The effect of carvedilol on metabolic parameters in patients with metabolic syndrome

Solubility enhancement of carvedilol using drug–drug cocrystallization with hydrochlorothiazide

Background

Increasing hydrophilicity of poorly water-soluble drugs is a major challenge in drug discovery and development. Cocrystallization is one of the techniques to enhance the hydrophilicity of such drugs. Carvedilol (CAR), a nonselective beta/alpha1 blocker, used in the treatment of mild to moderate congestive heart failure and hypertension, is classified under BCS class II with poor aqueous solubility and high permeability. Present work is an attempt to improve the solubility of CAR by preparing cocrystals using hydrochlorothiazide (HCT), a diuretic drug, as coformer. CAR-HCT (2:0.5) cocrystals were prepared by slurry conversion method and were characterized by DSC, PXRD, FTIR, Raman, and SEM analysis. The solubility, stability, and dissolution (in vitro) studies were conducted for the cocrystals.

Results

The formation of CAR-HCT cocrystals was confirmed based on melting point, DSC thermograms, PXRD data, FTIR and Raman spectra, and finally by SEM micrographs. The solubility of the prepared cocrystals was significantly enhanced (7.3 times), and the dissolution (in vitro) was improved by 2.7 times as compared to pure drug CAR. Further, these cocrystals were also found to be stable for 3 months (90 days).

Conclusion

It may be inferred that the drug–drug (CAR-HCT) cocrystallization enhances the solubility and dissolution rate of carvedilol significantly. Further, by combining HCT as coformer could well be beneficial pharmacologically too.

Role of antioxidant property of carvedilol in mild to moderate hypertensive patients: A prospective open-label study

Objective:

Carvedilol is a nonselective third generation β-blocker that does not display the negative effects of traditional β-blockers. Regarding the antioxidant, anti-inflammatory and distinct metabolic properties of carvedilol which are similar to that of high-density lipoprotein (HDL) and paraoxonase 1 (PON1), the present study intends to investigate the effects of carvedilol treatment on malondialdehyde (MDA) and soluble lectin-like ox-low-density lipoprotein (LDL) receptor (sLOX-1) as markers of oxidative stress in association to lipid profiles, apolipoproteins (apo), and PON1 activity in hypertensive patients.

Patients and Methods:

This clinical trial study was performed on forty patients with mild to moderate essential hypertension. Subjects were studied before and after 2 months treatment with carvedilol, 25 mg daily. Lipids and lipoproteins were measured using a biochemistry analyzer. PON and arylesterase activity were assayed using paraoxon and phenyl acetate as substrates, respectively. MDA was quantified using a chemical colorimetric assay. ELISA was used to measure sLOX-1.

Results:

Our results showed that carvedilol treatment decreased systolic and diastolic blood pressure as much as forty and 16 mmHg, respectively (P < 0.001). It also increased HDL, total cholesterol, and serum PON1 activity (P < 0.05), but the levels of triglyceride, LDL, apo A-I, and apo B did not significantly change. There was an inverse correlation between serum PON1 activity and serum MDA.

Conclusion:

This study confirmed the antihypertensive effect of the drug and its beneficial metabolic effects through augmenting HDL and PON1 activity. We propose that the antioxidant effects of carvedilol can be partially attributed to increased PON-1 activity.

Effects of Carvedilol Compared to Nebivolol on Insulin Resistance and Lipid Profile in Patients With Essential Hypertension

Background and aim:

Beta-blockers have unfavorable effects on metabolic parameters in hypertensive treatment. New generation beta-blockers with vasodilatory capabilities are superior to traditional beta-blockers, but studies examining their effects on metabolic parameters are still lacking. This study aimed to compare the effects of 2 new generation beta-blockers, carvedilol and nebivolol, on insulin resistance (IR) and lipid profiles in patients with essential hypertension.

Methods:

This was a prospective, randomized, open-label, single-center clinical trial. A total of 80 patients were randomized into 2 groups: the carvedilol group (n = 40, 25 mg of carvedilol daily) and the nebivolol group (n = 40, 5 mg of nebivolol daily). Follow-up was performed for 4 months. Fasting plasma glucose, insulin levels, and the lipid profile (high-density lipoprotein [HDL], low-density lipoprotein [LDL], total cholesterol, triglyceride, apolipoprotein AI, and apolipoprotein B levels) were measured and IR was calculated by the homeostasis model assessment (HOMA) index. These variables were compared before and 4 months after treatment.

Results:

Blood pressure and heart rate were significantly and similarly reduced in the carvedilol and nebivolol groups after treatment compared to those before treatment (both P < .001). Serum glucose ( P < .001), insulin ( P < .01), HOMA-IR (P < .01), HDL ( P < .001), LDL ( P < .001), total cholesterol ( P < .001), and apolipoprotein B ( P < .05) levels decreased in a similar manner in the carvedilol and nebivolol groups after treatment compared to those before treatment. Serum triglyceride and apolipoprotein AI levels did not change after treatment with both drugs.

Conclusion:

New generation beta-blockers, carvedilol and nebivolol, efficiently and similarly decrease blood pressure. They have similar favorable effects on glucose, insulin, IR, and the lipid profile.

THE EFFECTIVENESS OF CARVEDILOL AND EPROSARTAN IN PATIENTS WITH METABOLIC SYNDROME AND CHRONIC HEART FAILURE

Аim. of the study was to assess the effectiveness of carvedilol and eprosartan in addition to the traditional treatment (Nitrosorbid 30mg/day + Digoxin 0.25mg/day + TromboASS 100mg/day + Atorvastatin 20mg/day + Furosemid 40mg/day + Verospiron 50mg/day + Atenolol 12.5–25 mg/day) in patients with metabolic syndrome and chronic heart failure.

Materials and methods. 91 patients with MS and CHF included sharing mentioned criteria. Carvedilol in doses of 6,25 ÷ 25 mg/day and eprosartan in doses of 300 ÷ 600 mg/day were administered in addition to the traditional treatment.

Results. After 12 months of treatment systolic BP decreased by 23.6% and diastolic by 17.2%. Heart rate decreased by 23.1%, and exercise tolerance increased by 22.3%. Dynamics of the presented indicators are statistically significant.

Conclusion. Administration of an alpha-beta blocker carvedilol and angiotensin II receptor blocker eprosartan in the above dosages promote the longest remission of heart failure, improvement in functional class and regression of pathological remodeling.

Treating the metabolic syndrome

The metabolic syndrome (MS), a cluster of metabolic abnormalities with insulin resistance as its central component, is increasing in prevalence and is associated with an increased risk of cardiovascular disease and Type 2 diabetes mellitus (T2DM). Current evidence supports an aggressive intervention approach that comprises lifestyle modification in conjunction with drug treatment of the MS components. Healthier eating and regular exercise greatly reduce waistline and body mass index, lower blood pressure and improve lipid profile. Lifestyle modification has been proven to prevent T2DM development. Nevertheless, appropriate treatment of MS components often requires pharmacologic intervention with insulin-sensitizing agents, such as metformin and thiazolidinediones, while statins and fibrates, or angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers are the first-line lipid-modifying or antihypertensive drugs. Only severely obese patients require specific drug treatments. Very often, drug combinations will be necessary to manage multiple risk factors. As we progress in the understanding of the pathophysiology of the MS, new targets for therapies will probably be identified and new treatments will prove to be even more efficacious than those currently available for the management of this life-threatening condition.

Use of carvedilol in hypertension: an update

β-blockers are effective antihypertensive agents and, together with diuretics, have been the cornerstone of pioneering studies showing their benefits on cardiovascular morbidity and mortality as a consequence of blood pressure reduction in patients with hypertension. However, evidence from recent meta-analyses have demonstrated no benefit afforded by atenolol compared with placebo in risk of mortality, myocardial infarction, or stroke, and a higher risk of mortality and stroke with atenolol/propranolol compared with other antihypertensive drug classes. Thus, the effect of these agents on cardiovascular morbidity and mortality in hypertensive patients, especially their use in uncomplicated hypertension, has remained largely controversial. However, it is recognized that the clinical studies used in these meta-analyses were mainly based on the older second-generation β-blockers, such as atenolol and metoprolol. Actually, considerable heterogeneity in, eg, pharmacokinetic, pharmacological, and physicochemical properties exists across the different classes of β-blockers, particularly between the second-generation and newer third-generation agents. Carvedilol is a vasodilating noncardioselective third-generation β-blocker, without the negative hemodynamic and metabolic effects of traditional β-blockers, which can be used as a cardioprotective agent. Compared with conventional β-blockers, carvedilol maintains cardiac output, has a reduced prolonged effect on heart rate, and reduces blood pressure by decreasing vascular resistance. Studies have also shown that carvedilol exhibits favorable effects on metabolic parameters, eg, glycemic control, insulin sensitivity, and lipid metabolism, suggesting that it could be considered in the treatment of patients with metabolic syndrome or diabetes. The present report provides an overview of the main clinical studies concerning carvedilol administered as either monotherapy or in combination with another antihypertensive or more frequently a diuretic agent, with particular focus on the additional benefits beyond blood pressure reduction.

The impact of carvedilol and metoprolol on serum lipid concentrations and symptoms in patients with hyperthyroidism

BACKGROUND

Hyperthyroidism is associated with unpleasant symptoms and hypertension due to increased adrenergic tone. Therefore, beta-blockers are often used in hyperthyroid patients. While some beta-blockers (such as propronolol and metoprolol) may have unwanted effects on lipid profile, carvedilol, a new alpha- and beta-blocker, has been suggested to have some metabolic advantages with respect to lipid profiles in hypertensive patients. However, this has not been shown in hyperthyroid patients.

OBJECTIVE

We aimed to compare the effects of two beta-blockers (metoprolol and carvedilol) on the lipid profiles of hyperthyroid patients with hypertension.

METHODS

Thirty patients with hyperthyroidism and hypertension were randomly assigned to receive either carvedilol (n = 15) or metoprolol (n = 15). Thyroid-stimulating hormone (TSH), free T3, free T4, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglyceride, and total cholesterol levels were measured before and following 3 months of treatment.

RESULTS

Systolic and diastolic blood pressure, heart rate, TSH, and free T4 improved significantly in both treatment groups. There were no statistically significant changes in the lipid parameters in either of the two treatment groups; however, triglyceride levels slightly decreased with carvedilol treatment. There were also no differences between the two groups in terms of the typical symptoms of hyperthyroidism.

CONCLUSION

Carvedilol might be a preferred agent to treat hyperthyroid patients who have hypertension and dyslipidemia. This is likely due to the possible beneficial effect of carvedilol on lipid parameters, especially on triglyceride levels.

Dyslipidemia induced by drugs used for the prevention and treatment of vascular diseases

Dyslipidemia is a major vascular risk factor. Interestingly, several agents used for the prevention and treatment of vascular diseases have an adverse effect on the lipid profile. In addition, agents belonging to the same class (e.g. beta blockers) can have significantly different actions on lipid levels. We summarize the effects of drugs used for the prevention and treatment of vascular diseases on the lipid profile. These effects should be considered when selecting a specific agent, particularly in high-risk patients.

Hypertension, dyslipidemia, and insulin resistance in patients with diabetes mellitus or the cardiometabolic syndrome: benefits of vasodilating β-blockers

Hypertension frequently coexists with diabetes and the cardiometabolic syndrome. β-Blockers have been a mainstay for controlling blood pressure for nearly 4 decades. However, β-blockers are perceived to cause glucose and lipid metabolism dysregulation, including hypoglycemia masking, reduced glycemic control, insulin resistance, and dyslipidemia. It should be noted, however, that β-blockers are diverse in their effects on glucose and lipid metabolism. Potential mechanisms that contribute to these metabolic effects include hemodynamic differences, anti-inflammatory and anti-oxidative pathways, and/or weight changes. Traditional β-blockers decrease cardiac output while peripheral vascular resistance increases or remains unchanged, which may result in glucose and lipid abnormalities. In contrast, vasodilating β-blockers reduce peripheral vascular resistance but have little effect on cardiac output. Vasodilating β-blockers may therefore result in less impact on insulin sensitivity and glycemic control, a reduced new-onset diabetes risk, and improved dyslipidemia compared with traditional β-blockers. Because of these effects, vasodilating β-blockers may represent a favorable option in the treatment of high-risk patients with hypertension.

Comparison of carvedilol and metoprolol on serum lipid concentration in diabetic hypertensive patients

CONTEXT

Vasoconstricting beta-blocker use is associated with a reduction in HDL cholesterol, higher triglyceride, total cholesterol and LDL cholesterol levels, whereas carvedilol, a vasodilating beta-blocker, has not been associated with these effects.

OBJECTIVE

To compare in a randomized, double-blind study, the effects of the beta 1-blocker metoprolol tartrate with the combined alpha 1, beta-blocker carvedilol on serum lipid concentrations.

METHODS

A prospective randomized, double-blind, parallel-group trial compared the effects of carvedilol and metoprolol on total cholesterol, triglycerides, calculated LDL, HDL and non-HDL cholesterol levels at baseline and after 5 months of therapy as a secondary objective in the Glycemic Effects in Diabetes Mellitus: Carvedilol-Metoprolol Comparison in Hypertensive (GEMINI) study. In this study, 1235 participants with type 2 diabetes and hypertension who were receiving renin-angiotensin system blockers were randomized either to carvedilol, receiving 6.25-25 mg twice daily, or to metoprolol tartrate, receiving 50-200 mg twice daily. If needed, hydrochlorothiazide and a dihydropyridine calcium channel blocker were added to achieve blood pressure goals.

RESULTS

In the metoprolol tartrate group, triglycerides and non-HDL cholesterol increased and both the LDL and the HDL cholesterol levels decreased. In the carvedilol group, total LDL and HDL cholesterol decreased, non-HDL cholesterol was unchanged and triglycerides increased. Comparing the carvedilol and metoprolol tartrate groups, there was no statistically significant difference in LDL and HDL cholesterol levels, but there was a significantly greater decreases with carvedilol in total cholesterol [-2.9%, 95% confidence interval (CI) -4.60 to -1.15, p < 0.001], triglycerides (-9.8%, 95% CI -13.7, -5.75%, p < 0.001) and non-HDL cholesterol (-4.03%, 95% CI -6.3 to -1.8, p < 0.0006). At the end of the study, significantly more participants in the metoprolol tartrate group had had initiation of statin therapy or the statin dose increased than those in the carvedilol group (11 vs. 32%, p = 0.04).

CONCLUSIONS

In patients with type 2 diabetes currently receiving a renin-angiotensin blocker, compared with metoprolol tartrate, the addition of carvedilol for blood pressure control resulted in a significant decrease in triglyceride, total cholesterol and non-HDL cholesterol levels. The use of metoprolol resulted in a significantly greater rate of initiation of statin therapy or an increase in the dose of existing statin therapy when compared with carvedilol utilization.

Impact of carvedilol on the serum lipid profile

OBJECTIVE

To examine the evidence regarding the impact of carvedilol on the serum lipid profile.

DATA SOURCES

Searches in MEDLINE and International Pharmaceutical Abstracts (1966-December 2007) were conducted. Search terms included carvedilol, cholesterol, lipids, hyperlipidemia, and beta-blockers.

STUDY SELECTION AND DATA EXTRACTION

Published studies and case reports that evaluated the impact of carvedilol on the lipid profile were reviewed. One study was excluded because it evaluated carvedilol for an off-label use and was a small Phase 2 pilot study that evaluated the results of only 10 patients.

DATA SYNTHESIS

Twelve studies were available for review; 6 of these compared carvedilol with beta(1)-selective antagonists. Three studies compared carvedilol with other antihypertensive medications; 2 of those studies evaluated total cholesterol only. Carvedilol alone was evaluated for its effects on lipids in 3 small single-group studies. In 4 of the 12 studies, carvedilol independently improved the lipid profile significantly, while the drug had a nonsignificant, neutral effect on the lipid profile in 3 studies. Furthermore, in 4 of the 12 studies, carvedilol was compared with other antihypertensive medications. In 3 of these 4 studies, the other drugs worsened the lipid profile significantly compared with carvedilol, while carvedilol significantly improved the lipid profile in the other study. Finally, carvedilol had a potentially negative effect on high-density lipoprotein cholesterol in a single-group study, but p values were not reported.

CONCLUSIONS

It is clear that beta(1)-selective antagonists worsen the lipid profile compared with carvedilol. However, it is unclear whether carvedilol independently makes an improvement or has a neutral effect on the lipid profile. Carvedilol should be an important treatment consideration in patients with heart failure and/or hypertension with dyslipidemia. However, many questions remain regarding this issue.

Combination therapy with renin-angiotensin system blockers: Will amlodipine replace hydrochlorothiazide?

Amlodipine is a highly effective and safe antihypertensive dihydropyridine calcium channel blocker. It is even more effective when used in combination with other antihypertensive medications, including hydrochlorothiazide. When antihypertensive calcium channel blockers were first introduced, evidence in the laboratory that they had some natriuretic properties was adduced to suggest that they would be "the diuretics of the 1990s." This turned out not to be the case. Because of its clinical efficacy, amlodipine is frequently used in fixed-dose combination products, but it is not likely to replace hydrochlorothiazide.

Management of Hypertension in Children and Adolescents With the Metabolic Syndrome

Because elevated blood pressure is one of the defining criteria of the metabolic syndrome, treatment of hypertension will be required in many, if not most, children and adolescents diagnosed with the metabolic syndrome. This review highlights several aspects of the approach to treatment of hypertension in young patients with the metabolic syndrome, including the definition of hypertension, use of nonpharmacologic measures, indications for instituting antihypertensive medications, and the potential adjunctive role that insulin-sensitizing agents may play in blood pressure reduction. The choice of antihypertensive agent is also discussed, along with consideration of the diabetogenic effects of various classes of antihypertensive agents. Consideration of all of these issues is important in achieving blood pressure control in children and adolescents with the metabolic syndrome, as appropriate treatment may help to forestall the development not only of type 2 diabetes but also of the cardiovascular disease that is frequently already present at the time of diagnosis of type 2 diabetes in adults.