity is of primary importance in driving a congested heart failure phenotype and ultimately determining the response to diuretic therapy. Historically, mechanisms of kidney sodium avidity and resultant diuretic resistance were primarily extrapolated to cardiorenal syndrome from non-heart failure populations. Yet, the mechanisms appear to differ between these populations. Recent literature in acute decompensated heart failure has refuted several classically accepted diuretic resistance mechanisms and reshaped how we conceptualize diuretic resistance mechanisms in cardiorenal syndrome. Herein, we propose an anatomically based categorization of diuretic resistance mechanisms to establish the relative importance of specific transporters and translate findings toward therapeutic strategies. Within this categorical structure, we discuss classic and novel mechanisms of diuretic resistance.
Collapse
Affiliation(s)
- Zachary L. Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee,Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Veena S. Rao
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey M. Testani
- Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
10
|
Abstract
Despite recent advances in the treatment of chronic heart failure, therapeutic options for acute heart failure (AHF) remain limited. AHF admissions are associated with significant multi-organ dysfunction, especially worsening renal failure, which results in significant morbidity and mortality. There are several aspects of AHF management: diagnosis, decongestion, vasoactive therapy, goal-directed medical therapy initiation and safe transition of care. Effective diagnosis and prognostication could be very helpful in an acute setting and rely upon biomarker evaluation with noninvasive assessment of fluid status. Decongestive strategies could be tailored to include pharmaceutical options along with consideration of utilizing ultrafiltration for refractory hypervolemia. Vasoactive agents to augment cardiac function have been evaluated in patients with AHF but have shown to only have limited efficacy. Post stabilization, initiation of quadruple goal-directed medical therapy—angiotensin receptor-neprilysin inhibitors, mineral receptor antagonists, sodium glucose type 2 (SGLT-2) inhibitors, and beta blockers—to prevent myocardial remodeling is being advocated as a standard of care. Safe transition of care is needed prior to discharge to prevent heart failure rehospitalization and mortality. Post-discharge close ambulatory monitoring (including remote hemodynamic monitoring), virtual visits, and rehabilitation are some of the strategies to consider. We hereby review the contemporary approach in AHF diagnosis and management.
Collapse
Affiliation(s)
- Hayaan Kamran
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
11
|
Ha YJ, Ji E, Lee JH, Kim JH, Park EH, Chung SW, Chang SH, Yoo JJ, Kang EH, Ahn S, Song YW, Lee YJ. High Estimated 24-Hour Urinary Sodium Excretion Is Related to Symptomatic Knee Osteoarthritis: A Nationwide Cross-Sectional Population-Based Study. J Nutr Health Aging 2022; 26:581-589. [PMID: 35718867 DOI: 10.1007/s12603-022-1804-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES High salt intake results in various harmful effects on human health including hypertension, cardiovascular disease, and reduced bone density. Despite this, there are very few studies in the literature that have investigated the association between sodium intake and osteoarthritis (OA). Therefore, we aimed to explore these associations in a Korean population. METHODS This study used cross-sectional data from adult subjects aged 50-75 years from two consecutive periods of the Korean National Health and Nutrition Examination Survey V-VII (2010-2011 and 2014-2016). The estimated 24-hour urinary sodium excretion (24HUNa) was used as a surrogate marker of salt intake. In the 2010-2011 dataset, knee OA (KOA) was defined as the presence of the radiographic features of OA and knee pain. The association between KOA and salt intake was analysed using univariable and multivariable logistic regression methods. For the sensitivity analysis, the same procedures were conducted on subjects with self-reported OA (SR-OA) with knee pain in the 2010-2011 dataset and any site SR-OA in the 2014-2016 dataset. RESULTS Subjects with KOA had significantly lower energy intake, but higher 24HUNa than those without KOA. The restricted cubic spline plots demonstrated a J-shaped distribution between 24HUNa and prevalent KOA. When 24HUNa was stratified into five groups (<2, 2-3, 3-4, 4-5 and ≥5 g/day), subjects with high sodium intake (≥5 g/day) had a higher risk of KOA (odds ratio [OR] = 1.64, 95% confidence interval [CI] 1.03-2.62) compared to the reference group (3-4 g/day) after adjusting for covariates. The sensitivity analysis based on SR-OA with knee pain showed that high sodium intake was also significantly associated with increased prevalence of OA (OR = 1.84, 95% CI 1.10-3.10) compared with the reference group. Regarding SR-OA at any site in the 2014-2016 dataset, estimated 24HUNa showed a significantly positive association with the presence of SR-OA after adjusting for potential confounders. CONCLUSIONS This nationwide Korean representative study showed a significant association between symptomatic KOA and high sodium intake (≥5 g/day). Avoidance of a diet high in salt might be beneficial as a non-pharmacologic therapy for OA.
Collapse
Affiliation(s)
- Y-J Ha
- Yun Jong Lee, M.D., Ph.D., Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, 173 Beongil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Korea, Tel.: +82-31-787-7049, Fax.: +82-31-787-4051, E-mail:
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Peters AE, Mentz RJ, DeWald TA, Greene SJ. An evaluation of torsemide in patients with heart failure and renal disease. Expert Rev Cardiovasc Ther 2022; 20:5-11. [PMID: 34936522 PMCID: PMC8887994 DOI: 10.1080/14779072.2022.2022474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Torsemide is a loop diuretic that inhibits the Na+/K+/2Cl- cotransporter type 2 in the thick ascending loop of Henle, leading to increased excretion of urinary sodium and chloride and associated diuresis. While furosemide remains the dominant diuretic utilized in current practice, increasing evidence supports potential advantages of torsemide in heart failure (HF) and/or renal disease. AREAS COVERED This narrative review covers the evidence for use of torsemide in HF and renal disease. Comparative effectiveness with regards to clinical outcomes is reviewed, as well as the ongoing multicenter trial, TRANSFORM-HF, comparing the effect of torsemide versus furosemide among patients with HF. EXPERT OPINION Compared with furosemide, torsemide has favorable pharmacodynamics/pharmacokinetics including higher bioavailability, longer duration of effect, minor renal excretion, decreased kaliuresis, and enhanced natriuresis/diuresis. These properties may be further supported by differential effects on RAAS regulation and fibrosis modulation as compared with other diuretics. The limited current body of evidence indicates that torsemide may be superior to furosemide with respect to improving HF functional status and reducing HF hospitalization, and there are mixed data regarding effect on reducing overall cardiovascular hospitalizations/mortality. Further, randomized data are necessary to definitively determine if torsemide can reduce risk of mortality and hospitalization among patients with HF.
Collapse
Affiliation(s)
- Anthony E. Peters
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Robert J. Mentz
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Tracy A. DeWald
- Division of Clinical Pharmacology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Stephen J. Greene
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
13
|
Bae JH, Shin MY, Kang EH, Lee YJ, Ha YJ. Association of rheumatoid arthritis and high sodium intake with major adverse cardiovascular events: a cross-sectional study from the seventh Korean National Health and Nutrition Examination Survey. BMJ Open 2021; 11:e056255. [PMID: 34930746 PMCID: PMC8689190 DOI: 10.1136/bmjopen-2021-056255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES High salt intake has a harmful effect on hypertension; however, the association between major adverse cardiovascular events (MACE) and salt intake is still controversial. Rheumatoid arthritis (RA) is also characterised by excess cardiovascular risk. However, few studies have investigated the combined role of salt intake and RA in MACE in the general Korean population. Here, we evaluated this relationship among the Korean adult population. DESIGN Retrospective, cross-sectional. SETTING Population-based survey in Korea. METHODS This study was based on the data of the seventh Korean National Health and Nutrition Examination Survey (2016-2018). The estimated 24-hour urinary sodium excretion (24HUNa), a surrogate marker for daily sodium intake, was calculated using the Tanaka equation and was stratified into five groups (<3, 3-3.999, 4-4.999, 5-5.999 and ≥6 g/day). Finally, data from 13 464 adult participants (weighted n=90 425 888) were analysed; all analyses considered a complex sampling design. Multivariable logistic regression for MACE as primary dependent variable was performed and adjusted for potential covariates. RESULTS Participants with MACE had higher 24HUNa levels and RA proportion than those without MACE (p<0.001). The association of MACE with 24HUNa was J-shaped with a gradual increase from about 3 g/day. The highest 24HUNa (≥6 g/day) group was significantly associated with increased prevalence of MACE compared with the reference group (3-3.999 g/day) after adjusting for all associated covariates (OR 6.75, 95% CI 1.421 to 32.039). In the multivariate logistic regression analysis, RA (OR 2.05, 95% CI 1.283 to 3.264) and the highest 24HUNa group (OR 6.35, 95% CI 1.337 to 30.147) were significantly associated with MACE even after adjusting for baseline covariates. CONCLUSIONS These nationally representative data suggest that RA and extremely high sodium intake are associated with MACE in the general adult Korean population. Avoiding extremely high salt intake and considering RA as an important risk factor for MACE might help promote public cardiovascular health.
Collapse
Affiliation(s)
- Jeong-Hyeon Bae
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Min-Young Shin
- Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun Ha Kang
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yun Jong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - You-Jung Ha
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| |
Collapse
|
14
|
Cox ZL, Rao VS, Ivey-Miranda JB, Moreno-Villagomez J, Mahoney D, Ponikowski P, Biegus J, Turner JM, Maulion C, Bellumkonda L, Asher JL, Parise H, Wilson PF, Ellison DH, Wilcox CS, Testani JM. Compensatory post-diuretic renal sodium reabsorption is not a dominant mechanism of diuretic resistance in acute heart failure. Eur Heart J 2021; 42:4468-4477. [PMID: 34529781 DOI: 10.1093/eurheartj/ehab620] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 07/02/2021] [Accepted: 08/27/2021] [Indexed: 01/12/2023] Open
Abstract
AIMS In healthy volunteers, the kidney deploys compensatory post-diuretic sodium reabsorption (CPDSR) following loop diuretic-induced natriuresis, minimizing sodium excretion and producing a neutral sodium balance. CPDSR is extrapolated to non-euvolemic populations as a diuretic resistance mechanism; however, its importance in acute decompensated heart failure (ADHF) is unknown. METHODS AND RESULTS Patients with ADHF in the Mechanisms of Diuretic Resistance cohort receiving intravenous loop diuretics (462 administrations in 285 patients) underwent supervised urine collections entailing an immediate pre-diuretic spot urine sample, then 6-h (diuretic-induced natriuresis period) and 18-h (post-diuretic period) urine collections. The average spot urine sodium concentration immediately prior to diuretic administration [median 15 h (13-17) after last diuretic] was 64 ± 33 mmol/L with only 4% of patients having low (<20 mmol/L) urine sodium consistent with CPDSR. Paradoxically, greater 6-h diuretic-induced natriuresis was associated with larger 18-h post-diuretic spontaneous natriuresis (r = 0.7, P < 0.001). Higher pre-diuretic urine sodium to creatinine ratio (r = 0.37, P < 0.001) was the strongest predictor of post-diuretic spontaneous natriuresis. In a subgroup of patients (n = 43) randomized to protocol-driven intensified diuretic therapies, the mean diuretic-induced natriuresis increased three-fold. In contrast to the substantial decrease in spontaneous natriuresis predicted by CPDSR, no change in post-diuretic spontaneous natriuresis was observed (P = 0.47). CONCLUSION On a population level, CPDSR was not an important driver of diuretic resistance in hypervolemic ADHF. Contrary to CPDSR, a greater diuretic-induced natriuresis predicted a larger post-diuretic spontaneous natriuresis. Basal sodium avidity, rather than diuretic-induced CPDSR, appears to be the predominant determinate of both diuretic-induced and post-diuretic natriuresis in hypervolemic ADHF.
Collapse
Affiliation(s)
- Zachary L Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, 1 University Park Drive, Nashville, TN 37204, USA.,Department of Pharmacy, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN 37232, USA
| | - Veena S Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Juan B Ivey-Miranda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA.,Hospital de Cardiologia, Instituto Mexicano del Seguro Social, 330 Cuauhtemoc Avenue. Cuauhtemoc, Mexico City 06720, Mexico
| | - Julieta Moreno-Villagomez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA.,Universidad Nacional Autónoma de México, Avenida Insurgentes Sur, Mexico City 3000, Mexico
| | - Devin Mahoney
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Piotr Ponikowski
- Department of Heart Diseases, Wrocław Medical University, Rektorat, wybrzeże Ludwika Pasteura 1, Wroclaw 50-367, Poland
| | - Jan Biegus
- Clinical Military Hospital, Weigla 5, Wroclaw 50-981, Poland
| | - Jeffrey M Turner
- Department of Medicine, Division of Nephrology, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Christopher Maulion
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Lavanya Bellumkonda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Jennifer L Asher
- Department of Comparative Medicine, Yale University School of Medicine, 310 Cedar Street, New Haven, CT 06520, USA
| | - Helen Parise
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| | - Perry F Wilson
- Clinical and Translational Research Accelerator, Yale University School of Medicine, 60 Temple Street, New Haven, CT 06520, USA
| | - David H Ellison
- Oregon Clinical and Translational Research Institute, Oregon Health and Science University and the Veterans Affairs Portland Health Care System, 3181 S.W. Sam Jackson Park Road Portland, OR 97239, USA
| | - Christopher S Wilcox
- Division of Nephrology and Hypertension and Hypertension Center, Georgetown University, 3800 Reservoir Road, N.W., Washington, DC 20007, USA
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT 06510, USA
| |
Collapse
|
15
|
Jiang J, Ding FX, Zhou X, Bateman TJ, Dong S, Gu X, Keh deJesus R, Pio B, Tang H, Chobanian HR, Levorse D, Hu M, Thomas-Fowlkes B, Margulis M, Koehler M, Weinglass A, Gibson J, Houle K, Yudkovitz J, Hampton C, Pai LY, Samuel K, Cutarelli T, Sullivan K, Parmee ER, Davies I, Pasternak A. Discovery of MK-8153, a Potent and Selective ROMK Inhibitor and Novel Diuretic/Natriuretic. J Med Chem 2021; 64:7691-7701. [PMID: 34038119 DOI: 10.1021/acs.jmedchem.1c00406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A renal outer medullary potassium channel (ROMK, Kir1.1) is a putative drug target for a novel class of diuretics with potential for treating hypertension and heart failure. Our first disclosed clinical ROMK compound, 2 (MK-7145), demonstrated robust diuresis, natriuresis, and blood pressure lowering in preclinical models, with reduced urinary potassium excretion compared to the standard of care diuretics. However, 2 projected to a short human half-life (∼5 h) that could necessitate more frequent than once a day dosing. In addition, a short half-life would confer a high peak-to-trough ratio which could evoke an excessive peak diuretic effect, a common liability associated with loop diuretics such as furosemide. This report describes the discovery of a new ROMK inhibitor 22e (MK-8153), with a longer projected human half-life (∼14 h), which should lead to a reduced peak-to-trough ratio, potentially extrapolating to more extended and better tolerated diuretic effects.
Collapse
Affiliation(s)
- Jinlong Jiang
- Discovery Chemistry, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Fa-Xiang Ding
- Discovery Chemistry, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Xiaoyan Zhou
- Quantitative Biosciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Thomas J Bateman
- Pharmacokinetics Pharmacodynamics and Drug Metabolism, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Shuzhi Dong
- Discovery Chemistry, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Xin Gu
- Discovery Chemistry, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Reynalda Keh deJesus
- Discovery Chemistry, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Barbara Pio
- Discovery Chemistry, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Haifeng Tang
- Discovery Chemistry, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Harry R Chobanian
- Quantitative Biosciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Dorothy Levorse
- Discovery and Preclinical Sciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Mengwei Hu
- Discovery and Preclinical Sciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Brande Thomas-Fowlkes
- Quantitative Biosciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Michael Margulis
- Quantitative Biosciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Martin Koehler
- Quantitative Biosciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Adam Weinglass
- Quantitative Biosciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Jack Gibson
- Quantitative Biosciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Kevin Houle
- Quantitative Biosciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Joel Yudkovitz
- Quantitative Biosciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Caryn Hampton
- Quantitative Biosciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Lee-Yuh Pai
- Quantitative Biosciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Koppara Samuel
- Pharmacokinetics Pharmacodynamics and Drug Metabolism, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Timothy Cutarelli
- Discovery Process Chemistry, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Kathleen Sullivan
- Quantitative Biosciences, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Emma R Parmee
- Discovery Chemistry, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Ian Davies
- Discovery Chemistry, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| | - Alexander Pasternak
- Discovery Chemistry, Merck & Co., Inc., Kenilworth, New Jersey 07033, United States
| |
Collapse
|
16
|
Wilcox CS, Testani JM, Pitt B. Pathophysiology of Diuretic Resistance and Its Implications for the Management of Chronic Heart Failure. Hypertension 2020; 76:1045-1054. [PMID: 32829662 PMCID: PMC10683075 DOI: 10.1161/hypertensionaha.120.15205] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diuretic resistance implies a failure to increase fluid and sodium (Na+) output sufficiently to relieve volume overload, edema, or congestion, despite escalating doses of a loop diuretic to a ceiling level (80 mg of furosemide once or twice daily or greater in those with reduced glomerular filtration rate or heart failure). It is a major cause of recurrent hospitalizations in patients with chronic heart failure and predicts death but is difficult to diagnose unequivocally. Pharmacokinetic mechanisms include the low and variable bioavailability of furosemide and the short duration of all loop diuretics that provides time for the kidneys to restore diuretic-induced Na+ losses between doses. Pathophysiological mechanisms of diuretic resistance include an inappropriately high daily salt intake that exceeds the acute diuretic-induced salt loss, hyponatremia or hypokalemic, hypochloremic metabolic alkalosis, and reflex activation of the renal nerves. Nephron mechanisms include tubular tolerance that can develop even during the time that the renal tubules are exposed to a single dose of diuretic, or enhanced reabsorption in the proximal tubule that limits delivery to the loop, or an adaptive increase in reabsorption in the downstream distal tubule and collecting ducts that offsets ongoing blockade of Na+ reabsorption in the loop of Henle. These provide rationales for novel strategies including the concurrent use of diuretics that block these nephron segments and even sequential nephron blockade with multiple diuretics and aquaretics combined in severely diuretic-resistant patients with heart failure.
Collapse
Affiliation(s)
- Christopher Stuart Wilcox
- From the Division of Nephrology and Hypertension and Hypertension Center, Georgetown University, Washington DC (C.S.W.)
| | | | - Bertram Pitt
- Division of Cardiology, University of Michigan, Ann Arbor, MI (B.P.)
| |
Collapse
|
17
|
Griffin M, Rao VS, Ivey-Miranda J, Fleming J, Mahoney D, Maulion C, Suda N, Siwakoti K, Ahmad T, Jacoby D, Riello R, Bellumkonda L, Cox Z, Collins S, Jeon S, Turner JM, Wilson FP, Butler J, Inzucchi SE, Testani JM. Empagliflozin in Heart Failure: Diuretic and Cardiorenal Effects. Circulation 2020; 142:1028-1039. [PMID: 32410463 PMCID: PMC7521417 DOI: 10.1161/circulationaha.120.045691] [Citation(s) in RCA: 251] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors improve heart failure-related outcomes. The mechanisms underlying these benefits are not well understood, but diuretic properties may contribute. Traditional diuretics such as furosemide induce substantial neurohormonal activation, contributing to the limited improvement in intravascular volume often seen with these agents. However, the proximal tubular site of action of the sodium-glucose cotransporter-2 inhibitors may help circumvent these limitations. METHODS Twenty patients with type 2 diabetes mellitus and chronic, stable heart failure completed a randomized, placebo-controlled crossover study of empagliflozin 10 mg daily versus placebo. Patients underwent an intensive 6-hour biospecimen collection and cardiorenal phenotyping at baseline and again after 14 days of study drug. After a 2-week washout, patients crossed over to the alternate therapy with the above protocol repeated. RESULTS Oral empagliflozin was rapidly absorbed as evidenced by a 27-fold increase in urinary glucose excretion by 3 hours (P<0.0001). Fractional excretion of sodium increased significantly with empagliflozin monotherapy versus placebo (fractional excretion of sodium, 1.2±0.7% versus 0.7±0.4%; P=0.001), and there was a synergistic effect in combination with bumetanide (fractional excretion of sodium, 5.8±2.5% versus 3.9±1.9%; P=0.001). At 14 days, the natriuretic effect of empagliflozin persisted, resulting in a reduction in blood volume (-208 mL [interquartile range, -536 to 153 mL] versus -14 mL [interquartile range, -282 to 335 mL]; P=0.035) and plasma volume (-138 mL, interquartile range, -379 to 154±453 mL; P=0.04). This natriuresis was not, however, associated with evidence of neurohormonal activation because the change in norepinephrine was superior (P=0.02) and all other neurohormones were similar (P<0.34) during the empagliflozin versus placebo period. Furthermore, there was no evidence of potassium wasting (P=0.20) or renal dysfunction (P>0.11 for all biomarkers), whereas both serum magnesium (P<0.001) and uric acid levels (P=0.008) improved. CONCLUSIONS Empagliflozin causes significant natriuresis, particularly when combined with loop diuretics, resulting in an improvement in blood volume. However, off-target electrolyte wasting, renal dysfunction, and neurohormonal activation were not observed. This favorable diuretic profile may offer significant advantage in the management of volume status in patients with heart failure and may represent a mechanism contributing to the superior long-term heart failure outcomes observed with these agents. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03027960.
Collapse
Affiliation(s)
- Matthew Griffin
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Veena S. Rao
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Juan Ivey-Miranda
- Hospital de Cardiologia, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - James Fleming
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Devin Mahoney
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Christopher Maulion
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Nisha Suda
- Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Krishmita Siwakoti
- Department of Internal Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Alabama at Birmingham, Birmingham, AL
| | - Tariq Ahmad
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Daniel Jacoby
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Ralph Riello
- Division of Pharmacy, Yale University School of Medicine, New Haven, CT, USA
| | - Lavanya Bellumkonda
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - Zachary Cox
- Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, TN
| | - Sean Collins
- Deparment of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | | | - Jeffrey M. Turner
- Department of Medicine, Division of Nephrology, Yale University School of Medicine, New Haven CT
| | - F. Perry Wilson
- Program of Applied Translational Research, Yale University School of Medicine, New Haven, CT
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, MS
| | - Silvio E. Inzucchi
- Department of Internal Medicine, Section of Endocrinology, Yale University School of Medicine, New Haven, CT
| | - Jeffrey M. Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
18
|
Rangaswami J, Bhalla V, Blair JEA, Chang TI, Costa S, Lentine KL, Lerma EV, Mezue K, Molitch M, Mullens W, Ronco C, Tang WHW, McCullough PA. Cardiorenal Syndrome: Classification, Pathophysiology, Diagnosis, and Treatment Strategies: A Scientific Statement From the American Heart Association. Circulation 2020; 139:e840-e878. [PMID: 30852913 DOI: 10.1161/cir.0000000000000664] [Citation(s) in RCA: 598] [Impact Index Per Article: 149.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cardiorenal syndrome encompasses a spectrum of disorders involving both the heart and kidneys in which acute or chronic dysfunction in 1 organ may induce acute or chronic dysfunction in the other organ. It represents the confluence of heart-kidney interactions across several interfaces. These include the hemodynamic cross-talk between the failing heart and the response of the kidneys and vice versa, as well as alterations in neurohormonal markers and inflammatory molecular signatures characteristic of its clinical phenotypes. The mission of this scientific statement is to describe the epidemiology and pathogenesis of cardiorenal syndrome in the context of the continuously evolving nature of its clinicopathological description over the past decade. It also describes diagnostic and therapeutic strategies applicable to cardiorenal syndrome, summarizes cardiac-kidney interactions in special populations such as patients with diabetes mellitus and kidney transplant recipients, and emphasizes the role of palliative care in patients with cardiorenal syndrome. Finally, it outlines the need for a cardiorenal education track that will guide future cardiorenal trials and integrate the clinical and research needs of this important field in the future.
Collapse
|
19
|
Abstract
PURPOSE OF REVIEW Diuretic resistance (DR) occurs along a spectrum of relative severity and contributes to worsening of acute heart failure (AHF) during an inpatient stay. This review gives an overview of mechanisms of DR with a focus on loop diuretics and summarizes the current literature regarding the prognostic value of diuretic efficiency and predictors of natriuretic response in AHF. RECENT FINDINGS The pharmacokinetics of diuretics are impaired in chronic heart failure, but little is known about mechanisms of DR in AHF. Almost all diuresis after administration of a loop diuretic dose occurs in the first few hours after administration and within-dose DR can develop. Recent studies suggest that DR at the level of the nephron may be more important than defects in diuretic delivery to the tubule. Because loop diuretics induce natriuresis, urine sodium (UNa) concentration may serve as a functional, physiological, and direct measure for diuretic responsiveness to a given loop diuretic dose. Identifying and targeting individuals with DR for more aggressive, tailored therapy represents an important opportunity to improve outcomes. A better understanding of the mechanistic underpinnings of DR in AHF is needed to identify additional biomarkers and guide future trials and therapies.
Collapse
Affiliation(s)
- Richa Gupta
- Department of Cardiovascular Medicine, Vanderbilt University Medical Center, 1121 Medical Center Dr., Nashville, TN, 37212, USA
| | - Jeffrey Testani
- Department of Cardiovascular Medicine, Yale Medical Center, PO Box 208017, New Haven, CT, 06520, USA
| | - Sean Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, 1313 21st Ave. S, 703 Oxford House, Nashville, TN, 37232, USA.
| |
Collapse
|
20
|
Affiliation(s)
- David H Ellison
- Departments of Medicine and Physiology and Pharmacology, Oregon Health & Science University, Portland, Oregon; and Renal Section, Veterans Affairs Portland Health Care System, Portland, Oregon
| |
Collapse
|
21
|
Captopril Attenuates Cardiovascular and Renal Disease in a Rat Model of Heart Failure With Preserved Ejection Fraction. J Cardiovasc Pharmacol 2019; 71:205-214. [PMID: 29620605 DOI: 10.1097/fjc.0000000000000561] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF), a prevalent form of heart failure, is frequently accompanied by the metabolic syndrome and kidney disease. Because current treatment options of HFpEF are limited, evaluation of therapies in experimental models of HFpEF with the metabolic syndrome and kidney disease is needed. In this study, we evaluated the effects of captopril, furosemide, and their combination in aged, obese ZSF1 rats, an animal model of HFpEF with the metabolic syndrome and chronic kidney disease as comorbidities. Captopril (100 mg/kg), furosemide (50 mg/kg), or their combination was administered orally to obese ZSF1 rats aged 20 to 44 weeks. Untreated ZSF1 rats served as controls. After 24 weeks of treatment, captopril significantly lowered systemic blood pressure and attenuated HFpEF as evidenced by significantly reduced left ventricular end diastolic pressures (10.5 ± 1.4 vs. 4.9 ± 1.3 mm Hg in Control vs. Captopril, respectively) and significantly lower left ventricular relaxation time constants (28.1 ± 2.9 vs. 18.3 ± 3.1 ms in Control vs. Captopril, respectively). The captopril-induced improvement in left ventricular function was associated with reduced cardiac hypertrophy, ischemia, necrosis, and vasculitis. Captopril also increased renal blood flow and glomerular filtration rate, reduced renal vascular resistance and proteinuria, and improved renal histology (ie, reduced renal hypertrophy, glomerulosclerosis, and tubular atrophy/dilation). Furosemide alone provided little benefit; moreover, furosemide did not augment the therapeutic benefits of captopril. This study suggests that chronic administration of captopril, but not furosemide, could be beneficial in patients with HFpEF, particularly in those with comorbidities such as obesity, diabetes, and dyslipidemias.
Collapse
|