Comparison of the efficacy and tolerability of ivabradine and ranolazine in patients of chronic stable angina pectoris

Assessment of safety profile of ivabradine in real-world scenario using FDA adverse event reporting system database

BACKGROUND

Ivabradine is primarily indicated for patients with sinus rhythm and a heart rate ≥ 75 beats/min, who have NYHA class II-IV chronic heart failure with systolic dysfunction. There is currently a lack of large-scale, real-world studies concerning its drug adverse reactions.

RESEARCH DESIGN & METHODS

This research assesses the side effects of ivabradine by analyzing reports of adverse events (AEs) from the FDA's Adverse Event Reporting System (FAERS) database. To evaluate the importance of these AEs, four sequential analytic strategies were utilized.

RESULTS

In total, 2,701 ivabradine-related AE reports were identified in the FAERS database. We identified 26 ivabradine-induced AEs, each with more than 20 reports, including some significant AEs not mentioned on the product label. The timing of AEs was also analyzed, with the majority of AEs occurring within the first month of ivabradine use. Gender-specific analysis indicates that female have a higher risk of AEs, such as off-label use, tachycardia, drug effectiveness for unapproved indications, and rash compared to male.

CONCLUSION

This study provides important information for maximizing the usage of ivabradine, increasing its efficacy, and reducing any possible negative effects. The actual clinical use of the medication will be greatly aided by this knowledge.

Ranolazine Versus Allopurinol for Eligible Symptomatic Patients With a History of Angioplasty: Comparative Efficacy Study

Background

Recurrent angina, which is defined as a return of chest pain or chest discomfort, occurs in many patients undergoing coronary interventions.

Objective

This study aims to compare the antianginal efficacy of ranolazine versus allopurinol for eligible symptomatic patients with a history of angioplasty.

Methods

A total of 62 eligible symptomatic patients with a history of angioplasty were randomly allocated into two groups. For group A, 300 mg of allopurinol was administered twice daily, while for group B, 1000 mg of ranolazine daily was prescribed for a duration of 4 weeks. An initial screening visit was done for all participants where patients’ medical history was recorded and a physical examination was given; electrocardiography, blood pressure, and heart rate measurements were done as well. The patients were also given a blood and exercise test. At the end of the medication period, participants were revisited, and the tests were done again. All the required data were collected via a researcher-made form, and data analysis was conducted using SPSS. The study was approved by a formal ethics committee.

Results

The mean age of participants in the two groups (A and B) was 57.36 (SD 8.36) and 60.27 (SD 9.17) years, respectively. Among the 62 patients, 34 (59%) were men, while 28 (41%) were women. Creatinine, fasting blood sugar, C-reactive protein, N-terminal prohormone of brain natriuretic protein, uric acid, white blood cell, and hemoglobin levels of participants were not significantly different between groups (P>.05). Both allopurinol and ranolazine increased the total exercise time and decreased the ST depression of the patients. Additionally, they both improved the chest pain severity and Duke Treadmill Score of patients. At the same time, ranolazine had a statistically greater effect on ST depression reduction (mean 2.64, SD 0.74 vs mean 1.57, SD 0.49), while allopurinol showed better efficacy in reducing chest pain severity (mean 1.86, SD 0.37 vs mean 0.59, SD 0.21) and the Duke Treadmill Score (mean –14.77, SD 3.65 vs mean –6.88, SD 1.93).

Conclusions

Based on the results, the antianginal efficacy of allopurinol and ranolazine was approved but with different effects on ST depression, chest pain severity, and the Duke Treadmill Score. Therefore, the precise differences in their effects need to be explored further.

The HCN Channel Blocker ZD7288 Induces Emesis in the Least Shrew (Cryptotis parva)

Subtypes (1-4) of the hyperpolarization-activated cyclic nucleotide-gated (HCN) channels are widely expressed in the central and peripheral nervous systems, as well as the cells of smooth muscles in many organs. They mainly serve to regulate cellular excitability in these tissues. The HCN channel blocker ZD7288 has been shown to reduce apomorphine-induced conditioned taste aversion on saccharin preference in rats suggesting potential antinausea/antiemetic effects. Currently, in the least shew model of emesis we find that ZD7288 induces vomiting in a dose-dependent manner, with maximal efficacies of 100% at 1 mg/kg (i.p.) and 83.3% at 10 µg (i.c.v.). HCN channel subtype (1-4) expression was assessed using immunohistochemistry in the least shrew brainstem dorsal vagal complex (DVC) containing the emetic nuclei (area postrema (AP), nucleus tractus solitarius and dorsal motor nucleus of the vagus). Highly enriched HCN1 and HCN4 subtypes are present in the AP. A 1 mg/kg (i.p.) dose of ZD7288 strongly evoked c-Fos expression and ERK1/2 phosphorylation in the shrew brainstem DVC, but not in the in the enteric nervous system in the jejunum, suggesting a central contribution to the evoked vomiting. The ZD7288-evoked c-Fos expression exclusively occurred in tryptophan hydroxylase 2-positive serotonin neurons of the dorsal vagal complex, indicating activation of serotonin neurons may contribute to ZD7288-induced vomiting. To reveal its mechanism(s) of emetic action, we evaluated the efficacy of diverse antiemetics against ZD7288-evoked vomiting including the antagonists/inhibitors of: ERK1/2 (U0126), L-type Ca2+ channel (nifedipine); store-operated Ca2+ entry (MRS 1845); T-type Ca2+ channel (Z944), IP3R (2-APB), RyR receptor (dantrolene); the serotoninergic type 3 receptor (palonosetron); neurokinin 1 receptor (netupitant), dopamine type 2 receptor (sulpride), and the transient receptor potential vanilloid 1 receptor agonist, resiniferatoxin. All tested antiemetics except sulpride attenuated ZD7288-evoked vomiting to varying degrees. In sum, ZD7288 has emetic potential mainly via central mechanisms, a process which involves Ca2+ signaling and several emetic receptors. HCN channel blockers have been reported to have emetic potential in the clinic since they are currently used/investigated as therapeutic candidates for cancer therapy related- or unrelated-heart failure, pain, and cognitive impairment.

Management of Chronic Stable Angina

Chronic stable angina (CSA) is a symptomatic problem that is precipitated by ischemic heart disease. CSA is diagnosed when symptoms are present for at least 2 months without changes in severity, character, or triggering circumstances. This article is a summary of current treatment strategies aimed to prevent progression of atherosclerosis, and medication therapies to control angina symptoms and improve quality of life for the individual.

[Triple antianginal combinations in the treatment of elderly and senile patients with stable angina]

AIM

To compare the efficiency and safety of antianginal therapy (AAT) using a combination of bisoprolol, ivabradine, and trimetazidine or ranolazine in elderly and senile patients with stable angina.

SUBJECTS AND METHODS

The study enrolled 107 patients aged 60 to 79 years with coronary heart disease and Functional Class II and III angina. When the patients taking bisoprolol 1.25-2.5 mg once daily and ivabradine 2.5-7.5 mg twice daily continued to have angina and/or silent myocardial ischemia, after randomization 54 patients received an additional 35 mg of trimetazidine twice a day and 53 patients had ranolazine 500 mg twice daily. A comprehensive clinical and instrumental study was conducted prior to randomization and after 6 months of triple AAT.

RESULTS

The patients tolerated well both treatments that substantially improved the results of a treadmill exercise test. Trimetazidine reduced to a greater extent the duration of silent ST-segment depression, as evidenced by Holter monitoring. Trimetazidine and ranolazine comparably improved left ventricular systolic and diastolic function, large arterial structure and function, and quality of life in the patients.

CONCLUSION

The combinations of the low-dose β-blocker with ivabradine and trimetazidine or ranolazine may be used to treat refractory stable angina in elderly and senile patients. Trimetazidine is preferred due to its higher efficacy in treating silent myocardial ischemia and to its lower cost.

Safety reporting through a comprehensive and pragmatic pharmcovigilance process for India and emerging markets: an industry perspective

INTRODUCTION

Pharmacovigilance (PV) deals with the drug-related adverse reactions ensuring patients' safety. Emerging markets of India, South East Asia (SEA), Russia, Latin America (LA), Middle East and North Africa (MENA) have developed their own PV programs. However, under/manual reporting accompanied with lack of awareness regarding adverse drug reactions (ADRs) are major drawbacks that continue to exist due to lack of co-ordination and disparity in the regulatory approach.

AREAS COVERED

Of the 118 studies identified using various databases, 60 were included for the review. The authors discuss the present PV scenario of India, SEA, Russia, LA and MENA, and explain a basic process for uniform PV data input-output across industry, which includes data collection, analysis, processing, causality assessment and data distribution systems.

EXPERT OPINION

As the number of clinical trials conducted are rising in the emerging markets, there is a need to understand and implement a robust PV system, where electronically globalized, evidence based, public health oriented and regulatory compliant PV system is established. This would also improve transparency in system and ensure enhancement in safety data reporting ensuring premature and trouble-free detection of ADRs. It might result in implementing various PV boosting activities, which could yield robust patient safety data from India and emerging markets.

Ranolazine and Ivabradine: two different modalities to act against ischemic heart disease

Among the innovative drugs recently introduced for the management of chronic stable angina, Ranolazine and ivabradine represent two most true innovations. In fact, even if both drugs act by reducing myocardial work and thus oxygen consumption, this happens by a peculiar mechanism unlike that of conventional antischemic drugs. Ranolazine mediates its antianginal effects by the inhibition of cardiac late sodium current. This improves myocardial relaxation favoring myocardial perfusion. Ivabradine is a selective If channel blocker and acts by reducing firing rate of pacemaker cells in the sinoatrial node, without affecting the duration of action potential. The reduction of heart rate causes a reduction of left ventricular end diastolic pressure and increases the time useful to coronary flow by a prolongation of the diastole. A body of evidence found that two drugs are useful in ischemic patients whether at rest or during exercise. In addition, they can be used in monotherapy or in association with other conventional anti-ischemic drugs. The two medications could be used with advantage also in microvascular angina when standard therapy is ineffective. Thus, the two drugs represent an adjunctive and powerful therapeutic modality for the treatment of chronic stable angina, especially when conventional antianginal drugs were insufficient or inadequate.