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Trivedi P, Chaturvedi V. Interactive effect of oral anti-hyperglycaemic or anti-hypertensive drugs on the inhibitory and bactericidal activity of first line anti-TB drugs against M. tuberculosis. PLoS One 2023; 18:e0292397. [PMID: 38032920 PMCID: PMC10688676 DOI: 10.1371/journal.pone.0292397] [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: 05/31/2023] [Accepted: 09/19/2023] [Indexed: 12/02/2023] Open
Abstract
Co-existence of life style disorders, like, Diabetes or Hypertension, increases risk of, treatment failure, deaths and developing drug-resistant TB. Concomitant administration of drugs to treat dual/multi-morbidities may alter their effectiveness, in additive/synergistic or adverse/antagonistic manner. We evaluated interactive effect of 7 anti-hyperglycaemic (HG) and 6 anti-hypertensive (HT) drugs on the inhibitory (MICs) and bactericidal (% killing of intracellular bacilli) activities of anti-TB drugs, Isoniazid (INH), Rifampicin (RFM), Ethambutol (EMB) and Streptomycin (STR) against M. tuberculosis. Five anti-HG drugs, namely, Acarbose, Acetohexamide, Glyburide, Repaglinide and Sitagliptin imparted either 'additive' or 'no effect' on the activities (inhibition or % killing) of all the four anti-TB drugs, as evident by their lower FICs (Fractional Inhibitory concentrations) and higher bacterial killing in combination. Metformin and Rosiglitazone, however, exerted adverse effect on the Ethambutol (FICs >2.0). All the six anti-HT drugs, namely, Atenolol, Hydrochlorothiazide, Ramipril, Valsartan, Nifedipine and Verapamil exerted either 'additive'/'synergistic' or 'no effect' on the activities of anti-TB drugs. These findings may help clinicians to select safe and helpful anti-HG or anti-HT drugs for TB patients, if, suffering with diabetes or hypertension like co-morbidities and receiving DOTs (a set regimen for the treatment of TB based on the WHO guidelines).
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Affiliation(s)
- Priyanka Trivedi
- Biochemistry and Structural Biology Division, Central Drug Research Institute, Lucknow, UP, India
| | - Vinita Chaturvedi
- Biochemistry and Structural Biology Division, Central Drug Research Institute, Lucknow, UP, India
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A Selective and Accurate LC-MS/MS Method for Simultaneous Quantification of Valsartan and Hydrochlorothiazide in Human Plasma. SEPARATIONS 2023. [DOI: 10.3390/separations10020119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
The fixed dose combination of valsartan (VAL) and hydrochlorothiazide (HCTZ) is the most commonly prescribed medicine for the effective treatment of hypertension. In this study, a simple sensitive and accurate liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed for the simultaneous quantitation of VAL and HCTZ in human plasma by using irbesartan (IRB) and hydroflumethiazide (HFMZ) as their specific internal standards (ISs). HLB cartridge-based solid-phase extraction was used for the extraction of analytes and ISs. The chromatographic separation was achieved on Lichrocart RP Select (125 × 4 mm), 5 nm with the mobile phase composition of acetonitrile: 10 mM ammonium acetate buffer: 95:05, v/v, at flow rate of 0.5 mL/min. The turbo ion electrospray ionization in negative mode was used as ion source for the sample ionization. The precursor to product ion transitions were 434.10 > 179.10 (VAL), 295.70 > 204.90 (HCTZ), 427.10 > 192.90 (IRB), and 329.90 > 302.40 (HFMZ) for detection and quantification of analytes and their ISs. The retention times of VAL and HCTZ were 1.90 min and 2.30 min, respectively. The range for the calibration curves of VAL and HCTZ were 50.2–6018.6 ng/mL and 1.25–507.63 ng/mL, respectively, with good linearity having correlation coefficient values of ≥0.995 for both VAL and HCTZ. All validation parameter results (selectivity, precision and accuracy, matrix effects and stabilities) were within the acceptable range as per USFDA guideline for bioanalytical method validation. The intra-day and inter-day accuracy data for VAL were within the range of 105.68–114.22% and 98.41–108.16%, respectively, whereas for HCTZ they were 87.01–101.18% and 95.16–99.37%, respectively. The ion suppression effects produced for VAL and ion enhancement effects produced for HCTZ were insignificant according to the proposed sample cleanup procedure. The developed LC-MS/MS method was successfully applied to bioequivalence study on healthy volunteers.
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Barroso WKS, Brandão AA, Vitorino PVDO, Feitosa ADDM, Barbosa ECD, Miranda RD, Redon J, Camafort-Babkowski M, Coca A, Gomes MAM. Angiotensin Receptor Blockers Evaluated by Office and Home Blood Pressure Measurements. TeleHBPM Study. Arq Bras Cardiol 2022; 118:S0066-782X2022005005204. [PMID: 35544853 PMCID: PMC9345159 DOI: 10.36660/abc.20210504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/08/2021] [Accepted: 09/01/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Adequate treatment of arterial hypertension and achieving arterial hypertension goals in are important in reducing cardiovascular outcomes. OBJECTIVES To describe angiotensin receptor blockers in monotherapy or double combination therapy and the rate of arterial hypertension control. METHODS This cross-sectional study evaluated patients who were using angiotensin receptor blockers between 2017 and 2020. Those using three or more antihypertensive drugs were excluded. The analyzed variables included sex, age, body mass index, valid home blood pressure monitoring (HBPM) measurements, casual and HBPM systolic and diastolic blood pressure measurements, blood pressure variability, and antihypertensive and angiotensin receptor blocker class. Paired t, chi-square, and Fisher's exact tests were used, as well as overlapping 95% confidence intervals and a significance level of 5% (p < 0.05). RESULTS Of 17,013 patients, 12,813 met the inclusion criteria, 62.1% of whom were female. The mean number of valid measurements was 23.3 (SD, 2.0). The mean HBPM and casual measurements for systolic blood pressure were 126.8 (SD, 15.8) mmHg and 133.5 (SD, 20.1) mmHg (p <0.001), respectively, while those for diastolic blood pressure were 79.1 (SD, 9.7 mmHg) and 83.6 (SD, 11.9) mmHg (p <0.001), respectively. Losartan was the most common angiotensin receptor blocker and resulted in the highest blood pressure values. Combinations of angiotensin receptor blockers with diuretics or calcium channel antagonists resulted in lower blood pressure values. CONCLUSIONS More than half of the patients used losartan, although it was the least efficient drug for reducing and controlling blood pressure.
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Affiliation(s)
- Weimar Kunz Sebba Barroso
- Universidade Federal de GoiásLiga de Hipertensão ArterialGoiâniaGOBrasilUniversidade Federal de Goiás - Liga de Hipertensão Arterial, Goiânia, GO – Brasil
| | - Andréa Araujo Brandão
- Universidade do Estado do Rio de JaneiroRio de JaneiroRJBrasilUniversidade do Estado do Rio de Janeiro – Cardiologia, Rio de Janeiro, RJ – Brasil
| | - Priscila Valverde de Oliveira Vitorino
- Pontifícia Universidade Católica de GoiásEscola de Ciências Sociais e da SaúdeGoiâniaGOBrasilPontifícia Universidade Católica de Goiás - Escola de Ciências Sociais e da Saúde,Goiânia, GO – Brasil
| | - Audes Diógenes de Magalhães Feitosa
- Universidade de PernambucoRecifePEBrasilUniversidade de Pernambuco, Recife, PE – Brasil
- Universidade Católica de PernambucoRecifePEBrasilUniversidade Católica de Pernambuco, Recife, PE – Brasil
| | - Eduardo Costa Duarte Barbosa
- Complexo Hospitalar Santa Casa de Misericórdia de Porto AlegrePorto AlegreRSBrasilComplexo Hospitalar Santa Casa de Misericórdia de Porto Alegre – Cardiologia, Porto Alegre, RS - Brasil
| | - Roberto Dischinger Miranda
- Universidade Federal de São PauloEscola Paulista de MedicinaSão PauloSPBrasilUniversidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, SP – Brasil
| | - Josep Redon
- University of ValenciaValenciaEspanhaUniversity of Valencia – Hypertension, Valencia, Comunitat Valenciana – Espanha
| | - Miguel Camafort-Babkowski
- University of BarcelonaHospital ClínicHypertension UnitBarcelonaCatalunyaEspanhaUniversity of Barcelona - Hospital Clínic. Hypertension Unit, Barcelona, Catalunya – Espanha
| | - Antonio Coca
- Hypertension and Vascular Risk UnitHospital ClinicUniversity of BarcelonaBarcelonaEspanhaHypertension and Vascular Risk Unit. Hospital Clinic. University of Barcelona,Barcelona – Espanha
| | - Marco Antônio Mota Gomes
- Centro Universitário CESMACHospital do CoraçãoMaceióALBrasilCentro Universitário CESMAC - Hospital do Coração, Maceió, AL – Brasil
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Di Mizio G, Marcianò G, Palleria C, Muraca L, Rania V, Roberti R, Spaziano G, Piscopo A, Ciconte V, Di Nunno N, Esposito M, Viola P, Pisani D, De Sarro G, Raffi M, Piras A, Chiarella G, Gallelli L. Drug-Drug Interactions in Vestibular Diseases, Clinical Problems, and Medico-Legal Implications. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:12936. [PMID: 34948545 PMCID: PMC8701970 DOI: 10.3390/ijerph182412936] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/28/2021] [Accepted: 12/03/2021] [Indexed: 12/23/2022]
Abstract
Peripheral vestibular disease can be treated with several approaches (e.g., maneuvers, surgery, or medical approach). Comorbidity is common in elderly patients, so polytherapy is used, but it can generate the development of drug-drug interactions (DDIs) that play a role in both adverse drug reactions and reduced adherence. For this reason, they need a complex kind of approach, considering all their individual characteristics. Physicians must be able to prescribe and deprescribe drugs based on a solid knowledge of pharmacokinetics, pharmacodynamics, and clinical indications. Moreover, full information is required to reach a real therapeutic alliance, to improve the safety of care and reduce possible malpractice claims related to drug-drug interactions. In this review, using PubMed, Embase, and Cochrane library, we searched articles published until 30 August 2021, and described both pharmacokinetic and pharmacodynamic DDIs in patients with vestibular disorders, focusing the interest on their clinical implications and on risk management strategies.
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Affiliation(s)
- Giulio Di Mizio
- Department of Law, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
| | - Gianmarco Marcianò
- Department of Health Science, School of Medicine, University of Catanzaro, Clinical Pharmacology and Pharmacovigilance Unit, Mater Domini Hospital, 88100 Catanzaro, Italy
| | - Caterina Palleria
- Department of Health Science, School of Medicine, University of Catanzaro, Clinical Pharmacology and Pharmacovigilance Unit, Mater Domini Hospital, 88100 Catanzaro, Italy
| | - Lucia Muraca
- Department of Health Science, School of Medicine, University of Catanzaro, Clinical Pharmacology and Pharmacovigilance Unit, Mater Domini Hospital, 88100 Catanzaro, Italy
- Department of Primary Care, ASP 7, 88100 Catanzaro, Italy
| | - Vincenzo Rania
- Department of Health Science, School of Medicine, University of Catanzaro, Clinical Pharmacology and Pharmacovigilance Unit, Mater Domini Hospital, 88100 Catanzaro, Italy
| | - Roberta Roberti
- Department of Health Science, School of Medicine, University of Catanzaro, Clinical Pharmacology and Pharmacovigilance Unit, Mater Domini Hospital, 88100 Catanzaro, Italy
| | - Giuseppe Spaziano
- Department of Experimental Medicine L. Donatelli, Section of Pharmacology, School of Medicine, University of Campania Luigi Vanvitelli, 80123 Naples, Italy
| | - Amalia Piscopo
- Department of Law, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
| | - Valeria Ciconte
- Department of Law, Magna Graecia University of Catanzaro, 88100 Catanzaro, Italy
- Department of Health Science, School of Medicine, University of Catanzaro, Clinical Pharmacology and Pharmacovigilance Unit, Mater Domini Hospital, 88100 Catanzaro, Italy
| | - Nunzio Di Nunno
- Department of History, Society and Studies on Humanity, University of Salento, 83100 Lecce, Italy
| | - Massimiliano Esposito
- Department of Medical, Surgical Sciences and Advanced Technologies "G. F. Ingrassia", University of Catania, 95121 Catania, Italy
| | - Pasquale Viola
- Unit of Audiology, Department of Experimental and Clinical Medicine, Regional Centre of Cochlear Implants and ENT Diseases, Magna Graecia University, 88100 Catanzaro, Italy
| | - Davide Pisani
- Unit of Audiology, Department of Experimental and Clinical Medicine, Regional Centre of Cochlear Implants and ENT Diseases, Magna Graecia University, 88100 Catanzaro, Italy
| | - Giovambattista De Sarro
- Department of Health Science, School of Medicine, University of Catanzaro, Clinical Pharmacology and Pharmacovigilance Unit, Mater Domini Hospital, 88100 Catanzaro, Italy
- Research Center FAS@UMG, Department of Health Science, University of Catanzaro, 88100 Catanzaro, Italy
| | - Milena Raffi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40126 Bologna, Italy
| | - Alessandro Piras
- Department of Biomedical and Neuromotor Sciences, University of Bologna, 40126 Bologna, Italy
| | - Giuseppe Chiarella
- Unit of Audiology, Department of Experimental and Clinical Medicine, Regional Centre of Cochlear Implants and ENT Diseases, Magna Graecia University, 88100 Catanzaro, Italy
| | - Luca Gallelli
- Department of Health Science, School of Medicine, University of Catanzaro, Clinical Pharmacology and Pharmacovigilance Unit, Mater Domini Hospital, 88100 Catanzaro, Italy
- Research Center FAS@UMG, Department of Health Science, University of Catanzaro, 88100 Catanzaro, Italy
- Medifarmagen SRL, University of Catanzaro, 88100 Catanzaro, Italy
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Saleem U, Zubair S, Riaz A, Anwar F, Ahmad B. Effect of Venlafaxine, Pramipexole, and Valsartan on Spermatogenesis in Male Rats. ACS OMEGA 2020; 5:20481-20490. [PMID: 32832801 PMCID: PMC7439459 DOI: 10.1021/acsomega.0c02587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 07/23/2020] [Indexed: 05/04/2023]
Abstract
The study's aim was to explore the effect of venlafaxine, valsartan, and pramipexole on spermatogenesis. It was hypothesized that these drugs may affect the male fertility because of their long-term use in treatment of depression, hypertension, and Parkinson's diseases. Male rats were given venlafaxine, valsartan, and pramipexole at low- and high-dose levels orally once daily for 10 weeks. Testosterone (25 mg/kg) was given as a standard via an intramuscular route once weekly. Rats were sacrificed after blood collection by cardiac puncture, and testes were removed. Sperm parameters were examined from spermatozoa of the cauda epididymis, and testes were treated for histopathological analysis. Results showed nonsignificant effect of venlafaxine on the sperm count, whereas a decreased sperm count was noted in all the treatment groups as compared to that of the control except valsartan at a low dose, which significantly (p < 0.001) raised the sperm count (96.26 ± 2.4) in reference with the control value (49.13 ± 2.3). Treatments had variable effects on total sperm motility and morphological parameters, but valsartan at a low dose showed maximum sperm motility (71.55 ± 0.7) among all. DNA integrity of spermatozoa remained intact in all groups. Luteinizing hormone and follicle-stimulating hormone levels decreased, and testosterone levels increased in all treatment groups as compared to control values, which indicate fertility. Histopathology revealed normal texture of testes with venlafaxine and valsartan, but testicular damage occurred with high-dose pramipexole. It is concluded that the use of venlafaxine, valsartan, and pramipexole at a low dose is devoid of any harmful effect on spermatogenesis, whereas pramipexole at a high dose adversely affect it.
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Affiliation(s)
- Uzma Saleem
- Department
of Pharmacology, Faculty of Pharmaceutical Sciences, Govt. College University, Faisalabad 38000, Pakistan
- . Tel: +92-333 4904928
| | - Sidra Zubair
- Riphah
Institute of Pharmaceutical Sciences, Riphah
International University Lahore, Lahore 54000, Pakistan
| | - Amjad Riaz
- Department
of Theriogenology, University of Veterinary
and Animal Sciences, Lahore 54000, Pakistan
| | - Fareeha Anwar
- Riphah
Institute of Pharmaceutical Sciences, Riphah
International University Lahore, Lahore 54000, Pakistan
| | - Bashir Ahmad
- Riphah
Institute of Pharmaceutical Sciences, Riphah
International University Lahore, Lahore 54000, Pakistan
- . Tel: +92-336 4409575
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Alzoubi KH, Bayraktar E, Khabour O, Al-Azzam SI. Vitamin B12 protects against DNA damage induced by hydrochlorothiazide. Saudi Pharm J 2018; 26:786-789. [PMID: 30202218 PMCID: PMC6128724 DOI: 10.1016/j.jsps.2018.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 04/02/2018] [Indexed: 12/14/2022] Open
Abstract
DNA damage induced by hydrochlorothiazide was previously reported in cultured human lymphocytes. In this study, we aimed to investigate the harmful effects of hydrochlorothiazide on DNA by measuring the spontaneous frequency of sister chromatid exchanges (SCEs) in cultured human lymphocytes. We also aimed to investigate the possible protection of that damage by vitamin B12. The results showed that hydrochlorothiazide (5 µg/mL) significantly increased the frequency of sister chromatid exchanges (P < 0.001) in human lymphocytes in comparison with control. Additionally, the frequency of hydrochlorothiazide-induced SCEs was significantly decreased by co-treatment with vitamin B12 at concentration of 13.5 µg/mL (P < 0.001). In conclusion, hydrochlorothiazide is genotoxic to human lymphocytes and its toxicity is reduced by vitamin B12.
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Affiliation(s)
- Karem H Alzoubi
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Erva Bayraktar
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Omar Khabour
- Department of Medical Laboratory Sciences, Jordan University of Science and Technology, Irbid, Jordan
| | - Sayer I Al-Azzam
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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Lee J, Lee H, Jang K, Lim KS, Shin D, Yu KS. Evaluation of the pharmacokinetic and pharmacodynamic drug interactions between cilnidipine and valsartan, in healthy volunteers. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:1781-8. [PMID: 25336921 PMCID: PMC4199974 DOI: 10.2147/dddt.s68574] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE Although cilnidipine and valsartan are widely coadministered to patients with hypertension, their drug-drug interaction potential has not been investigated. This study compared the pharmacokinetic (PK), pharmacodynamic (PD), and tolerability profiles of cilnidipine and valsartan, both alone and in combination, in healthy male subjects. PATIENTS AND METHODS Fifty-four subjects, enrolled into an open-label, single-dose, three-treatment, three-period crossover study, randomly received cilnidipine (10 mg), valsartan (160 mg), or both according to one of six sequences. Blood samples were collected at baseline and up to 24 hours after drug administration in each period. Plasma concentrations of cilnidipine and valsartan were determined by liquid chromatography with tandem mass spectrometry. Maximum plasma concentration (Cmax) and area under the concentration-time curve from 0 to the last measurable time (AUC(last)) were estimated using a noncompartmental method. Tolerability was evaluated by assessing adverse events (AEs), vital signs, electrocardiograms, and clinical laboratory tests. Blood pressure was also measured for PD assessment. RESULTS A total of 51 subjects completed the study. The PK profile of cilnidipine was not significantly affected by coadministered valsartan; the geometric mean ratio and 90% confidence interval (90% CI) of AUC(last) for cilnidipine with and without valsartan was 1.04 (0.98-1.10). Likewise, cilnidipine did not affect the PK of valsartan; the geometric mean ratio (90% CI) of AUC(last) for valsartan with and without cilnidipine was 0.94 (0.83-1.07). Coadministration of cilnidipine and valsartan reduced blood pressure in an additive way. No serious AEs were reported, and both cilnidipine and valsartan were well tolerated. CONCLUSION Coadministered cilnidipine and valsartan do not cause a significant PK or PD interaction, and they are well tolerated.
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Affiliation(s)
- Jieon Lee
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Howard Lee
- Clinical Trials Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyungho Jang
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Kyoung Soo Lim
- Department of Clinical Pharmacology and Therapeutics, CHA University School of Medicine and CHA Bundang Medical Center, Seongnam, Republic of Korea
| | - Dongseong Shin
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
| | - Kyung-Sang Yu
- Department of Clinical Pharmacology and Therapeutics, Seoul National University College of Medicine and Hospital, Seoul, Republic of Korea
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Suzuki O, Ishii H, Kobayashi S. Effects of an angiotensin 2 receptor blocker plus diuretic combination drug in chronic heart failure complicated by hypertension. J Int Med Res 2011; 39:1420-6. [PMID: 21986143 DOI: 10.1177/147323001103900429] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The effects of 24 weeks' treatment with an angiotensin 2 receptor blocker (ARB)/diuretic combination drug were investigated in an open-label study of 61 patients with stabilized chronic heart failure. Renin-angiotensin-aldosterone system inhibitors were replaced with a tablet containing hydrochlorothiazide 6.25 mg plus candesartan 8 mg, administered orally, once daily, in patients with systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg while under optimal treatment. Both SBP and DBP declined significantly during the ARB/diuretic combination treatment. Diuretics administered previously were discontinued during the study period in 15 patients, decreasing the number of drugs being taken. During ARB/diuretic combination treatment, the blood urea nitrogen level worsened but no significant changes were noted in potassium or estimated glomerular filtration rate, which had been a matter of concern. Additionally, the level of brain natriuretic peptide, an indicator of the severity of heart failure, was improved, indicating effectiveness and safety of the ARB/diuretic combination drug.
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Affiliation(s)
- O Suzuki
- Division of Cardiovascular Disease, Inazawa City Hospital, Inazawa City, Aichi, Japan.
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Stepan AF, Walker DP, Bauman J, Price DA, Baillie TA, Kalgutkar AS, Aleo MD. Structural alert/reactive metabolite concept as applied in medicinal chemistry to mitigate the risk of idiosyncratic drug toxicity: a perspective based on the critical examination of trends in the top 200 drugs marketed in the United States. Chem Res Toxicol 2011; 24:1345-410. [PMID: 21702456 DOI: 10.1021/tx200168d] [Citation(s) in RCA: 488] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Because of a preconceived notion that eliminating reactive metabolite (RM) formation with new drug candidates could mitigate the risk of idiosyncratic drug toxicity, the potential for RM formation is routinely examined as part of lead optimization efforts in drug discovery. Likewise, avoidance of "structural alerts" is almost a norm in drug design. However, there is a growing concern that the perceived safety hazards associated with structural alerts and/or RM screening tools as standalone predictors of toxicity risks may be over exaggerated. In addition, the multifactorial nature of idiosyncratic toxicity is now well recognized based upon observations that mechanisms other than RM formation (e.g., mitochondrial toxicity and inhibition of bile salt export pump (BSEP)) also can account for certain target organ toxicities. Hence, fundamental questions arise such as: When is a molecule that contains a structural alert (RM positive or negative) a cause for concern? Could the molecule in its parent form exert toxicity? Can a low dose drug candidate truly mitigate metabolism-dependent and -independent idiosyncratic toxicity risks? In an effort to address these questions, we have retrospectively examined 68 drugs (recalled or associated with a black box warning due to idiosyncratic toxicity) and the top 200 drugs (prescription and sales) in the United States in 2009 for trends in physiochemical characteristics, daily doses, presence of structural alerts, evidence for RM formation as well as toxicity mechanism(s) potentially mediated by parent drugs. Collectively, our analysis revealed that a significant proportion (∼78-86%) of drugs associated with toxicity contained structural alerts and evidence indicating that RM formation as a causative factor for toxicity has been presented in 62-69% of these molecules. In several cases, mitochondrial toxicity and BSEP inhibition mediated by parent drugs were also noted as potential causative factors. Most drugs were administered at daily doses exceeding several hundred milligrams. There was no obvious link between idiosyncratic toxicity and physicochemical properties such as molecular weight, lipophilicity, etc. Approximately half of the top 200 drugs for 2009 (prescription and sales) also contained one or more alerts in their chemical architecture, and many were found to be RM-positive. Several instances of BSEP and mitochondrial liabilities were also noted with agents in the top 200 category. However, with relatively few exceptions, the vast majority of these drugs are rarely associated with idiosyncratic toxicity, despite years of patient use. The major differentiating factor appeared to be the daily dose; most of the drugs in the top 200 list are administered at low daily doses. In addition, competing detoxication pathways and/or alternate nonmetabolic clearance routes provided suitable justifications for the safety records of RM-positive drugs in the top 200 category. Thus, while RM elimination may be a useful and pragmatic starting point in mitigating idiosyncratic toxicity risks, our analysis suggests a need for a more integrated screening paradigm for chemical hazard identification in drug discovery. Thus, in addition to a detailed assessment of RM formation potential (in relationship to the overall elimination mechanisms of the compound(s)) for lead compounds, effects on cellular health (e.g., cytotoxicity assays), BSEP inhibition, and mitochondrial toxicity are the recommended suite of assays to characterize compound liabilities. However, the prospective use of such data in compound selection will require further validation of the cellular assays using marketed agents. Until we gain a better understanding of the pathophysiological mechanisms associated with idiosyncratic toxicities, improving pharmacokinetics and intrinsic potency as means of decreasing the dose size and the associated "body burden" of the parent drug and its metabolites will remain an overarching goal in drug discovery.
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Affiliation(s)
- Antonia F Stepan
- Worldwide Medicinal Chemistry, Pfizer Worldwide Research and Development, Groton, Connecticut 06340, USA
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