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Roux C, Verollet K, Prouvot J, Prelipcean C, Pambrun E, Moranne O. Choosing the right chronic medication for hemodialysis patients. A short ABC for the dialysis nephrologist. J Nephrol 2023; 36:521-536. [PMID: 36472789 DOI: 10.1007/s40620-022-01477-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 10/01/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adapting drug treatments for patients on hemodialysis with multiple chronic pathologies is a complex affair. When prescribing a medication, the risk-benefit analysis usually focuses primarily on the indication of the drug class prescribed. However, the pharmacokinetics of the chosen drug should also be taken into account. The purpose of our review was to identify the drugs to be favored in each therapeutic class, according to their safety and pharmacokinetic profiles, for the most common chronic diseases in patients on chronic hemodialysis. METHODS We conducted a narrative review of the literature using Medline and Web of Science databases, targeting studies on the most commonly-prescribed drugs for non-communicable diseases in patients on chronic hemodialysis. RESULTS The search identified 1224 articles, 95 of which were further analyzed. The main classes of drugs included concern the cardiovascular system (anti-hypertensives, anti-arrhythmics, anti-thrombotics, hypocholesterolemics), the endocrine and metabolic pathways (anti-diabetics, gastric anti-secretory, anticoagulant, thyroid hormones, anti-gout) and psychiatric and neurological disorders (antidepressants, anxiolytics, antipsychotics and anti-epileptics). CONCLUSION We report on the most often prescribed drugs for chronic pathologies in patients on chronic hemodialysis. Most of them require adaptation, and in some cases one better alternative stands out among the drug class. More pharmacokinetic data are needed to define the pharmacokinetics in the various dialysis techniques.
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Affiliation(s)
- Clarisse Roux
- Service Pharmacie, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France.
- Institut Desbrest d'Epidemiologie et Santé publique (IDESP), INSERM, Montpellier, France.
| | - Kristelle Verollet
- Service Pharmacie, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France
| | - Julien Prouvot
- Institut Desbrest d'Epidemiologie et Santé publique (IDESP), INSERM, Montpellier, France
- Service Néphrologie Dialyse Apherese, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France
| | - Camelia Prelipcean
- Service Néphrologie Dialyse Apherese, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France
| | - Emilie Pambrun
- Service Néphrologie Dialyse Apherese, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France
| | - Olivier Moranne
- Institut Desbrest d'Epidemiologie et Santé publique (IDESP), INSERM, Montpellier, France.
- Service Néphrologie Dialyse Apherese, Hopital Universitaire de Nimes, CHU Carémeau, Nîmes, France.
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2
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Evaluation of Renal Impairment Influence on Metabolic Drug Clearance using a Modelling Approach. Clin Pharmacokinet 2023; 62:307-319. [PMID: 36631686 DOI: 10.1007/s40262-022-01205-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVE Chronic kidney disease (CKD) may alter drug renal elimination but is also known for interacting with hepatic metabolism via multiple uremic components. However, few global models, considering the five major cytochromes, have been published, and none specifically address the decrease in cytochrome P450 (CYP450) activity. The aim of our study was to estimate the possibility of quantifying residual cytochrome activity as a function of filtration rate, according to the data available in the literature. METHODS For each drug in the DDI-predictor database, we collected available pharmacokinetic data comparing drug exposition in the healthy patient and in various stages of CKD, before building a model capable of predicting the variation of exposure according to the degree of renal damage. We followed an In vivo Mechanistic Static Model (IMSM) approach, previously validated for predicting change in liver clearance. We estimated the remaining fraction parameters at glomerular filtration rate (GFR) = 0 and the alpha value of GFR to 50% impairment for the 5 major cytochromes using a non-linear constrained regression using Matlab software. RESULTS Thirty-one compounds had usable pharmacokinetic data, with 51 AUC ratios between healthy and renal impaired patients. The remaining CYP3A4 activity was estimated to be 0.4 when CYP2D6, 2C9, 2C19 and 1A2 activity was estimated to be 0.43; 1; 0.73 and 0.7, respectively. The alpha value was estimated to be at 6.62; 25; 9.8; 1.38 and 11.04 for each cytochrome. In comparison with published data, all estimates but one were correctly predicted in the range of 0.5-2. CONCLUSION Our approach was able to describe the impact of CKD on metabolic elimination. Modelling this process makes it possible to anticipate changes in clearance and drug exposure in CKD patients, with the advantage of greater simplicity than approaches based on physiologically-based pharmacokinetic modelling. However, a precise estimation of the impact of renal failure is not possible with an IMSM approach due to the large variability of the published data, and thus should rely on specific pharmacokinetic modelling for narrow therapeutic margin drugs.
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Watson K, Kukin A, Wasik AK, Shulenberger CE. Nonsteroidal Mineralocorticoid Receptor Antagonists: Exploring Role in Cardiovascular Disease. J Cardiovasc Pharmacol 2021; 77:685-698. [PMID: 34057158 DOI: 10.1097/fjc.0000000000000990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 01/28/2021] [Indexed: 12/20/2022]
Abstract
ABSTRACT Aldosterone, a mineralocorticoid hormone, plays a role in the pathophysiology of many cardiovascular disease states. Mineralocorticoid receptor antagonists (MRAs) have been shown to improve clinical outcomes in select patient populations. However, use of available steroidal receptor antagonists, eplerenone and spironolactone, is often limited by the risk or development of hyperkalemia. Nonsteroidal MRAs have been designed to overcome this limitation. The nonsteroidal MRAs have been studied in patients with heart failure with reduced ejection fraction, hypertension, and to lower the risk of cardiac and renal outcomes in those with type 2 diabetes and renal disease. In this review, the pharmacology of the MRAs is compared, the data evaluating the use of nonsteroidal MRAs are examined, and the place of this new generation of therapy is discussed. At this time, it seems that there could be a future role for nonsteroidal MRAs to reduce the risk of renal outcomes in high-risk individuals.
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Affiliation(s)
- Kristin Watson
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
- ATRIUM Cardiology Collaborative, Baltimore, MD
| | - Alina Kukin
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Allie K Wasik
- Department of Pharmacy, Northwestern Memorial Hospital Bluhm Cardiovascular Institute, Chicago, IL; and
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Punt AM, Stienstra NA, van Kleef MEA, Lafeber M, Spiering W, Blankestijn PJ, Bots ML, van Maarseveen EM. Screening of cardiovascular agents in plasma with LC-MS/MS: A valuable tool for objective drug adherence assessment. J Chromatogr B Analyt Technol Biomed Life Sci 2019; 1121:103-110. [PMID: 31146083 DOI: 10.1016/j.jchromb.2019.05.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/07/2019] [Accepted: 05/12/2019] [Indexed: 11/30/2022]
Abstract
Adherence to cardiovascular preventive agents is important to prevent short and long term cardiovascular events. Recently, qualitatively compound screening using liquid chromatography-tandem mass spectrometry (LC-MS/MS) has gained interest for drug adherence assessment in patients at high risk of cardiovascular events. Therefore, we developed and tested an assay including 52 compounds and metabolites, covering over 95% of the antihypertensive and antithrombotic agents available worldwide. Trichloroacetic acid was used as simple and fast method for protein precipitation. The assay was validated for lower limit of quantification (LLOQ), linearity, stability for freeze/thaw, room temperature, autosampler and matrix effects. The LLOQ for each compound was targeted under the population trough concentration (PTC) as reported in literature to assure high sensitivity for adherence detection. This was accomplished for 50 of 52 compounds with a LLOQ equal or lower compared to the PTC. Linearity was confirmed for all compounds (r2 > 0.995), except for acetylsalicylic acid (r2 = 0.991). For room temperature stability, 12 compounds showed degradation over 20% after 20 h. 3 compounds suffer from matrix effect with recoveries < 50%. After analytical validation, blood samples from 91 patients with difficult-to-treat hypertension were analyzed. Patients were unaware of adherence assessment. Adherence varied largely per agent and per concentration ratio (CR) (ratio of the detected concentration with LC-MS/MS and the PTC) cut-off value. Additionally, stratification by adherence group showed that the percentage of patients classified as non-adherent increased from 6.6% for qualitative analysis (pos/neg) to 19.8% for a CR cut-off of 0.5. The data imply that using the CR cut off values has a significant and relevant effect on patient adherence classification.
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Affiliation(s)
- A M Punt
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, Netherlands.
| | - N A Stienstra
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, Netherlands
| | - M E A van Kleef
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - M Lafeber
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - W Spiering
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - P J Blankestijn
- Department of Nephrology & Hypertension, University Medical Center Utrecht, Utrecht, Netherlands
| | - M L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - E M van Maarseveen
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, Netherlands
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Eplerenone Versus Spironolactone in Resistant Hypertension: an Efficacy and/or Cost or Just a Men’s Issue? Curr Hypertens Rep 2019; 21:22. [DOI: 10.1007/s11906-019-0924-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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6
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Granberg KL, Yuan ZQ, Lindmark B, Edman K, Kajanus J, Hogner A, Malmgren M, O’Mahony G, Nordqvist A, Lindberg J, Tångefjord S, Kossenjans M, Löfberg C, Brånalt J, Liu D, Selmi N, Nikitidis G, Nordberg P, Hayen A, Aagaard A, Hansson E, Hermansson M, Ivarsson I, Jansson-Löfmark R, Karlsson U, Johansson U, William-Olsson L, Hartleib-Geschwindner J, Bamberg K. Identification of Mineralocorticoid Receptor Modulators with Low Impact on Electrolyte Homeostasis but Maintained Organ Protection. J Med Chem 2018; 62:1385-1406. [DOI: 10.1021/acs.jmedchem.8b01523] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Dongmei Liu
- Pharmaron Beijing Co., Ltd., No. 6 Taihe Road, BDA, Beijing 100176, P. R. China
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Girerd S, Frimat L, Ducloux D, Le Meur Y, Mariat C, Moulin B, Mousson C, Rieu P, Dali-Youcef N, Merckle L, Lepage X, Rossignol P, Girerd N, Jaisser F. EPURE Transplant (Eplerenone in Patients Undergoing Renal Transplant) study: study protocol for a randomized controlled trial. Trials 2018; 19:595. [PMID: 30376884 PMCID: PMC6208100 DOI: 10.1186/s13063-018-2956-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 10/01/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Despite advances in immunosuppressive therapy, kidney graft survival has failed to improve during the last decades. Ischemia/reperfusion injury (IRI) is one of the main pathophysiological mechanisms underlying delayed graft function, which is associated with poor long-term graft survival. Due to organ shortage, the proportion of grafts from expanded criteria donors (ECDs) is ever growing. These grafts may particularly benefit from IRI prevention. In preclinical models, mineralocorticoid receptor antagonists (MRAs) have been shown to efficiently prevent IRI. This study aims to assess the effect of MRA administration in the early phase of kidney transplantation (KT) among recipients of ECD grafts on mid-term graft function. METHODS/DESIGN This is a multicenter, double-blind, placebo-controlled, randomized clinical trial. Patients on hemodialysis and undergoing a single or a dual KT from an ECD will be eligible for inclusion. We plan to randomize 132 patients. Included patients will be randomized (1:1) to receive either eplerenone 25 mg every 12 h during 4 days (the first dose being administered just prior to KT) or placebo. The primary outcome is graft function at 3 months, assessed by glomerular filtration rate (GFR, in mL/min/1.73m2) measured using iohexol clearance. Secondary outcomes include (1) proportion of patients with either dialysis dependency or a GFR < 30 mL/min/1.73m2 at 3 months, (2) proportion of patients with immediate, slow, or delayed graft function, (3) proteinuria at 3 months, (4) occurrence of hyperkalemia during the first week following KT, (5) length of hospital stay for the KT, and (6) occurrence of biopsy-proven acute rejection in the first 3 months following KT. Estimated GFR, graft, and patient survival will also be collected at 1, 3, and 10 years via the national database of organ recipients. DISCUSSION Improvement of ECD grafts is a public health priority, since better ECD outcomes could eventually limit organ shortage. MRA administration in the early phase of KT may prevent IRI and subsequently improve mid-term graft function. The trial will also assess the safety of MRA administration in this population, primarily the absence of threatening hyperkalemia. TRIAL REGISTRATION ClinicalTrials.gov, NCT02490904 . Registered on 1 July 2015.
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Affiliation(s)
- Sophie Girerd
- Transplant Unit, Nephrology Department, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France. .,INSERM U1116, Clinical Investigation Center, Lorraine University, Vandoeuvre-lès-Nancy, France. .,INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France.
| | - Luc Frimat
- Transplant Unit, Nephrology Department, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France.,INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France
| | - Didier Ducloux
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France.,Transplant Unit, Nephrology Department, Besançon University Hospital, Bourgogne Franche-Comté University, Besançon, France
| | - Yannick Le Meur
- Department of Nephrology, Brest University Hospital, Brest University, Brest, France
| | - Christophe Mariat
- Transplant Unit, Nephrology Department, Saint-Etienne University Hospital, Jean Monnet University, Saint-Etienne, France
| | - Bruno Moulin
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France.,Nephrology and Transplantation Department, Strasbourg University Hospital, Strasbourg University, Strasbourg, France
| | - Christiane Mousson
- Transplant Unit, Nephrology Department, Dijon University Hospital, Bourgogne Franche-Comté University, Dijon, France
| | - Philippe Rieu
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France.,Transplant Unit, Nephrology Department, Reims University Hospital, Reims Champagne-Ardenne University, Reims, France
| | - Nassim Dali-Youcef
- Department of Biochemistry and Molecular Biology, Strasbourg University Hospital, Strasbourg University, Strasbourg, France.,Department of functional Genomics and Cancer, Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC)/ CNRS UMR 7104/ INSERM U 964/ Strasbourg University, 1 rue Laurent Fries, 67404, Illkirch, France
| | - Ludovic Merckle
- INSERM U1116, Clinical Investigation Center, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Xavier Lepage
- INSERM U1116, Clinical Investigation Center, Lorraine University, Vandoeuvre-lès-Nancy, France
| | - Patrick Rossignol
- INSERM U1116, Clinical Investigation Center, Lorraine University, Vandoeuvre-lès-Nancy, France.,INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France
| | - Nicolas Girerd
- INSERM U1116, Clinical Investigation Center, Lorraine University, Vandoeuvre-lès-Nancy, France.,INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France
| | - Frédéric Jaisser
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France.,INSERM, UMRS 1138, Team 1, Centre de Recherche des Cordeliers, Pierre et Marie Curie University, Paris Descartes University, Paris, France
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8
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Girerd S, Jaisser F. Mineralocorticoid receptor antagonists in kidney transplantation: time to consider? Nephrol Dial Transplant 2018; 33:2080-2091. [DOI: 10.1093/ndt/gfy065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 02/27/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Sophie Girerd
- Transplant Unit, Nephrology Department, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
- INSERM U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
| | - Frédéric Jaisser
- INSERM U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
- INSERM, UMRS 1138, Team 1, Centre de Recherche des Cordeliers, Pierre et Marie Curie University, Paris Descartes University, Paris, France
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Good ME, Chiu YH, Poon IKH, Medina CB, Butcher JT, Mendu SK, DeLalio LJ, Lohman AW, Leitinger N, Barrett E, Lorenz UM, Desai BN, Jaffe IZ, Bayliss DA, Isakson BE, Ravichandran KS. Pannexin 1 Channels as an Unexpected New Target of the Anti-Hypertensive Drug Spironolactone. Circ Res 2017; 122:606-615. [PMID: 29237722 DOI: 10.1161/circresaha.117.312380] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 12/06/2017] [Accepted: 12/12/2017] [Indexed: 12/16/2022]
Abstract
RATIONALE Resistant hypertension is a major health concern with unknown cause. Spironolactone is an effective antihypertensive drug, especially for patients with resistant hypertension, and is considered by the World Health Organization as an essential medication. Although spironolactone can act at the mineralocorticoid receptor (MR; NR3C2), there is increasing evidence of MR-independent effects of spironolactone. OBJECTIVE Here, we detail the unexpected discovery that Panx1 (pannexin 1) channels could be a relevant in vivo target of spironolactone. METHODS AND RESULTS First, we identified spironolactone as a potent inhibitor of Panx1 in an unbiased small molecule screen, which was confirmed by electrophysiological analysis. Next, spironolactone inhibited α-adrenergic vasoconstriction in arterioles from mice and hypertensive humans, an effect dependent on smooth muscle Panx1, but independent of the MR NR3C2. Last, spironolactone acutely lowered blood pressure, which was dependent on smooth muscle cell expression of Panx1 and independent of NR3C2. This effect, however, was restricted to steroidal MR antagonists as a nonsteroidal MR antagonist failed to reduced blood pressure. CONCLUSIONS These data suggest new therapeutic modalities for resistant hypertension based on Panx1 inhibition.
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Affiliation(s)
- Miranda E Good
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Yu-Hsin Chiu
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Ivan K H Poon
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Christopher B Medina
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Joshua T Butcher
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Suresh K Mendu
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Leon J DeLalio
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Alexander W Lohman
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Norbert Leitinger
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Eugene Barrett
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Ulrike M Lorenz
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Bimal N Desai
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Iris Z Jaffe
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Douglas A Bayliss
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Brant E Isakson
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.).
| | - Kodi S Ravichandran
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
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Sica DA, Gehr TW, Frishman WH. Use of Diuretics in the Treatment of Heart Failure in Older Adults. Heart Fail Clin 2017; 13:503-512. [DOI: 10.1016/j.hfc.2017.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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11
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Gromotowicz-Poplawska A, Szoka P, Kolodziejczyk P, Kramkowski K, Wojewodzka-Zelezniakowicz M, Chabielska E. New agents modulating the renin-angiotensin-aldosterone system-Will there be a new therapeutic option? Exp Biol Med (Maywood) 2016; 241:1888-1899. [PMID: 27439538 DOI: 10.1177/1535370216660211] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/22/2016] [Indexed: 12/19/2022] Open
Abstract
The renin-angiotensin-aldosterone system (RAAS) is more complex than it was originally regarded. According to the current subject knowledge, there are two main axes of the RAAS: (1) angiotensin-converting enzyme (ACE)-angiotensin II-AT1 receptor axis and (2) ACE2-angiotensin-(1-7)-Mas receptor axis. The activation of the first axis leads to deleterious effects, including vasoconstriction, endothelial dysfunction, thrombosis, inflammation, and fibrosis; therefore, blocking the components of this axis is a highly rational and commonly used therapeutic procedure. The ACE2-Ang-(1-7)-Mas receptor axis has a different role, since it often opposes the effects induced by the classical ACE-Ang II-AT1 axis. Once the positive effects of the ACE2-Ang-(1-7)-Mas axis were discovered, the alternative ways of pharmacotherapy activating this axis of RAAS appeared. This article briefly describes new molecules affecting the RAAS, namely: recombinant human ACE2, ACE2 activators, angiotensin-(1-7) peptide and non-peptide analogs, aldosterone synthase inhibitors, and the third and fourth generation of mineralocorticoid receptor antagonists. The results of the experimental and clinical studies are encouraging, which leads us to believe that these new molecules can support the treatment of cardiovascular diseases as well as cardiometabolic disorders.
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Affiliation(s)
| | - Piotr Szoka
- Department of Biopharmacy, Medical University of Bialystok, 15-089 Bialystok, Poland
| | - Patrycjusz Kolodziejczyk
- Department of Pharmaceutical Analysis, Medical University of Bialystok, 15-522 Bialystok, Poland
| | - Karol Kramkowski
- Department of Biopharmacy, Medical University of Bialystok, 15-089 Bialystok, Poland
| | | | - Ewa Chabielska
- Department of Biopharmacy, Medical University of Bialystok, 15-089 Bialystok, Poland
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Du M, Pan C, Chen J, Song M, Zhu T, Hang T. A validated stability-indicating ultra performance liquid chromatography method for the determination of potential process-related impurities in eplerenone. J Sep Sci 2016; 39:2907-18. [DOI: 10.1002/jssc.201600324] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/18/2016] [Accepted: 05/24/2016] [Indexed: 11/07/2022]
Affiliation(s)
- Mingluo Du
- Department of Pharmaceutical Analysis; China Pharmaceutical University; Nanjing Jiangsu P. R. China
| | - Chunyan Pan
- Department of Pharmaceutical Analysis; China Pharmaceutical University; Nanjing Jiangsu P. R. China
| | - Jing Chen
- Department of Pharmaceutical Analysis; China Pharmaceutical University; Nanjing Jiangsu P. R. China
| | - Min Song
- Department of Pharmaceutical Analysis; China Pharmaceutical University; Nanjing Jiangsu P. R. China
| | - Tingting Zhu
- Department of Pharmaceutical Analysis; China Pharmaceutical University; Nanjing Jiangsu P. R. China
| | - Taijun Hang
- Department of Pharmaceutical Analysis; China Pharmaceutical University; Nanjing Jiangsu P. R. China
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13
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Safety profile of mineralocorticoid receptor antagonists: Spironolactone and eplerenone. Int J Cardiol 2015; 200:25-9. [DOI: 10.1016/j.ijcard.2015.05.127] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 05/17/2015] [Indexed: 11/19/2022]
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14
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Evidence for a gastrointestinal–renal kaliuretic signaling axis in humans. Kidney Int 2015; 88:1383-1391. [DOI: 10.1038/ki.2015.243] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 06/18/2015] [Accepted: 06/18/2015] [Indexed: 01/20/2023]
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15
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Hwang MH, Yoo JK, Luttrell M, Kim HK, Meade TH, English M, Talcott S, Jaffe IZ, Christou DD. Acute effect of mineralocorticoid receptor antagonism on vascular function in healthy older adults. Exp Gerontol 2015; 73:86-94. [PMID: 26639352 DOI: 10.1016/j.exger.2015.11.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 11/04/2015] [Accepted: 11/26/2015] [Indexed: 12/27/2022]
Abstract
Mineralocorticoid receptor (MR) activation by aldosterone may regulate vascular function in health or contribute to vascular dysfunction in cardiovascular disease. Whether the effects are beneficial or detrimental to vascular function appear to be dependent on the integrity of the vascular endothelium and whether the responses are short-term or chronic. Acute modulation of MR activation has resulted in conflicting outcomes on vascular function in young healthy adults. Little is known about the vascular role of aldosterone and MR activation in healthy human aging. The primary objective of this study was to examine whether acute inhibition of MR by the selective antagonist eplerenone, influences vascular function in healthy older adults. We performed a randomized, double-blind, placebo-controlled crossover study in 22 adults (61±1 years; mean±SE, 53-79 years) who were free from overt clinical cardiovascular disease. We measured brachial artery flow-mediated endothelium-dependent dilation and endothelium-independent dilation to sublingual nitroglycerin (0.4 mg) following eplerenone (100 mg/dose, 2 doses, 24h between doses) or placebo. In response to acute MR antagonism, flow-mediated dilation decreased by 19% (from 6.9±0.5 to 5.6±0.6%, P=0.02; placebo vs. eplerenone). Endothelial nitric oxide synthase (eNOS) activity also decreased following MR antagonism based on the ratio of phosphorylated eNOS(Ser1177) to total eNOS (1.53±0.08 vs. 1.29±0.06, P=0.02). Nitroglycerin-induced dilation and blood pressure were unaffected (nitroglycerin-induced dilation: 21.9±1.9 vs. 21.0±1.5%, P=0.5 and systolic/diastolic blood pressure: 135/77±4/2 vs. 134/77±4/2 mmHg, P≥0.6). In conclusion, acute MR antagonism impairs vascular endothelial function in healthy older adults without influencing vascular smooth muscle responsiveness to exogenous nitric oxide or blood pressure.
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Affiliation(s)
- Moon-Hyon Hwang
- Dept of Applied Physiology & Kinesiology, University of Florida, Gainesville, FL, United States; Division of Health and Exercise Science, Incheon National University, Incheon, Korea
| | - Jeung-Ki Yoo
- Dept of Applied Physiology & Kinesiology, University of Florida, Gainesville, FL, United States
| | - Meredith Luttrell
- Dept of Human Physiology, University of Oregon, Eugene, OR, United States
| | - Han-Kyul Kim
- Dept of Applied Physiology & Kinesiology, University of Florida, Gainesville, FL, United States
| | - Thomas H Meade
- Dept of Cardiology, Baylor Scott & White Health, College Station, TX, United States; Texas A&M University Health Science Center, Bryan, TX, United States
| | - Mark English
- Dept of Family & Community Medicine, Baylor Scott & White Health, College Station, TX, United States
| | - Susanne Talcott
- Dept of Nutrition and Food Science and Dept of Veterinary Physiology and Pharmacology, Texas A&M University, College Station, TX, United States
| | - Iris Z Jaffe
- Molecular Cardiology Research Institute and Division of Cardiology, Department of Medicine, Tufts Medical Center, Boston, MA, United States
| | - Demetra D Christou
- Dept of Applied Physiology & Kinesiology, University of Florida, Gainesville, FL, United States.
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Schwenk MH, Hirsch JS, Bomback AS. Aldosterone blockade in CKD: emphasis on pharmacology. Adv Chronic Kidney Dis 2015; 22:123-32. [PMID: 25704349 DOI: 10.1053/j.ackd.2014.08.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/11/2014] [Indexed: 12/16/2022]
Abstract
Besides its epithelial effect on sodium retention and potassium excretion in the distal tubule, aldosterone promotes inflammation and fibrosis in the heart, kidneys, and blood vessels. As glomerular filtration rate falls, aldosterone is inappropriately elevated relative to extracellular fluid expansion. In addition, studies in CKD patients on angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and/or direct renin inhibitors have shown that aldosterone levels paradoxically rise in approximately 30% to 40% of patients on these renin-angiotensin system-blocking drugs. Hence, there is interest in using mineralocorticoid receptor blockers that directly target the inflammatory and fibrotic effects of aldosterone in CKD patients. This interest, however, is tempered by a number of unresolved issues, including the safety of using such drugs in advanced CKD and ESRD populations, and the potential for differences in drug efficacy according to race and ethnicity of patient populations. A better understanding of mineralocorticoid receptor blocker pharmacology should help inform future research directions and clinical practice decisions as to how best to use these agents in CKD.
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Clinical Pharmacokinetics of Drugs in Patients with Heart Failure: An Update (Part 2, Drugs Administered Orally). Clin Pharmacokinet 2014; 53:1083-114. [DOI: 10.1007/s40262-014-0189-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Elnagar N, Satoh M, Hosaka M, Asayama K, Ishikura K, Obara T, Mano N, Ohkubo T, Imai Y. The velocity of home blood pressure reduction in response to low-dose eplerenone combined with other antihypertensive drugs determined by exponential decay function analysis. Clin Exp Hypertens 2014; 36:83-91. [DOI: 10.3109/10641963.2014.892117] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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The integration of allometry and virtual populations to predict clearance and clearance variability in pediatric populations over the age of 6 years. Clin Pharmacokinet 2014; 52:693-703. [PMID: 23588537 DOI: 10.1007/s40262-013-0065-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Pharmacokinetics play an integral role in the pediatric drug development process. The determination of pharmacokinetic parameters, particularly clearance, in different age groups directly informs dosing strategies for subsequent efficacy trials. Allometric scaling for prediction of pediatric clearance from the observed clearance in adults has been used in this effort. Clinical trial simulation, a powerful tool used to inform clinical trial design, requires both an estimate of clearance along with an estimate of the expected pharmacokinetic variability. The standard deviations (SD) of individual clearance values for adults are typically used and may lead to inaccurate predictions by not taking into account the more widespread distribution of factors such as body weight in the pediatric population. The objective of this study was to assess the accuracy of allometric prediction of drug clearance as well as methods for predicting clearance variability in children 6 years of age and older. METHODS US Food and Drug Administration (FDA) clinical pharmacology reviews of pediatric studies conducted from 2002 onwards were reviewed to collate adult and pediatric clearance and clearance variability for studies including children 6 years of age and older. A set of 1,000 virtual adults {A} and a set of 5,000 virtual children (aged 2-17) {P} were generated on the basis of the White American NHANES database. Pediatric clearances were predicted in method 1 by using the geometric mean adult clearance from the in vivo study and calculating pediatric clearance for each virtual child within a subset {P'} of {P} that contained only those children that were within the age range of the in vivo pediatric study. In method 2, adult clearance values were randomly generated from the geometric mean adult clearance and standard deviation and assigned to each virtual adult in {A}. For each adult, allometric clearance scaling was completed with each virtual child within {P'}. The prediction error for the predicted and observed clearance and the clearance variability metric, coefficient of variation (CV), was calculated. The prediction accuracy as a function of the lowest age range (2 years and older) included in the study was also assessed. RESULTS Thirty-nine unique drugs were included in the study. For both method 1 and method 2, 100 % of predicted pediatric mean clearances were within 2-fold of the observed values and approximately 82 % were within a 30 % prediction error. There was a significant increase in the prediction accuracy of CV using method 2 vs. method 1. There was a major bias towards underprediction of pediatric CV in method 1 whereas method 2 was precise and not biased. Clearance and CV prediction accuracy were not a function of the age range included in the in vivo studies. The observed CV between the adult and pediatric study groups was not significantly different although, on average, the observed pediatric CV was 32 % greater than that from adult studies. CONCLUSIONS Allometric scaling may be a useful tool during pediatric drug development to predict drug clearance and dosing requirements in children 6 years of age and older. A novel methodology is reported that employs virtual adult and pediatric populations and adult pharmacokinetic data to accurately predict clearance variability in specific pediatric subpopulations. This approach has important implications for both clinical trial simulations and sample size determination for pediatric pharmacokinetic studies.
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Tamargo J, Segura J, Ruilope LM. Diuretics in the treatment of hypertension. Part 2: loop diuretics and potassium-sparing agents. Expert Opin Pharmacother 2014; 15:605-21. [DOI: 10.1517/14656566.2014.879117] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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22
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Strategies for managing ACTH dependent mineralocorticoid excess induced by abiraterone. Cancer Treat Rev 2013; 39:966-73. [PMID: 23582279 DOI: 10.1016/j.ctrv.2013.03.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 03/01/2013] [Accepted: 03/06/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND Abiraterone strongly inhibits androgen synthesis but may lead to an increase in mineralocorticoid hormones that may impair its long term tolerability in patients with prostate cancer. How to implement available therapies in the management and prevention of these potential side effects is a matter of current clinical research. METHODS The acute and long term consequences of mineralocorticoid excess and the effects of available treatments have been reviewed. Prospective studies in which abiraterone was employed were identified to assess the frequency and severity of the mineralocorticoid excess syndrome and the efficacy of ameliorating therapeutic approaches. RESULTS Glucocorticoids to inhibit the ACTH increase that drives mineralocorticoid synthesis and mineralocorticoid receptor (MR) antagonists can be used in the management of the abiraterone-induced mineralocorticoid excess syndrome. Phase I and II trials of abiraterone without additional therapies revealed that mineralocorticoid excess symptoms occur in the majority of patients. Eplerenone, a specific MR antagonist, seems to be effective but it does not control the mineralocorticoid excess. Glucorticoid supplementation to control ACTH drive is therefore needed. In several randomized trials the addition of prednisone (10mg daily) to abiraterone was not able to prevent mineralocorticoid excess syndrome in many cases and thus cannot be considered the gold standard. CONCLUSION At present, the best conceivable treatment for managing the abiraterone-induced mineralocorticoid excess consists of the administration of glucocorticoid replacement at the lowest effective dose ± MR antagonists and salt deprivation. The drug doses should be modulated by monitoring blood pressure, fluid retention and potassium levels during therapy.
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Richards J, Lim AC, Hay CW, Taylor AE, Wingate A, Nowakowska K, Pezaro C, Carreira S, Goodall J, Arlt W, McEwan IJ, de Bono JS, Attard G. Interactions of abiraterone, eplerenone, and prednisolone with wild-type and mutant androgen receptor: a rationale for increasing abiraterone exposure or combining with MDV3100. Cancer Res 2012; 72:2176-82. [PMID: 22411952 DOI: 10.1158/0008-5472.can-11-3980] [Citation(s) in RCA: 217] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Prostate cancer progression can be associated with androgen receptor (AR) mutations acquired following treatment with castration and/or an antiandrogen. Abiraterone, a rationally designed inhibitor of CYP17A1 recently approved for the treatment of docetaxel-treated castration-resistant prostate cancer (CRPC), is often effective, but requires coadministration with glucocorticoids to curtail side effects. Here, we hypothesized that progressive disease on abiraterone may occur secondary to glucocorticoid-induced activation of mutated AR. We found that prednisolone plasma levels in patients with CRPC were sufficiently high to activate mutant AR. Mineralocorticoid receptor antagonists, such as spironolactone and eplerenone that are used to treat side effects related to mineralocorticoid excess, can also bind to and activate signaling through wild-type or mutant AR. Abiraterone inhibited in vitro proliferation and AR-regulated gene expression of AR-positive prostate cancer cells, which could be explained by AR antagonism in addition to inhibition of steroidogenesis. In fact, activation of mutant AR by eplerenone was inhibited by MDV3100, bicalutamide, or greater concentrations of abiraterone. Therefore, an increase in abiraterone exposure could reverse resistance secondary to activation of AR by residual ligands or coadministered drugs. Together, our findings provide a strong rationale for clinical evaluation of combined CYP17A1 inhibition and AR antagonism.
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Affiliation(s)
- Juliet Richards
- Section of Medicine, The Institute of Cancer Research, Sutton, Surrey, United Kingdom
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Nappi JM, Sieg A. Aldosterone and aldosterone receptor antagonists in patients with chronic heart failure. Vasc Health Risk Manag 2011; 7:353-63. [PMID: 21731887 PMCID: PMC3119593 DOI: 10.2147/vhrm.s13779] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Indexed: 01/11/2023] Open
Abstract
Aldosterone is a mineralocorticoid hormone synthesized by the adrenal glands that has several regulatory functions to help the body maintain normal volume status and electrolyte balance. Studies have shown significantly higher levels of aldosterone secretion in patients with congestive heart failure compared with normal patients. Elevated levels of aldosterone have been shown to elevate blood pressure, cause left ventricular hypertrophy, and promote cardiac fibrosis. An appreciation of the true role of aldosterone in patients with chronic heart failure did not become apparent until the publication of the Randomized Aldactone Evaluation Study. Until recently, the use of aldosterone receptor antagonists has been limited to patients with severe heart failure and patients with heart failure following myocardial infarction. The Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF) study added additional evidence to support the expanded use of aldosterone receptor antagonists in heart failure patients. The results of the EMPHASIS-HF trial showed that patients with mild-to-moderate (New York Heart Association Class II) heart failure had reductions in mortality and hospitalizations from the addition of eplerenone to optimal medical therapy. Evidence remains elusive about the exact mechanism by which aldosterone receptor antagonists improve heart failure morbidity and mortality. The benefits of aldosterone receptor antagonist use in heart failure must be weighed against the potential risk of complications, ie, hyperkalemia and, in the case of spironolactone, possible endocrine abnormalities, in particular gynecomastia. With appropriate monitoring, these risks can be minimized. We now have evidence that patients with mild-to-severe symptoms associated with systolic heart failure will benefit from the addition of an aldosterone receptor antagonist to the standard therapies of angiotensin-converting enzyme inhibitors and beta-blockers. This review will address the pharmacologic basis of aldosterone receptor antagonists in patients with heart failure and the clinical impact of this therapy.
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Affiliation(s)
- Jean M Nappi
- Clinical Pharmacy and Outcome Sciences, South Carolina College of Pharmacy, Medical University of South Carolina Campus, Charleston, SC, USA.
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Interference Between Eplerenone and Digoxin in Fluorescence Polarization Immunoassay, Microparticle Enzyme Immunoassay, and Affinity Column-Mediated Immunoassay. Ther Drug Monit 2010; 32:774-7. [DOI: 10.1097/ftd.0b013e3181e649a0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sica DA, Flack JM. Treatment Considerations With Aldosterone Receptor Antagonists. J Clin Hypertens (Greenwich) 2010; 13:65-9. [DOI: 10.1111/j.1751-7176.2010.00377.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Barbanoj MJ, Ballester MR, Antonijoan RM, Gich I, Pelagio P, Gropper S, Santos B, Guglietta A. Comparison of repeated-dose pharmacokinetics of prolonged-release and immediate-release torasemide formulations in healthy young volunteers. Fundam Clin Pharmacol 2009; 23:115-25. [PMID: 19267775 DOI: 10.1111/j.1472-8206.2008.00643.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The major aim of the study was to compare the pharmacokinetic profile of repeated-dose administration of a prolonged-release (PR) formulation of torasemide with that of an immediate-release (IR) dosage. Sixteen volunteers received one daily dose, on four consecutive days, of 10 mg of torasemide-PR or torasemide-IR in a single-blind, two-treatment, two-period, repeated-dose, cross-over, sequence-randomized clinical trial. Blood samples were collected at various time points on day 1 (single-dose) and on day 4 (repeated-dose) and torasemide concentrations were analysed by LC/MS/MS. Diuretic effect and urine electrolytes were measured. Urinary urgency was subjectively assessed by visual analogue scales. Safety and tolerability were also determined. Based on logged values, bioequivalence parameters, were: on day 1, ratio = 1.07 (90% CI 1.02-1.1), C(max) ratio = 0.69 (90% CI 0.67-0.73); and on day 4, ratio = 1.02 (90% CI 0.98-1.05), C(max) ratio = 0.62 (90% CI 0.55-0.70). PR had longer t(max) than IR and showed significantly lower fluctuations of plasma concentrations. Urine evaluations were similar with both formulations, although PR showed a lower urine volume in the first hours post-administration. Episodes of acute urinary urgency occurred later and were subjectively less intensive with PR. No significant adverse events were reported.
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Affiliation(s)
- M J Barbanoj
- Drug Research Centre (CIM), Research Institute of Santa Creu and Sant Pau Hospital, Department of Pharmacology and Therapeutics, Autonomous University of Barcelona (UAB), Barcelona, Spain.
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Muldowney III JAS, Schoenhard JA, Benge CD. The clinical pharmacology of eplerenone. Expert Opin Drug Metab Toxicol 2009; 5:425-32. [DOI: 10.1517/17425250902837973] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Diuretics are tools of considerable therapeutic importance. First, they effectively reduce blood pressure, while at the same time decreasing the morbidity and mortality associated with hypertension. Diuretics are currently recommended as first-line therapy for the treatment of hypertension. In addition, they remain an important component of heart failure therapy, in that they improve the symptoms of congestion, which typify the more advanced stages of heart failure. This article reviews the mode of action of the various diuretic classes and the physiologic adaptations that follow; sets up the basis for their use in the treatment of volume-retaining states, particularly as applies to the elderly; and reviews diuretic-related side effects that are normally encountered.
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Affiliation(s)
- Domenic A Sica
- Virginia Commonwealth University Health System, Richmond, VA, USA
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Sica DA, Gehr TWB, Frishman WH. Use of diuretics in the treatment of heart failure in the elderly. Clin Geriatr Med 2007; 23:107-21. [PMID: 17126757 DOI: 10.1016/j.cger.2006.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Diuretics are tools of considerable therapeutic importance. First, they effectively reduce blood pressure, while at the same time decreasing the morbidity and mortality associated with hypertension. Diuretics are currently recommended as first-line therapy for the treatment of hypertension. In addition, they remain an important component of heart failure therapy, in that they improve the symptoms of congestion, which typify the more advanced stages of heart failure. This article reviews the mode of action of the various diuretic classes and the physiologic adaptations that follow; sets up the basis for their use in the treatment of volume-retaining states, particularly as applies to the elderly; and reviews diuretic-related side effects that are normally encountered.
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Affiliation(s)
- Domenic A Sica
- Division of Nephrology, Virginia Commonwealth University Health System, Richmond, VA, USA
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Epstein M, Williams GH, Weinberger M, Lewin A, Krause S, Mukherjee R, Patni R, Beckerman B. Selective aldosterone blockade with eplerenone reduces albuminuria in patients with type 2 diabetes. Clin J Am Soc Nephrol 2006; 1:940-51. [PMID: 17699311 DOI: 10.2215/cjn.00240106] [Citation(s) in RCA: 294] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Previous studies have shown that the selective aldosterone blocker eplerenone, in doses of up to 200 mg/d, reduces albuminuria in patients with type 2 diabetes. This study was conducted to ascertain whether lower doses of eplerenone (50 or 100 mg/d) co-administered with the angiotensin-converting enzyme (ACE) inhibitor enalapril would produce a similar antialbuminuric effect while obviating the hyperkalemia observed previously. After open-label run-in with enalapril 20 mg/d, patients with diabetes and a urinary albumin:creatinine ratio (UACR) > or = 50 mg/g were randomly assigned to receive enalapril plus one of three double-blind daily treatments for 12 wk: placebo, eplerenone 50 mg (EPL50), or eplerenone 100 mg (EPL100). After week 4, amlodipine 2.5 to 10 mg/d was allowed for BP control (systolic/diastolic BP < or = 130/80 mmHg). The primary study end points were the percentage change from baseline at week 12 in UACR and the incidence of hyperkalemia. Secondary end points included percentage changes from baseline in UACR at weeks 4 and 8 and changes from baseline in systolic and diastolic BP. Treatment with EPL50 or EPL100 but not placebo significantly reduced albuminuria from baseline. By week 12, UACR was reduced by 7.4% in the placebo group, by 41.0% in the EPL50 group, and by 48.4% in the EPL100 group (both eplerenone groups, P < 0.001 versus placebo). The incidences of sustained and severe hyperkalemia were not significantly different in any of the three treatment arms and did not differ on the basis of quartile of estimated GFR (all NS). For the secondary end points, both eplerenone treatment groups significantly reduced albuminuria from baseline as early as week 4 (P < 0.001), whereas placebo treatment (including enalapril) did not result in any significant decreases in UACR. Systolic BP decreased significantly in all treatment groups at all time points, but, generally, all treatment groups experienced similar decreases in BP. Co-administration of EPL50 or EPL100 with an ACE inhibitor as compared with an ACE inhibitor alone significantly reduces albuminuria in patients with diabetes without producing significant increases in hyperkalemia.
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Affiliation(s)
- Murray Epstein
- University of Miami School of Medicine, Miami, Florida, USA.
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Covic A, Gusbeth-Tatomir P, Goldsmith DJA. Is it time for spironolactone therapy in dialysis patients? Nephrol Dial Transplant 2006; 21:854-8. [PMID: 16449287 DOI: 10.1093/ndt/gfk086] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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