Aldosterone Synthase Inhibition With Lorundrostat for Uncontrolled Hypertension: The Target-HTN Randomized Clinical Trial

Importance

Excess aldosterone production contributes to hypertension in both classical hyperaldosteronism and obesity-associated hypertension. Therapies that reduce aldosterone synthesis may lower blood pressure.

Objective

To compare the safety and efficacy of lorundrostat, an aldosterone synthase inhibitor, with placebo, and characterize dose-dependent safety and efficacy to inform dose selection in future trials.

Design, Setting, and Participants

Randomized, placebo-controlled, dose-ranging trial among adults with uncontrolled hypertension taking 2 or more antihypertensive medications. An initial cohort of 163 participants with suppressed plasma renin (plasma renin activity [PRA] ≤1.0 ng/mL/h) and elevated plasma aldosterone (≥1.0 ng/dL) were enrolled, with subsequent enrollment of 37 participants with PRA greater than 1.0 ng/mL/h.

Interventions

Participants were randomized to placebo or 1 of 5 dosages of lorundrostat in the initial cohort (12.5 mg, 50 mg, or 100 mg once daily or 12.5 mg or 25 mg twice daily). In the second cohort, participants were randomized in a 1:6 ratio to placebo or lorundrostat, 100 mg once daily.

Main Outcomes and Measures

The primary end point was change in automated office systolic blood pressure from baseline to study week 8.

Results

Between July 2021 and June 2022, 200 participants were randomized, with final follow-up in September 2022. Following 8 weeks of treatment in participants with suppressed PRA, changes in office systolic blood pressure of -14.1, -13.2, -6.9, and -4.1 mm Hg were observed with 100 mg, 50 mg, and 12.5 mg once daily of lorundrostat and placebo, respectively. Observed reductions in systolic blood pressure in individuals receiving twice-daily doses of 25 mg and 12.5 mg of lorundrostat were -10.1 and -13.8 mm Hg, respectively. The least-squares mean difference between placebo and treatment in systolic blood pressure was -9.6 mm Hg (90% CI, -15.8 to -3.4 mm Hg; P = .01) for the 50-mg once-daily dose and -7.8 mm Hg (90% CI, -14.1 to -1.5 mm Hg; P = .04) for 100 mg daily. Among participants without suppressed PRA, 100 mg once daily of lorundrostat decreased systolic blood pressure by 11.4 mm Hg (SD, 2.5 mm Hg), which was similar to blood pressure reduction among participants with suppressed PRA receiving the same dose. Six participants had increases in serum potassium above 6.0 mmol/L that corrected with dose reduction or drug discontinuation. No instances of cortisol insufficiency occurred.

Conclusions and Relevance

Among individuals with uncontrolled hypertension, use of lorundrostat was effective at lowering blood pressure compared with placebo, which will require further confirmatory studies.

Trial Registration

ClinicalTrials.gov Identifier: NCT05001945.

Straight talk with...BT Slingsby. Interviewed by Cassandra Willyard

Japan boasts the second-largest pharmaceutical industry in the world. With its rich background in medical research, the country has turned its attention to diseases of the developing world with this year's launch of the Global Health Innovative Technology (GHIT) Fund--a new public-private partnership between five Japanese pharmaceutical companies, two government ministries and the Bill & Melinda Gates Foundation. In November, the Tokyo-based fund announced its first round of awards totaling $5.7 million. The six grants will go to partnerships aimed at developing new drugs and vaccines to fight malaria, tuberculosis and Chagas disease, a neglected disease endemic to Latin America. Leading the new $120 million, five-year initiative is BT Slingsby, a US-born scholar of the Japanese healthcare industry who most recently served as director of global partner solutions at Eisai, a Tokyo-based drugmaker. On a recent trip to New York, Slingsby, who serves as GHIT's executive director and CEO, met with Cassandra Willyard to discuss the new fund and how Japan can help drive development of medicines and vaccines for diseases of the developing world.

Translation and linguistic validation of the Allergy-CONTROL-ScoreTM for use in Japan

BACKGROUND

Symptom and medication scores are recommended to measure the primary outcome on allergies. The Allergy Control Score was proved to be a valid and reliable instrument to assess allergy severity in clinical trials and may be used in observational studies of respiratory allergic diseases in many countries. We translated the Allergy Control Score and adapted it for use in Japan.

METHODS

We translated the original English version into Japanese according to the Mapi approach to linguistic validation: conceptual definition, forward translation by two native Japanese speakers, reconciliation, back-translation by an independent translator, review in consultation with original developer, and pilot testing on 12 patients of an allergy clinic and 3 volunteers with seasonal/non-seasonal allergic rhinitis and/or asthma.

RESULTS

Two of the ten back-translated items needed slight modifications and some words were revised. In the pilot test, the average time required to complete the questionnaire was 55 seconds for the section on symptoms and 25 seconds for the section on medication. All participants were able to self-complete the questionnaire.

CONCLUSIONS

By applying the Mapi approach to linguistic validation, we ensured a close match between the Japanese and English versions of the Allergy Control Score. The Allergy Control Score Japanese version is accessible and acceptable to persons with respiratory allergic symptoms in Japan.

Accelerating the development of a therapeutic vaccine for human Chagas disease: rationale and prospects

Chagas disease is a leading cause of heart disease affecting approximately 10 million people in Latin America and elsewhere worldwide. The two major drugs available for the treatment of Chagas disease have limited efficacy in Trypanosoma cruzi-infected adults with indeterminate (patients who have seroconverted but do not yet show signs or symptoms) and determinate (patients who have both seroconverted and have clinical disease) status; they require prolonged treatment courses and are poorly tolerated and expensive. As an alternative to chemotherapy, an injectable therapeutic Chagas disease vaccine is under development to prevent or delay Chagasic cardiomyopathy in patients with indeterminate or determinate status. The bivalent vaccine will be comprised of two recombinant T. cruzi antigens, Tc24 and TSA-1, formulated on alum together with the Toll-like receptor 4 agonist, E6020. Proof-of-concept for the efficacy of these antigens was obtained in preclinical testing at the Autonomous University of Yucatan. Here the authors discuss the potential for a therapeutic Chagas vaccine as well as the progress made towards such a vaccine, and the authors articulate a roadmap for the development of the vaccine as planned by the nonprofit Sabin Vaccine Institute Product Development Partnership and Texas Children's Hospital Center for Vaccine Development in collaboration with an international consortium of academic and industrial partners in Mexico, Germany, Japan, and the USA.

A model of learning clinical reasoning at a US-based workshop: interactive reasoning

BACKGROUND

Since 2001 the University of Hawaii School of Medicine has conducted a 5-day workshop on clinical reasoning for Japanese medical students. To determine how Japanese medical students learn clinical reasoning at a US-based educational workshop.

MATERIAL/METHODS

This qualitative study used 20 semi-structured interviews with students, non-participant observation, and videotapes of 40 standardized-patient encounters.

RESULTS

Participants initially struggled with linguistic and cultural differences, then acquired an understanding of medical interviewing. Students understood clinical reasoning as a process of connecting with the patient using rapport building in order to gather information necessary to form a differential diagnosis and test hypotheses in conjunction with the physical examination. These findings supported a model of Interactive Reasoning.

CONCLUSIONS

Our findings suggest that foreign medical students can overcome linguistic and cultural barriers at a US-based workshop and acquire an understanding of medical interviewing and clinical reasoning.

Characteristics of qualitative studies in influential journals of general medicine: a critical review

Although qualitative studies have increased since the 1990s, some reports note that relatively few influential journals published them up until 2000. This study critically reviewed the characteristics of qualitative studies published in top tier medical journals since 2000. We assessed full texts of qualitative studies published between 2000 and 2004 in the Annals of Internal Medicine, BMJ, JAMA, Lancet, and New England Journal of Medicine. We found 80 qualitative studies, of which 73 (91%) were published in BMJ. Only 10 studies (13%) combined qualitative and quantitative methods. Sixty-two studies (78%) used only one method of data collection. Interviews dominated the choice of data collection. The median sample size was 36 (range: 9-383). Thirty-three studies (41%) did not specify the type of analysis used but rather described the analytic process in detail. The rest indicated the mode of data analysis, in which the most prevalent methods were the constant comparative method (23%) and the grounded theory approach (22%). Qualitative data analysis software was used by 33 studies (41%). Among influential journals of general medicine, only BMJ consistently published an average of 15 qualitative study reports between 2000 and 2004. These findings lend insight into what qualities and characteristics make a qualitative study worthy of consideration to be published in an influential journal, primarily BMJ.

Barriers to vaccination among Japanese medical students: focus group interviews

BACKGROUND

To date, medical schools and clinical training hospitals in Japan that require students to show immunity for measles, mumps, rubella, varicella (chickenpox), and hepatitis B prior to the commencement of residency are limited.

METHODS

This qualitative study used focus group interviews to elucidate why medical students do not undergo vaccination. A total of three groups were identified and interviewed: group A (two men, three women), group B (two men, two women), group C (three men, two women). All recorded interviews were transcribed verbatim and analyzed according to the constant comparative method with a series of codes and categories.

RESULTS

Findings elucidated that vaccination for medical students is not mandatory in Japan. Analysis found that the factors that influence willingness to be vaccinated can be divided into three dimensions (individual level, university/regional hospital level, governmental level) and two primary categories (cost of vaccination, awareness of vaccination) consisting of 10 codes. These factors did not exist in isolation, but have mutually overlapping areas.

CONCLUSIONS

Vaccination against vaccine-preventable diseases is essential to a hospital's infectious-disease countermeasures and cannot continue to be overlooked by physicians (at the individual level), by universities and residency programs (at the community level) nor by the government (at the national level).

A template for informed consent forms in medical examination and treatment: an intervention study

BACKGROUND

There are few studies to use a template to ensure that information provided to the patient in the process of informed consent is consistent. To examine the differences between informed consent forms based on a template and those not based on a template.

MATERIAL/METHODS

An intervention study using a template for informed consent forms that could be modified according to test/treatment, specialty, setting and patient. Our sample included 22 departments at the University of Tokyo Hospital, a 1100-bed care referral center. Twelve items in each informed consent form were scored. Items included diagnosis and current condition, purpose of procedure, details and nature of procedure, effectiveness, patient specific information, changing one's mind, and the use of illustrations and figures. The 36 possible points for each form were summed for a total possible score of 108 points. Total scores and scores for each item were then compared between pre- and post-test forms.

RESULTS

Total number of points significantly increased from 70.9 to 96.9 between pre- and post intervention (p<0.001, paired t test). Internal medicine (pre: 68.6 to post: 101.9) showed a more significant increase in score than surgery (71.9 to 95.2) (ANOVA, pre-post: F(1,106)=324.8 p<0.001; interaction: F(1,106)=11.2, p<0.01). There was no difference in the rate of improvement between treatment and examination forms (ANOVA, pre-post: F(1, 106)=253.3, p<0.001; interaction: F(1,106)=2.8, p=0.1).

CONCLUSIONS

A template can increase the number of items described and the thoroughness in which they are described.

Physician strategies for addressing patient adherence to prescribed psychotropic medications in Japan: a qualitative study

BACKGROUND AND OBJECTIVES

Effective psychiatric care requires physicians to address the problems of patient adherence to prescribed medications. The aim of this study was to understand physician-perceived barriers to, and effective strategies for, prescribing anti-depressants in Japan.

METHODS

A qualitative study using semi-structured and key-informant interviews with a purposive sample of Japanese psychiatrists and key-informant physicians who had practiced in both the US and Japan.

RESULTS

Japanese psychiatrists recognize patient misperceptions, social stigma and resistance to acceptance of prescribed anti-depressant medication. Physicians also recognize that selective serotonin reuptake inhibitors (SSRIs) decrease rather than reinforce patient resistance. Physicians initially underdose, employ euphemisms and accept patient decisions to decline treatment by medication.

DISCUSSION

Even after the introduction of SSRI anti-depressants in 1999, Japanese psychiatrists' primary adherence strategy to initially underdose prescribed anti-depressants remains. The unstated physician strategy is to allow the pharmaceutical industry to address patient misperceptions, social stigma and the resistance to prescription therapies.

CONCLUSIONS

The results of this study delineate the fundamental strategies employed by Japanese physicians to address patient adherence to prescribed psychotropic medications, primarily to reduce the initial dose rather than to stress patient education.

Eye on Religion: Considering the Influence of Buddhist and Shinto Thought on Contemporary Japanese Bioethics

Religious traditions can play a significant role in the shaping of bioethical thought. In Japan, traditional Buddhist and Shinto thought continue to influence contemporary bioethical perspectives. To better define this relationship, this paper examines the correlation between Japanese bioethical perspectives and Buddhist and Shinto thought. An in-depth discussion explores how Buddhist and Shinto scholars have used fundamental concepts with each religious tradition to agree and disagree with the disclosure of an incurable disease to a patient, brain death, and brain-dead organ transplantation.

Four physician communication styles in routine Japanese outpatient medical encounters

BACKGROUND

Few studies have explored how physicians approach medical encounters in Japan.

OBJECTIVE

This study examined how Japanese physicians conduct routine medical encounters in the context of outpatient care to patients with nonmalignant disorders.

DESIGN

Qualitative study using semi-structured interviews and direct observation.

SETTING

The outpatient department of a general hospital located in an urban area of Japan.

PARTICIPANTS

Physicians and nurses providing care and patients receiving care for nonmalignant disorders.

RESULTS

A 2-dimensional model was developed, with patient communication (how physician interacted with patients) along 1 axis, and nurse communication (how physicians collaborated with nursing staff) along the other axis. Four physician communication styles (individually adaptive, individually defined, collaboratively adaptive, and collaboratively defined) were identified as typical ways in which the Japanese physicians in the sample interacted with patients and nurses during routine medical encounters.

CONCLUSIONS

Results suggest the need for a multiprovider-patient model of medical communication among physician, nurse, and patient. Further research is needed to establish the applicability of this model to the communication styles of physicians in other countries.

A model of donors' decision-making in adult-to-adult living donor liver transplantation in Japan: having no choice

This study examined the decision-making processes of donors in adult-to-adult living donor liver transplantation. Twenty-two donors were interviewed using a semi-structured format. Interview contents were transcribed verbatim and analyzed qualitatively using grounded theory. A decision-making model was developed consisting of 5 stages: (1) recognition, (2) digestion, (3) decision-making, (4) reinforcement, and (5) resolution. The second and the third stages described donors' experiences of "reaching a decision"; the fourth and fifth stages described those of "facing transplantation." The central theme of this model was "having no choice," which consisted of 4 codes: (1) priority of life, (2) only LDLT, (3) for family, and (4) only me. In conclusion, this model can help health care professionals to understand the donor experience and, based on that understanding, to provide sufficient support to the donor.

Professional approaches to stroke treatment in Japan: a relationship-centred model

RATIONALE

To examine how stroke professionals in Japan approach rehabilitation therapy.

METHODS

This qualitative study was based on Grounded Theory. Data collection included (1) non-participatory observation, (2) non-structured interviews, and (3) semi-structured interviews. A national hospital located in an urban area of the prefecture of Kanagawa in Japan specializing in the treatment of stroke and other neurological disorders. Stroke professionals (doctors, nurses, clinical psychologists, physiotherapists, occupational therapists and speech therapists), patients and patients' families.

RESULTS

(1) Professionals recognized patient motivation as a factor related to rehabilitation outcome, but believed it to be a direct product of fostered fiduciary relationships and effective patient interaction. (2) Professionals regarded fiduciary relationships as the most important determinant of rehabilitation outcome. (3) Professionals adapted their behaviour and communication style in aims of fostering fiduciary relationships. These findings informed a three-component model of care: the Relationship-centred Model.

CONCLUSIONS

The Relationship-centred Model describes how stroke professionals in Japan approach rehabilitative therapy. This model of care may be preferred by patients in other countries who also favour a family-centred approach to decision making.

Informed consent revisited: Japan and the U.S

Informed consent, decision-making styles and the role of patient-physician relationships are imperative aspects of clinical medicine worldwide. We present the case of a 74-year-old woman afflicted with advanced liver cancer whose attending physician, per request of the family, did not inform her of her true diagnosis. In our analysis, we explore the differences in informed-consent styles between patients who hold an "independent" and "interdependent" construal of the self and then highlight the possible implications maintained by this position in the context of international clinical ethics. Finally, we discuss the need to reassess informed-consent styles suitable to the needs of each patient regardless of whether he or she resides in the United States or in Japan.

Japan's ethical guidelines for epidemiologic research: a history of their development

During the latter half of the 1990s, Japanese healthcare professionals and policy-makers recognized the value of an "evidence-based" approach. At the same time, an increased social awareness of the need to protect research participants and personal information began to appear. Recognition of an evidence-based approach further promoted epidemiologic research while regulations on personal information protection imposed certain limitations on this same research. In April 2000, as a solution to this conflict, a working group funded by Japan's Ministry of Health and Welfare (MHW; currently the Ministry of Health, Labour and Welfare: MHLW) proposed a first draft of ethical guidelines for epidemiologic research. Over the next two years, the collection of domestic and foreign data by working groups and governmental ad hoc committees, questions raised by the mass media, and public statements made by organizations, such as the Science Council of Japan and the Japan Epidemiologic Association (JEA), led to a collaborative effort between the Ministry of Education, Culture, Sports, Science and Technology and the MHLW. This effort led to the creation of the Ethical Guidelines for Epidemiologic Research in June 2002, which was revised in 2004. Furthermore, JEA also announced the Ethical Guidelines for Conducting of Epidemiologic Research in October 2002. While the development of these ethical guidelines has been a challenge for Japanese epidemiologists, it has also allowed the epidemiologic community to understand their role in society. This review aims to provide insight into the interaction between the epidemiologic community and society by assessing historically the developmental process of these ethical guidelines.

The nature of relative subjectivity: a reflexive mode of thought

Ethical principles including autonomy, justice and equality function in the same paradigm of thought, that is, logocentrism--an epistemological predilection that relies on the analytic power of deciphering between binary oppositions. By studying observable behavior with an analytical approach, however, one immediately limits any recognition and possible understanding of modes of thought based on separate epistemologies. This article seeks to reveal an epistemological predilection that diverges from logocentrism yet continues to function as a fundamental component of ethical behavior. The issue of cancer disclosure in Japan is used to exemplify the nature of relative subjectivity (kankeiteki-shukansei), a term I define and believe to be an epistemological predisposition fundamental to ethical behavior. Relative subjectivity denotes an epistemology quintessential to the behavior of individuals who attend to the respective tides of each particular situation, each interpersonal relationship or, in the context of clinical medicine, to the needs and values of each patient.

Decision-making models in Japanese psychiatry: transitions from passive to active patterns

This study deconstructs the current dynamics of the physician-patient relationship in the treatment of minor mood disorders including depression in Japan. An in-depth qualitative investigation was conducted on psychiatrists employed at mental health clinics, university hospitals, and psychiatric hospitals. Triangulation was conducted concurrently using key informant interviews and periodic non-structured interviews with additional physicians and patients. Results revealed two patterns of omakase (entrusting) (Omakase Model) and an emerging pattern of patient participation in decision making (Participatory Model). The pattern traditionally denoted by the Omakase Model encompasses an active and passive entrusting model. The phenomenon of an emerging Participatory Model was uncovered whereby an in-depth analysis led to an understanding behind the associative physician-patient relationship, communication patterns, and a patient's level of awareness. It was found that while active participation in medical decision making is capable of raising the level of treatment efficacy, it is not only active participation in medical decision making, but also active participation in medical treatment that is valued in the physician-patient relationship. Ultimately, a patient actively participates in his or her medical treatment under either the active Omakase Model or Participatory Model, be it entrusting or participatory. Consequently, the active Omakase Model will continue to remain functional alongside the Participatory Model while the passive Omakase Model is likely to fade away in time.

Three patterns of voluntary consent in the case of adult-to-adult living related liver transplantation in Japan

To elucidate the psychosocial aspects of the donors' decisions to engage in adult-to-adult living related liver transplantation, we interviewed a total of five institutional ethics committee members who had experience with reassessing informed consent prior to surgery. Qualitative analysis revealed several nuances of voluntary consent consisting of three patterns: "unconditional consent" is consent from the bottom of one's heart to save a family member's life; "pressured consent" describes a donor who feels implicit pressure to donate despite fear; and "ulterior-motivated consent" defines a donor who has a hidden motive. This study diverges from previous work in that it employs a qualitative approach to deconstructing the psychosocial intricacies of the informed consent process in adult-to-adult LRLT. This initial study raises several questions on the meaning of voluntary informed consent in adult-to-adult living related liver transplantation.

Perspectives on advance directives in Japanese society: A population-based questionnaire survey

Background

In Japan, discussion concerning advance directives (ADs) has been on the rise during the past decade. ADs are one method proposed to facilitate the process of communication among patients, families and health care providers regarding the plan of care of a patient who is no longer capable of communicating. In this paper, we report the results of the first in-depth survey on the general population concerning the preferences and use of ADs in Japan.

Method

A self-administered questionnaire was sent via mail to a stratified random sampling of 560 residents listed in the residential registry of one district of Tokyo, Japan (n = 165,567). Association between correlating factors and specific preferences toward ADs was assessed using contingency table bivariate analysis and multivariate regression model to estimate independent contribution.

Results

Of the 560 questionnaires sent out, a total of 425 participants took part in the survey yielding a response rate of 75.9 %. The results of the present study indicate that: 1) the most important components to be addressed are the specifics of medical treatment at the end of life stage and disclosure of diagnosis and prognosis; 2) the majority of participants found it suitable to express their directives by word to family and/or physician and not by written documentation; 3) there is no strong need for legal measures in setting up an AD; 4) it is permissible for family and physician to loosely interpret one's directives; 5) the most suitable proxy is considered to be a family member, relative, or spouse. Multivariate analysis found the following five factors as significantly associated with preferences: 1) awareness regarding living wills, 2) experience with the use of ADs, 3) preferences for end-of-life treatment, 4) preferences for information disclosure, and 5) intentions of creating a will.

Conclusions

Written ADs might be useful in the Japanese setting when the individual either wishes: 1) to not provide a lot of leeway to surrogates and/or caregivers, and/or 2) to ensure his or her directives in the cases of terminal illness, brain death, and pain treatment, as well as regarding information disclosure.

The Prozac boom and its placebogenic counterpart -- a culturally fashioned phenomenon

BACKGROUND

The placebo effect describes the mind-body process of altering the body's physiological state as well as the brain's neurological state. Catalyzed by the mind's believing in a certain drug, ritual, and/or treatment, it generally refers to the phenomenon of an ill individual recovering to health. Subsequent to the Prozac boom (fluoxetine), which occurred during the 1980s and 90s in the United States, a new form of placebogenic phenomena was defined: 'cosmetic psychopharmacology', whereby the healthy individual is transformed to fit better in his/her cultural medium (defined by one's values and beliefs). In order to discover how cultural metaphors (e.g. media-generated symbolism, social ideals) influence psychopharmacological treatment, this report investigates the following questions: Is the Prozac Boom culturally fashioned? Is cosmetic psychopharmacology culturally fashioned? Are cosmetic psychopharmacology and its ability to better the individual (relative to American ideals) a placebogenic phenomenon?

MATERIAL/METHODS

The data and speculation for the present report was obtained via a cultural and critical review.

RESULTS

It would appear that (1) the Prozac Boom and subsequently its by product, cosmetic psychopharmacology, are culturally fashioned; (2) cosmetic psychopharmacology is considered to result from one's belief in a drug and thus is placebo-influenced.

CONCLUSIONS

Media-generated symbolism, which represents and reciprocally fashions the ideals and values of that society, influence the social perceptions of a drug's effectiveness and the quality of a particular treatment. In the clinical setting, the influential role of these preconceived notions about a certain treatment and/or drug need to be further considered and studied.

The placebo effect and relaxation response: neural processes and their coupling to constitutive nitric oxide

The placebo effect appears to be a real phenomenon as is the scientifically demonstrated and examined relaxation response. Given this, we attempt to understand how these phenomena work in light of our current understanding of central and peripheral nervous system mechanisms. Central to our hypothesis is the significance of norepinephrine, nitric oxide and opioid signaling both in the central and peripheral nervous system. In this regard, we find that nitric oxide controls norepinephrine processes on many levels, including synthesis, release and actions. In closing, we conclude that enough scientific information exists to support these phenomena as actual physical processes that can be harnessed to provide better patient care.