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Dockery S, Dupré A, Deflorio P, Murray BP. Emergency Department Presentation of Life-threatening Symptomatic Hyperkalemia From an Angiotensin Receptor Blocker in a Low-risk Individual. Mil Med 2023; 188:3242-3247. [PMID: 36454619 DOI: 10.1093/milmed/usac376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 06/22/2022] [Accepted: 11/14/2022] [Indexed: 08/31/2023] Open
Abstract
Hyperkalemia is a common electrolyte abnormality with characteristic electrocardiogram changes. Both angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) increase the risk of developing hyperkalemia. This case highlights a rare life-threatening episode of hyperkalemia in an individual whose only risk factor was an ARB. A 58-year-old female presented with sudden-onset chest pressure, light-headedness, and diaphoresis. Her initial electrocardiogram showed a nearly sinusoidal rhythm with a widened ventricular depolarization (QRS) and prolonged QT-interval (QTc). Life-threatening hyperkalemia of 9.1 mmol/L was confirmed with a rapid point-of-care electrolyte panel. She was rapidly treated with calcium, potassium-shifting and eliminating medications, and emergent hemodialysis. After stabilization, a thorough workup found that the patient's only risk factor for hyperkalemia was her use of an ARB. While both ARBs and ACEIs are commonly associated with mild hyperkalemia, life-threatening hyperkalemia is rare, particularly in patients without concomitant renal failure, diabetes mellitus, adrenal disease, or potassium-sparing diuretic use. However, this case illustrates that life-threatening hyperkalemia is possible in patients solely taking an ARB without prior significant risk factors. Despite normal renal function in an individual without heart failure or diabetes, this patient developed life-threatening hyperkalemia.
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Affiliation(s)
- Samuel Dockery
- Wright State University Boonshoft School of Medicine, Dayton, OH 45435, USA
| | - Alan Dupré
- Wright State University Boonshoft School of Medicine, Dayton, OH 45435, USA
| | - Paul Deflorio
- Wright State University Boonshoft School of Medicine, Dayton, OH 45435, USA
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2
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Raghunatha P, Inamdar MN, Asdaq SMB, Almuqbil M, Alzahrani AR, Alaqel SI, Kamal M, Alsubaie FH, Alsanie WF, Alamri AS, Rabbani SI, Attimarad M, Mohan S, Alhomrani M. New Thiazole Acetic Acid Derivatives: A Study to Screen Cardiovascular Activity Using Isolated Rat Hearts and Blood Vessels. Molecules 2022; 27:molecules27196138. [PMID: 36234675 PMCID: PMC9572953 DOI: 10.3390/molecules27196138] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/15/2022] [Accepted: 09/16/2022] [Indexed: 11/16/2022] Open
Abstract
Cardiovascular diseases are one of the major causes of mortalities worldwide. In the present research, new synthetic derivatives of thiazole were studied using isolated hearts and blood vessels of rats. The heart and thoracic aorta were tested with six new synthesized thiazole acetic acid derivatives (SMVA-10, SMVA-35, SMVA-40, SMVA-41, SMVA-42 and SMVA-60), and the data obtained were statistically analyzed and compared. Isolated rat hearts were used to record the changes in developed tension and heart rate, while thoracic aortas were used to measure the contractile response, before and after treatments. Analysis of the results indicated a significant (p < 0.01) increase in developed tension with the addition of SMVA-35, SMVA-40, SMVA-41 and SMVA-42, which was augmented in the presence of adrenaline without affecting the heart rate. On the other hand, acetylcholine significantly decreased the developed tension, which was significantly reversed (p < 0.01) in the presence of compounds (SMVA-35 and SMVA-60). However, in the presence of SMVA-35 and SMVA-40, acetylcholine-induced bradycardia was significantly (p < 0.01) reduced. Furthermore, only SMVA-42 induced a dose-dependent contractile response in the isolated blood vessel, which was abolished in the presence of prazosin. Therefore, it can be concluded that some of the new synthesized thiazole derivatives exhibited promising results by raising the developed tension without changing the heart rate or blood vessel function, which could be helpful in failing heart conditions. However, more research is required to fully comprehend the function, mechanism and effectiveness of the compounds.
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Affiliation(s)
- P. Raghunatha
- Department of Pharmacology, Al-Ameen College of Pharmacy, Bangalore 560027, India
| | - Mohammed Naseeruddin Inamdar
- Department of Pharmacology, Al-Ameen College of Pharmacy, Bangalore 560027, India
- Department of Pharmacology, East West College of Pharmacy, Bangalore 560091, India
| | - Syed Mohammed Basheeruddin Asdaq
- Department of Pharmacy Practice, College of Pharmacy, AlMaarefa University, Dariyah, Riyadh 13713, Saudi Arabia
- Correspondence: or
| | - Mansour Almuqbil
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh 11451, Saudi Arabia
| | - Abdullah R. Alzahrani
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Al-Abidiyah, P.O. Box 13578, Makkah 21955, Saudi Arabia
| | - Saleh I. Alaqel
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Northern Border University, Rafha 91911, Saudi Arabia
| | - Mehnaz Kamal
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj 11942, Saudi Arabia
| | - Firas Hamdan Alsubaie
- Medical Sale Representative, Jamjoom Pharmaceutical Company, Riyadh 12211, Saudi Arabia
| | - Walaa F. Alsanie
- Department of Clinical Laboratory Sciences, The Faculty of Applied Medical Sciences, Taif University, Taif 21944, Saudi Arabia
- Centre of Biomedical Sciences Research (CBSR), Deanship of Scientific Research, Taif University, Taif 21944, Saudi Arabia
| | - Abdulhakeem S. Alamri
- Department of Clinical Laboratory Sciences, The Faculty of Applied Medical Sciences, Taif University, Taif 21944, Saudi Arabia
- Centre of Biomedical Sciences Research (CBSR), Deanship of Scientific Research, Taif University, Taif 21944, Saudi Arabia
| | - Syed Imam Rabbani
- Department of Pharmacology and Toxicology, College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia
| | - Mahesh Attimarad
- Department of Pharmaceutical Sciences, College of Clinical Pharmacy, King Faisal University, Al-Ahsa 31982, Saudi Arabia
| | - S. Mohan
- Faculty of Pharmaceutical Sciences, PES University, Bengaluru 560085, India
| | - Majid Alhomrani
- Department of Clinical Laboratory Sciences, The Faculty of Applied Medical Sciences, Taif University, Taif 21944, Saudi Arabia
- Centre of Biomedical Sciences Research (CBSR), Deanship of Scientific Research, Taif University, Taif 21944, Saudi Arabia
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3
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Alharbi FF, Kholod AA, Souverein PC, Meyboom RH, de Groot MC, de Boer A, Klungel OH. The impact of age and sex on the reporting of cough and angioedema with renin-angiotensin system inhibitors: a case/noncase study in VigiBase. Fundam Clin Pharmacol 2017; 31:676-684. [DOI: 10.1111/fcp.12313] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/26/2017] [Accepted: 07/25/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Fawaz F. Alharbi
- Division of Pharmacoepidemiology and Clinical Pharmacology; Utrecht Institute for Pharmaceutical Sciences; Utrecht University; PO Box 80 082 3508 TB Utrecht The Netherlands
| | - Anzhelika A.V. Kholod
- Division of Pharmacoepidemiology and Clinical Pharmacology; Utrecht Institute for Pharmaceutical Sciences; Utrecht University; PO Box 80 082 3508 TB Utrecht The Netherlands
| | - Patrick C. Souverein
- Division of Pharmacoepidemiology and Clinical Pharmacology; Utrecht Institute for Pharmaceutical Sciences; Utrecht University; PO Box 80 082 3508 TB Utrecht The Netherlands
| | - Ronald H. Meyboom
- Division of Pharmacoepidemiology and Clinical Pharmacology; Utrecht Institute for Pharmaceutical Sciences; Utrecht University; PO Box 80 082 3508 TB Utrecht The Netherlands
| | - Mark C.H. de Groot
- Division of Laboratory and Pharmacy; Department of Clinical Chemistry and Haematology; University Medical Center Utrecht; PO Box 85500 3508 GA Utrecht The Netherlands
| | - Anthonius de Boer
- Division of Pharmacoepidemiology and Clinical Pharmacology; Utrecht Institute for Pharmaceutical Sciences; Utrecht University; PO Box 80 082 3508 TB Utrecht The Netherlands
| | - Olaf H. Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology; Utrecht Institute for Pharmaceutical Sciences; Utrecht University; PO Box 80 082 3508 TB Utrecht The Netherlands
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; PO Box 85500 3508 GA Utrecht The Netherlands
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trans-(3S,4S)-Disubstituted pyrrolidines as inhibitors of the human aspartyl protease renin. Part I: prime site exploration using an amino linker. Bioorg Med Chem Lett 2015; 25:1782-1786. [PMID: 25782742 DOI: 10.1016/j.bmcl.2015.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 02/11/2015] [Accepted: 02/16/2015] [Indexed: 11/20/2022]
Abstract
Recently, we reported on the discovery of (3S,4S)-disubstituted pyrrolidines (e.g., 2) as inhibitors of the human aspartyl protease renin. In our effort to further expand the scope of this novel class of direct renin inhibitors, a new sub-series was designed in which the prime site substituents are linked to the pyrrolidine core by a (3S)-amino functional group. In particular, analogs bearing the corresponding sulfonamide spacer (50, 51 and 54a) demonstrated a pronounced increase in in vitro potency compared to compound 2.
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Sellner H, Cottens S, Cumin F, Ehrhardt C, Kosaka T, Lorthiois E, Ostermann N, Webb RL, Rigel DF, Wagner T, Maibaum J. trans -3,4-Disubstituted pyrrolidines as inhibitors of the human aspartyl protease renin. Part II: Prime site exploration using an oxygen linker. Bioorg Med Chem Lett 2015; 25:1787-1791. [DOI: 10.1016/j.bmcl.2015.02.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 02/11/2015] [Accepted: 02/16/2015] [Indexed: 10/24/2022]
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Structural insights into mode of actions of novel substituted 4- and 6-azaindole-3-carboxamides analogs as renin inhibitors: molecular modeling studies. Med Chem Res 2015. [DOI: 10.1007/s00044-014-1163-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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8
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Trimethoprim-induced hyperkalemia in burn patients treated with intravenous or oral trimethoprim sulfamethoxazole for methicillin-resistant Staphylococcus aureus and other infections: nature or nurture? J Burn Care Res 2013; 34:127-32. [PMID: 23292580 DOI: 10.1097/bcr.0b013e3182700b18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Trimethoprim is well known to cause rashes; however, what is not commonly known is that it causes sudden and profound hyperkalemia in 10 to 20% of treated patients. The uniqueness of burn patients begs the question whether changes known to occur in these patients might also increase this trimethoprim effect. After institutional review board approval, a retrospective study evaluated 224 patients with thermal injury who had been treated with trimethoprim sulfamethoxazole (TMP-SMX), 24 of whom had underlying renal impairment (creatinine clearances <50 ml/min) and were excluded, leaving 200 patients for analysis. Three definitions of drug-induced hyperkalemia were used: 1) a ≥ 1 mEq/L rise, 2) a >0.8 mEq rise in potassium in <24 hours warranting early discontinuation of TMP-SMX, and 3) "marked" hyperkalemia defined as serum potassium of ≥ 5.5 mEq/L within 48 hours. A potassium level before trimethoprim exposure (TxK) and after TxK were collected retrospectively. Demographic data were analyzed with Student's t-test and trimethoprim dose alone, demonstrating a significant difference. Analysis of 200 patients exposed to trimethoprim demonstrated an elevation of potassium (first definition) in 31 patients (15.5%), a rapid change in serum potassium in two patients (second definition), and marked hyperkalemia (>5.5 mEq/L) in 13 patients (6.5%). Hyperkalemia never occurred in 166 of 200 patients (82%; before TxK, 3.9 ± 0.4; after TxK, 4.3 ± 0.5 mEq/L). Change in serum potassium among patients with hyperkalemia was 4.0 ± 0.5 mEq/L before TxK and 5.3 ± 0.7 mEq/L after TxK. Twelve published hyperkalemia risk factors were reviewed in these 200 patients and only history of hypertension and need for intubation was more common in those with hyperkalemia. A nearly 20% incidence of hyperkalemia and 6% serious hyperkalemia in burn patients is consistent with reports in patients without burn injury. These data also suggest that the metabolic and hormonal changes associated with burn injury do not increase further the genetically predisposed hyperkalemia resulting from exposure to trimethoprim. These data suggest patients treated with TMP-SMX should have routine serum potassium monitoring before discharge.
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Lorthiois E, Breitenstein W, Cumin F, Ehrhardt C, Francotte E, Jacoby E, Ostermann N, Sellner H, Kosaka T, Webb RL, Rigel DF, Hassiepen U, Richert P, Wagner T, Maibaum J. The discovery of novel potent trans-3,4-disubstituted pyrrolidine inhibitors of the human aspartic protease renin from in silico three-dimensional (3D) pharmacophore searches. J Med Chem 2013; 56:2207-17. [PMID: 23425156 DOI: 10.1021/jm3017078] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The small-molecule trans-3,4-disubstituted pyrrolidine 6 was identified from in silico three-dimensional (3D) pharmacophore searches based on known X-ray structures of renin-inhibitor complexes and demonstrated to be a weakly active inhibitor of the human enzyme. The unexpected binding mode of the more potent enantiomer (3S,4S)-6a in an extended conformation spanning the nonprime and S1' pockets of the recombinant human (rh)-renin active site was elucidated by X-ray crystallography. Initial structure-activity relationship work focused on modifications of the hydrophobic diphenylamine portion positioned in S1 and extending toward the S2 pocket. Replacement with an optimized P3-P1 pharmacophore interacting to the nonsubstrate S3(sp) cavity eventually resulted in significantly improved in vitro potency and selectivity. The prototype analogue (3S,4S)-12a of this new class of direct renin inhibitors exerted blood pressure lowering effects in a hypertensive double-transgenic rat model after oral administration.
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Affiliation(s)
- Edwige Lorthiois
- Novartis Pharma AG, Institutes for BioMedical Research, Novartis Campus, CH-4056 Basel, Switzerland.
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Fournier PA, Arbour M, Cauchon E, Chen A, Chefson A, Ducharme Y, Falgueyret JP, Gagné S, Grimm E, Han Y, Houle R, Lacombe P, Lévesque JF, MacDonald D, Mackay B, McKay D, Percival MD, Ramtohul Y, St-Jacques R, Toulmond S. Design and synthesis of potent, isoxazole-containing renin inhibitors. Bioorg Med Chem Lett 2012; 22:2670-4. [DOI: 10.1016/j.bmcl.2012.03.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 03/02/2012] [Accepted: 03/05/2012] [Indexed: 11/27/2022]
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3,4-Diarylpiperidines as potent renin inhibitors. Bioorg Med Chem Lett 2012; 22:1953-7. [DOI: 10.1016/j.bmcl.2012.01.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 01/12/2012] [Accepted: 01/13/2012] [Indexed: 01/21/2023]
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12
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Identification of a new biaryl scaffold generating potent renin inhibitors. Bioorg Med Chem Lett 2010; 20:5822-6. [DOI: 10.1016/j.bmcl.2010.07.127] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 07/27/2010] [Accepted: 07/28/2010] [Indexed: 11/23/2022]
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Abstract
Hypertension, a serious disease affecting almost a billion people (25% of adults) worldwide, is a major modifiable risk factor for cardiovascular (CV) and renal disease. Despite numerous advances in the pharmacologic treatment of high blood pressure (BP) and availability of several antihypertensive drugs to treat hypertension, a significant proportion of treated hypertensive patients still have uncontrolled high BP, and thus, face serious morbidity and mortality. Furthermore, it is not sufficient to aim for optimum BP control, but to treat all CV risk factors, protect end-organ damage, prevent progression of disease, and prevent long-range adverse effects of the drugs. Therefore, new therapeutic modalities have to be developed to achieve the above objectives. Some years ago, investigators identified renin inhibition as the preferred pharmacologic approach to blockade of the renin-angiotensin system. Renin is a monospecific enzyme that catalyzes the rate-limiting step in the synthesis of angiotensin II. Amplified enzymatic activity and additional physiologic effects occur when renin and prorenin bind to the (pro)renin receptor. Until very recently, development of clinically effective renin inhibitors remained elusive but molecular modeling was used to develop aliskiren and other renin inhibitors that produce sustained suppression of plasma renin activity after oral administration with a dose-dependent BP. Additional studies will ultimately determine the place of renin inhibition in the treatment of hypertension and related CV disorders.
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Pasha Y, Gusbeth-Tatomir P, Covic A, Goldsmith D. Direct renin inhibitors: ONTARGET for success? Int Urol Nephrol 2009; 41:341-55. [PMID: 19296235 DOI: 10.1007/s11255-009-9556-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2009] [Accepted: 02/27/2009] [Indexed: 11/26/2022]
Abstract
Direct renin inhibitors are the first new class of antihypertensive to emerge since angiotensin II receptor blockers. We discuss their reno- and cardioprotective potential, based on extrapolation from animal models and phase three trials that are currently ongoing. This paper reviews the potential benefits of direct renin inhibitors (DRIs), the only new anti-hypertensive class developed in the last decade, as compared to pre-existing classes of drug inhibiting more downstream, such as Angiotensin Converting Enzyme inhibitors (ACEI), Angiotensin 2 Receptor Blockers (ARBS).
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Affiliation(s)
- Yasmin Pasha
- Chelsea and Westminster Hospital, Fulham Road, London, UK
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15
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Hamet P. Direct renin inhibition: Mechanistic advantages and disadvantages compared with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers. Can J Cardiol 2008. [DOI: 10.1016/s0828-282x(08)71038-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Abstract
PURPOSE The pharmacology, bioavailability and pharmacokinetics, clinical efficacy, adverse effects and toxicity, drug interactions, and dosage and administration of aliskiren as well as safety and economic issues related to its use are reviewed. SUMMARY Aliskiren is the first of a new class of antihypertensive agents, direct renin inhibitors, that act by blocking the rate- limiting step of the renin-angiotensin- aldosterone system (RAAS). It was approved by the Food and Drug Administration in 2007 for use as monotherapy or in combination with other antihypertensives. Clinical studies comparing aliskiren monotherapy with placebo indicated a dose-dependent reduction in both systolic and diastolic blood pressure (BP). Greater reductions in BP have been achieved when aliskiren was used in combination with hydrochlorothiazide or an angiotensin-receptor blocker. The most common adverse effects reported in clinical trials were headache, fatigue, dizziness, diarrhea, and nasopharyngitis. Aliskiren has not been studied in patients with moderate renal dysfunction; as a RAAS-acting drug, it should be prescribed for such patients only with caution. CONCLUSION Aliskiren at a dosage of 150 or 300 mg daily may be a good option for control of mild-to-moderate hypertension in patients with or without diabetes in whom first-line antihypertensives have failed to adequately control BP; comparative studies with other antihypertensives are needed to determine which patients can most benefit from aliskiren therapy.
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Affiliation(s)
- Kimberly K Daugherty
- Department of Clinical and Administrative Sciences, Sullivan University College of Pharmacy, Louisville, KY, USA
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Hollenberg N. Inhibición de renina. HIPERTENSION Y RIESGO VASCULAR 2008. [DOI: 10.1016/s1889-1837(08)71739-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Evidence that renin system blockade is useful in many patients with hypertension is overwhelming. Two recent lines of investigation have suggested that more complete blockade leads to improved clinical outcomes. One line of investigation involves the use of a combination of an angiotensin-converting enzyme inhibitor with an angiotensin-receptor blocker. The second line of investigation involves the use of very high dose angiotensin-receptor blocker. The interaction of renin with substrate is the rate-limiting step in the renin cascade; thus, the recent development of a powerful renin inhibitor also favors more complete blockade of the system. In many patients, this is likely to lead to improved treatment.
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Affiliation(s)
- Norman K Hollenberg
- Department of Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston, MA 02115, USA.
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Holsworth DD, Jalaie M, Belliotti T, Cai C, Collard W, Ferreira S, Powell NA, Stier M, Zhang E, McConnell P, Mochalkin I, Ryan MJ, Bryant J, Li T, Kasani A, Subedi R, Maiti SN, Edmunds JJ. Discovery of 6-ethyl-2,4-diaminopyrimidine-based small molecule renin inhibitors. Bioorg Med Chem Lett 2007; 17:3575-80. [DOI: 10.1016/j.bmcl.2007.04.052] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Revised: 04/17/2007] [Accepted: 04/18/2007] [Indexed: 11/30/2022]
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