Combination therapy in hypertension: an Asia-Pacific consensus viewpoint

Potential application of bisoprolol derivative compounds as antihypertensive drugs: synthesis and in silico study

Two bisoprolol derivatives, N-acetyl bisoprolol and N-formyl bisoprolol, belonging to the beta-blocker class of antihypertensive drugs, were synthesized using acetylation and formylation reactions. The yields of the reactions were determined to be 32.40% for N-acetyl bisoprolol and 20.20% for N-formyl bisoprolol. In silico methods such as molecular docking, molecular dynamics simulation and SwissADME prediction were employed to evaluate the potential of these bisoprolol derivatives as antihypertensive drugs. These methods were used to assess the interaction between the bisoprolol derivatives and various receptors associated with hypertension, including human angiotensin I-converting enzyme (PDB ID: 1O8A), renin (PDB ID: 2V0Z), beta-1 adrenergic receptors (PDB ID: 4BVN, 7BVQ), voltage-dependent L-type calcium channel subunit alpha-1S (PDB ID: 6JP5) and mineralocorticoid receptor (PDB ID: 6L88). Our results demonstrated the highest binding energy when bisoprolol and its derivatives bound to 4BVN, with binding energy values of 6.74 kcal mol-1, 7.03 kcal mol-1 and 7.63 kcal mol-1 for bisoprolol, N-acetyl bisoprolol and N-formyl bisoprolol, respectively. The stability of these complexes was confirmed by molecular dynamics simulations, with a root-mean-square deviation value of approximately 2. Furthermore, the SwissADME results indicated that both derivatives exhibited similar properties to the reference drug bisoprolol.

Access to hypertension care and services in primary health-care settings in Vietnam: a systematic narrative review of existing literature

Background: Health care in Vietnam is challenged by a high burden of hypertension (HTN). Since 2000, several interventions were implemented to manage HTN; it is not clear what is the status of patient access to HTN care. Objective: This article aims to perform a systematic narrative review of the available evidence on access to HTN care and services in primary health-care settings in Vietnam. Methods: Search engines were used to identify relevant records of scientific and grey literature. Data from selected articles were analysed using standardised spreadsheets and MaxQDA and following a framework synthesis methodology. Results: There has been increasing interest in research and policy concerning the burden of HTN in Vietnam, covering many aspects of access to treatment at the primary health-care level. Vietnam's National HTN Programme is managed as a vertical programme and its services integrated into the network of primary health-care facilities across the public sector in selected provinces. The Programme financed population-wide screening campaigns for the early detection of HTN among people above 40 years of age. There was no information on the acceptability of HTN health services, especially regarding the interaction between patients and health professionals. In general, articles reported good availability of medication, but problems in accessing them included: fragmentation and lack of consistency in prescribing medication between different levels and short timespans for dispensing medication at primary health-care facilities. There was limited information related to the cost and economic impact of HTN treatment. Treatment adherence among hypertensive patients based on four studies did not exceed 70%. Conclusions: Although the Vietnamese health-care system has taken steps to accommodate some of the needs of HTN patients, it is crucial to scale-up interventions that allow for regular, systematic, and integrated care, especially at the lowest levels of care.

Bisoprolol/amlodipine combination therapy improves blood pressure control in patients with essential hypertension following monotherapy failure

OBJECTIVE

The efficacy of a bisoprolol/amlodipine fixed-dose combination (FDC) in patients with essential hypertension who had not responded to bisoprolol or amlodipine monotherapy was investigated.

RESEARCH DESIGN AND METHODS

In an 18 week, multicenter, randomized, comparative phase III study (ClinicalTrials.gov identifier: NCT01977794), patients with blood pressure uncontrolled by bisoprolol or amlodipine monotherapy (5 mg OD) began treatment with bisoprolol/amlodipine FDC 5/5 mg OD. Patients with controlled blood pressure (BP) at week 6/12 continued at current FDC strength, and patients with uncontrolled BP received FDC dose uptitration (maximum dose: 10/10 mg). The primary efficacy endpoint was change in systolic blood pressure (SBP) at week 18 versus baseline (corresponding to SBP under monotherapy), and secondary endpoints included change from baseline in SBP after week 6/12 and percentage of BP-controlled patients at week 6, 12 and 18. Safety was assessed by number/types of adverse events (AEs).

RESULTS

Two hundred patients were randomized to treatment (100 with uncontrolled BP under bisoprolol and 100 under amlodipine monotherapy). Overall, 196 patients were eligible for analysis. The patient groups displayed similar mean SBP reductions from baseline by study end (bisoprolol monotherapy failure: 25.9 ± 12.82 mmHg reduction; amlodipine monotherapy failure: 24.7 ± 11.67 mmHg reduction; p < 0.001 for both). Overall mean SBP decreased by 25.3 ± 12.25 mmHg (p < 0.001). Mean heart rate reductions were also observed (bisoprolol monotherapy failure: 6.6 ± 9.67 bpm reduction; amlodipine monotherapy failure: 11.5 ± 8.65 bpm reduction; p < 0.001 for both). Most patients (83.2%) displayed BP control with bisoprolol/amlodipine 5/5 mg at 6 weeks. Treatment was well tolerated at all dose levels; treatment-related AEs (mostly of mild/moderate intensity) were reported by 52.5% of patients, with no severe or serious treatment-related AEs reported. As the study focused on hypertension, total cardiovascular risk was not assessed.

CONCLUSIONS

Bisoprolol/amlodipine FDC therapy is associated with significant BP improvements in patients with essential hypertension following monotherapy failure.

How does prescribing for antihypertensive products stack up against guideline recommendations? An Australian population-based study (2006-2014)

AIMS

We describe choice of first-line antihypertensive drug therapy and uptake of fixed-dose combinations (FDCs) in Australia, and investigate the impact of initiation on FDCs and other non-recommended first-line therapies on treatment discontinuation.

METHOD

This was a population-based retrospective cohort study using a random 10% sample of persons dispensed an Australian Pharmaceutical Benefits Scheme listed medicine from 1 July 2005 to 30 June 2014. The primary outcomes were adherence to Australian recommendations at initiation of antihypertensive therapy, discontinuation of initial therapy and discontinuation of any therapy in the first year after initiation.

RESULTS

In our sample of 55 937 persons initiating therapy, 42.0% did so outside Australian recommendations, including not initiating on recommended monotherapy (26.3%) and not initiating on the lowest recommended dose (30.6%). Only 1.7% of individuals who were dispensed an FDC established therapy on the free combination regimen (as recommended) prior to switching. After adjusting for covariates, persons initiating on non-recommended monotherapy (OR = 2.64, 95% CI 2.47-2.83) or FDCs of two or more antihypertensives (OR = 1.42, 95% CI 1.30-1.55), were more likely to discontinue all antihypertensive drug treatment in the first year compared to persons initiating on recommended monotherapy.

CONCLUSION

More than half of antihypertensive initiators conformed to Australian guidelines. Initiation on FDCs and other non-recommended treatments was associated with lower persistence on antihypertensive therapy in the first year. Long-term effectiveness and outcomes may be enhanced by initiating with low dose monotherapy.