Clinical positioning of indapamide sustained release 1.5mg in management protocols for hypertension

Therapeutic Drug Monitoring in Arterial Hypertension

(1) Background: This study was planned to assess the concentration of antihypertensive drugs (AHD) in the blood serum in patients with controlled and uncontrolled arterial hypertension (AH). (2) Methods: We assessed 46 patients with AH. Based on the results of 24 h blood pressure monitoring (ABPM), the patients were randomized into two groups. The first group consisted of the patients with controlled AH; the second group consisted of the patients with uncontrolled AH. Venous blood was taken in both groups of patients in the morning before and 2 h after taking drugs to assess the concentration of lisinopril, amlodipine, valsartan, and indapamide. (3) Results. The first group included 27 patients, and the second group 19 patients. In patients with uncontrolled AH, the median concentrations of lisinopril, indapamide, amlodipine, and valsartan before and after taking the drugs did not differ from patients who reached the target BP values. (p > 0.05). In some patients with uncontrolled and controlled (shown for the first time) AH the concentration of AHD was below the limit of quantitative determination. (4) Conclusions. The obtained results indicate that the pharmacokinetics of AHD, apparently, does not play a significant role in the development of ineffectiveness of the ongoing therapy for AH. Therapeutic drug monitoring can be used to test adherence to the treatment.

The Results of ACES (Antihypertensive Combinations' Long Term Efficacy Comparing Study): Analysis of Metabolic Effects of Antihypertensive Combination Therapies

BACKGROUND

More than 50 % of hypertensive patients have lipid disorders, and one-third of hypertensive patients have impaired glucose metabolism. Owing to the high prevalence of metabolic risk factors and/or comorbidities, antihypertensives with favorable or neutral metabolic effects are preferred. Based on the available evidence, diuretics and β-blockers are heterogeneous regarding their metabolic effects.

OBJECTIVE

The aim of ACES (Antihypertensive Combinations' Long Term Efficacy Comparing Study) was to compare the efficacy and metabolic effects of a carvedilol/indapamide free combination, a fixed-dose combination of perindopril/amlodipine, and a fixed combination of perindopril/indapamide in everyday practice.

METHODS

This study was a 6-month, multi-center, prospective, observational, non-interventional, open-label clinical study. The data of 9124 outpatients (4898 female, 4226 male; mean age 61.7 ± 11.7 years) with mild, moderate, or severe essential (primary) hypertension with one or more metabolic risk factors were subjected to statistical analysis. At visits one (day 1), three (month 3), and four (month 6), the following metabolic parameters were monitored: fasting blood glucose, glycosylated hemoglobin, estimated glomerular filtration rate, total cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, triglycerides, and serum potassium, sodium, creatinine, and uric acid levels. A total of 3888 patients took perindopril/amlodipine, while 2992 took perindopril/indapamide, and 2244 took a combination of carvedilol/indapamide. Statistical analysis was carried out using the one-paired t test and the Chi square test; the two-sided level of significance was set at 0.05.

RESULTS

The observed changes in the main metabolic parameters were favorable and similar in all therapeutic groups: fasting blood glucose decreased by 5.5-5.5-5.5 %, total cholesterol by 9.0-10.2-9.9 %, and triglycerides by 12.7-15.4-13.8 % (respectively in perindopril/amlodipine, perindopril/indapamide and carvedilol/indapamide groups).

CONCLUSIONS

Based on our findings, we conclude that the metabolic profile of indapamide is very similar to the metabolically neutral and well-documented metabolic profiles of the calcium-channel blocker amlodipine and the vasodilator β-blocker carvedilol and that all the combinations studied had similar beneficial effects on the main metabolic parameters. The favorable changes of metabolic parameters are because of the discontinuation of active substances (e.g., conventional thiazides, second-generation β-blockers) used in the previous therapy, which were associated with unfavorable metabolic effects, and to the increase in the ratio of administered lipid-lowering drugs and oral antidiabetic drugs.

Development and experimental design of a novel controlled-release matrix tablet formulation for indapamide hemihydrate

CONTEXT

Development, experimental design and in vitro in vivo correlation (IVIVC) of controlled-release matrix formulation.

OBJECTIVE

Development of novel oral controlled delivery system for indapamide hemihydrate, optimization of the formulation by experimental design and evaluation regarding IVIVC on a pilot scale batch as a confirmation of a well-established formulation.

MATERIALS AND METHODS

In vitro dissolution profiles of controlled-release tablets of indapamide hemihydrate from four different matrices had been evaluated in comparison to the originator's product Natrilix (Servier) as a direction for further development and optimization of a hydroxyethylcellulose-based matrix controlled-release formulation. A central composite factorial design had been applied for the optimization of a chosen controlled-release tablet formulation.

RESULTS

The controlled-release tablets with appropriate physical and technological properties had been obtained with a matrix: binder concentration variations in the range: 20-40w/w% for the matrix and 1-3w/w% for the binder. The experimental design had defined the design space for the formulation and was prerequisite for extraction of a particular formulation that would be a subject for transfer on pilot scale and IVIV correlation.

CONCLUSIONS

The release model of the optimized formulation has shown best fit to the zero order kinetics depicted with the Hixson-Crowell erosion-dependent mechanism of release. Level A correlation was obtained.

Molecular Dynamics and Physical Stability of Coamorphous Ezetimib and Indapamide Mixtures

Low physical stability is the main reason limiting the widespread use of amorphous pharmaceuticals. One approach to overcome this problem is to mix these drugs with various excipients. In this study coamorphous drug-drug compositions of different molar ratios of ezetimib and indapamid (i.e., EZB 10:1 IDP, EZB 5:1 IDP, EZB 2:1 IDP, EZB 1:1 IDP and EZB 1:2 IDP) were prepared and investigated using differential scanning calorimetry (DSC), broadband dielectric spectroscopy (BDS), and X-ray diffraction (XRD). Our studies have shown that the easily recrystallizing ezetimib drug can be significantly stabilized in its amorphous form by using even a small amount of indapamid (8.8 wt %). DSC experiments indicate that the glass transition temperature (Tg) of the tested mixtures changes with the drug concentration in accordance with the Gordon-Taylor equation. We also investigated the effect of indapamid on the molecular dynamics of the ezetimib. As a result it was found that, with increasing indapamid content, the molecular mobility of the binary drug-drug system is slowed down. Finally, using the XRD technique we examined the long-term physical stability of the investigated binary systems stored at room temperature. These measurements prove that low-molecular-weight compounds are able to significantly improve the physical stability of amorphous APIs.

Blood pressure-lowering efficacy of monotherapy with thiazide diuretics for primary hypertension

BACKGROUND

Hypertension is a modifiable cardiovascular risk factor. Although it is established that low-dose thiazides reduce mortality as well as cardiovascular morbidity, the dose-related effect of thiazides in decreasing blood pressure has not been subject to a rigorous systematic review. It is not known whether individual drugs within the thiazide diuretic class differ in their blood pressure-lowering effects and adverse effects.

OBJECTIVES

To determine the dose-related decrease in systolic and/or diastolic blood pressure due to thiazide diuretics compared with placebo control in the treatment of patients with primary hypertension. Secondary outcomes included the dose-related adverse events leading to patient withdrawal and adverse biochemical effects on serum potassium, uric acid, creatinine, glucose and lipids.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, Issue 1), Ovid MEDLINE (1946 to February 2014), Ovid EMBASE (1974 to February 2014) and ClinicalTrials.gov.

SELECTION CRITERIA

We included double-blind, randomized controlled trials (RCTs) comparing fixed-dose thiazide diuretic monotherapy with placebo for a duration of 3 to 12 weeks in the treatment of adult patients with primary hypertension.

DATA COLLECTION AND ANALYSIS

Two authors independently screened articles, assessed trial eligibility, extracted data and determined risk of bias. We combined data for continuous variables using a mean difference (MD) and for dichotomous outcomes we calculated the relative risk ratio (RR) with 95% confidence interval (CI).

MAIN RESULTS

We included 60 randomized, double-blind trials that evaluated the dose-related trough blood pressure-lowering efficacy of six different thiazide diuretics in 11,282 participants treated for a mean duration of eight weeks. The mean age of the participants was 55 years and baseline blood pressure was 158/99 mmHg. Adequate blood pressure-lowering efficacy data were available for hydrochlorothiazide, chlorthalidone and indapamide. We judged 54 (90%) included trials to have unclear or high risk of bias, which impacted on our confidence in the results for some of our outcomes.In 33 trials with a baseline blood pressure of 155/100 mmHg, hydrochlorothiazide lowered blood pressure based on dose, with doses of 6.25 mg, 12.5 mg, 25 mg and 50 mg/day lowering blood pressure compared to placebo by 4 mmHg (95% CI 2 to 6, moderate-quality evidence)/2 mmHg (95% CI 1 to 4, moderate-quality evidence), 6 mmHg (95% CI 5 to 7, high-quality evidence)/3 mmHg (95% CI 3 to 4, high-quality evidence), 8 mmHg (95% CI 7 to 9, high-quality evidence)/3 mmHg (95% CI 3 to 4, high-quality evidence) and 11 mmHg (95% CI 6 to 15, low-quality evidence)/5 mmHg (95% CI 3 to 7, low-quality evidence), respectively.Direct comparison of doses did not show evidence of dose dependence for blood pressure-lowering for any of the other thiazides for which RCT data were available: bendrofluazide, chlorthalidone, cyclopenthiazide, metolazone or indapamide.In seven trials with a baseline blood pressure of 163/88 mmHg, chlorthalidone at doses of 12.5 mg to 75 mg/day reduced average blood pressure compared to placebo by 12.0 mmHg (95% CI 10 to 14, low-quality evidence)/4 mmHg (95% CI 3 to 5, low-quality evidence).In 10 trials with a baseline blood pressure of 161/98 mmHg, indapamide at doses of 1.0 mg to 5.0 mg/day reduced blood pressure compared to placebo by 9 mmHg (95% CI 7 to 10, low-quality evidence)/4 (95% CI 3 to 5, low-quality evidence).We judged the maximal blood pressure-lowering effect of the different thiazides to be similar. Overall, thiazides reduced average blood pressure compared to placebo by 9 mmHg (95% CI 9 to 10, high-quality evidence)/4 mmHg (95% CI 3 to 4, high-quality evidence).Thiazides as a class have a greater effect on systolic than on diastolic blood pressure, therefore thiazides lower pulse pressure by 4 mmHg to 6 mmHg, an amount that is greater than the 3 mmHg seen with angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and renin inhibitors, and the 2 mmHg seen with non-selective beta-blockers. This is based on an informal indirect comparison of results observed in other Cochrane reviews on ACE inhibitors, ARBs and renin inhibitors compared with placebo, which used similar inclusion/exclusion criteria to the present review.Thiazides reduced potassium, increased uric acid and increased total cholesterol and triglycerides. These effects were dose-related and were least for hydrochlorothiazide. Chlorthalidone increased serum glucose but the evidence was unclear for other thiazides. There is a high risk of bias in the metabolic data. This review does not provide a good assessment of the adverse effects of these drugs because there was a high risk of bias in the reporting of withdrawals due to adverse effects.

AUTHORS' CONCLUSIONS

This systematic review shows that hydrochlorothiazide has a dose-related blood pressure-lowering effect. The mean blood pressure-lowering effect over the dose range 6.25 mg, 12.5 mg, 25 mg and 50 mg/day is 4/2 mmHg, 6/3 mmHg, 8/3 mmHg and 11/5 mmHg, respectively. For other thiazide drugs, the lowest doses studied lowered blood pressure maximally and higher doses did not lower it more. Due to the greater effect on systolic than on diastolic blood pressure, thiazides lower pulse pressure by 4 mmHg to 6 mmHg. This exceeds the mean 3 mmHg pulse pressure reduction achieved by ACE inhibitors, ARBs and renin inhibitors, and the 2 mmHg pulse pressure reduction with non-selective beta-blockers as shown in other Cochrane reviews, which compared these antihypertensive drug classes with placebo and used similar inclusion/exclusion criteria.Thiazides did not increase withdrawals due to adverse effects in these short-term trials but there is a high risk of bias for that outcome. Thiazides reduced potassium, increased uric acid and increased total cholesterol and triglycerides.

Antihypertensive efficacy of indapamide SR in hypertensive patients uncontrolled with a background therapy: the NATIVE study

OBJECTIVES

Antihypertensive monotherapy rarely achieves blood pressure (BP) control. NATIVE (NATrilix SR use in combInation antihypertensiVe thErapy) evaluated indapamide sustained release (SR) in hypertensive patients receiving background therapy.

RESEARCH DESIGN AND METHODS

Patients remaining hypertensive (systolic BP [SBP], 145-180 mmHg; diastolic BP [DBP], 95-105 mmHg) while receiving an angiotensin-converting enzyme (ACE) inhibitor (n = 709), beta-blocker (n = 629), calcium-channel blocker (CCB; n = 493), angiotensin II type 1 receptor blocker (ARB; n = 75), alpha-blocker (n = 29) or other therapy (n = 6) were enrolled, recruited by physicians from 228 centres in Pakistan. Indapamide SR 1.5 mg was administered daily for 3 months with background therapy. BP was assessed every 2 weeks, and blood glucose and total cholesterol were evaluated at baseline and study end in a patient subgroup. Adverse events were also recorded.

MAIN OUTCOME MEASURES AND RESULTS

Of 2073 enrolled patients (49% males; mean age 51 years), 1941 received indapamide SR and background therapy. SBP and DBP decreased significantly (SBP, 166 +/- 16 mmHg at baseline vs. 132 +/- 12 mmHg at 3 months; DBP, 102 +/- 8 mmHg vs. 83 +/- 6 mmHg; both p < 0.0001 vs. baseline). Patients uncontrolled with an ACE inhibitor, beta-blocker, CCB or ARB achieved an SBP/DBP decrease of 34 +/- 15/19 +/- 9, 33 +/- 17/19 +/- 10, 33 +/- 15/18 +/- 8 or 35 +/- 16/20 +/- 12 mmHg, respectively (all p < 0.0001). In all, 84% of patients achieved target SBP (< or = 140 mmHg) and 61% achieved BP normalisation (SBP < 140, DBP < 90 mmHg). The absence of placebo control may lead to an overestimation of the extent of the BP reduction achieved. Glucose and cholesterol levels were unaffected by indapamide SR. Four percent of patients experienced side-effects, which were mild-to-moderate in severity.

CONCLUSIONS

In patients with hypertension despite antihypertensive therapy, indapamide SR significantly reduced BP with a good acceptability profile. Indapamide SR may represent an effective additional therapy for patients who do not achieve BP goals with other antihypertensive agents.

In vitro and in vivo evaluation of ruthenium(II)-arene PTA complexes

The antitumor activity of the organometallic ruthenium(II)-arene complexes, RuCl(2)(eta(6)-arene)(PTA), (arene = p-cymene, toluene, benzene, benzo-15-crown-5, 1-ethylbenzene-2,3-dimethylimidazolium tetrafluoroborate, ethyl benzoate, hexamethylbenzene; PTA = 1,3,5-triaza-7-phosphaadamantane), abbreviated RAPTA, has been evaluated. In vitro biological experiments demonstrate that these compounds are active toward the TS/A mouse adenocarcinoma cancer cell line whereas cytotoxicity on the HBL-100 human mammary (nontumor) cell line was not observed at concentrations up to 0.3 mM, which indicates selectivity of these ruthenium(II)-arene complexes to cancer cells. Analogues of the RAPTA compounds, in which the PTA ligand is methylated, have also been prepared, and these prove to be cytotoxic toward both cell lines. RAPTA-C and the benzene analogue RAPTA-B were selected for in vivo experiments to evaluate their anticancer and antimetastatic activity. The results show that these complexes can reduce the growth of lung metastases in CBA mice bearing the MCa mammary carcinoma in the absence of a corresponding action at the site of primary tumor growth. Pharmacokinetic studies of RAPTA-C indicate that ruthenium is rapidly lost from the organs and the bloodstream.

Interaction of Oxaliplatin, Cisplatin, and Carboplatin with Hemoglobin and the Resulting Release of a Heme Group

Oxaliplatin, carboplatin, and cisplatin are widely used to treat a number of cancers. While their DNA adducts are believed to cause cell death, the involvement of their protein adducts in the toxicity and action of these drugs is unclear. Here, we report the interactions of hemoglobin (Hb) with the three platinum (Pt) drugs, demonstrating the formation of Hb-Pt complexes and the release of a heme group from Hb. Oxaliplatin (0.05 microM) was able to form three major complexes with Hb (3-10 microM) after 1 h of incubation at room temperature, and these complexes accounted for approximately 60% of the total oxaliplatin. Cisplatin and carboplatin formed one major and two minor complexes only after 24 and 96 h of incubation, respectively. Incubation of these Pt drugs (0.05-10 microM) with whole blood of healthy volunteers and the analysis of red blood cells confirmed the relative ability of these Pt drugs binding to Hb. For the whole blood samples incubated with oxaliplatin and cisplatin for 24 h, only protein complexes were detected in red blood cells, indicating a complete binding of oxaliplatin and cisplatin to the protein. In contrast, carboplatin was partially bound; both the free and the protein-bound carboplatin species were detected in red blood cells. The binding of the Pt drugs to Hb was accompanied by the release of a heme group from Hb, which was monitored by size fractionation, chromatographic separation, and selective detection of both Pt- and iron (Fe)-containing molecular species. The released heme was further identified by size fractionation and nanospray mass spectrometry. The findings of the Pt drug interaction with Hb and the dissociation of heme from Hb are potentially useful for a better understanding of the toxicity and side effects of these chemotherapeutic drugs.

Preparation of indapamide slow-release pellets

During the process of developing a slow-release formulation of indapamide, researchers created a drug-containing pellet coated with Eudragit RS100 (Rohm GMbH & Co. KG, Darmstadt, Germany) to control the rate at which the drug was released. The two main variables were the agglomerants used in the pellet preparation and the amount of Eudragit RS100 used to coat them. The optimal outcome was indicated by the greatest number of drug-containing pellets recovered through an 18- to 24-mesh sieve and a satisfactory 24-hour release curve. The kinetics of dissolution fit the Higuchi kinetics model. Stability tests of the drug pellets showed no notable changes in the rate of drug release, related substances (mean byproducts or impurities from interactions or decompositions), and drug content.

Factors influencing conformer equilibria in retro models of cisplatin-DNA adducts as revealed by moderately dynamic (N,N'-dimethyl-2,3-diaminobutane)PtG(2) retro models (G = a guanine derivative)

Typical cis-PtA(2)G(2) models of key DNA lesions formed by cis-type Pt anticancer drugs are very dynamic and difficult to characterize (A(2) = diamine or two amines; G = guanine derivative). Retro models have A(2) carrier ligands designed to decrease dynamic motion without eliminating any of three possible conformers with bases oriented head-to-tail (two: DeltaHT and LambdaHT) or head-to-head (one: HH). All three were found in NMR studies of eight Me(2)DABPtG(2) retro models (Me(2)DAB = N,N'-dimethyl-2,3-diaminobutane with S,R,R,S and R,S,S,R configurations at the chelate ring N, C, C, and N atoms, respectively; G = 5'-GMP, 3'-GMP, 5'-IMP, and 3'-IMP). The bases cant to the left (L) in (S,R,R,S)-Me(2)DABPtG(2) adducts and to the right (R) in (R,S,S,R)-Me(2)DABPtG(2) adducts. Relative to the case in which the bases are both not canted, canting will move the six-membered rings closer in to each other ("6-in" form) or farther out from each other ("6-out" form). Interligand interactions between ligand components near to Pt (first-first sphere communication = FFC) or far from Pt (second-sphere communication = SSC) influence stability. In typical cases at pH < 8, the "6-in" form is favored, although the larger six-membered rings of the bases are close. In minor "6-out" HT forms, the proximity of the smaller five-membered rings could be sterically favorable. Also, G O6 is closer to the sterically less demanding NH part of the Me(2)DAB ligand, possibly allowing G O6-NH hydrogen bonding. These favorable FFC effects do not fully compensate for possibly stronger FFC dipole effects in the "6-in" form. SSC, phosphate-N1H cis G interactions favor LambdaHT forms in 5'-GMP and 5'-IMP complexes and DeltaHT forms in 3'-GMP and 3'-IMP complexes. When SSC and FFC favor the same HT conformer, it is present at >90% abundance. In six adducts [four (S,R,R,S)-Me(2)DABPtG(2) and (R,S,S,R)-Me(2)DABPtG(2) (G = 3'-GMP and 3'-IMP)], the minor "6-out" HT form at pH approximately 7 becomes the major form at pH approximately 10, where G N1H is deprotonated, because the large distance between the negatively charged N1 atoms minimizes electrostatic repulsion and probably because the G O6-(NH)Me(2)DAB H-bond (FFC) is strengthened by N1H deprotonation. At pH approximately 10, phosphate-negative N1 repulsion is an unfavorable SSC term. This factor disfavors the LambdaHT R form of two (R,S,S,R)-Me(2)DABPtG(2) (G = 5'-GMP and 5'-IMP) adducts to such an extent that the "6-in" DeltaHT R form remains the dominant form even at pH approximately 10.