Drug evaluation of clevidipine for acute hypertension

The Current Role of Clevidipine in the Management of Hypertension

Acute hypertension, which may damage blood vessels, causes irreversible organ damage to the vasculature, central nervous system, kidney, and heart. Clevidipine, the first third-generation calcium channel antagonist approved by the Food and Drug Administration (FDA) in the past 20 years, is an ultra-short-acting calcium channel blocker that inhibits L-type calcium channels with high clearance and low distribution, can be rapidly metabolized into the corresponding inactive acid, and is rapidly hydrolyzed into inactive metabolites by esterase in arterial blood. Clevidipine is the same as nicardipine in that the main physiological effect is vasodilation and the main target is the arterial system, which has a limited effect on capacitor vessels. Unlike nitroglycerin, clevidipine has a limited effect on preload. In contrast to other direct-acting vasodilators, clevidipine has an ultra-short half-life due to metabolism by nonspecific blood and tissue esterases. Clevidipine trials conducted in adult populations have proven that it can rapidly control blood pressure in cardiac surgery situations and that adverse reactions to clevidipine are similar to those with other antihypertensive agents. In recent years, clinical trials have shown that clevidipine has excellent blood pressure-lowering capability in patients with acute neurological injury (hemorrhage, stroke, and subarachnoid and acute intracerebral hemorrhage), those  undergoing coronary artery bypass graft or spinal surgery, and in those with cerebral aneurysm/pheochromocytoma, acute heart failure, acute aortic syndromes, or renal insufficiency with severe hypertension, and it is equivalent to commonly used blood pressure-lowering medicines such as nicardipine or nitroglycerin. However, there is a lack of large-scale clinical trial data on the efficacy and safety of clevidipine in children during the perioperative period.

In vitro assessment of clevidipine using the profilin1 hypertensive mouse model

Hypertension represents a major risk factor for cardiovascular events, associating with vascular hypertrophy and dysfunction in resistance vessels. Clevidipine is a novel antihypertensive drug working as a selective calcium channel antagonist with an ultra-short half-life that lowers arterial blood pressure by reducing systemic arterial resistance. The aim was to assess the effect of clevidipine on the hypertrophic vessels of profilin1 hypertensive transgenic mice compared to sodium nitroprusside (SNP) and labetalol using wire myograph techniques. The effects of clevidipine, SNP and labetalol on the hypertrophic vessels were studied on mesenteric arterial function from 8 profilin1 hypertrophic mice and eight non-transgenic controls. Our results showed a significant difference between the effects of the three drugs on the hypertrophic mesenteric arteries of transgenic profilin1 mice compared to the non-transgenic controls. The half maximal effective concentration (EC50) of clevidipine, SNP and labetalol in profilin1 mice (1.90 ± 0.05, 0.97 ± 0.07, 2.80 ± 0.05 nM, respectively) were significantly higher than the EC50 in non-transgenic controls (0.91 ± 0.06, 0.32 ± 0.06, 0.80 ± 0.09 nM, respectively). Moreover, the increase in the EC50 for clevidipine (2-fold) to produce the same effect on both normal and hypertrophic arteries was less than that of SNP (3-fold) and labetalol (3.5-fold). Therefore, we concluded clevidipine exhibited the lowest dose shift to relax the hypertrophic vessels compared to SNP and labetalol in the profilin1 hypertrophic animal mouse model.

Pharmacological management of hypertensive emergencies and urgencies: focus on newer agents

INTRODUCTION

Hypertensive crises are categorized as hypertensive emergencies and urgencies depending on the presence of acute target-organ damage; the former are potentially life-threatening medical conditions, requiring urgent treatment under close monitoring. Although several short-acting intravenous antihypertensive agents are approved for this purpose, until recently little evidence from proper trials on the relative merits of different therapies was available.

AREAS COVERED

This article discusses in brief the pathophysiology, epidemiology and diagnostic approach of hypertensive crises and provides an extensive overview of established and emerging pharmacological agents for the treatment of patients with hypertensive emergencies and urgencies.

EXPERT OPINION

Agents such as sodium nitroprusside, nitroglycerin and hydralazine have been used for many years as first-line options for patients with hypertensive emergencies, although their potential adverse effects and difficulties in use were well known. With time, equally potent and less toxic alternatives, including nicardipine, fenoldopam, labetalol and esmolol are increasingly used worldwide. Recently, clevidipine, a third-generation dihydropyridine calcium-channel blocker with unique pharmacodynamic and pharmacokinetic properties was added to our therapeutic armamentarium and was shown in clinical trials to reduce mortality when compared with nitroprusside. In view of such evidence, a change in pharmacological treatment practices for hypertensive crises toward newer and safer agents is warranted.

Clevidipine butyrate: a promising new drug for the management of acute hypertension

Clevidipine butyrate is an ultrashort-acting intravenous dihydropyridine calcium-channel blocker that has been approved by the FDA for the reduction of blood pressure when oral therapy is not feasible. Hypertension is a global disease that affects more than 1 billion people worldwide and 75 million people in the USA. There are multiple agents available for the management of hypertension. The acute setting is where the challenge arises for developing new agents that not only decrease, but more importantly, optimally control blood pressure. Many drugs lower blood pressure; however, only a few have the capacity to precisely control hypertension in the acute phase. Clevidipine has unique pharmacodynamic and pharmacokinetic properties that enable the fast, safe and adequate reduction of blood pressure in hypertensive emergencies, with unique precision necessary to maintain the target blood pressure range. Its use in different clinical settings has been evaluated in several Phase I, II and III clinical studies. It is easily administered and titrated with minimal side effects, achieves fast control with low doses, is highly successful as monotherapy and allows excellent transition to oral medication. Thus, clevidipine is a promising new agent for the management of acute hypertension in a variety of clinical settings.

Intravenous clevidipine for management of hypertension

Hypertension remains one of the most prevalent diseases affecting our society, and its complications lead the list of causes of mortality all over the world. Most efforts to control the disease are unsuccessful, failing in at least two-thirds of affected patients, despite the availability of multiple drugs for its treatment. The limited number of medications available for aggressive management of hypertensive crises has intensified the search for novel drugs that can achieve a rapid decrease in blood pressure without increasing the possible complications. Clevidipine is a novel, vasculoselective, dihydropyridine calcium channel blocker characterized by a very fast onset and offset of action. Metabolism of clevidipine does not occur in the liver or kidneys, and thus there are no restrictions to using clevidipine in patients with hepatic or renal dysfunction. This agent has been widely used to reduce blood pressure when oral therapy is not appropriate, and its use in the perioperative setting has been shown to be beneficial. This manuscript reviews the key characteristics of clevidipine and its role in the management of acute hypertension.

Clevidipine: an ultra short-acting calcium channel antagonist for acute hypertension

OBJECTIVE

To review the safety, efficacy, and pharmacologic characteristics of clevidipine, a new ultra short-acting intravenous antihypertensive agent for the treatment of moderate-to-severe hypertension.

DATA SOURCES

A literature search was conducted through MEDLINE (1966-March 2009), International Pharmaceutical Abstracts (1970-March 2009), and EMBASE (1988-March 2009) using the search terms clevidipine, H324/38, hypertension, and hypertensive crisis.

STUDY SELECTION AND DATA EXTRACTION

Available studies, abstracts, and review articles published in English that evaluated the pharmacology, pharmacokinetics, safety, and clinical efficacy of clevidipine were reviewed and critically evaluated.

DATA SYNTHESIS

Clevidipine is a new third-generation dihydropyridine calcium-channel blocker available for intravenous management of moderate-to-severe hypertension. Clevidipine is an ultra short-acting, selective arteriolar vasodilator that acts similar to other L-type dihydropyridine calcium-channel blockers by inhibiting influx of extracellular calcium into the vascular smooth muscle. Its safety and efficacy have been primarily evaluated in the perioperative setting in patients undergoing cardiac surgery requiring management of elevated blood pressure. In comparison to most other intravenous antihypertensives, clevidipine has a rapid onset of action, is ultra short-acting, easily titratable with a predictable dose response, and is void of drug-drug interactions and need for dose adjustment in patients with hepatic or renal insufficiency, thus making it a valuable antihypertensive in both the intraoperative and critical care settings. In clinical trials, clevidipine was well tolerated at infusion rates from 2-32 mg per hour, for up to 72 hours.

CONCLUSIONS

Clevidipine is the first intravenous antihypertensive approved by the Food and Drug Administration in nearly a decade. Based on available published clinical trials, clevidipine appears to be safe and effective in the acute management of moderate-to-severe elevations in blood pressure and a viable alternative to other agents such as nitroglycerin, sodium nitroprusside, and nicardipine.

Clevidipine: a novel ultra-short-acting calcium antagonist

Hypertension is the most common cardiovascular condition in the United States. It can lead to end organ damage and increased mortality risk if it is not properly controlled. In most situations where blood pressure has to be brought down quickly, an intravenous agent with a quick onset of action is often used. Clevidipine is the first third-generation IV dihydropyridine calcium channel blocker that has a high degree of vascular selectivity and an ultra-fast onset and offset of blood pressure lowering effect. In various clinical trials, clevidipine has shown to be safe and effective in controlling acute blood pressure elevations in patients with hypertensive emergencies, preoperative hypertension, and postoperative hypertension. The most common adverse events noted are atrial fibrillation, nausea, headache, and acute renal failure. Overall, clevidipine is a useful addition to available intravenous agents in reducing blood pressure during acute situations. The acceptance of this agent to hospital formularies may ultimately depend on its perceived ease of administration, clinically relevant benefits over other available agents, and acquisition costs.