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Bargagli M, Anderegg MA, Fuster DG. Effects of thiazides and new findings on kidney stones and dysglycemic side effects. Acta Physiol (Oxf) 2024; 240:e14155. [PMID: 38698738 DOI: 10.1111/apha.14155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/08/2024] [Accepted: 04/22/2024] [Indexed: 05/05/2024]
Abstract
Thiazide and thiazide-like diuretics (thiazides) belong to the most frequently prescribed drugs worldwide. By virtue of their natriuretic and vasodilating properties, thiazides effectively lower blood pressure and prevent adverse cardiovascular outcomes. In addition, through their unique characteristic of reducing urine calcium, thiazides are also widely employed for the prevention of kidney stone recurrence and reduction of bone fracture risk. Since their introduction into clinical medicine in the early 1960s, thiazides have been recognized for their association with metabolic side effects, particularly impaired glucose tolerance, and new-onset diabetes mellitus. Numerous hypotheses have been advanced to explain thiazide-induced glucose intolerance, yet underlying mechanisms remain poorly defined. Regrettably, the lack of understanding and unpredictability of these side effects has prompted numerous physicians to refrain from prescribing these effective, inexpensive, and widely accessible drugs. In this review, we outline the pharmacology and mechanism of action of thiazides, highlight recent advances in the understanding of thiazide-induced glucose intolerance, and provide an up-to-date discussion on the role of thiazides in kidney stone prevention.
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Affiliation(s)
- Matteo Bargagli
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Swiss National Centre of Competence in Research (NCCR) Kidney.CH, University of Zürich, Zürich, Switzerland
- Department for Biomedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Manuel A Anderegg
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Swiss National Centre of Competence in Research (NCCR) Kidney.CH, University of Zürich, Zürich, Switzerland
- Department for Biomedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Daniel G Fuster
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Swiss National Centre of Competence in Research (NCCR) Kidney.CH, University of Zürich, Zürich, Switzerland
- Department for Biomedical Research (DBMR), University of Bern, Bern, Switzerland
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Talebi SS, Rezaie S, Hajmiri MS, Zamanirafe M, Ranjbar A, Moridi H, Mirjalili M, Mehrpooya M. Comparison of the effects of empagliflozin and sitagliptin, as add-on to metformin, on serum levels of asprosin and metabolic parameters in patients with type 2 diabetes mellitus. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03219-z. [PMID: 38900252 DOI: 10.1007/s00210-024-03219-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/04/2024] [Indexed: 06/21/2024]
Abstract
The effect of sitagliptin and empagliflozin on serum levels of asprosin and metabolic parameters in patients with type 2 diabetes mellitus (T2DM) was assessed in a non-randomized, prospective observational study. Seventy-nine T2DM patients, without adequate glycemic control with metformin monotherapy, were included in the study. In addition to the ongoing metformin treatment, patients received sitagliptin 100 mg and empagliflozin 10 mg once daily for 12 weeks. Anthropometric parameters, lipid and glycemic profile, insulin resistance (homeostasis model assessment of insulin resistance index [HOMA-IR]), and asprosin serum levels were assessed at baseline and after 12 weeks of therapy. Both empagliflozin and sitagliptin treatments led to similar, significant improvement in fasting blood glucose (FBG) and hemoglobin A1C (HbA1C). Compared to baseline, triglyceride (TG) and high-density lipoprotein cholesterol (HDL-C) were improved with both treatments, but empagliflozin led to the more improvement. No significant change of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) were observed in either group. Insulin resistance was significantly attenuated in both groups, but to a greater degree with empagliflozin treatment. The reduction in serum asprosin levels from baseline was significantly higher in patients taking empagliflozin compared to those receiving sitagliptin. Additionally, individuals on empagliflozin exhibited a more decrease in body mass index (BMI) and body weight compared to those on sitagliptin. According to our findings, the addition of empagliflozin to metformin appeared to offer greater benefits compared to the addition of sitagliptin in terms of decreasing asprosin levels and improving certain metabolic parameters in T2DM patients.
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Affiliation(s)
- Seyed Saman Talebi
- Department of Internal Medicine, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Shabnam Rezaie
- Department of Clinical Pharmacy, School of Pharmacy, Hamadan University of Medical Sciences, Shahid Fahmideh Ave, Hamadan, 6517838678, Iran
| | - Minoo Sadat Hajmiri
- Department of Internal Medicine, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Maryam Zamanirafe
- Medical Faculty, Hamadan University of Medical Science, Hamadan, Iran
| | - Akram Ranjbar
- Department of Pharmacology Toxicology, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Heresh Moridi
- Department of Medical Laboratory Sciences, Faculty of Paramedical Sciences, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - Mahtabalsadat Mirjalili
- Department of Clinical Pharmacy, School of Pharmacy, Yazd University of Medical Sciences, Yazd, Iran
| | - Maryam Mehrpooya
- Department of Clinical Pharmacy, School of Pharmacy, Hamadan University of Medical Sciences, Shahid Fahmideh Ave, Hamadan, 6517838678, Iran.
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Kucharczyk P, Albano G, Deisl C, Ho TM, Bargagli M, Anderegg M, Wueest S, Konrad D, Fuster DG. Thiazides Attenuate Insulin Secretion Through Inhibition of Mitochondrial Carbonic Anhydrase 5b in β -Islet Cells in Mice. J Am Soc Nephrol 2023; 34:1179-1190. [PMID: 36927842 PMCID: PMC10356162 DOI: 10.1681/asn.0000000000000122] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 02/26/2023] [Indexed: 03/18/2023] Open
Abstract
SIGNIFICANCE STATEMENT Thiazide diuretics (thiazides) are among the most widely prescribed drugs worldwide, but their use is associated with glucose intolerance and new-onset diabetes mellitus. The molecular mechanisms remain elusive. Our study reveals that thiazides attenuate insulin secretion through inhibition of the mitochondrial carbonic anhydrase isoform 5b (CA5b) in pancreatic β cells. We furthermore discovered that pancreatic β cells express only one functional carbonic anhydrase isoform, CA5b, which is critical in replenishing oxaloacetate in the mitochondrial tricarboxylic acid (TCA) cycle (anaplerosis). These findings explain the mechanism for thiazide-induced glucose intolerance and reveal a fundamental role of CA5b in TCA cycle anaplerosis and insulin secretion in β cells. BACKGROUND Thiazide diuretics are associated with glucose intolerance and new-onset diabetes mellitus. Previous studies demonstrated that thiazides attenuate insulin secretion, but the molecular mechanisms remain elusive. We hypothesized that thiazides attenuate insulin secretion via one of the known molecular thiazide targets in β cells. METHODS We performed static insulin secretion experiments with islets of wild-type, Sodium/chloride co-transporter (NCC) (SLC12A3), and sodium-driven chloride/bicarbonate exchanger (NDCBE) (SLC4A8) knock-out (KO) mice and with murine Min6 cells with individual knockdown of carbonic anhydrase (CA) isoforms to identify the molecular target of thiazides in β cells. CA isoform 5b (CA5b) KO mice were then used to assess the role of the putative thiazide target CA5b in β -cell function and in mediating thiazide sensitivity in vitro and in vivo . RESULTS Thiazides inhibited glucose- and sulfonylurea-stimulated insulin secretion in islets and Min6 cells at pharmacologically relevant concentrations. Inhibition of insulin secretion by thiazides was CO 2 /HCO 3- -dependent, not additive to unselective CA inhibition with acetazolamide, and independent of extracellular potassium. By contrast, insulin secretion was unaltered in islets of mice lacking the known molecular thiazide targets NCC or NDCBE. CA expression profiling with subsequent knockdown of individual CA isoforms suggested mitochondrial CA5b as a molecular target. In support of these findings, thiazides significantly attenuated Krebs cycle anaplerosis through reduction of mitochondrial oxaloacetate synthesis. CA5b KO mice were resistant to thiazide-induced glucose intolerance, and thiazides did not alter insulin secretion in CA5b KO islets. CONCLUSIONS Thiazides attenuate insulin secretion via inhibition of the mitochondrial CA5b isoform in β cells of mice.
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Affiliation(s)
- Patrycja Kucharczyk
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- National Centre of Competence in Research (NCCR) TransCure, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Giuseppe Albano
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- National Centre of Competence in Research (NCCR) TransCure, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Christine Deisl
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- National Centre of Competence in Research (NCCR) TransCure, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Tin Manh Ho
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- National Centre of Competence in Research (NCCR) TransCure, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Matteo Bargagli
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- National Centre of Competence in Research (NCCR) TransCure, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Manuel Anderegg
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- National Centre of Competence in Research (NCCR) TransCure, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Stephan Wueest
- Division of Pediatric Endocrinology and Diabetology, University Children's Hospital, University of Zürich, Zürich, Switzerland
- Children's Research Center, University Children's Hospital, University of Zürich, Zürich, Switzerland
| | - Daniel Konrad
- Division of Pediatric Endocrinology and Diabetology, University Children's Hospital, University of Zürich, Zürich, Switzerland
- Children's Research Center, University Children's Hospital, University of Zürich, Zürich, Switzerland
| | - Daniel G. Fuster
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- National Centre of Competence in Research (NCCR) TransCure, University of Bern, Bern, Switzerland
- Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
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Hsieh KL, Plascencia-Villa G, Lin KH, Perry G, Jiang X, Kim Y. Synthesize heterogeneous biological knowledge via representation learning for Alzheimer's disease drug repurposing. iScience 2023; 26:105678. [PMID: 36594024 PMCID: PMC9804117 DOI: 10.1016/j.isci.2022.105678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/04/2022] [Accepted: 11/23/2022] [Indexed: 11/27/2022] Open
Abstract
Developing drugs for treating Alzheimer's disease has been extremely challenging and costly due to limited knowledge of underlying mechanisms and therapeutic targets. To address the challenge in AD drug development, we developed a multi-task deep learning pipeline that learns biological interactions and AD risk genes, then utilizes multi-level evidence on drug efficacy to identify repurposable drug candidates. Using the embedding derived from the model, we ranked drug candidates based on evidence from post-treatment transcriptomic patterns, efficacy in preclinical models, population-based treatment effects, and clinical trials. We mechanistically validated the top-ranked candidates in neuronal cells, identifying drug combinations with efficacy in reducing oxidative stress and safety in maintaining neuronal viability and morphology. Our neuronal response experiments confirmed several biologically efficacious drug combinations. This pipeline showed that harmonizing heterogeneous and complementary data/knowledge, including human interactome, transcriptome patterns, experimental efficacy, and real-world patient data shed light on the drug development of complex diseases.
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Affiliation(s)
- Kang-Lin Hsieh
- Center for Secure Artificial Intelligence for Healthcare, School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - German Plascencia-Villa
- Department of Neuroscience, Developmental and Regenerative Biology, University of Texas at San Antonio, San Antonio, TX 78729, USA
| | - Ko-Hong Lin
- Center for Secure Artificial Intelligence for Healthcare, School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - George Perry
- Department of Neuroscience, Developmental and Regenerative Biology, University of Texas at San Antonio, San Antonio, TX 78729, USA
| | - Xiaoqian Jiang
- Center for Secure Artificial Intelligence for Healthcare, School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Yejin Kim
- Center for Secure Artificial Intelligence for Healthcare, School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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Renna N, Piskorz D, Stisman D, Martinez D, Lescano L, Vissani S, Espeche W, Marquez D, Parodi R, Naninni D, Baroni M, Llanos D, Martinez R, Barochinner J, Staffieri G, Lanas F, Velásquez M, Marin M, Williams B, Ennis I. Position statement on use of pharmacological combinations in a single pill for treatment of hypertension by Argentine Federation of Cardiology (FAC) and Argentine Society of Hypertension (SAHA). J Hum Hypertens 2021:10.1038/s41371-021-00557-w. [PMID: 34088992 DOI: 10.1038/s41371-021-00557-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 05/03/2021] [Accepted: 05/21/2021] [Indexed: 11/09/2022]
Abstract
The present document provides scientific evidence reviewed and analysed by a group of specialist clinicians in hypertension that aims to give an insight into a pharmacological strategy to improve blood pressure control. Evidence shows that most hypertensive patients will need at least two drugs to achieve blood pressure goals. There is ample evidence showing that treatment adherence is inversely related to the number of drugs taken. Observational studies show that use of drug combinations to initiate treatment reduces the time to reach the treatment goal and reduces CVD, especially with single pill combinations (SPCs). This work, based on recommendations of the Argentine Federation of Cardiology and Argentine Society of Hypertension as a reference, aims to review the more recent evidence on SPC, and to serve as guidelines for health professionals in their clinical practice and to the wider use of SPCs for the treatment of hypertension. Evidence from clinical trials on the effectiveness and adverse effects of using SPCs are provided. An analysis is also made of the main contributions of SPCs in special populations, e.g., elderly and diabetic patients, and its use in high risk and resistant hypertension. The effects of SPCs on hypertensive-mediated organ damage is also examined. Finally, we provide some aspects to consider when choosing treatments in the economic context of Latin-America for promoting the most efficient use of resources in a scarce environment and to provide quality information to decision makers to formulate safe, cost-effective, and patient-centered health policies. Finally, future perspectives and limitations in clinical practice are also discussed.
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Affiliation(s)
- Nicolás Renna
- Unit of Hypertension, Hospital Español de Mendoza. School of Medicine. National University of Cuyo. IMBECU-CONICET, Mendoza, Argentina.
| | - Daniel Piskorz
- Sanatorio Británico Cardiology Institute, Rosario, Argentina
| | - Diego Stisman
- Instituto de Cardiología, San Miguel de Tucumán, Tucumán, Argentina
| | | | - Ludmila Lescano
- Servicio de Cardiología Hospital San Bernardo, Salta, Argentina
| | - Sergio Vissani
- Centro de neurología y rehabilitación-CENYR, San Luis, Argentina
| | | | - Diego Marquez
- Servicio de Nefrología Hospital San Bernardo, Salta, Argentina
| | - Roberto Parodi
- Facultad de Ciencias Médicas, Universidad Nacional de Rosario, Rosario, Argentina
| | - Diego Naninni
- Instituto Especialidades de la Salud Rosario, Santa Fe, Argentina
| | | | - Daniel Llanos
- Consultorio de Cardiología Clínica e Hipertensión Arterial en CEDIT / Clínica Chapelco y Centro Médico Roca, San Martìn de los Andes, Neuquèn, Argentina
| | - Rocio Martinez
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | - Fernando Lanas
- Departamento de Medicina Interna y CIGES, Universidad de La Frontera, Temuco, Chile
| | - Mónica Velásquez
- Departamento de Especialidades Médicas. CIGES, Universidad de La Frontera, Temuco, Chile
| | - Marcos Marin
- Hospital Italiano Ctro. Agustín Rocca-San Justo (HICAR), Buenos Aires, Argentina
| | - Bryan Williams
- Institute of Cardiovascular Sciences and NIHR University College London Hospitals Biomedical Research Centre, University College London, London, UK
| | - Irene Ennis
- Centro de Investigaciones Cardiovasculares, Facultad de Ciencias Médicas, UNLP-CONICET, La Plata, Argentina
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Ali W, Bakris GL. How to Manage Hypertension in People With Diabetes. Am J Hypertens 2020; 33:935-943. [PMID: 32307510 DOI: 10.1093/ajh/hpaa067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 11/14/2022] Open
Abstract
Hypertension is a common condition that is often seen in patients with diabetes. Both diseases increase the risk of morbidity and mortality from CV events and kidney disease progression. Factors that influence blood pressure (BP) control in diabetes include the persons' genetic background for hypertension and kidney disease, level of obesity and insulin resistance, the magnitude of preexisting kidney disease, and lifestyle factors, such as level of sodium and potassium intake, sleep quality and exercise effort all of which can affect levels of sympathetic nerve activity and contribute to increased BP variability. Lifestyle intervention is a key component to the effective management of diabetes and hypertension and can markedly reduce event rates of both heart and kidney outcomes. The approach to pharmacologic treatment of BP in diabetes is crucial since certain classes of agents for both BP and diabetes confer significant benefits to reduce cardiorenal outcomes.
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Affiliation(s)
- Waleed Ali
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago Medicine, Chicago, Illinois, USA
| | - George L Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago Medicine, Chicago, Illinois, USA
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A Prospective Noninterventional, Observational Study to Describe the Effectiveness and Safety of Trandolapril and Verapamil Single-Pill Combination in the Management of Patients with Hypertension and Type 2 Diabetes Mellitus: A Harvest TR Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2123601. [PMID: 32964020 PMCID: PMC7492926 DOI: 10.1155/2020/2123601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/14/2020] [Accepted: 08/17/2020] [Indexed: 11/17/2022]
Abstract
Maintaining regular blood pressure control usually requires multidrug regimens rather than monotherapy. The objective of this study was to describe the effectiveness and safety of an angiotensin-converting enzyme inhibitor and a nondihydropyridine calcium channel blocker in a single-tablet combination in patients with hypertension, a heart rate higher than 70 beats/min, and type 2 diabetes mellitus (T2DM). This study was conducted in Turkey as a prospective, noninterventional, observational study. At 22 clinical sites, the data of 200 patients with hypertension were used for efficacy analysis; however, 262 patients received at least one dose of trandolapril/verapamil fixed-dose combination at two dose strengths. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate, PR interval, glycated haemoglobin (HbA1c), and albumin/creatinine ratios were recorded during 8 weeks of treatment. With treatment, the mean (±SD) SBP that was recorded as 162.8 (±14.642) mm Hg at baseline was reduced to 131.7 ± 11.1 mm Hg at week 8 (p < 0.05). Similarly, the mean DBP was reduced from 93.76 ± 9.16 mm Hg to 77.6 ± 7.6 mm Hg (p < 0.001). Following 8 weeks of treatment, SBP and DBP values were reduced below 140 mm Hg and 90 mm Hg in most patients (81.5%), respectively. The mean heart rate as evaluated using electrocardiography measurements was reduced to 78.25 beats/min at week 8 as compared with baseline during trandolapril/verapamil single-pill combination treatment (p < 0.001). Treatment with trandolapril and verapamil was well tolerated over 8 weeks with no unexpected safety signals. In conclusion, the single-pill combination of trandolapril and verapamil was considered effective in reducing and controlling blood pressure in patients with hypertension and T2DM. There was a significant improvement in HbA1c and ACR levels in a smaller subgroup of the patient cohort. The trandolapril/verapamil combination was evaluated as being safe and well-tolerated following a treatment period of 8 weeks. This trial was registered with NCT02298556.
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Thiazide Diuretic-Induced Change in Fasting Plasma Glucose: a Meta-analysis of Randomized Clinical Trials. J Gen Intern Med 2020; 35:1849-1860. [PMID: 32157653 PMCID: PMC7280437 DOI: 10.1007/s11606-020-05731-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/10/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Prior meta-analyses measuring thiazide-induced glycemic change have demonstrated an increased risk of incident diabetes; however, this measure's definition has changed over time. AIM To determine the magnitude of change in fasting plasma glucose (FPG) for thiazide diuretics. DATA SOURCES A research librarian designed and conducted searches in Medline®, EMBASE, and EBM Reviews-Cochrane Central Register of Controlled Trials (inception through July 2018) and International Pharmaceutical Abstracts (inception to December 2014). STUDY SELECTION Randomized, controlled trials comparing a thiazide or thiazide-like diuretic to any comparator reporting FPG were identified. Trials enrolling < 50 participants, those with a follow-up period of < 4 weeks, and conference abstracts were excluded. DATA EXTRACTION Independent duplicate screening of citations and full-text articles, data extraction, and assessment of risk of bias was conducted. DATA SYNTHESIS Ninety-five studies were included (N = 76,608 participants), with thiazides compared with placebo, beta-blockers, calcium channel blockers, renin-angiotensin-aldosterone-system inhibitors, potassium-sparing diuretic, and others alone or in combination. Thiazide diuretics marginally increased FPG (weighted mean difference 0.20 mmol/L (95% CI 0.15-0.25); I2 = 84%) (1 mmol/L = 18 mg/dL). Results did not change substantially when considering dose or duration, comparing thiazides with placebo or an active comparator, or using thiazides as monotherapy or combination therapy, even when combined with a potassium-correcting agent. CONCLUSION Thiazide diuretics have a small and clinically unimportant impact on FPG.
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Rosenzweig JL, Bakris GL, Berglund LF, Hivert MF, Horton ES, Kalyani RR, Murad MH, Vergès BL. Primary Prevention of ASCVD and T2DM in Patients at Metabolic Risk: An Endocrine Society* Clinical Practice Guideline. J Clin Endocrinol Metab 2019; 104:3939-3985. [PMID: 31365087 DOI: 10.1210/jc.2019-01338] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To develop clinical practice guidelines for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes mellitus (T2DM) in individuals at metabolic risk for developing these conditions. CONCLUSIONS Health care providers should incorporate regular screening and identification of individuals at metabolic risk (at higher risk for ASCVD and T2DM) with measurement of blood pressure, waist circumference, fasting lipid profile, and blood glucose. Individuals identified at metabolic risk should undergo 10-year global risk assessment for ASCVD or coronary heart disease to determine targets of therapy for reduction of apolipoprotein B-containing lipoproteins. Hypertension should be treated to targets outlined in this guideline. Individuals with prediabetes should be tested at least annually for progression to diabetes and referred to intensive diet and physical activity behavioral counseling programs. For the primary prevention of ASCVD and T2DM, the Writing Committee recommends lifestyle management be the first priority. Behavioral programs should include a heart-healthy dietary pattern and sodium restriction, as well as an active lifestyle with daily walking, limited sedentary time, and a structured program of physical activity, if appropriate. Individuals with excess weight should aim for loss of ≥5% of initial body weight in the first year. Behavior changes should be supported by a comprehensive program led by trained interventionists and reinforced by primary care providers. Pharmacological and medical therapy can be used in addition to lifestyle modification when recommended goals are not achieved.
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Affiliation(s)
| | | | | | - Marie-France Hivert
- Harvard Pilgrim Health Care Institute, Harvard Medical School, Boston, Massachusetts
| | | | - Rita R Kalyani
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - Bruno L Vergès
- Centre Hospitalier Universitaire Dijon Bourgogne, Dijon, France
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The effect of SGLT-2 inhibitors on blood pressure: a pleiotropic action favoring cardio- and nephroprotection. Future Med Chem 2019; 11:1285-1303. [PMID: 31161798 DOI: 10.4155/fmc-2018-0514] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Strict blood pressure (BP) control in patients with diabetes is associated with reductions in cardiovascular and renal risk. SGLT-2 inhibitors act in the proximal tubule to reduce glucose reabsorption. They also have mild natriuretic and diuretic effects, combining properties of proximal tubule diuretics and osmotic diuretics, which are expected to reduce BP. Several lines of evidence suggests that SGLT-2 inhibitors produce mild but meaningful reductions in BP and also decrease the incidence of renal outcomes, cardiovascular events and mortality. Thus, recent guidelines for type 2 diabetes suggest that among oral agents to use together with metformin, SGLT-2 inhibitors should be preferred in patients at increased cardiovascular risk, kidney disease or heart failure. This review summarizes current literature on the effect of SGLT-2 inhibitors on BP, and its potential relationships with cardio- and nephroprotection.
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Kelley EF, Snyder EM, Alkhatib NS, Snyder SC, Sprissler R, Olson TP, Akre MK, Abraham I. Economic evaluation of a pharmacogenomic multi-gene panel test to optimize anti-hypertension therapy: simulation study. J Med Econ 2018; 21:1246-1253. [PMID: 30280614 DOI: 10.1080/13696998.2018.1531011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIMS Hypertension is the strongest modifiable risk factor for cardiovascular disease, affecting 80 million individuals in the US and responsible for ∼360,000 deaths, at total annual costs of $93.5 billion. Antihypertension therapies guided by single genotypes are clinically more effective and may avert more adverse events than the standard of care of layering anti-hypertensive drug therapies, thus potentially decreasing costs. This study aimed to determine the economic benefits of the implementation of multi-gene panel guided therapies for hypertension from the payer perspective within a 3-year time horizon. MATERIALS AND METHODS A simulation analysis was conducted for a panel of 10 million insured patients categorized clinically as untreated, treated but uncontrolled, and treated and controlled over a 3-year treatment period. Inputs included research data; empirical data from a 11-gene panel with known functional, heart, blood vessel, and kidney genotypes; and therapy efficacy and safety estimates from literature. Cost estimates were categorized as related to genetic testing, evaluation and management, medication, or adverse events. RESULTS Multi-gene panel guided therapy yielding savings of $6,256,607,500 for evaluation and management, $908,160,000 for medications, and $37,467,508,716 for adverse events, after accounting for incremental genetic testing costs of $2,355,540,000. This represents total 3-year savings of $42,276,736,216, or a 47% reduction, and 3-year savings of $4,228 and annual savings of $1,409 per covered patient. CONCLUSIONS A precision medicine approach to genetically guided therapy for hypertension patients using a multi-gene panel reduced total 3-year costs by 47%, yielding savings exceeding $42.3 billion in an insured panel of 10 million patients. Importantly, 89% of these savings are generated by averting specific adverse events and, thus, optimizing choice of therapy in function of both safety and efficacy.
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Affiliation(s)
- Eli F Kelley
- a University of Minnesota , Minneapolis , MN , USA
| | | | - Nimer S Alkhatib
- c University of Arizona, Center for Health Outcomes and Pharmaco Economic Research , Tucson , AZ , USA
| | | | - Ryan Sprissler
- b Geneticure, Inc. , Rochester , MN , USA
- d University of Arizona Genomics Core , Tucson , AZ , USA
- e University of Arizona, Center for Applied Genetics and Genomic Medicine , Tucson , AZ , USA
| | - Thomas P Olson
- f Mayo Clinic, College of Medicine , Rochester , MN , USA
| | | | - Ivo Abraham
- c University of Arizona, Center for Health Outcomes and Pharmaco Economic Research , Tucson , AZ , USA
- e University of Arizona, Center for Applied Genetics and Genomic Medicine , Tucson , AZ , USA
- g University of Arizona , Department of Family and Community Medicine , Tucson , AZ , USA
- h Matrix45 , Tucson , AZ , USA
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Pongpanich P, Pitakpaiboonkul P, Takkavatakarn K, Praditpornsilpa K, Eiam-Ong S, Susantitaphong P. The benefits of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers combined with calcium channel blockers on metabolic, renal, and cardiovascular outcomes in hypertensive patients: a meta-analysis. Int Urol Nephrol 2018; 50:2261-2278. [DOI: 10.1007/s11255-018-1991-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 09/19/2018] [Indexed: 11/29/2022]
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13
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Guerrero-García C, Rubio-Guerra AF. Combination therapy in the treatment of hypertension. Drugs Context 2018; 7:212531. [PMID: 29899755 PMCID: PMC5992964 DOI: 10.7573/dic.212531] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 01/01/2023] Open
Abstract
Hypertension is a major preventable risk factor for atherosclerosis and ischemic heart disease. Although modern and effective antihypertensive drugs are available, most patients remain with a suboptimal blood pressure control. Most hypertensive patients will need a combination of antihypertensive agents to achieve the therapeutic goals – recent guidelines recommend initiating treatment with two drugs in those patients with a systolic blood pressure >20 mmHg and/or a diastolic blood pressure >10 mmHg above the goals, and in those patients with high cardiovascular risk. In addition, approximately 25% of patients will require three antihypertensive agents to achieve the therapeutic targets. In this review, we analyse the latest information available regarding the treatment of hypertension with combination therapy.
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Affiliation(s)
- Carolina Guerrero-García
- Unidad de Investigación Clínico-Metabólica, Hospital General de Ticomán SS DF, Mexico City, Mexico.,Mexican Group for Basic and Clinical Research in Internal Medicine, A.C., Mexico City, Mexico
| | - Alberto Francisco Rubio-Guerra
- Unidad de Investigación Clínico-Metabólica, Hospital General de Ticomán SS DF, Mexico City, Mexico.,Mexican Group for Basic and Clinical Research in Internal Medicine, A.C., Mexico City, Mexico
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Impact of long-term potassium supplementation on thiazide diuretic-induced abnormalities of glucose and uric acid metabolisms. J Hum Hypertens 2018; 32:301-310. [PMID: 29497150 DOI: 10.1038/s41371-018-0036-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 08/05/2017] [Accepted: 08/25/2017] [Indexed: 12/18/2022]
Abstract
Treatment of hypertension with thiazide diuretics may trigger hypokalemia, hyperglycemia, and hyperuricemia. Some studies suggest simultaneous potassium supplementation in hypertensive patients using thiazide diuretics. However, few clinical studies have reported the impact of long-term potassium supplementation on thiazide diuretic-induced abnormalities in blood glucose and uric acid (UA) metabolisms. One hundred hypertensive patients meeting the inclusion criteria were equally randomized to two groups: IND group receiving indapamide (1.25-2.5 mg daily) alone, and IND/KCI group receiving IND (1.25-2.5 mg daily) plus potassium chloride (40 mmol daily), both for 24 weeks. At the end of 24-week follow-up, serum K+ level in IND group decreased from 4.27 ± 0.28 to 3.98 ± 0.46 mmol/L (P < 0.001), and fasting plasma glucose (FPG) and UA increased from 5.11 ± 0.52 to 5.31 ± 0.57 mmol/L (P < 0.05), and from 0.404 ± 0.078 to 0.433 ± 0.072 mmol/L (P < 0.05), respectively. Serum K+ level in IND/KCl group decreased from 4.27 ± 0.36 to 3.89 ± 0.28 mmol/L (P < 0.001), and FPB and UA increased from 5.10 ± 0.41 to 5.35 ± 0.55 mmol/L (P < 0.01), and from 0.391 ± 0.073 to 0.457 ± 0.128 mmol/L (P < 0.001), respectively. The difference value between the serum K+ level and FPG before and after treatment was not statistically significant between the two groups. However, the difference value in UA in IND/KCl group was significantly higher than that in IND group (0.066 (95% confidence interval (CI): 0.041-0.090) mmol/L vs. 0.029 (95% CI: 0.006-0.058) mmol/L, P < 0.05). The results showed that long-term routine potassium supplementation could not prevent or attenuate thiazide diuretic-induced abnormalities of glucose metabolism in hypertensive patients; rather, it may aggravate the UA metabolic abnormality.
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Sarafidis PA, Alexandrou ME, Ruilope LM. A review of chemical therapies for treating diabetic hypertension. Expert Opin Pharmacother 2017; 18:909-923. [DOI: 10.1080/14656566.2017.1328054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Pantelis A. Sarafidis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
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16
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[Pathophysiology of hypertension secondary to obesity]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2017; 87:336-344. [PMID: 28262443 DOI: 10.1016/j.acmx.2017.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 02/01/2017] [Accepted: 02/01/2017] [Indexed: 11/21/2022] Open
Abstract
The obesity is a problem with a high morbidity and mortality all over the world. It has now been designated as a cardiovascular risk factor. It often predisposes the development of many diseases that reduce quality of life, such as hypertension, dyslipidaemia, and diabetes. These diseases are associated with some of the criteria that should be considered in the diagnosis of metabolic syndrome. During this review, explanations will be presented on the relationship between obesity, metabolic syndrome, and the development of hypertension from neurohumoral, biochemical and mechanical concepts.
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17
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Nádházi Z, Dézsi CA. The Results of ACES (Antihypertensive Combinations' Long Term Efficacy Comparing Study): Analysis of Metabolic Effects of Antihypertensive Combination Therapies. Clin Drug Investig 2017; 36:819-27. [PMID: 27405983 DOI: 10.1007/s40261-016-0431-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Zoltán Nádházi
- 2nd Department of Internist Medicine Center, Semmelweis University of Budapest, Budapest, Hungary
| | - Csaba András Dézsi
- Department of Cardiology, Petz Aladár County Teaching Hospital, Vasvári Pál str. 2-4., Győr, 9024, Hungary.
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18
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Sodium-glucose cotransporter-2 inhibitors and blood pressure decrease: a valuable effect of a novel antidiabetic class? J Hypertens 2016; 33:2185-97. [PMID: 26372321 DOI: 10.1097/hjh.0000000000000719] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diabetes mellitus is a major issue of public health, affecting more than 300 million people worldwide. Inhibitors of the sodium-glucose cotransporter-2 (SGLT-2) in the renal proximal tubule are a novel class of agents for the treatment of type 2 diabetes mellitus. Inhibition of the SGLT-2 results in reduced glucose reabsorption and improvement in glycemic control. Alongside glucose excretion, SGLT-2 inhibitors also have mild natriuretic and diuretic effects, combining actions of a proximal tubule diuretic and an osmotic diuretic; these properties are expected to lead to small blood pressure (BP) reductions. Clinical studies with dapagliflozin, canagliflozin, empagliflozin, ipragliflozin, luseogliflozin, and tofogliflozin used either as monotherapy or add-on therapy and compared with placebo or active treatment have also examined the effect of these agents on BP as a secondary endpoint. Although with some differences between individual agents, all of the approved SGLT-2 inhibitors provided a mild but meaningful reduction in office SBP and DBP. Recent studies with the use of ambulatory blood pressure monitoring suggest that the magnitude of this BP reduction can be even greater. The aim of this review is to systematically summarize and present the studies reporting the effect of approved SGLT-2 inhibitors on BP.
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19
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Bonora E, Bryzinski B, Hirshberg B, Cook W. A post hoc analysis of saxagliptin efficacy and safety in patients with type 2 diabetes stratified by UKPDS 10-year cardiovascular risk score. Nutr Metab Cardiovasc Dis 2016; 26:374-379. [PMID: 27033025 DOI: 10.1016/j.numecd.2015.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 11/01/2015] [Accepted: 11/07/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS To assess the efficacy and safety of saxagliptin 2.5 and 5 mg/d in patients with type 2 diabetes mellitus (T2DM) and high risk of coronary heart disease (CHD) or stroke as estimated by the United Kingdom Prospective Diabetes Study (UKPDS) risk engine. METHODS AND RESULTS Post hoc analysis of data pooled from 5 previously reported phase 3, randomized, placebo-controlled, 24-week studies was conducted. Patients were stratified into subgroups by UKPDS 10-year CHD and/or stroke risk ≥20% and CHD and stroke risk <20%. End points were adjusted mean change from baseline in glycated hemoglobin (HbA1c), fasting plasma glucose (FPG), 120-min postprandial glucose (PPG), and body weight and the proportion of patients achieving HbA1c <7% and ≤8% at week 24. Pooled safety data were analyzed for adverse events (AEs) and hypoglycemia. Both doses of saxagliptin reduced HbA1c, FPG, and PPG to a greater extent than placebo regardless of UKPDS risk score. The proportions of patients achieving HbA1c <7% and ≤8% were greater with saxagliptin than placebo and consistent across risk score groups. AE profile and hypoglycemia incidence were similar for saxagliptin and placebo across UKPDS risk score groups. CONCLUSION Saxagliptin was well tolerated and improved glycemic control in patients with T2DM regardless of their CHD and stroke UKPDS risk score. Clinical trial registration numbers: Clinicaltrials.gov NCT00121641, NCT00316082, NCT00121667, NCT00313313, and NCT00295633.
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Affiliation(s)
- E Bonora
- University and University Hospital of Verona, Verona, Italy.
| | | | | | - W Cook
- AstraZeneca, Gaithersburg, MD, USA
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20
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Brown MJ, Williams B, Morant SV, Webb DJ, Caulfield MJ, Cruickshank JK, Ford I, McInnes G, Sever P, Salsbury J, Mackenzie IS, Padmanabhan S, MacDonald TM. Effect of amiloride, or amiloride plus hydrochlorothiazide, versus hydrochlorothiazide on glucose tolerance and blood pressure (PATHWAY-3): a parallel-group, double-blind randomised phase 4 trial. Lancet Diabetes Endocrinol 2016; 4:136-47. [PMID: 26489809 PMCID: PMC4728199 DOI: 10.1016/s2213-8587(15)00377-0] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 09/14/2015] [Accepted: 09/22/2015] [Indexed: 11/14/2022]
Abstract
BACKGROUND Potassium depletion by thiazide diuretics is associated with a rise in blood glucose. We assessed whether addition or substitution of a potassium-sparing diuretic, amiloride, to treatment with a thiazide can prevent glucose intolerance and improve blood pressure control. METHODS We did a parallel-group, randomised, double-blind trial in 11 secondary and two primary care sites in the UK. Eligible patients were aged 18-80 years; had clinic systolic blood pressure of 140 mm Hg or higher and home systolic blood pressure of 130 mmHg or higher on permitted background drugs of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, β blockers, calcium-channel blockers, or direct renin inhibitors (previously untreated patients were also eligible in specific circumstances); and had at least one component of the metabolic syndrome in addition to hypertension. Patients with known diabetes were excluded. Patients were randomly assigned (1:1:1) to 24 weeks of daily oral treatment with starting doses of 10 mg amiloride, 25 mg hydrochlorothiazide, or 5 mg amiloride plus 12·5 mg hydrochlorothiazide; all doses were doubled after 12 weeks. Random assignment was done via a central computer system. Both participants and investigators were masked to assignment. Our hierarchical primary endpoints, assessed on a modified intention-to-treat basis at 12 and 24 weeks, were the differences from baseline in blood glucose measured 2 h after a 75 g oral glucose tolerance test (OGTT), compared first between the hydrochlorothiazide and amiloride groups, and then between the hydrochlorothiazide and combination groups. A key secondary endpoint was change in home systolic blood pressure at 12 and 24 weeks. This trial is registered with ClinicalTrials.gov, number NCT00797862, and the MHRA, Eudract number 2009-010068-41, and is now complete. FINDINGS Between Nov 18, 2009, and Dec 15, 2014, 145 patients were randomly assigned to amiloride, 146 to hydrochlorothiazide, and 150 to the combination group. 132 participants in the amiloride group, 134 in the hydrochlorothiazide group, and 133 in the combination group were included in the modified intention-to-treat analysis. 2 h glucose concentrations after OGTT, averaged at 12 and 24 weeks, were significantly lower in the amiloride group than in the hydrochlorothiazide group (mean difference -0·55 mmol/L [95% CI -0·96 to -0·14]; p=0·0093) and in the combination group than in the hydrochlorothiazide group (-0·42 mmol/L [-0·84 to -0·004]; p=0·048). The mean reduction in home systolic blood pressure during 24 weeks did not differ significantly between the amiloride and hydrochlorothiazide groups, but the fall in blood pressure in the combination group was significantly greater than that in the hydrochlorothiazide group (p=0·0068). Hyperkalaemia was reported in seven (4·8%) patients in the amiloride group and three (2·3%) patients in the combination group; the highest recorded potassium concentration was 5·8 mmol/L in a patient in the amiloride group. 13 serious adverse events occurred but the frequency did not differ significantly between groups. INTERPRETATION The combination of amiloride with hydrochlorothiazide, at doses equipotent on blood pressure, prevents glucose intolerance and improves control of blood pressure compared with montherapy with either drug. These findings, together with previous data about morbidity and mortality for the combination, support first-line use of amiloride plus hydrochlorothiazide in hypertensive patients who need treatment with a diuretic. FUNDING British Heart Foundation and National Institute for Health Research.
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Affiliation(s)
- Morris J Brown
- Clinical Pharmacology Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
| | - Bryan Williams
- Institute of Cardiovascular Sciences, University College London, London, UK; National Institute for Health Research, University College London Hospitals Biomedical Research Centre, London, UK
| | - Steve V Morant
- Medicines Monitoring Unit, Medical Research Institute, University of Dundee, Dundee, Scotland, UK
| | - David J Webb
- Clinical Pharmacology Unit, University of Edinburgh, Centre for Cardiovascular Science, Queen's Medical Research Institute, Edinburgh, Scotland, UK
| | - Mark J Caulfield
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland, UK
| | - Gordon McInnes
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - Peter Sever
- International Centre for Circulatory Health, Imperial College London, London, UK
| | - Jackie Salsbury
- Clinical Pharmacology Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Isla S Mackenzie
- Medicines Monitoring Unit, Medical Research Institute, University of Dundee, Dundee, Scotland, UK
| | - Sandosh Padmanabhan
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - Thomas M MacDonald
- Medicines Monitoring Unit, Medical Research Institute, University of Dundee, Dundee, Scotland, UK
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Mancia G. Preventing new-onset diabetes in thiazide-treated patients. Lancet Diabetes Endocrinol 2016; 4:90-2. [PMID: 26489807 DOI: 10.1016/s2213-8587(15)00391-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 10/05/2015] [Indexed: 01/02/2023]
Affiliation(s)
- Giuseppe Mancia
- University of Milano-Bicocca, Milan 20126, Italy; IRCCS Istituto Auxologico Italiano, Milan, Italy.
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The impacts of obesity on the cardiovascular and renal systems: cascade of events and therapeutic approaches. Curr Hypertens Rep 2016; 17:7. [PMID: 25620635 DOI: 10.1007/s11906-014-0520-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There is a neglected epidemic of both obesity and metabolic syndrome in industrialized and unindustrialized countries all over the globe. Both conditions are associated with a high incidence of other serious pathologies, such as cardiovascular and renal diseases. In this article, we review the potential underlying mechanisms by which obesity and metabolic syndrome promote hypertension, including changes in cardiovascular-renal physiology induced by leptin, the sympathetic nervous system, the renin-angiotensin-aldosterone system, insulin resistance, free fatty acids, natriuretic peptides, and proinflammatory cytokines. We also discuss the potential underlying mechanisms by which obesity promotes other cardiovascular and renal conditions, as well as available nonpharmacologic and pharmacologic approaches for treating obesity-induced hypertension. The findings presented herein suggest that adipocytes may be a key regulator of cardiovascular and renal function.
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Seravalle G, Brambilla G, Pizzalla DP, Casati A, Riva M, Cuspidi C, Bombelli M, Mancia G, Grassi G. Differential effects of enalapril-felodipine versus enalapril-lercanidipine combination drug treatment on sympathetic nerve traffic and metabolic profile in obesity-related hypertension. ACTA ACUST UNITED AC 2016; 10:244-51. [PMID: 26831124 DOI: 10.1016/j.jash.2016.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/05/2016] [Accepted: 01/05/2016] [Indexed: 01/12/2023]
Abstract
Scanty information is available on the effects of combination drug treatment based on an ACE inhibitor and a calcium channel blocker on the neurometabolic alterations characterizing obesity-related hypertension (OHT). After 2-week run-in with enalapril (20 mg), 36 OHTs were randomized according to a double-blind crossover design to a combination therapy with either lercanidipine 10 mg (L) or felodipine extended release 5 mg (F), each lasting 8 weeks. Measurements included clinic and ambulatory blood pressure (BP) and heart rate, homeostasis model assessment index, plasma norepinephrine, and muscle sympathetic nerve activity. Patients with uncontrolled BP were then uptitrated to 20 mg/d (L) and 10 mg/d (F) combined with enalapril 20 mg, respectively, for further 8 weeks. For similar BP reductions, enalapril-lercanidipine (EL) caused norepinephrine and MSNA increases significantly less pronounced than those seen with enalapril-felodipine, the lesser sympathoexcitation observed with EL being coupled with a significant improvement in homeostasis model assessment index. This was the case also when L and F were uptitrated in the combination. In OHT, at variance from enalapril-felodipine, EL combination is almost entirely devoid of any major sympathoexcitatory effect and is associated with an improvement in insulin sensitivity.
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Affiliation(s)
| | - Gianmaria Brambilla
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | | | - Anna Casati
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Marta Riva
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Cesare Cuspidi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Michele Bombelli
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | | | - Guido Grassi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; IRCCS Multimedica, Sesto San Giovanni, Milano, Italy.
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Brown MJ, Williams B, MacDonald TM, Caulfield M, Cruickshank JK, McInnes G, Sever P, Webb DJ, Salsbury J, Morant S, Ford I. Comparison of single and combination diuretics on glucose tolerance (PATHWAY-3): protocol for a randomised double-blind trial in patients with essential hypertension. BMJ Open 2015; 5:e008086. [PMID: 26253567 PMCID: PMC4539390 DOI: 10.1136/bmjopen-2015-008086] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Thiazide diuretics are associated with increased risk of diabetes mellitus. This risk may arise from K(+)-depletion. We hypothesised that a K(+)-sparing diuretic will improve glucose tolerance, and that combination of low-dose thiazide with K(+)-sparing diuretic will improve both blood pressure reduction and glucose tolerance, compared to a high-dose thiazide. METHODS AND ANALYSIS This is a parallel-group, randomised, double-blind, multicentre trial, comparing hydrochlorothiazide 25-50 mg, amiloride 10-20 mg and combination of both diuretics at half these doses. A single-blind placebo run-in of 1 month is followed by 24 weeks of blinded active treatment. There is forced dose-doubling after 3 months. The Primary end point is the blood glucose 2 h after oral ingestion of a 75 g glucose drink (OGTT), following overnight fasting. The primary outcome is the difference between 2 h glucose at weeks 0, 12 and 24. Secondary outcomes include the changes in home systolic blood pressure (BP) and glycated haemoglobin and prediction of response by baseline plasma renin. Eligibility criteria are: age 18-79, systolic BP on permitted background treatment ≥ 140 mm Hg and home BP ≥ 130 mm Hg and one component of the metabolic syndrome additional to hypertension. Principal exclusions are diabetes, estimated-glomerular filtration rate <45 mL/min, abnormal plasma K(+), clinic SBP >200 mm Hg or DBP >120 mm Hg (box 2). The sample size calculation indicates that 486 patients will give 80% power at α=0.01 to detect a difference in means of 1 mmol/L (SD=2.2) between 2 h glucose on hydrochlorothiazide and comparators. ETHICS AND DISSEMINATION PATHWAY-3 was approved by Cambridge South Ethics Committee, number 09/H035/19. The trial results will be published in a peer-reviewed scientific journal. TRIAL REGISTRATION NUMBERS Eudract number 2009-010068-41 and clinical trials registration number: NCT02351973.
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Affiliation(s)
- Morris J Brown
- Clinical Pharmacology Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Trial Executive for the British Hypertension Society's PATHWAY Programme of Trials
- Steering Committee for the British Hypertension Society's PATHWAY Programme of Trials
| | - Bryan Williams
- Trial Executive for the British Hypertension Society's PATHWAY Programme of Trials
- Steering Committee for the British Hypertension Society's PATHWAY Programme of Trials
- Institute of Cardiovascular Sciences, University College London, London, UK
| | - Thomas M MacDonald
- Trial Executive for the British Hypertension Society's PATHWAY Programme of Trials
- Steering Committee for the British Hypertension Society's PATHWAY Programme of Trials
- Medicines Monitoring Unit, Medical Research Institute, University of Dundee, Dundee, Tayside, UK
| | - Mark Caulfield
- Steering Committee for the British Hypertension Society's PATHWAY Programme of Trials
- William Harvey Institute, QMUL, London, UK
| | | | - Gordon McInnes
- Institute of Cardiovascular Medical Sciences, Western Infirmary, London, UK
| | - Peter Sever
- Steering Committee for the British Hypertension Society's PATHWAY Programme of Trials
- Centre of Circulatory Health, Imperial College, London, UK
| | - David J Webb
- Steering Committee for the British Hypertension Society's PATHWAY Programme of Trials
- Clinical Pharmacology Unit, University of Edinburgh, Edinburgh, UK
| | - Jackie Salsbury
- Clinical Pharmacology Unit, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Steve Morant
- Medicines Monitoring Unit, Medical Research Institute, University of Dundee, Dundee, Tayside, UK
| | - Ian Ford
- Trial Executive for the British Hypertension Society's PATHWAY Programme of Trials
- Steering Committee for the British Hypertension Society's PATHWAY Programme of Trials
- Robertson Centre, University of Glasgow, Glasgow, UK
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Takihata M, Nakamura A, Kondo Y, Kawasaki S, Kimura M, Terauchi Y. Comparison of Azelnidipine and Trichlormethiazide in Japanese Type 2 Diabetic Patients with Hypertension: The COAT Randomized Controlled Trial. PLoS One 2015; 10:e0125519. [PMID: 25938807 PMCID: PMC4418830 DOI: 10.1371/journal.pone.0125519] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 02/27/2015] [Indexed: 01/13/2023] Open
Abstract
Objective This study compared the efficacy and safety of azelnidipine with that of trichlormethiazide in Japanese type 2 diabetic patients with hypertension. Methods In a multicenter, open-label trial, 240 patients with adequately controlled diabetes (HbA1c ≤ 7.0%) under lifestyle modification and/or administration of hypoglycemic agents and inadequately controlled hypertension (systolic blood pressure [sBP] ≥ 130 mmHg or diastolic blood pressure [dBP] ≥ 80 mmHg) who were being treated with olmesartan were enrolled. Participants were randomly assigned to an azelnidipine group or a trichlormethiazide group and were followed up for 48 weeks. Main outcome measure was the difference in the change in HbA1c levels from the baseline values at 48 weeks between these two groups. Results Of the 240 subjects that were enrolled, 209 subjects (azelnidipine group: 103 patients, trichlormethiazide group: 106 patients) completed this trial. At 48 weeks, the following changes were observed in the azelnidipine and trichlormethiazide groups, respectively: HbA1c levels, 0.19 ± 0.52% and 0.19 ± 0.54%; sBP/dBP, -10.7 ± 9.6/-6.6 ± 6.6 mmHg and -7.1 ± 7.7/-3.3 ± 6.1 mmHg (P < 0.001 for both sBP and dBP). In both groups, dizziness (12 patients [11.7%] and 16 patients [15.1%]) and edema (16 patients [15.5%] and 7 patients [6.6%], P = 0.047) were observed during the 48-week follow-up period. Conclusions Azelnidipine was more effective for controlling blood pressure than trichlormethiazide in Japanese type 2 diabetes patients, whereas trichlormethiazide was more effective for reducing albuminuria than azelnidipine. Both of these agents, however, similarly exacerbated glycemic control in type 2 diabetic patients with hypertension. Trial Registration UMIN 000006081.
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Affiliation(s)
- Masahiro Takihata
- Department of Endocrinology and Metabolism, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Akinobu Nakamura
- Department of Endocrinology and Metabolism, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Yoshinobu Kondo
- Department of Endocrinology and Metabolism, Chigasaki Municipal Hospital, Chigasaki, Kanagawa, Japan
| | - Satsuki Kawasaki
- Department of Endocrinology and Metabolism, Shonan Fujisawa Tokushukai Hospital, Fujisawa, Kanagawa, Japan
| | - Mari Kimura
- Department of Endocrinology and Metabolism, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
| | - Yasuo Terauchi
- Department of Endocrinology and Metabolism, Yokohama City University School of Medicine, Yokohama, Kanagawa, Japan
- * E-mail:
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26
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Greathouse MK, Weir MR. The Role of ARBs Alone or with HCTZ in the Treatment of Hypertension and Prevention of Cardiovascular and Renal Complications. Postgrad Med 2015; 124:40-52. [DOI: 10.3810/pgm.2012.03.2535] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kalaitzidis R, Bakris G. Are Renin-Angiotensin-Aldosterone System Blockers Distinguishable Based on Cardiovascular and Renal Outcomes in Nephropathy? Postgrad Med 2015; 121:77-88. [DOI: 10.3810/pgm.2009.03.1979] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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28
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Teramachi H, Takahashi T, Tachi T, Noguchi Y, Nagasawa H, Ino Y, Mizui T, Goto C, Tsuchiya T. Influence of angiotensin II receptor blocker combination tablet prescription on drug number and cost. SAGE Open Med 2014; 2:2050312114563318. [PMID: 26770757 PMCID: PMC4712752 DOI: 10.1177/2050312114563318] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Accepted: 11/11/2014] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Combination therapy using an angiotensin II receptor blocker is expected to promote medication adherence and alleviate economic burden among patients by reducing the number of drugs taken, and thereby to lower associated medical costs. In the present retrospective study, we conducted a survey on the use of angiotensin II receptor blocker-containing combination tablets as anti-hypertensive drugs, in particular angiotensin II receptor blocker/diuretic and angiotensin II receptor blocker/calcium channel blocker combinations, in order to investigate the number of prescribed drugs and drug cost. METHODS We performed a retrospective study of patients who visited the outpatient clinic of GifuMunicipalHospital and received anti-hypertensive agents between June 2006 and December 2011. RESULTS No reductions in the number of prescribed drugs or drug cost were seen following a change in prescription to an angiotensin II receptor blocker/diuretic. Patients receiving an angiotensin II receptor blocker/calcium channel blocker had a significant reduction in the number of prescribed drugs and a slight decrease in drug cost. CONCLUSION In this study, a reduction in the number of prescribed drugs and a decrease in economic burden were not observed after prescription of angiotensin II receptor blocker-containing combination tablets. In order to assess the usefulness of angiotensin II receptor blocker combination tablets, further studies are necessary to investigate their hypotensive effects, safety profile, and other factors.
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Affiliation(s)
- Hitomi Teramachi
- Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Tatsuya Takahashi
- Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Tomoya Tachi
- Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Yoshihiro Noguchi
- Laboratory of Clinical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | | | - Yoko Ino
- Department of Pharmacy, Showa University Northern Yokohama Hospital, Japan
| | - Takashi Mizui
- Department of Pharmacy, Gifu Municipal Hospital, Gifu, Japan
| | - Chitoshi Goto
- Department of Pharmacy, Gifu Municipal Hospital, Gifu, Japan
| | - Teruo Tsuchiya
- Community Health Support and Research Center, Gifu, Japan
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Szentes V, Kovács G, Dézsi CA. Domestic practice of antihypertensive treatment of diabetic hypertensive patients. Orv Hetil 2014; 155:1695-700. [DOI: 10.1556/oh.2014.29988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Diabetes mellitus as comorbidity is present in 20–25% of patients suffering from high blood pressure. Because simultaneous presence of these two diseases results in a significant increase of cardiovascular risk, various guidelines focus greatly on the anti-hyperintensive treatment of patients with diabetes. Combined drug therapy is usually required to achieve the blood pressure target value of <140/85 mmHg defined for patients with diabetes, which must be based on angiotensin converting enzyme-inhibitors or angiotensin receptor blockers. These can be/must be combined with low dose, primarily thiazid-like diuretics, calcium channel blockers with neutral metabolic effect, and further options include the addition of beta blockers, imidazolin-l-receptor antagonists, or alpha-1-adrenoreceptor blockers. Evidence-based guidelines are obviously present in local practice. Although most of the patients receive angiotensin converting enzyme-inhibitor+indapamid or angiotensin converting enzyme-inhibitor+calcium channel blocker combined therapy with favorable metabolic effects, yet the use of angiotensin converting enzyme-inhibitors containing hidrochlorotiazide having diabetogenic potencial, and angiotensin receptor blocker fixed combinations is still widespread. Similarly, interesting therapeutic practice can be observed with the use of less differentiated beta blockers, where the 3rd generation carvediolol and nebivolol are still in minority. Orv. Hetil., 2014, 155(43), 1695–1700.
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Affiliation(s)
- Veronika Szentes
- Petz Aladár Megyei Oktató Kórház Kardiológiai Osztály Győr Vasvári Pál u. 2–4. 9024
| | - Gabriella Kovács
- Petz Aladár Megyei Oktató Kórház Kardiológiai Osztály Győr Vasvári Pál u. 2–4. 9024
| | - Csaba András Dézsi
- Petz Aladár Megyei Oktató Kórház Kardiológiai Osztály Győr Vasvári Pál u. 2–4. 9024
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Spinar J, Vitovec J, Soucek M. Anti-hypertensive strategies in patients with MEtabolic parameters, DIabetes mellitus and/or NephropAthy (the M E D I N A study). Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2014; 158:412-21. [DOI: 10.5507/bp.2013.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 07/02/2013] [Indexed: 11/23/2022] Open
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Ueda S, Morimoto T, Ando SI, Takishita SI, Kawano Y, Shimamoto K, Ogihara T, Saruta T. A randomised controlled trial for the evaluation of risk for type 2 diabetes in hypertensive patients receiving thiazide diuretics: Diuretics In the Management of Essential hypertension (DIME) study. BMJ Open 2014; 4:e004576. [PMID: 25031188 PMCID: PMC4120409 DOI: 10.1136/bmjopen-2013-004576] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Thiazide diuretics are one of the first choice antihypertensives but not optimally utilised because of concerns regarding their adverse effects on glucose metabolism. The Diuretics In the Management of Essential hypertension (DIME) study was designed, for the first time, to assess the risk for type 2 diabetes mellitus in patients with essential hypertension during antihypertensive treatment with low-dose thiazide diuretics compared to those not treated with diuretics. DESIGN Multicentre, unblinded, pragmatic, randomised, controlled trial with blinded assessment of end points and intention-to-treat analysis that was started in 2004 and finished in 2012. SETTING Hypertension clinics at 106 sites in Japan, including general practitioners' offices and teaching hospitals. PARTICIPANTS Non-diabetic patients with essential hypertension. INTERVENTIONS Antihypertensive treatment with low-dose thiazide diuretics at 12.5 mg/day of hydrochlorothiazide or equivalent (Diuretics group) or that without thiazide diuretics (No-diuretics group). MAIN OUTCOME The primary outcome was new onset of type 2 diabetes diagnosed according to WHO criteria and the criteria of Japanese Society of Diabetes. RESULTS 1130 patients were allocated to Diuretics (n=544) or No-diuretics group (n=586). Complete end point information was collected for 1049 participants after a median follow-up of 4.4 years. Diabetes developed in 25 (4.6%) participants in the Diuretics group, as compared with 29 (4.9%) in the No-diuretics group (HR 0.93; 95% CI 0.55 to 1.58; p=0.800). CONCLUSIONS Antihypertensive treatment with thiazide diuretics at low doses may not be associated with an increased risk for new onset of type 2 diabetes. This result might suggest safety of use of low doses of thiazide diuretics. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT00131846.
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Affiliation(s)
- Shinichiro Ueda
- Department of Clinical Pharmacology & Therapeutics, University of the Ryukyus, Okinawa, Japan
| | - Takeshi Morimoto
- Department of Internal Medicine, Hyogo Collage of Medicine, Nishinomiya, Japan
| | - Shin-ichi Ando
- Department of Cardiology, Saiseikai-Futsukaichi Hospital, Chikushino, Japan
- Sleep Apnea Centre, Kyushu University Hospital, Fukuoka, Japan
| | | | - Yuhei Kawano
- Division of Hypertension and Renal Medicine, National Cardiovascular Research Centre, Suita, Japan
| | | | - Toshio Ogihara
- Department of Geriatric Medicine, Osaka University, Suita, Japan
| | - Takao Saruta
- Department of Medicine, Keio University, Tokyo, Japan
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Takahashi T, Teramachi H, Tachi T, Noguchi Y, Nagasawa H, Mizui T, Goto C, Tsuchiya T. [Effects of the combination of angiotensin receptor blockers and thiazide diuretics on laboratory values (levels of serum potassium, sodium, and uric acid)]. YAKUGAKU ZASSHI 2014; 134:767-74. [PMID: 24882654 DOI: 10.1248/yakushi.14-00002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The combination of angiotensin receptor blockers (ARB) and a thiazide diuretic (hereafter, ARB/diuretic) is expected to improve patient adherence and increase the therapeutic effects because of the lower number of pills that require to be administered. In addition, an ARB/diuretic combination alleviates hypokalemia that frequently develops in patients receiving thiazide diuretics. In this study, we used electronic medical records to investigate the laboratory values (serum levels of potassium, sodium, and uric acid) of 194 ambulatory and hospitalized patients at the Gifu Municipal Hospital who received ARB/diuretic combination therapy for the first time between February 2010 and September 2012. According to the grade of classification of low serum potassium and sodium levels, the serum potassium level in one patient was grade 3 and the serum sodium level in two patients was grade 3 after the initiation of ARB/diuretic combination therapy. After administration of ARB/diuretic combination therapy, two patients received potassium supplements because their serum potassium levels decreased below the reference value. Similarly, one patient received a sodium supplement because of a decrease in the sodium level below the reference value. Uric acid level increased above the reference value after administration of the ARB/diuretic combination therapy in one patient; thus, this patient received antihyperuricemic agents. Therefore, pharmacists must carefully monitor the serum levels of potassium, sodium, and uric acid, particularly in the first six months after the initiation of ARB/diuretic combination therapy.
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Maldonado J, Pereira T, Tavares A. Efficacy and safety of a lercanidipine/enalapril fixed-dose combination in hypertensive patients in Portugal. Drugs R D 2014; 14:147-54. [PMID: 24831818 PMCID: PMC4070459 DOI: 10.1007/s40268-014-0046-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background Fixed-dose combinations of hypertensive drugs have been advocated as a suitable option for hypertensive patients who require two or more drugs to achieve blood pressure (BP) targets. Objectives Our objective was to assess the efficacy and safety of lercanidipine/enalapril in clinical practice. Methods This observational study collected data for patients with hypertension treated by 46 specialists at clinics across Portugal with lercanidipine/enalapril (10/20 mg). The primary outcome measure was the reduction from baseline in systolic BP (SBP) and diastolic BP (DBP). Results The registry enrolled 315 patients (59.1 % females; mean age 64.84 ± 12.18 years). Baseline SBP and DBP were 159.11 ± 16.93 and 88.32 ± 12.35 mmHg, respectively. At a mean 2.88 ± 1.75 months after starting lercanidipine/enalapril, the mean change from baseline in SBP and DBP were −18.08 ± 15.91 and −10.10 ± 11.46 mmHg, respectively (both p < 0.001). This corresponded to reductions of 11.4 and 11.3 % in SBP and DBP, respectively. SBP was reduced independently of sex and age, and DBP was reduced independently of sex. The BP control (<140/90 mmHg) rate significantly increased from 10.2 % at baseline to 51.0 % after a mean of 2.88 months of treatment with lercanidipine/enalapril (p < 0.001). Adverse effects were seen in only one patient (0.3 %), who developed a persistent dry cough. Conclusions Treatment with the fixed-dose combination lercanidipine/enalapril was associated with significant reductions in SBP and DBP, and a significant increase in the BP control rate. This fixed-dose combination has been shown to effectively reduce BP, generally independently of age and sex, and with an excellent safety profile.
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Affiliation(s)
- João Maldonado
- Instituto de Investigação e Formação Cardiovascular/Clínica da Aveleira, Quinta da Portela, Rua Princesa Sindazunda Lote 9.3/Loja 94, 3030-503, Coimbra, Portugal
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Reboldi G, Gentile G, Angeli F, Verdecchia P. Exploring the optimal combination therapy in hypertensive patients with diabetes mellitus. Expert Rev Cardiovasc Ther 2014; 7:1349-61. [DOI: 10.1586/erc.09.133] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Buscemi S, Nicolucci A, Lucisano G, Galvano F, Grosso G, Massenti FM, Amodio E, Bonura A, Sprini D, Rini GB. Impact of chronic diuretic treatment on glucose homeostasis. Diabetol Metab Syndr 2013; 5:80. [PMID: 24330854 PMCID: PMC3880098 DOI: 10.1186/1758-5996-5-80] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 12/10/2013] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The use of diuretics for hypertension has been associated with unfavorable changes in cardiovascular risk factors, such as uric acid and glucose tolerance, though the findings in the literature are contradictory. METHODS This study investigated whether diuretic use is associated with markers of metabolic and cardiovascular risk, such as insulin-resistance and uric acid, in a cohort of adults without known diabetes and/or atherosclerotic cardiovascular disease. Nine hundred sixty-nine randomly selected participants answered a questionnaire on clinical history and dietary habits. Laboratory blood measurements were obtained in 507 participants. RESULTS Previously undiagnosed type 2 diabetes was recognized in 4.2% of participants who were on diuretics (n = 71), and in 2% of those who were not (n = 890; P = 0.53). Pre-diabetes was diagnosed in 38% of patients who were on diuretics, and in 17.4% (P < 0.001) of those who were not. Multivariate analysis showed that insulin-resistance (HOMA-IR) was associated with the use of diuretics (P = 0.002) independent of other well-known predisposing factors, such as diet, physical activity, body mass index, and waist circumference. The use of diuretics was also independently associated with fasting plasma glucose concentrations (P = 0.001) and uric acid concentrations (P = 0.01). CONCLUSIONS The use of diuretics is associated with insulin-resistance and serum uric acid levels and may contribute to abnormal glucose tolerance.
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Affiliation(s)
- Silvio Buscemi
- Dipartimento Biomedico di Medicina Interna e Specialistica (DIBIMIS) – Laboratorio di Nutrizione Clinica, University of Palermo, Via del Vespro, 129, Palermo 90127, Italy
| | - Antonio Nicolucci
- Dipartimento di Farmacologia Clinica ed Epidemiologia, Consorzio Mario Negri Sud, Via Nazionale per Lanciano, 8, S. Maria Imbaro, Chieti, Italy
| | - Giuseppe Lucisano
- Dipartimento di Farmacologia Clinica ed Epidemiologia, Consorzio Mario Negri Sud, Via Nazionale per Lanciano, 8, S. Maria Imbaro, Chieti, Italy
| | - Fabio Galvano
- Dipartimento di Scienze del Farmaco, University of Catania, viale Andrea Doria,6, Catania 95124, Italy
| | - Giuseppe Grosso
- Dipartimento di Scienze del Farmaco, University of Catania, viale Andrea Doria,6, Catania 95124, Italy
| | - Fatima M Massenti
- Dipartimento di Scienze per la Promozione della Salute e Materno Infantile, University of Palermo, Via del Vespro, 129, Palermo 90128, Italy
| | - Emanuele Amodio
- Dipartimento di Scienze per la Promozione della Salute e Materno Infantile, University of Palermo, Via del Vespro, 129, Palermo 90128, Italy
| | - Alice Bonura
- Dipartimento Biomedico di Medicina Interna e Specialistica (DIBIMIS) – Laboratorio di Nutrizione Clinica, University of Palermo, Via del Vespro, 129, Palermo 90127, Italy
| | - Delia Sprini
- Dipartimento Biomedico di Medicina Interna e Specialistica (DIBIMIS) – Laboratorio di Nutrizione Clinica, University of Palermo, Via del Vespro, 129, Palermo 90127, Italy
| | - Giovam B Rini
- Dipartimento Biomedico di Medicina Interna e Specialistica (DIBIMIS) – Laboratorio di Nutrizione Clinica, University of Palermo, Via del Vespro, 129, Palermo 90127, Italy
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Simonyi G. [Advantages of ramipril/amlodipin fixed combination therapy. When should we use it?]. Orv Hetil 2013; 154:1658-64. [PMID: 24121218 DOI: 10.1556/oh.2013.29715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Hypertension is one of the most frequent chronic disease in Hungary and one of the most important cardiovascular risk factor. Treatment of blood pressure to target value lowers significantly the risk of coronary artery disease, stroke and chronic renal disease as well as it decreases mortality. Blood pressure control has a great importance in high risk patients. In addition to life style changes, drug treatment plays an essential role in the management of hypertensive patients. The complexity of drug regimen, characteristics of drug class, age and gender are all exert impacts on patient adherence. Antihypertensive drugs should preferably have metabolically neutral properties and cardiovascular protective effects. Ramipril/amlodipine fixed combination meets these criteria and adherence of patients is favorable.
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Affiliation(s)
- Gábor Simonyi
- Szent Imre Egyetemi Oktatókórház Anyagcsere Központ Budapest Tétényi út 12-16. 1115
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Ferdinand KC, Nasser SA. A review of the efficacy and tolerability of combination amlodipine/valsartan in non-white patients with hypertension. Am J Cardiovasc Drugs 2013; 13:301-13. [PMID: 23784267 PMCID: PMC3781303 DOI: 10.1007/s40256-013-0033-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
This article discusses racial/ethnic disparities in hypertension, with particular focus on non-white populations including blacks, Hispanics/Latinos, and Asians. Hypertension and its related morbidity and mortality affect a disproportionate number of black patients compared with white patients. Blacks, Hispanics/Latinos, and Asians have poor rates of hypertension awareness, treatment, and control. Given the high prevalence of comorbidities (e.g., obesity, diabetes, and metabolic syndrome) in these populations, renin–angiotensin–aldosterone system blockers are a good choice for foundation therapy. This review also discusses the importance of adherence and persistence with antihypertensive medication, which remain suboptimal in these non-white populations. Evidence suggests improvement with the use of single-pill combination therapy. Lastly, clinical trial data on the antihypertensive efficacy and safety of the combination of a dihydropyridine calcium channel blocker and an angiotensin receptor blocker, a widely utilized combination, in non-white populations are presented. PubMed was searched using the title/abstract key words (amlodipine AND valsartan AND [hypertension OR hypertensive] AND [black(s) OR African American(s) OR Hispanic(s) OR Latino(s) OR Mexican(s) OR Asian(s)]). In total, eight studies in patients with stage 1 or 2 hypertension were identified (n = 1,111 black, n = 389 Hispanic/Latino, and n = 3,094 Asian). Results showed that treatment with the combination of amlodipine plus valsartan is a reasonable choice for initial therapy or in patients who fail to respond to monotherapy. These drug classes have complementary mechanisms of action and, when used concomitantly, the magnitude of blood pressure lowering in these non-white populations is generally comparable with that seen in non-Hispanic white patients.
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Affiliation(s)
- Keith C Ferdinand
- Division of Cardiology, Tulane University School of Medicine, and Association of Black Cardiologists, Inc., 1430 Tulane Ave., SL-48, New Orleans, LA, 70112, USA,
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Merchant N, Rahman ST, Ahmad M, Parrott JM, Johnson J, Ferdinand KC, Khan BV. Changes in biomarkers and 24 hours blood pressure in hypertensive African Americans with the metabolic syndrome: Comparison of amlodipine/olmesartan versus hydrochlorothiazide/losartan. ACTA ACUST UNITED AC 2013; 7:386-94. [DOI: 10.1016/j.jash.2013.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/06/2013] [Accepted: 05/06/2013] [Indexed: 01/03/2023]
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Price AL, Lingvay I, Szczepaniak EW, Wiebel J, Victor RG, Szczepaniak LS. The metabolic cost of lowering blood pressure with hydrochlorothiazide. Diabetol Metab Syndr 2013; 5:35. [PMID: 23837919 PMCID: PMC3711837 DOI: 10.1186/1758-5996-5-35] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 07/05/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The landmark Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT) placed a new spotlight on thiazide diuretics as the first-line therapy for hypertension. This is concerning as thiazide-diuretics may contribute to comorbidities associated with the current epidemic of obesity. Previous randomized clinical trials have linked thiazide diuretic treatment to insulin resistance, metabolic syndrome, and increased incidence of type 2 diabetes. METHODS This proof of concept, longitudinal, randomized, double-blind study evaluated the effects of the angiotensin II receptor blocker Valsartan and the specific thiazide diuretic Hydrochlorothiazide (HCTZ) on hepatic triglyceride level (primary outcome), as well as triglyceride levels within other organs including the heart, skeletal muscle, and pancreas. Additionally, we evaluated whether myocardial function, insulin sensitivity, and insulin secretion were affected by these treatments. RESULTS Hepatic TG levels increased by 57% post HCTZ treatment: ∆hTG HCTZ = 4.12% and remained unchanged post Valsartan treatment: ∆hTG V = 0.06%. The elevation of hepatic TG levels after HCTZ treatment was additionally accompanied by a reduction in insulin sensitivity: ∆SI HCTZ = -1.14. Treatment with Valsartan resulted in improved insulin sensitivity: ∆SI V = 1.24. Treatment-induced changes in hepatic TG levels and insulin sensitivity were statistically significant between groups (phTG = 0.0098 and pSI = 0.0345 respectively). Disposition index, DI, remained unchanged after HCTZ treatment: ∆DI HCTZ = -141 but it was increased by a factor of 2 after treatment with Valsartan: ∆DI V =1018). However, the change between groups was not statistically significant. Both therapies did not modify abdominal visceral and subcutaneous fat mass as well as myocardial structure and function. Additionally, myocardial, pancreatic, and skeletal muscle triglyceride deposits remained unchanged in both therapeutic arms. CONCLUSIONS Our findings are two-fold and relate to hepatic steatosis and insulin sensitivity. HCTZ treatment worsened hepatic steatosis measured as hepatic triglyceride content and reduced insulin sensitivity. Valsartan treatment did not affect hepatic triglyceride levels and improved insulin sensitivity. The results of this study reinforce the message that in patients at risk for type 2 diabetes it is particularly important to choose an antihypertensive regimen that lowers blood pressure without exacerbating patient's metabolic profile.
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Affiliation(s)
- Angela L Price
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ildiko Lingvay
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | | | - Jaime Wiebel
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ronald G Victor
- Cedars -Sinai Medical Center, The Heart Institute, Los Angeles, California, USA
| | - Lidia S Szczepaniak
- Cedars -Sinai Medical Center, The Heart Institute, Los Angeles, California, USA
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Wehling M. Morbus Diureticus in the Elderly: Epidemic Overuse of a Widely Applied Group of Drugs. J Am Med Dir Assoc 2013; 14:437-42. [DOI: 10.1016/j.jamda.2013.02.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 02/04/2013] [Accepted: 02/05/2013] [Indexed: 01/23/2023]
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Nishimura H, Shintani M, Maeda K, Otoshi K, Fukuda M, Okuda J, Nishi S, Ohashi S, Kato S, Baba Y. Which is a better treatment for hypertensive patients with diabetes: a combination of losartan and hydrochlorothiazide or a maximum dose of losartan? Clin Exp Hypertens 2013; 35:582-8. [PMID: 23496265 DOI: 10.3109/10641963.2013.776564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND This 12-month study compared the effects of a combination of losartan 50 mg and hydrochlorothiazide 12.5 mg with a maximum dose of losartan (100 mg) in hypertensive patients with diabetes. METHODS This was a multicenter randomized open-label study. RESULTS A similar reduction in systolic/diastolic blood pressure from baseline to month 3 was observed in both groups. There was also a similar decrease in UACR in both groups. A significant decrease in uric acid was observed in the maximum-dose group only. eGFR decreased in the combination group after 1 year. CONCLUSIONS The combination of losartan and a diuretic may be a useful option in such hypertensive patients with diabetes, provided that metabolic parameters are closely monitored. In patients with hyperuricemia and impaired renal function, a maximum dose of losartan may be more beneficial.
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Affiliation(s)
- Haruo Nishimura
- Division of Diabetes and Endocrinology, Osaka Saiseikai Nakatsu Hospital , Osaka , Japan
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Affiliation(s)
- Franz H Messerli
- Division of Cardiology, St Luke's Roosevelt Hospital, Columbia University College of Physicians and Surgeons, New York, NY 10019, USA.
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Yamamuro M, Yamamoto K, Kan H, Takashio S, Tayama S, Kaikita K, Hokimoto S, Sumida H, Sugiyama S, Ogawa H. Effects of a Fixed Combination of Losartan With Hydrochlorothiazide on Glucose Tolerance in Hypertensive Patients Uncontrolled with Angiotensin II Receptor Blockers Alone. J Atheroscler Thromb 2013; 20:238-44. [DOI: 10.5551/jat.14464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Chapter 2: Lifestyle and pharmacological treatments for lowering blood pressure in CKD ND patients. Kidney Int Suppl (2011) 2012; 2:347-356. [PMID: 25018961 PMCID: PMC4089631 DOI: 10.1038/kisup.2012.52] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Standl E, Erbach M, Schnell O. What should be the antihypertensive drug of choice in diabetic patients and should we avoid drugs that increase glucose levels? Pro and Cons. Diabetes Metab Res Rev 2012; 28 Suppl 2:60-6. [PMID: 23280868 DOI: 10.1002/dmrr.2355] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
It has long been known that antihypertensive drugs may affect blood glucose in a differential manner. In particular new onset diabetes is significantly increased in association with the use of thiazides or beta-blockers, respectively, compared to placebo, whereas treatment with angiotensin-conversion-enzyme-inhibitors or angiotensin-receptor-blockers is associated with a lower than expected frequency, as also assessed in several meta-analyses. In line with these notions, the NAVIGATOR Trial was the first to report a significant preventive effect of an angiotensin-receptor-blocker on new onset diabetes evaluated as a primary outcome in a prospective randomized study. Hence, and in view of the fact that comparable blood pressure lowering with any of the five major classes of antihypertensive drugs, including calcium-channel-blockers, give comparable benefits in reducing cardiovascular complications, unless there are specific indications or contraindications for an individual drug, caution should be exercised, therefore, to use beta-blockers or thiazides as first-line drugs for blood pressure lowering indications in subjects at high risk to develop diabetes, especially in patients with so called metabolic syndrome. The potential of glycemic worsening in overt diabetic patients with thiazides or beta-blockers has less well been studied systematically, yet paradigmatically in UKPDS evaluating a randomized comparison of a beta-blocker with an angiotensin-conversion-enzyme(ACE)-inhibitor. Not only was there HbA1c worsening with beta-blocker use which required additional blood glucose lowering therapy, but also significantly more weight gain which still was detectable at the 20 year follow-up. On the other hand, the overall cardiovascular outcomes were comparable in the two treatment groups irrespective whether therapy was based on the beta blocker atenolol or the ACE-inhibitor captopril. Awareness of these facts and highly individualized therapy seem to be the way forward.
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Affiliation(s)
- Eberhard Standl
- Munich Diabetes Research Group e.V., Munich Helmholtz Centre, Ingolstaedter Landstrasse 1, Munich-Neuherberg, Germany.
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Bakris GL, Sowers JR. Treatment of hypertension in patients with diabetes-an update. ACTA ACUST UNITED AC 2012; 3:150-5. [PMID: 20409955 DOI: 10.1016/j.jash.2009.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- George L Bakris
- Hypertensive Diseases and Diabetes Center, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
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Abstract
Systemic hypertension is a long-term risk factor for the development of atherosclerotic vascular disease and when uncontrolled is a short-term trigger of acute vascular events such as acute coronary syndromes and stroke. Thus, rapid reduction in BP is desirable. Patients at high risk for vascular disease, such as those with diabetes mellitus, have aggressive goal BP targets because studies have shown that achieving these targets reduces events. Given the dual goals in high-risk patients of reducing BP quickly and to aggressively low targets, the classic 'step therapy' of one drug titrated at a time to reduce BP is inadequate. Combination therapy with at least two potent medications makes more sense, and manufacturers are now increasing their offerings of single-pill combinations for hypertension. Combination pills are popular with patients and increase compliance with therapy. Many believe that renin-angiotensin aldosterone system (RAAS) blockers are the cornerstone of hypertension treatment in patients at high risk for vascular disease. The newer combination pills include a RAAS blocker and diuretics or a long-acting calcium channel antagonist (CCA). Recent studies have shown that a RAAS blocker plus a dihydropyridine CCA is superior to older diuretic-based combinations for preventing cardiovascular events. These considerations support a new approach to the higher risk hypertensive patient: effective doses of RAAS blocker/CCA combination pills to rapidly lower BP to <130/80 mmHg.
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Affiliation(s)
- Michael H Crawford
- Division of Cardiology, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California 94143-0124, USA.
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Suárez C. Single-pill telmisartan and amlodipine: a rational combination for the treatment of hypertension. Drugs 2012; 71:2295-305. [PMID: 22085386 DOI: 10.2165/11594510-000000000-00000] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Despite the well documented benefits conferred by adequate control of hypertension, the majority of hypertensive patients display suboptimal control and few patients achieve blood pressure (BP) levels <140/90 mmHg. As a consequence, combination therapy will be required in the majority of patients to achieve target BP. Fixed-dose combinations of antihypertensives not only simplify treatment regimens, contributing to enhanced patient adherence, they provide superior BP-lowering efficacy and an improved tolerability profile. Fixed-dose combinations have become the strategy of choice in high-risk patients or those with stage 2-3 hypertension. The combination of a renin-angiotensin system inhibitor (RASI) with a calcium channel blocker (CCB) is a first-line combination that, in addition to its antihypertensive efficacy, reduces oedema, the main adverse effect of the dihydropyridine CCB and the main factor limiting their use. In morbidity/mortality studies, this fixed-dose combination has also demonstrated superiority over a RASI combined with a diuretic. The single-pill combination of telmisartan and amlodipine has been shown to produce a dose-dependent BP-lowering effect significantly greater than that of either agent administered as monotherapy. These findings have been confirmed by ambulatory BP monitoring in patients with stage 1 and 2 hypertension, which demonstrated that single-pill telmisartan/amlodipine provides substantial 24-hour BP-lowering efficacy. A higher proportion of patients achieved 24-hour BP goals of <130/80 mm Hg on combination therapy. The superior efficacy of combination therapy has been demonstrated across a broad range of patients, including those with moderate-to-severe hypertension, diabetes mellitus and obesity. Moreover, combined use of telmisartan and amlodipine reduces the incidence of amlodipine-induced oedema, making it a preferred combination for the treatment of hypertension.
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Affiliation(s)
- Carmen Suárez
- Hypertension and Vascular Risk Unit, Department of Internal Medicine, Hospital Universitario de La Princesa, Madrid, Spain.
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Deedwania PC, Zappe DH, Egan BM, Purkayastha D, Samuel R, Sowers JR. Does response of RAS blockade on serum K+ levels influence its glycemic-mitigating response when combined with hydrochlorothiazide? J Clin Hypertens (Greenwich) 2012; 14:415-21. [PMID: 22747613 DOI: 10.1111/j.1751-7176.2012.00635.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The authors previously reported that addition of valsartan ameliorated the negative metabolic effects of hydrochlorothiazide in obese hypertensive patients through an enhanced postprandial insulin response. In this secondary analysis, the authors tested whether this enhanced insulin response to valsartan/hydrochlorothiazide was influenced by serum potassium levels, which were reduced to a lesser extent, when compared with amlodipine/hydrochlorothiazide. Results showed that the early insulin response with valsartan plus hydrochlorothiazide occurred regardless of serum potassium levels. Heightened insulin response was, however, not significantly different when patients with normal potassium (>3.9 mEq/L) at baseline and low potassium (≤3.9 mEq/L) at the end of the study were compared with the amlodipine/hydrochlorothiazide group. Despite the influence of serum potassium on insulin secretory response to a glucose challenge, the addition of valsartan maintained normoglycemia in patients given hydrochlorothiazide. Thus, the metabolic response to hydrochlorothiazide was improved with addition of valsartan through an enhanced insulin response that was not greatly affected by changes in potassium levels.
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Affiliation(s)
- Prakash C Deedwania
- Cardiology Division, University of California at San Francisco School of Medicine, San Francisco, CA, USA.
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