Modified-release formulation of trimetazidine for exceptional control of angina pectoris: fact or fiction

Bioequivalence and Pharmacokinetic Profiles of 2 Trimetazidine Modified-release Tablets Under Fasting and Fed Conditions in Chinese Healthy Subjects

This study aims to assess the bioequivalence of test and reference formulations of trimetazidine dihydrochloride in healthy Chinese volunteers under fasting and fed conditions, and to determine the effect of food on the pharmacokinetic profiles of both formulations. A randomized, open-label, crossover, four-period study with a 7-day washout period was conducted in 24 healthy Chinese subjects. The subjects fasted for at least 10 hours before being given a single 35-mg dose of the test and reference tablets. Venous blood samples were taken from predose at 0 hours to postdose at 36 hours at scheduled time points. The main pharmacokinetic parameters were calculated with a noncompartmental model. The nonparametric test of T_max under both conditions showed no significant difference between the two formulations (P > .05). The 90% confidence intervals of geometric mean ratio of lnC_max and lnAUC_0→∞ (the logarithmic values of area under the plasma concentration-time curve [AUC] and mean maximum plasma concentration [C_max ]) all fell within 80%-125%. C_max in the fed state was slightly higher than that in the fasting state (P < .05), while other pharmacokinetic parameters were comparable. No severe adverse events occurred. The test and reference formulations were bioequivalent under both fasting and fed conditions. Food did not affect the pharmacokinetic profiles of trimetazidine in Chinese healthy volunteers, therefore trimetazidine is suitable for administration under fasting or fed conditions.

Single Ascending Dose Study to Assess Pharmacokinetic Linearity, Safety, and Tolerability of Trimetazidine - Modified Release in Healthy Human Subjects

AIM

This study assessed the linearity of pharmacokinetics (PK) of trimetazidine (TMZ) modified-release tablets (indicated in adults as an add-on therapy for stable angina pectoris) and measured its renal elimination, safety, and tolerability in healthy subjects.

METHODS

This was a randomized, open-label, single-ascending dose study in healthy subjects. Subjects were administered with a single dose of 35, 70, or 105 mg TMZ-modified release tablets (six subjects each). Pharmacokinetic evaluations and safety analysis were performed before the first dose and till 48 h post-first dose.

RESULTS

Following administration of 35, 70, and 105 mg TMZ-modified release; the C_max (mean±SD) was 79.32 (±23.08), 153.17 (±23.08), and 199.67 (±23.08) ng/mL, the T_max was 5.42 (±0.49), 4.51 (±1.27), and 4.57 (±0.96) h, t_1/2 was 7.75 (±1.62), 6.40 (±1.23), and 6.50 (±1.18) h, AUC_(0-inf) was 1116.89 (±378.35), 1838.39 (±284.50), and 2504.84 (±348.35) ng.h/mL, CL_R was 13.70 (±2.24), 14.80 (±5.91), and 19.58 (±6.24) L·h^-1 and CL/F was 33.69 (±8.51), 38.85 (±6.15), and 42.74 (±7.10) L·h^-1, respectively. Slope estimates for AUC_(0-inf), AUC_(0-t), and C_max were less than 1. Corresponding 95% CI of the slope for the AUC parameters excluded 1, indicating that the deviation from dose-proportionality was statistically significant. Corresponding 95% CI of the slope for C_max included 1, indicating that the less than dose-proportional increase in C_max was not statistically significant. No significant adverse events were observed.

CONCLUSION

Substantial deviation from a dose-proportional increase in AUC_(0-inf) and AUC_(0-t) suggested a non-linear PK for TMZ-modified release. Single dose of TMZ-modified release was well tolerated and safe.

Effect of age and renal impairment on the pharmacokinetics and safety of trimetazidine: An open-label multiple-dose study

This study evaluated the effect of age and renal impairment on pharmacokinetics of trimetazidine (TMZ) in healthy elderly and renally impaired subjects and assess safety and tolerability. In this open-label, multi-dose study, 73 subjects were divided into six treatment groups: (1) 55-65 years; (2) 66-75 years; (3) >75 years (dosing for groups 1-3 [healthy]: B.D. for 4 days), (4) mild renally impaired (dosed B.D. for 8 days); (5) moderate renally impaired (dosed O.D. for 8 days); and (6) severe renally impaired-no dialysis (dosed once every 48 h for 8 days). Blood and urine samples were collected and analyzed. The geometric least squares mean ratios for; Group 2 and 1 of AUC_(0-τ)ss was 112.2 (90% CI; 92.0-136.8) and C_max,ss was 109.9 (89.6-134.8), Group 3 and 1 of AUC_(0-τ),ss was 140.5 (115.9-170.3) and C_max,ss was 137.8 (112.9-168.2), Group 4 and 1 of AUC_(0-τ),ss was 114.2 (90.3-144.4) and C_max,ss was 120.8 (92.5-157.8), Group 5 and 1 of; AUC_(0-τ),ss was 213.0 (153.1-296.3) and C_max,ss was 123.3 (92.2-164.7) and Group 6 and 1 of AUC_(0-τ),ss was 247.4 (197.8-309.6) and C_max,ss was 95.6 (73.0-125.1). Significant increase in systemic exposure of TMZ was observed in subjects; over 75 year's age and renally impaired compared to healthy subjects. TMZ was safe and well-tolerated.

Stable Angina Medical Therapy Management Guidelines: A Critical Review of Guidelines from the European Society of Cardiology and National Institute for Health and Care Excellence

Most patients with stable angina can be managed with lifestyle changes, especially smoking cessation and regular exercise, along with taking antianginal drugs. Randomised controlled trials show that antianginal drugs are equally effective and none of them reduced mortality or the risk of MI, yet guidelines prefer the use of beta-blockers and calcium channel blockers as a first-line treatment. The European Society of Cardiology guidelines for the management of stable coronary artery disease provide classes of recommendation with levels of evidence that are well defined. The National Institute for Health and Care Excellence (NICE) guidelines for the management of stable angina provide guidelines based on cost and effectiveness using the terms first-line and second-line therapy. Both guidelines recommend using low-dose aspirin and statins as disease-modifying agents. The aim of this article is to critically appraise the guidelines’ pharmacological recommendations for managing patients with stable angina.

The risk of cardiovascular side effects with anti-anginal drugs

INTRODUCTION

Angina pectoris is a common presenting symptom of underlying coronary artery disease or reduced coronary flow reserve. Patients with angina have impaired quality of life; and need to be treated optimally with antianginal drugs to control symptoms and improve exercise performance. A wide range of antianginal medications are approved for the treatment of angina, and often more than one class of antianginal drugs are used to adequately control the symptoms. This expert opinion highlights the likely cardiac adverse effects of available antianginal drugs, and how to minimize these in individual patients and especially during combination treatment. Areas covered: All approved antianginal drugs, including the older and newly approved medications with different mechanism of action to the older drugs as well as some of the unapproved herbal medications. The safety profiles and potential cardiac side effects of these medications when used as monotherapy or as combination therapy are discussed and highlighted. Expert opinion: Because of the different cardiac safety profiles and possible side effects, we recommend selection of initial drug or adjustment of therapy based on the resting heart rate; blood pressure, hemodynamic status; and resting left ventricular function, concomitant medications and any associated comorbidities.

Selection of optimal therapy for chronic stable angina

Patients with chronic stable angina (CSA) seek a medical opinion for relief of their symptoms and because of fear of having a heart attack. The underlying lesion responsible for CSA is often a severe narrowing of one or more coronary arteries. In addition, the coronary arteries of patients with CSA contain many more nonobstructive lesions, which progress at variable rates, and are prone to rupture and may manifest as acute coronary syndromes (myocardial infarction , unstable angina , or sudden ischemic death). Most patients with CSA can be managed with medical treatment. For angina relief, optimum doses of one of the antianginal drugs (beta blockers , long-acting organic nitrates, or calcium channel blockers ) should be used. If the patient remains symptomatic, combination treatment of BBs plus nitrates or BBs plus dihydropyridine CCBs, or nondihydropyridine CCBs plus nitrates should be tried. Triple therapy has not been shown to be more effective than treatment with two agents. To reduce the incidence of MI, UA, and sudden ischemic death, treatment strategies should include smoking cessation, daily aspirin, daily exercise, and pharmacologic therapy for dyslipidemias, and for elevated blood pressure. Patients who remain symptomatic despite medical therapy and those not willing to take or unable to tolerate antianginal drugs should be considered for percutaneous or surgical coronary revascularization. Patients who do not respond to medical therapy and are not candidates for a revascularization procedure may be considered for additional treatment with trimetazidine or nicorandil (these drugs are not available in the United States or approved by the US Food and Drug Administration, but are available in some other countries). Ranolazine also looks promising but is not yet available for clinical use. As a last resort, enhanced external counterpulsation, spinal cord stimulation, sympathectomy, or direct transmyocardial revascularization should be considered for symptom relief.