Neuro-modulatory impact of felodipine against experimentally-induced Parkinson's disease: Possible contribution of PINK1-Parkin mitophagy pathway

Parkinson's disease (PD) is a prevalent neurodegenerative disorder, characterized by motor and psychological dysfunction. Palliative treatment and dopamine replenishment therapy are the only available therapeutic options. Calcium channel blockers (CCBs) have been reported to protect against several neurodegenerative disorders. The current study was designed to evaluate the neuroprotective impact of Felodipine (10 mg/kg, orally) as a CCB on motor and biochemical dysfunction associated with experimentally induced PD using rotenone (2.5 mg/kg, IP) and to investigate the underlying mechanisms. Rotenone induced deleterious neuromotor outcomes, typical of those associated with PD. The striatum revealed increased oxidative burden and NO levels with decreased antioxidant capacity. Nrf2 content significantly decreased with the accumulation of α-synuclein and tau proteins in both the substantia nigra and striatum. These observations significantly improved with felodipine treatment. Of note, felodipine increased dopamine levels in the substantia nigra and striatum as confirmed by the suppression of inflammation and the significant reduction in striatal NF-κB and TNF-α contents. Moreover, felodipine enhanced mitophagy, as confirmed by a significant increase in mitochondrial Parkin and suppression of LC3a/b and SQSTM1/p62. In conclusion, felodipine restored dopamine synthesis, attenuated oxidative stress, inflammation, and mitochondrial dysfunction, and improved the mitophagy process resulting in improved PD-associated motor impairment.

Long-term outcomes of lercanidipine versus other calcium channel blockers in newly diagnosed hypertension: a nationwide cohort study

OBJECTIVE

Calcium channel blockers (CCBs) have been proved to have beneficial effects on cardiovascular (CV) outcomes, especially in stroke. Lercanidipine, a highly lipophilic CCB, lacks data regarding long-term outcomes including: CV, stroke, renal and all-cause mortality. This retrospective cohort study aims to clarify this.

PATIENTS AND METHODS

A total of 144,630 newly diagnosed hypertension (HTN) patients (age: 18-65 years) in 2005 from the Taiwan's National Health Insurance Research Database were enrolled in this observational study. A pure hypertension population was fetched by excluding all chronic diseases in the Charlson Comorbidities Index. Patients were stratified into the lercanidipine group (n = 1303) and the propensity-score-matched comparative group (nifedipine, amlodipine or felodipine, n = 15,301).

RESULTS

Compared to other CCBs, lercanidipine didn't have a significant difference on the study endpoints. In individual head-to-head comparisons, lercanidipine was shown to be superior to nifedipine in incident stroke with an adjusted HR with 95% CI of 0.526 (0.347-0.797) (p = .0025). The key limitations were that personal variables, such as smoking habits, alcohol intake, body mass index and physical activity and blood pressure profiles were not available in the nationwide registry database.

CONCLUSION

In newly diagnosed patients with hypertension, lercanidipine was superior to nifedipine in the six-year period when the analyzed endpoint was stroke.

Effects of lercanidipine hydrochloride versus felodipine sustained-release on day-to-day home blood pressure variability

OBJECTIVE

The objective of this study was to compare the effectiveness of lercanidipine with felodipine in patients with mild-to-moderate hypertension on day-to-day home blood pressure variability.

METHODS

This is a sub-study of a multicenter, randomized, open-label, parallel group and active controlled clinical trial. Hypertensive patients aged 18-75 (i.e. diastolic blood pressure ≥90 mmHg and <110 mmHg; systolic blood pressure ≥140 mmHg and <180 mmHg) and 24 h mean BP >130/80 mmHg) were eligible for this study. During the study, blood pressure (BP) and heart rate (HR) were recorded. The day-to-day BP variability (BPV) and HR variability (HRV) were obtained by the standard deviation (SD) of daily BP/HR average (of six readings) in 7 days.

RESULTS

There were 186 patients (89 and 97 patients in the lercanidipine and felodipine groups, respectively) included in this study. Lercanidipine hydrochloride 10 mg/d and felodipine sustained-release tablets 5 mg/d were given to their respective groups. After 6 weeks of treatment, SD of home BP significantly reduced compared with baseline in both groups (P < .05) while SD of home HR also changed significantly after treatment (P < .05). There was no significant difference in SD of home BPV between the lercanidipine and felodipine groups after treatment.

CONCLUSION

Treatment with lercanidipine and felodipine both resulted in reduction of BPV and HRV. There was no significant inter-group difference in reduction of BPV between the groups. Lercanidipine is an effective antihypertensive drug in improving BPV. National clinical trial: NCT01520285.

Lercanidipine hydrochloride versus felodipine sustained-release for mild-to-moderate hypertension: a multi-center, randomized clinical trial

OBJECTIVE

Lercanidipine hydrochloride and felodipine sustained-release tablets comparison for the treatment of patients with mild-to-moderate primary hypertension.

RESEARCH DESIGN AND METHODS

The study was designed as a multicenter, randomized, open-label, parallel-group clinical trial. A total of 281 adult patients (18-75 years) with a mild-to-moderate primary hypertension diagnosis were randomly assigned, in a 1:1 ratio, to lercanidipine hydrochloride (n = 139; 81 males) or felodipine sustained-release tablets (n = 142; 87 males). Study duration was 8 weeks, including two run-in weeks and 6 weeks of treatment.

MAIN OUTCOME MEASURES

The mean seated diastolic blood pressure (BP) change from baseline to 6 weeks of treatment was the primary endpoint. Main secondary efficacy parameters were: (i) mean seated systolic BP change from baseline to 6 weeks of treatment; (ii) normalization BP rate. The incidence of adverse events was also considered.

RESULTS

BP monitoring showed a significant decrease compared with baseline in diastolic BP (lercanidipine: from 96 ± 4 to 83 ± 6 mmHg, p < 0.0001; felodipine: from 96 ± 4 to 82 ± 5 mmHg, p < 0.0001). The mean systolic BP decreased, when compared with baseline values, by 18 mmHg and 19 mmHg in the lercanidipine and felodipine arm, respectively (p < 0.0001 versus baseline for both comparisons). The normalization rates of BP were 79.5% and 87.2%, in the lercanidipine and felodipine groups, respectively (in-office monitoring; p = n.s.). In total, 73 patients experienced 103 AEs: 26.6% (37/139) in the lercanidipine group and 25.3% (36/142) in the felodipine arm (p = n.s.). The analysis of safety showed no unexpected adverse events.

CONCLUSIONS

Although the overall short follow-up of the present study should be taken into account, lercanidipine is an effective and safe treatment option for BP control in adult patients with mild-to-moderate primary hypertension.

[Efficacy and safety of aranidipine in Chinese patients with mild-to-moderate essential hypertension]

OBJECTIVE

To assess the efficacy and safety of aranidipine versus retard-released felodipine in Chinese patients with mild-to-moderate essential hypertension.

METHODS

This was a multicenter, randomized, double-blind, placebo and active antihypertensive drug parallel-controlled study. After 2 weeks of placebo run-in period, 315 patients at 6 centers with diastolic blood pressure (DBP) between 95 to 109 mm Hg (1 mm Hg = 0.133 kPa) while systolic blood pressure (SBP) below 180 mm Hg were randomized to receive aranidipine 5-20 mg/d (n = 126) or retard-released felodipine 5-10 mg/d (n = 126) for 12 weeks. Others (n = 63) received placebo for 4 weeks. Their blood pressures were evaluated at baseline and the end of Weeks 4, 8 and 12.

RESULTS

After a 12-week treatment, SBP decreased from 148.8 ± 10.7 mm Hg to (132.8 ± 11.2) mm Hg while DBP dropped from ( 98.4 ± 2.8) mm Hg to (83.9 ± 7.5) mm Hg. There were significant differences with the baseline values (P < 0.0001). After a 4-week treatment, the reductions of SBP in aranidipine and retard-released felodipine groups were (12.1 ± 11.0) mm Hg and (12.2 ± 11.2) mm Hg while the reductions of DBP in two groups (11.8 ± 6.9) mm Hg and (12.1 ± 7.9) mm Hg respectively. The reductions of SBP and DBP in two groups were (2.3 ± 8.4) mm Hg and (4.0 ± 5.1) mm Hg and they were significantly superior to that in placebo group (P < 0.0001). But no significant difference existed between aranidipine and retard-released felodipine groups. Also no significant differences were found between these two antihypertensive therapy groups at the end of Weeks 4, 8 and 12 in the reduction of blood pressure, total response rate and blood pressure control rate. But 20 mg daily aranidipine was significantly superior to 10 mg daily retard-released felodipine in the control rates of SBP and DBP. Adverse events occurred at 24.22% and 29.92% in aranidipine and retard-released felodipine groups respectively (P = 0.305).

CONCLUSION

Administration of aranidipine 5-20 mg/d can effectively control blood pressure and is not inferior to retard-released felodipine 5-10 mg/d. The efficacy of 20 mg/d aranidipine is superior to that of retard-released felodipine 5-10 mg/d. And the effectiveness and safety of aranidipine are similar to those of retard-released felodipine.

Calcium Antagonists Use and Its Association with Lower Urinary Tract Symptoms: A Cross-Sectional Study

Background

Lower urinary tract symptoms (LUTS) have been reported amongst the side effects of calcium antagonists (CA). CAs act on the bladder by affecting the ability of the detrusor muscle to create enough contractile force to overcome obstruction to normal voiding. We aimed to determine the relationship between CA use and LUTS in general medical inpatients.

Methods and Findings

In this cross-sectional study we recruited 278 medical inpatients (including 85 CA users) aged ≥40 (72.1±13.7) years. LUTS was assessed using the International Prostate Symptoms Score (IPSS) questionnaire. A Logistic regression model using a ‘backwards-elimination’ strategy was used to identify variables associated with LUTS and for calculating the adjusted odds ratios and the 95% confidence intervals (CI). After adjusting for other risk factors and drugs, patients on amlodipine/nifedipine and diltiazem/verapamil (compared to non-users) were more likely to suffer from severe LUTS [Males: 12.45(CI: 1.57–98.63) and Females: 7.75(CI: 0.94–63.94)] and moderate-to-severe LUTS [Males: 17.43(CI: 2·26–134.39) and Females: 47.8(CI: 6.22–367.37)]. Patients on felodipine/lercanidipine were less likely to suffer from either severe or moderate-to-severe LUTS. Further, 19 (22.4%) CA-users were on treatment for LUTS compared to 18 (9.3%) of the non-users group, p = 0.003. Both male and female CA-users were three times more likely to be on alpha-blockers than non-users, p<0.001. CA-users were more likely to have undergone urinary tract-related surgery (Males: two times, p = 0.07 and females: nine times, p = 0.029). The study was limited by the fact that a causal relationship could not be established between CA use and LUTS.

Conclusions

Our results demonstrate an association between CA use and an increasing severity of LUTS. They also demonstrate that CA-users are more likely to have medical or surgical treatment for LUTS. However, these CA’s effects on LUTS vary, and the use of highly vascular selective agents does not appear to pose significant risk.

[Calcium channels blocker felodipin in the treatment of patients with arterial hypertension and chronic cardial failure with preserved cardiac output]

The article is devoted to issues of clinical diagnosis and treatment of patients with chronic cardiac failure and normal ejection fraction (CCF-NEF). Original clinical trials of felodipin efficacy designed to be maximally close to every-day clinical practice in Russia included hypertensive patients with CCF-NEF. The results of these trials bring about the conclusion that felodipin not only maintain blood pressure at the target level but also improves diastolic function of the myocardium.

[Therapeutic effect on essential hypertension treated with combined therapy of acupuncture and medication]

OBJECTIVE

To explore the mechanism of acupuncture combined with medication for treatment of essential hypertension (EH).

METHODS

Sixty cases of EH were randomly divided into a combined acupuncture and medication group (group A) and a medication group (group B), 30 cases in each one, treated with acupuncture in combination with oral administration of Felodipine, and simple oral administration of Felodipine respectively. Before and after treatment, the changes of blood pressure, and the contents of E-selectin (Es), iNOS and eNOS were determined.

RESULTS

After treatment, the blood pressure declined in either group. The total effective rate in group A was 86.7% (26/30), which was superior to that of 73.3% (22/30) in group B. After treatment, the plasma Es and iNOS contents in two groups decreased as compared with those before treatment (both P < 0.01), of which, plasma Es content in group A decreased apparently as compared with group B (P < 0.01). After treatment, the content of plasma eNOS increased as compared with that before treatment in group A (P < 0.01).

CONCLUSION

The mechanism of acupuncture on anti-blood pressure probably relies on the improvements in vascular endothelial cellular function so that Es, iNOS and eNOS expression can be recovered to normal level and ultimately blood pressure is adjusted.

Pharmacokinetic interaction involving sorafenib and the calcium-channel blocker felodipine in a patient with hepatocellular carcinoma

Sorafenib, an orally active multi-kinase inhibitor approved for the treatment of hepatocellular carcinoma (HCC), is primarily metabolized both via cytochrome P450 3A4 isoform (CYP3A4) and UGT1A9. Due to the contribution of these two biotransformation pathways, sorafenib is considered to be less susceptible than other agents to CYP3A4 drug-drug interactions. This report discusses a clinically relevant pharmacokinetic CYP3A4 drug-drug interaction between sorafenib and felodipine in an 80-year-old Caucasian patient with HCC. On day 15, after the introduction of sorafenib (400 mg bid), sorafenib plasma concentration was at 3.6 mg/L. Felodipine (5 mg bid), an anti-hypertensive agent that is exclusively CYP3A4 substrate, was then introduced due to grade 2 sorafenib-related hypertension. On day 30, hypertension was well controlled. However, sorafenib plasma concentration was 3-fold greater (11.4 mg/L) and the patient experienced grade-3 anorexia. Since neither diarrhea nor cutaneous side effects were noticed at this time, sorafenib treatment was continued at the same daily dosage. On day 45, sorafenib plasma concentration was stable (10.8 mg/L) before declining on days 60 and 75 (7.0 mg/L and 7.4 mg/L, respectively), which was probably related to an occurrence of grade-2 diarrhea. This observation suggests a pharmacokinetic interaction involving CYP3A4 inhibition by felodipine. According to the Drug Interaction Probability Scale, this interaction was possible. Since hypertension is a common toxicity of sorafenib, clinicians should be aware of this possible interaction. The clinical relevance of pharmacokinetic interactions involving CYP3A4 inhibition in HCC patients receiving sorafenib is analyzed in this case report.

[Effect between felodipine plus irbesartan and felodipine plus metoprolol regimen on the sexual function in young and middle-aged women with hypertension]

OBJECTIVE

To compare the effects between felodipine plus irbesartan and felodipine plus metoprolol regimen on blood pressure and the sexual function in young and middle-aged hypertensive women.

METHODS

In this prospective, randomized, parallelized, controlled and fixed combined therapy trial, 99 female patients (aged 18 to 60) with grade 1 and grade 2 hypertension (BP ≥ 140/90 mm Hg and < 179/109 mm Hg, 1 mm Hg = 0.133 kPa) were assigned to felodipine 5 mg q.d + irbesartan 150 mg q.d (F + I group, n = 49) and felodipine 5 mg q.d + metoprolol 47.5 mg q.d (F + M group, n = 50) group. Target blood pressure was < 140/90 mm Hg. The female sexual function index (FSFI) questionnaire, levels of serum estradiol and testosterone were assessed. Female sexual dysfunction was defined as a FSFI score of less than 25.5. Patients were followed up for 24 weeks.

RESULTS

The rate of achieving blood pressure goal between 2 groups was similar at the 4th, 8th, 12th and 24th weeks respectively (42.9% vs. 62.0% at 4th week, 89.8% vs. 90.0% at 8th week, 93.9% vs. 94.0% at 12th week, 98.0% vs. 96.0% at 24th week, P > 0.05). Compared to baseline, scores for the items related to "desire" and "arousal" were significantly improved (P < 0.05), the level of the serum estradiol was significantly elevated [(50.3 ± 37.4) pg/L vs. (54.4 ± 10.8) pg/L before menopause, (18.4 ± 2.9) pg/L vs. (20.2 ± 3.1)pg/L after menopause, P < 0.05] and the level of the serum testosterone was significantly decreased [(722.8 ± 277.1) ng/L vs. (650.0 ± 156.0) ng/L before menopause, (841.2 ± 279.3) ng/L vs. (761.9 ± 197.8) ng/L after menopause, P < 0.05] in the F + I group, while scores for the items related to "sexual desire" and "lubrication" were statistically reduced (P < 0.01), the concentration of the serum estradiol was significantly reduced [(57.4 ± 9.7) pg/L vs. (51.1 ± 12.1) pg/L before menopause, (19.8 ± 2.3) pg/L vs. (17.8 ± 3.3) pg/L after menopause, P < 0.01] and the level of the serum testosterone was significantly increased [(775.6 ± 217.8) ng/L vs. (886.0 ± 186.4) ng/L before menopause, (812.5 ± 311.3) ng/L vs. (914.4 ± 300.2) ng/L after menopause, P < 0.01] in the F + M group. FSFI score was negatively correlated with age and systolic blood pressure levels.

CONCLUSION

felodipine plus irbesartan or metoprolol for 24 weeks equally reduced blood pressure and the former regimen is superior to the latter on sexual function improvement in this patient cohort.

[Calcium antagonists: on the way to expanding the indications]

The paper discusses indications for the use of long-acting dihydropyridine calcium blockers, such as felodipine, as well as perspectives for using this class of drugs.

[Effect of felodipine on the expression of NF-kappaB in rat model of atherosclerosis]

OBJECTIVE

To investigate the possible mechanism of felodipine on experimental atheroselerosis formation in rats.

METHODS

The rat model of atherosclerosis was established by the methods of intraperitoneal injection of Vitamin D3 and high-fat diet. Thirty male SD rats were randomly divided into normal group, atherosclerosis model group and felodipine treating group. At the end of 6 weeks, the expression of NF-kappaB (nuclear transcription fator-kappaB) in endothelial cells and smooth muscle cells of aorta were determined.

RESULTS

The positive rates of NF-kappaB in both atherosclerosis model group and felodipine treating group (46.59+/-5.68, 20.47+/-1.97) were higher than that of normal group (4.38+/-1.07, P<0.01). The expression of NF-kappaB in atherosclerosis model group was higher than that of felodipine treating group (P<0.01).

CONCLUSIONS

The mechanism of felodipine in relieving atheroselerosis may correlate with the inhibition of NF-kappaBp65 activation.

[Structural-functional properties of the vascular wall in hypertensive patients with coronary heart disease: effects of felodipin and perindopril]

AIM

To study endothelial function and vascular elasticity in hypertensive patients with coronary heart disease (CHD) and approaches to correction of the impairments with felodipin and perindopril.

MATERIAL AND METHODS

The trial included 34 hypertensive patients with CHD and 17 controls free of cardiovascular diseases. The above cardiovascular patients were randomized into two groups: 15 patients of group 1 received felodipin, 19 patients of group 2 were given perindopril. If the target blood pressure was not achieved after 4 weeks of treatment, 12.5 mg hydrochlorotiazide was added. 24-h monitoring of blood pressure, reactive hyperemia and nitroglycerin tests were made initially and after 8-week treatment. Also, calculations were made of pulse wave velocity (PWV) on the carotid-femoral and carotid-radial segments (Ve and Vm), of elastic modulus for arteries of the elastic and muscular types (Ee and Em).

RESULTS

Baseline endothelium-dependent and non-endothelium-dependent vasodilations (EDVD and NEDVD) in cardiovascular patients were lower than in the controls while Ve and Ee were higher. Systolic blood pressure (SBP), pulse blood pressure (PBP), stress SBP and EDVD correlated. The treatment led to reduction of mean circadian, diurnal and nocturnal SBP, diastolic blood pressure (DBP), PBP, Ve and Ee, to elevation of EDVD.

CONCLUSION

EDVD in hypertensive patients with CHD is related with SBP and PBP. Felopidin had both an antihypertensive and vasoprotective effects due to improved endothelial function and better elasticity of the major arteries comparable to effects of perindopril.

[Curative effects on mild to moderate primary hypertension and influence on pulse wave velocity of slow releasing felodipine]

OBJECTIVE

To evaluate the curative effects of slow releasing felodipine on mild to moderate primary hypertension and its influence on the pulse wave velocity of slow of the patients.

METHODS

260 patients with mild to moderate primary hypertension, aged 35-79, received slow releasing felodipine with the initial dosage of 5 mg once daily for 2 weeks. By the end of the second week, 222 of the 260 patients with their blood pressure (BP) levels<140/90 mm Hg were treated by the same regimen for 12 weeks. Pulse wave velocity (PWV) was measured before the treatment, and by the ends of the second and fourteenth weeks. Intention to treat analysis (ITT analysis) was adopted.

RESULTS

After 2-week treatment the systolic BP decreased by 21.4 mm Hg and diastolic BP by 14.2 mm Hg (both P<0.01). After 14-week treatment, the BP decreased by 24.8/17.5 mm Hg (P<0.01), the systolic BP decreased by 16.5% and the diastolic BP decreased by 18.4%. The BP of the patients with their BP levels up to standard decreased by 22.8/15.1 mm Hg (P<0.01) by the end of the second week and decreased by 25.0/17.9 mm Hg by the end of the 14th weeks. The PWV of all patients decreased by 0.58 m/s after 2-week treatment (P<0.05) and by 0.86 m/s after 14-week treatment (P<0.05). The PWV of those up to standard decreased by 0.55 m/s after 2-week treatment (P<0.05) and by 0.86 m/s after 14-week treatment (P<0.05). Adverse events were observed in 56 patients (21.5%), including headache, flush, and dizziness, however, no severe adverse event was found. No significant changes in laboratory examinations and ECG were found after treatment.

CONCLUSION

Slow releasing felodipine is effective in treating mild to moderate primary hypertension, with sustained efficacy of lowering blood pressure and PWV.

Effect and tolerability of felodipine ER (Feloten) in the treatment of hypertension assessed by office blood pressure and home blood pressure

OBJECTIVES

To assess the efficacy of once daily dose generic Felodipine ER, Feloten in terms of BP lowering as assessed by office BP measurement (OBPM) and Home BP monitoring (HBPM) MATERIAL AND METHOD: Mild and moderate hypertensive patients (n = 60) were enrolled by primary care physicians. After a 2 week run-in phase in which all patients received placebo, subjects received generic felodipine ER 5 mg for 3 weeks. After 3 weeks of treatment, patients whose blood pressure target was not achieved were given 10 mg of felodipine ER for 3 weeks. OBPM and HBPM were performed in the morning, noon, evening, and nighttime for 1 day at baseline, 3 weeks, and 6 weeks.

RESULTS

After 6 weeks, Generic felodipine ER reduced the average systolic BP (SBP) and diastolic BP (DBP) measured by OBPM and HBPM. The effect on SBP showed every time on HBPM and was more pronounced in the morning (trough drug level). However, the effects on DBP were not significant in the morning and noon. No serious adverse drug side effect was detected

CONCLUSION

Generic felodipine ER is effective in SBP reduction, in both OBPM and HBPM. It can be used once daily to control the blood pressure for 24 hours.

[Efficacy, safety and tolerance of Felodipine controlled release tablets and Felodipine controlled release tablets associated combination therapy in the treatment of mild to moderate essential hypertension in China]

OBJECTIVE

To evaluate the efficacy, safety and tolerance of Felodipine controlled release tablets and Felodipine controlled release tablets associated combination each with Metoprolol, Lisinopril or Hydrochlorothiazide in the 12 weeks treatment of mild to moderate essential hypertension in China.

METHODS

Multicenter, random samples, and open study have been processed.

RESULTS

(1)After 12 weeks associated combination treatment of anti-hypertension, the percentages of the persons who had attained the target were 80.2% of ITT group in Felodipine controlled release tablets associated combination with Hydrochlorothiazide, 74.1% of ITT group in with Metoprolol,and 80.5% of ITT group in with Lisinopril, respectively. (2)Mean reductions of systolic/diastolic blood pressure from baseline were 16.8/10.6 mm Hg in combination with Hydrochlorothiazide, 16.6/10.7 mm Hg in combination with Metoprolol,and 18.0/12.8 mm Hg in combination with Lisinopril each. There was no significant difference among these three groups (P>0.05). With the Felodipine controlled release tablets treatment alone, the mean reductions from baseline was 24.8/17.5 mm Hg. But in combination with Lisinopril, the blood pressure could lower more quickly, and then could reach the target more rapidly. (3)In the ITT group, the drug compliance with Felodipine controlled release tablets was 97.7%, with those in combination with Hydrochlorothiazide 89.8%, with those in combination with Metoprolol 100.0%, and with those in combination with Lisinopril 96.4%. The main adverse event related to Felodipine was headache, and to Lisinopril was cough.

CONCLUSION

Antihypertensive drug Felodipine controlled release tablets are good and effective. And Felodipine controlled release tablet associated combination each with Metoprolol, Lisinopril or Hydrochlorothiazide can make most patients reach the treatment target, with safety, good tolerance, and high compliance.

Optimal Treatment of Obesity-Related Hypertension

Background— Current guidelines for the treatment of hypertension do not provide specific recommendations for obese hypertensive patients. To identify an optimal treatment regimen for obese hypertensive patients, we studied the interactions between a drug-based weight loss approach by sibutramine and different antihypertensive drug regimens.

Methods and Results— This was a prospective, 16-week double-blind placebo-controlled randomized multicenter study in 171 obese hypertensive patients. After a 2-week run-in period, patients receiving 1 of the 3 antihypertensive combination therapies (felodipine 5 mg/ramipril 5 mg [n=57], verapamil 180 mg/trandolapril 2 mg [n=55], or metoprolol succinate 95 mg/hydrochlorothiazide 12.5 mg [metoprolol/hydrochlorothiazide; n=59]) were assigned randomly to sibutramine (15 mg) or placebo. Sibutramine treatment resulted in a significantly greater decrease in body weight, body mass index, and waist circumference and a significant increase in diastolic blood pressure during 24-hour blood pressure monitoring compared with placebo treatment. Sibutramine-induced weight loss and reduction of visceral obesity were markedly attenuated in the metoprolol/hydrochlorothiazide group compared with the other groups. Consistently, improvement in glucose tolerance and hypertriglyceridemia by sibutramine was abrogated in the cohort treated with metoprolol/hydrochlorothiazide compared with the other groups.

Conclusions— The present study demonstrates for the first time that an antihypertensive combination therapy regimen with angiotensin-converting enzyme inhibitors and calcium channel blockers is more advantageous than a β-blocker/diuretic–based regimen in supporting the weight-reducing actions and concomitant metabolic changes induced by sibutramine in obese hypertensive patients. These data may help to develop future comprehensive treatment strategies and guidelines for this high-risk patient population.

A review of calcium channel antagonists in the treatment of pediatric hypertension

All children aged > or = 3 years should have an annual blood pressure (BP) measurement taken during a routine physical examination. Physicians should become familiar with recommended pediatric normative BP tables. BP above the 95th percentile may require drug therapy. There are several categories of antihypertensives available to the clinician. Calcium channel antagonists (CCAs) are a class of drugs that exert their antihypertensive effect by inhibiting the influx of calcium ions across the cell membranes. This results in dilatation of peripheral arterioles. When given orally, CCAs are metabolised in the liver by cytochrome P450 (CYP) enzyme CYP3A4; hence, some CCAs will affect the half-life of drugs that share this enzyme system for their metabolism. CCAs can be safely used in children with renal insufficiency or failure and as a general rule there is no need to modify drug dosage in this population. CCAs are generally well tolerated; most adverse effects appear to be dose related. Headache, flushing, gastrointestinal upset, and edema of the lower extremities are the most common symptoms reported with the use of CCAs. Pediatric data regarding safety and efficacy of CCAs have mostly been obtained from retrospective analyses. Extended-release nifedipine and amlodipine are the two most commonly used oral CCAs in the management of pediatric hypertension. These drugs can be given once a day, although many children require twice-daily administration. Extended-release nifedipine has to be swallowed whole; hence, its use in younger children who cannot swallow pills is limited. Amlodipine can be made into a solution without compromising its long duration of action; therefore, it is the CCA of choice for very young children. Oral short-acting nifedipine and intravenous nicardipine are safe and effective CCAs for the management of hypertensive crisis in children. Short-acting nifedipine can cause unpredictable changes in BP; hence, it should be used cautiously and in low doses. Intravenous nicardipine has a rapid onset of action and a short half-life. Intravenous infusion of nicardipine can be titrated for effective control of BP. Intravenous nicardipine has been used safely in hospitalized children and newborns for the management of hypertensive crisis, and for controlled hypotension during surgery. CCAs are a class of antihypertensives that are safe and effective in pediatric patients. They have relatively few adverse effects and are well tolerated by children. This article reviews CCAs as antihypertensives in the management of pediatric hypertension.

[The FEVER (Felodipine EVEnt Reduction) trial; a randomised, double-blind, placebo-controlled trial in Chinese hypertensive patients]

The FEVER trial observed the difference between intense and less intense treatment of hypertension by comparing combination therapy consisting of a low diuretic dose (12.5 mg of hydrochlorothiazide) and a low calcium antagonist dose (5 mg of felodipine) with monotherapy based on a low diuretic dose (12.5 mg of hydrochlorothiazide) in Chinese hypertensive patients. The trial enrolled 9711 hypertonics (of which 4841 on hydrochlorothiazide + felodipine combination and 4870 on hydrochlorothiazide + placebo combination). Blood pressure decreased from 158.7/92.4 to 138.1/82.3 mmHg and from 158.0/92.7 to 141.6/83.9 mmHg in the combination therapy group and monotherapy group, respectively. The average difference throughout the trial was 4.2/2.1 mmHg. The primary endpoint--fatal and non-fatal stroke (CVA)--was reduced by 27% in the combination therapy group. Among secondary endpoints, the success ratio of combination therapy was expressed by 27% reduction of all cardiovascular events, 35% reduction of all cardiac events, 32% reduction of coronary events and 31% reduction of deaths. The minor difference between systolic and diastolic blood pressure of approximately 4/2 mmHg was related to a decrease in the incidence of CVA and cardiovascular events in Chinese hypertonics.

Additional antihypertensive effect of drugs in hypertensive subjects uncontrolled on diltiazem monotherapy: a randomized controlled trial using office and home blood pressure monitoring

The purpose of this study was to compare several diltiazem-based antihypertensive drug combinations and assess the usefulness of home blood pressure monitoring in the evaluation of the efficacy of combination pharmacotherapy. Sixteen general practitioners recruited hypertensive subjects uncontrolled on diltiazem monotherapy, who were randomized to receive eight weeks of add-on therapy with a diuretic (chlorthalidone), a dihydropyridine calcium antagonist (felodipine), an ACE inhibitor (lisinopril), or an angiotensin blocker (valsartan). Sitting office and home blood pressure was measured using electronic devices A&D 767. A total of 211 patients were randomized, and 185 completed the study. Of 52 subjects randomized to felodipine, 15 were withdrawn due to ankle edema. The additional antihypertensive effect of the second drug was smaller in 18 subjects with a white coat effect (p < 0.01). All combinations produced a significant decline in office (21.2 +/- 14.8 / 7.7 +/- 9.7 mmHg) and home (17.1 +/- 11.9 / 6.0 +/- 7.0) blood pressure (systolic / diastolic, p < 0.001). There were no differences in the efficacy of the four combinations assessed using office or home blood pressure monitoring. These data suggest that diuretics, dihydropyridines, ACE inhibitors, and angiotensin receptor blockers provide significant additional antihypertensive effects in hypertensive patients uncontrolled on diltiazem monotherapy. The diltiazem-dihydropyridine combination is often intolerable because of ankle edema. Home blood pressure monitoring is useful in the assessment of the efficacy of combination pharmacotherapy and also allows for the detection of subjects who do not require treatment intensification.

Comparative study of barnidipine and felodipine in Chinese patients with essential hypertension

This study evaluated the efficacy and safety of barnidipine for the treatment of mild-to-moderate essential hypertension in Chinese patients. A total of 131 patients were randomized to receive either barnidipine (10 -15 mg) or felodipine (5 - 10 mg) once daily for 4 weeks. Both drugs reduced blood pressure significantly, with > or = 87% of patients obtaining a marked or moderate effect. The mean +/- SD reductions in systolic and diastolic blood pressure were 19.2 +/- 13.6 and 14.4 +/- 7.0 mmHg, respectively, for barnidipine treatment, and 20.3 +/- 11.3 and 14.7 +/- 7.7 mmHg, respectively, for felodipine treatment. There were no significant differences between the two drugs in terms of anti-hypertensive effect, heart rate, laboratory test results or incidence of adverse events. More patients taking felodipine experienced palpitations, but this difference was not statistically significant. Barnidipine is as efficacious and safe as felodipine in the treatment of essential hypertension in Chinese patients.

A factorial study of combination hypertension treatment with metoprolol succinate extended release and felodipine extended release results of the Metoprolol Succinate-Felodipine Antihypertension Combination Trial (M-FACT)

BACKGROUND

Many hypertensive patients require combination therapy to achieve target blood pressure (BP). beta-Blockers and dihydropyridine calcium channel blockers are effective as monotherapy in hypertensive patients and have complementary mechanisms for lowering BP.

METHODS

This multicenter, randomized, placebo-controlled, unbalanced factorial study included a 4- to 5-week single-blind placebo, 9-week, double-blind treatment as well as a 2-week double-blind, down-titration period. Patients (N = 1092) were randomized to one of 16 treatment groups: extended-release (ER) metoprolol succinate (25, 100, or 400 mg), ER felodipine (2.5, 10, or 20 mg), ER felodipine/ER metoprolol succinate (2.5/25, 2.5/100, 2.5/400, 10/25, 10/100, 10/400, 20/25, 20/100, or 20/400 mg), or placebo.

RESULTS

At baseline, treatment groups were well balanced; mean sitting BP was 152.6/99.9 mm Hg. Monotherapy with ER metoprolol succinate induced dose-related reductions in sitting systolic/diastolic BP (DBP) (mean 8.1/7.7 to 9.7/11.1 mm Hg) as did ER felodipine (mean 7.7/7.7 to 14.0/11.8) and the combinations reflected additive effects (mean 13.8/11.0 to 19.8/15.2). The decline in the placebo group was 2.1/4.0 mm Hg. All combinations were more effective than their components (P < .05 for all but ER metoprolol succinate 25/ER felodipine 20). When compared with the highest doses of the individual agents (ER metoprolol succinate 400 mg; ER felodipine 20 mg), the low-dose combination ER metoprolol succinate 25/ER felodipine 2.5 was approximately as effective (differences in DBP <1 mm Hg). The most common adverse events leading to discontinuation were peripheral edema (4%), headache (2%), and fatigue (1%). Higher rates of peripheral edema and flushing were associated with high-dose ER felodipine, either alone or in combination.

CONCLUSIONS

The antihypertensive effects of ER metoprolol succinate and ER felodipine are dose-related, and when given in combination, their BP-lowering effects are additive over a wide dose range. Low-dose combination therapy is comparable in effectiveness to high-dose monotherapy but is better tolerated.

Impaired Capacity for Stimulated Fibrinolysis in Primary Hypertension Is Restored by Antihypertensive Therapy

The increased risk for myocardial infarction and ischemic stroke in primary hypertension suggests that the condition is associated with prothrombotic mechanisms. We have shown that patients with hypertension have an impaired capacity for acute endothelial tissue-type plasminogen activator (t-PA) release, an important local protective response to prevent formation of intravascular thrombi. The aim of the present study was to investigate whether this impairment could be restored by the lowering of blood pressure. The capacity for acute t-PA release in response to intraarterial infusion of substance P at 8 pmol/min was investigated in a perfused-forearm study in 20 hypertensive patients (12 men and 8 women). Studies were performed when patients were untreated and after 8 weeks of randomized treatment with lisinopril or felodipine that lowered blood pressure by 26/10 and 24/12 mm Hg, respectively. The t-PA release response increased significantly with treatment (ANOVA, P =0.0001), with a similar effect in the 2 treatment groups. The peak release of t-PA increased from 257 (58) to 445 (77) ng/min×L/tissue −1 ( t test, P =0.02). Also, treatment shortened the average time to peak secretion from 6.7 (1.4) to 2.7 (0.3) min ( t test, P =0.01). In 6 patients with a delayed secretory peak (9 minutes or later), treatment normalized the response (χ 2 test, P =0.008). Antihypertensive therapy restores the capacity for acute t-PA release and improves the rapidity of the response in patients with primary hypertension. Similar responses with the 2 regimens suggest that the improvement is related to the blood pressure reduction as such. This effect may contribute to the thromboprotective effect of antihypertensive treatment.

CACNA1C polymorphisms are associated with the efficacy of calcium channel blockers in the treatment of hypertension

Retrospective pharmacogenetic analysis was performed on 120 Caucasian subjects. Subjects were obtained in collaboration with the Estonian Genome Project and Egeen Inc. (CA, USA), who provided blinded medical record and genetic data to the researchers, respectively. Subjects selected from the Estonian Genome Project had a diagnosis of hypertension confirmed by at least two blood pressure measurements and multiple follow-up measurements for assessing calcium channel blocker antihypertensive treatment outcome. Treatment outcome was scored positive if at least three follow-up blood pressure measurements were nonhypertensive and no more than one follow-up measurement was hypertensive (>140/90). The genotypes of 62 single nucleotide polymorphisms (SNPs) in the calcium channel, voltage-dependent, L type, α 1C subunit (CACNA1C) gene were obtained for each subject from a blood sample. Univariate analyses with multiple test correction were conducted using family-wise error rate and false discovery rate methods. Three SNPs in CANCA1C had significant associations with antihypertensive outcome, combining to yield a positive treatment outcome of less than 15 to 80%.

Sympatho-excitatory responses to once-daily dihydropyridines in young versus older hypertensive patients: amlodipine versus felodipine extended release

BACKGROUND

Once-daily dihydropyridines exert both indirect sympatho-excitatory and direct central sympatho-inhibitory effects. Age may affect this balance by influencing blood pressure (BP) or renin responses.

METHODS

We evaluated BP, sympathetic and cardiac responses after the first dose and after 8 weeks of treatment with placebo, amlodipine 5 mg/day or felodipine extended release (ER) 5 mg/day in 29 young (22-50 years) versus 37 older (60-77 years) hypertensive patients, using a double-blind, parallel group design.

RESULTS

In the young group, neither dihydropyridine dose decreased BP after the first dose and both caused decreases by 5-10 mmHg after chronic treatment. In the older group, felodipine ER decreased BP rapidly and amlodipine more gradually, and after chronic treatment, systolic BP decreased by 20-25 mmHg. Felodipine ER increased the heart rate by 5-10 bpm after the first dose in both age groups and caused persistent increases in the cardiac index (by 0.2 l/min per square metre) and the ejection fraction only in the older group. Amlodipine did not affect cardiac function in the young, and with chronic dosing decreased the heart rate by 3-5 bpm and the cardiac index by 0.2 l/min per square metre in the older group. In the young hypertensive patients, both dihydropyridines increased plasma norepinephrine (NE) after chronic dosing, with little effect after the first dose. In contrast, in the older group felodipine ER increased plasma NE after the first dose but not with chronic dosing, whereas amlodipine had no effect after the first dose, and after chronic dosing tended to decrease plasma NE.

CONCLUSION

We conclude that age is a major determinant not only of the BP but also of the cardiac and sympathetic responses to once-daily dihydropyridines.

Felodipine-metoprolol combination tablet: maintained health-related quality of life in the presence of substantial blood pressure reduction

BACKGROUND

Most treated hypertensive patients do not achieve adequate blood pressure (BP) control. Initiating therapy with two drugs has been suggested when BP is >20/10 mm Hg above goal. To ensure patients' compliance, such treatment needs to be well tolerated and must not compromise health-related quality of life (HRQL). The primary objective of this study was to compare the effects on HRQL of initiating treatment with felodipine + metoprolol (F+M) fixed combination tablets, or enalapril (E), or placebo (P).

METHODS

A total of 947 patients of both sexes with primary hypertension (diastolic BP 95 to 110 mm Hg), aged 20 to 70 years, participated in this randomized, double-blind, parallel group, 12-week, multicenter trial. Treatment was initiated with F+M 5 + 50 mg, or E 10 mg, or P. Doses were doubled after 4 or 8 weeks if diastolic BP was >90 mm Hg. The HRQL was measured at baseline and at the last visit using two validated questionnaires: the Psychological General Well-being Index (PGWB) and the Subjective Symptom Assessment Profile (SSA-P). Office BP was measured at trough, that is, 24 h after the previous dose.

RESULTS

The HRQL was high at baseline and generally well maintained during the study. For example, the mean (SD) PGWB total score was 104 (16) at baseline and 105 (16) at 12 weeks in all three treatment groups. The BP reductions after F+M (18/14 mm Hg) and E (12/9 mm Hg) were significantly greater than after P (7/7 mm Hg), and the reduction after F+M was significantly greater than after E.

CONCLUSIONS

The HRQL is maintained in the presence of substantial BP reduction during antihypertensive treatment with F+M fixed combination tablets.

Dihydropyridines, felodipine, and PHARMAC

Calcium antagonists have evolved as useful drugs in the treatment of hypertension and angina. Dihydropyridines are the largest subgroup and various products have been marketed. Safety concerns have largely been allayed by comparative outcome trials but concern remains over short-acting products. In New Zealand, many patients requiring fully subsidised dihydropyridines have had several changes of product imposed due to successive reference pricing and sole-supply arrangements, along with deregistering and reregistering of generic felodipine. Some narrowly avoided a complete loss of access to a suitable low dose of any dihydropyridine. Generic substitution and sole-supply arrangements may make useful savings but can leave the supply of key pharmaceuticals vulnerable and impose significant loss in quality of healthcare from multiple changes in pharmaceutical preparation.

[The effect and mechanism of felodipine and valsartan on a novel salt-sensitive hypertensive rat induced by sensory denervation]

OBJECTIVE

To investigate the effect and mechanism of valsartan and felodipine extended release tablets (Plendil) on a novel salt-sensitive hypertensive rat induced by sensory denervation.

METHODS

Newborn Wistar rats were given 50 mg/kg capsaicin subcutaneously on the 1st and 2nd day of life. Control rats were treated with vehicle solution (10%ethanol, 10%Tween 80 in saline). After weanling period (3 weeks), male rats were divided into 5 groups and subject to the following treatment for 4 weeks: control + high salt diet (4%, CON-HS), capsaicin + normal salt diet (0.5%, CAP-NS), capsaicin + high salt diet (CAP-HS), capsaicin + high salt diet + Valsartan (30 mg/kg per day, by orally) (CAP-HS-VAL), capsaicin + high salt diet + Plendil (30 mg/kg per day, by orally) (CAP-HS-PLE). Tail-cuff systolic blood pressure, body weight, intralymphocytic [Ca(2+)](i), plasma calcitonin gene-related peptide concentration ([CGRP]), angiotensin II concentration ([AngII]) and 24 hour water intake, urinary volume, urinary Na(+) and K(+) concentrations were examined.

RESULTS

Tail-cuff systolic blood pressure and intralymphocytic [Ca(2+)](i) were lower in CAP-HS-VAL or CAP-HS-PLE group than those in CAP-HS group. Plasma [AngII] were higher in CAP-HS-VAL group than that in other groups. Tail-cuff systolic blood pressure were lower in CAP-HS-VAL group than that in CAP-HS-PLE group. Intralymphocytic [Ca(2+)](i) were lower in CAP-HS-PLE group than that in CAP-HS-VAL group. The 24 hour urine sodium excretion was higher in CAP-HS-PLE group than that in CAP-HS or CAP-HS-VAL group.

CONCLUSION

Valsartan or Plendil could prevent the development of salt-sensitive hypertension induced by sensory denervation and the overloading of intracellular [Ca(2+)](i), which indicated that salt-sensitive hypertension induced by sensory nerve degeneration might be related to renin-angiotensin-aldosterone system (RAAS) and the over loading intracellular [Ca(2+)](i), and might be more closely to RAAS.

Ramipril/Felodipine Extended-Release Fixed-Dose Combination

Ramipril/felodipine extended release (ER) [Triapin and Triapin Mite, Unimax] is a once-daily fixed-dose combination of the ACE inhibitor ramipril and the ER formulation of the dihydropyridine calcium channel antagonist felodipine. It is indicated in adult patients with essential hypertension whose blood pressure (BP) is inadequately controlled with ramipril or felodipine monotherapy. In this patient population, commercially available fixed-dose combinations (i.e. 2.5 mg/2.5 mg and 5 mg/5 mg) of ramipril and felodipine ER are more effective at controlling hypertension than the individual components used as monotherapy at the same dosages. Likewise, the 5 mg/5 mg combination is as effective as felodipine ER 10 mg, and more effective than ramipril 10 mg administered as monotherapy. The addition of low-dose ramipril plus felodipine ER (fixed-dose or combination of individual components) to the existing antihypertensive regimen also appears to provide adequate BP control and renal protection in hypertensive patients with non-diabetic chronic renal disease. In these patients, the low-dose combination of ramipril and felodipine ER was as effective as standard-dose felodipine ER, but more effective than standard-dose ramipril, in providing diastolic BP (DBP) control, and as effective as standard-dose ramipril, but more effective than standard-dose felodipine ER, in slowing the rate of regression of glomerular filtration. The ramipril/felodipine ER combination is as well tolerated as ramipril or felodipine ER monotherapy administered at the same dosages, and is better tolerated than felodipine ER monotherapy given at twice the dosage used in the combination. Overall, ramipril/felodipine ER appears to be an effective option for the treatment of adults with essential hypertension that is poorly controlled with monotherapy. In addition, a fixed, low-dose combination of ramipril/felodipine ER is a potential alternative to monotherapy for the initial management of essential hypertension.

Determination of the lack of a drug interaction between azithromycin and warfarin

STUDY OBJECTIVE

To determine the effect on the international normalized ratio (INR) of adding azithromycin to patients receiving stable dosages of warfarin.

DESIGN

Retrospective chart review.

SETTING

Outpatient clinic.

PATIENTS

Ambulatory patients receiving warfarin and azithromycin concurrently who had a documented therapeutic INR value before the start of azithromycin therapy (pre-INR) and a documented INR value within 30 days after the start of azithromycin therapy (post-INR).

MEASUREMENTS AND MAIN RESULTS

Patients given felodipine during long-term warfarin therapy formed a comparative control group. Patient demographics were similar in both treatment groups. Mean age of the azithromycin group (17 patients) was 59 +/- 13 years and of the control group (20 patients) 65 +/- 12 years. All 17 patients in the azithromycin group and 16 of the controls were women. Mean change from pre-INR to post-INR in the azithromycin and control groups, respectively, was 0.14 +/- 0.64 (pre-INR 2.46, post-INR 2.61) and 0.19 +/- 0.54 (pre-INR 2.46, post-INR 2.66) (p = 0.74). A post hoc power analysis based on a pooled standard deviation of 0.60 revealed that the study had 68% power to detect a 0.5 change in the INR value.

CONCLUSION

No interaction between azithromycin and warfarin was observed in ambulatory patients with therapeutic baseline INR values.

Adherence to Calcium Channel Blocker Therapy in Older Adults: A Comparison of Amlodipine and Felodipine

The efficacy of dihydropyridine calcium channel blockers for treating hypertension appears to be similar, but a variety of factors, including patient characteristics, tolerability and pharmacokinetic properties, may influence treatment adherence and outcome. We aimed to evaluate treatment adherence in clinical practice among older hypertensive adults (50+ years) prescribed amlodipine or felodipine for the first time as part of the California Medicaid (Medi-Cal) program. We used a retrospective, matched, cohort-analysis design. Over 1 year, patients prescribed amlodipine were 21% less likely to discontinue study treatment than those prescribed felodipine. Discontinuation tended to occur early, with 20% and 30% of amlodipine and felodipine patients, respectively, discontinuing treatment after one prescription. A non-significant difference in favour of amlodipine was demonstrated for anti-anginal medication use among patients taking these drugs at baseline. This study suggests that use of amlodipine may be associated with improved adherence, compared with felodipine, among older out-patients in the Medi-Cal program.

The effect of Ca2+ channel antagonists on plasma concentrations of matrix metalloproteinase-2 and -9 in essential hypertension

The ability of some antihypertensive drugs to protect from vascular damage in hypertension might be partially due to their ability to control matrix metalloproteinase (MMP)-mediated extracellular matrix metabolism, which in turn may contribute to vascular remodeling. This study was designed to investigate whether treatment with felodipine or diltiazem has any effect on plasma levels of MMP-2 and MMP-9 in essential hypertensive patients. We measured plasma levels of active MMP-2 and MMP-9 in 72 hypertensive subjects and 45 controls, both before and after 6 months of treatment with felodipine (group A) or diltiazem (group B). Mean adjusted differences, before and after each treatment, for MMP-2 and MMP-9 levels were: 19.8 (P =.01) for MMP-2, 0.2 (P =.5) for MMP-9 (group A), and 1.4 (P =.4) for MMP-2, 0.2 (P =.7) for MMP-9 (group B). These findings show that MMP-2 level is raised by treatment with felodipine but not diltiazem, whereas MMP-9 is unaffected by either treatment.

[Efficacy and tolerability of felodipine based antihypertensive therapy in hospitalized patients with hypertension]

AIM

To compare efficacy and tolerability of felodipine based antihypertensive therapy with those of standard hospital treatment of hypertension.

MATERIAL

Inhospital patients were randomized 1:2 to standard antihypertensive therapy or to therapy which included felodipine (n=50 and 100, 36 and 35% men, mean age 66.0+/-8.4 and 64.3+/-8.1 years, initial blood pressure 162.4+/-9.3/99.3+/-6.4 and 163.2+/-10.3/98.2+/-6.5 mm Hg, respectively). Felodipine was used: (1) as first drug with subsequent addition of other drugs as required; (2) after cessation of previously ineffective therapy; (3) in cases of intolerance to previous therapy, (4) as supplementation to previously insufficiently effective therapy. Results. At discharge in felodipine group 6, 25, 29 and 40% of patients received mono- (felodipine 10 mg/day), 2, 3 and 4 component therapy, respectively. In standard treatment group all patients received combination therapy with 3 (48%) or 4 (52%) drugs. Felodipine group compared with group of standard therapy was characterized by less frequent correction of antihypertensive therapy (0.8+/-0.6 and 2.2+/-0.9, p<0.05), smaller number of drugs used (3.03+/-0.95 and 3.52+/-0.5, p<0.01), more frequently achievement of target blood pressure level (88 and 64%, p=0.0075), less pronounced difference between morning and evening self-measured blood pressure.

CONCLUSION

The use of felodipine in hospitalized patients with hypertension allowed achieving target blood pressure with fewer drugs. Felodipine was safe and well tolerated.

Evaluation of a therapeutic conversion from amlodipine to felodipine

STUDY OBJECTIVES

To determine patient satisfaction with and tolerability of a conversion from a long-acting calcium channel blocker, amlodipine, to felodipine. Secondary objectives were to compare the effect of the change on blood pressure and heart rate and the economic impact of the change.

DESIGN

Retrospective study.

SETTING

Veterans Affairs health care system.

PATIENTS

Two hundred eighty-three men who were taking amlodipine to manage hypertension.

INTERVENTION

Patients who were converted to felodipine were mailed a survey quantifying subjective symptoms; the survey also included questions specific to the change program. Transitory blood pressure and heart rate measurements retrieved by electronic chart review were evaluated during therapy with both amlodipine and felodipine.

MEASUREMENTS AND MAIN RESULTS

Ninety-five percent of patients were satisfied with the conversion process and tolerated the switch from amlodipine to felodipine. Mean systolic and diastolic blood pressures were reduced by 4.4 and 2.6 mm Hg, respectively (p=0.166 and 0.187, respectively). Heart rate was reduced significantly by 4.2 beats/minute (p=0.008). The conversion realized a net annual drug cost savings of approximately dollars 16,000.

CONCLUSION

Our patient population was satisfied with the conversion from amlodipine to felodipine, and the new drug was found to be effective, well tolerated, and associated with a modest cost reduction.

Comparative effect of lercanidipine, felodipine, and nifedipine GITS on blood pressure and heart rate in patients with mild to moderate arterial hypertension: the Lercanidipine in Adults (LEAD) Study

This multicenter, double-blind, parallel-group study compared the effects of three dihydropyridine calcium channel blockers (lercanidipine, felodipine, and nifedipine gastrointestinal therapeutic system) on blood pressure and heart rate in 250 patients with mild to moderate hypertension (diastolic blood pressure > or =95 and 109 mm Hg). Patients were randomized to 4 weeks of treatment with once-daily doses of lercanidipine 10 mg, felodipine 10 mg, or nifedipine gastrointestinal therapeutic system 30 mg. After 4 weeks of treatment, the dose was doubled in nonresponding patients. At 8 weeks, no significant differences in blood pressure were observed among the three groups. Increases in heart rate in all three groups induced by stressful conditions before and after treatment were not exacerbated during active treatment. The incidence of adverse drug reactions was lower in the lercanidipine and nifedipine groups than in the felodipine group (p<0.05); in particular, the incidence of edema for lercanidipine was 5.5% vs. 13% for felodipine and 6.6% for nifedipine.

A comparative analysis of amlodipine and felodipine in a military outpatient population: efficacy, outcomes, and cost considerations

BACKGROUND

This retrospective study compared the efficacy, tolerability, and cost of two dihydropyridine calcium channel blockers.

METHODS

Charts of patients who had been on continuous antihypertensive therapy with amlodipine or felodipine for at least 6 months were reviewed. Analyses include mean changes in blood pressure, percentage of patients achieving blood pressure (BP) < 140/90 mm Hg, average dose, and cost per day of the two calcium channel blockers, average cost of additional medication, total medication cost per day, and cost to achieve BP control.

RESULTS

Eighty-seven percent of amlodipine-treated patients achieved BP control compared with 33% of felodipine-treated patients. Total medication cost to achieve BP control was 0.87 dollars per day for patients on amlodipine compared with 1.79 dollars per day for patients on felodipine.

CONCLUSIONS

Amlodipine produced BP control in a greater percentage of patients than did felodipine at a lower total cost to achieve BP control. When evaluating the total cost of antihypertensive treatment, the cost of a drug alone can be misleading.

Health economics in the Hypertension Optimal Treatment (HOT) study: costs and cost-effectiveness of intensive blood pressure lowering and low-dose aspirin in patients with hypertension

OBJECTIVES

To investigate the marginal cost-effectiveness of different targets for the reduction of blood pressure and the cost-effectiveness of adding acetylsalicylic acid (ASA) to the treatment of hypertension.

DESIGN

Patients with hypertension were randomized to three target groups for blood pressure; < or =90, < or =85 and < or =80 mmHg. Patients were also randomly assigned ASA and placebo. The average follow-up time was 3.8 years. The direct costs for drugs, visits, hospitalizations, and side-effects were calculated and related to clinical outcome.

SETTING

Resource utilization data from all the 26 countries in the study were pooled, and Swedish unit costs were applied to the aggregated resource utilization.

SUBJECTS

A total of 18 790 patients, 50-80 years of age (mean 61.5 years), with a diastolic blood pressure between 100 and 115 mmHg (mean 105 mmHg).

INTERVENTIONS

Antihypertensive treatment with the long-acting calcium antagonist felodipine was given to all patients. Additional therapy and dose increments in four further steps were prescribed to reach the randomized target blood pressure. Fifty per cent of the patients were randomized to a low dose, 75 mg daily, of acetylsalicylic acid.

MAIN OUTCOME MEASURES

Direct health care costs, major cardiovascular (CV) events (myocardial infarction and stroke) and CV death.

RESULTS

The average cost of drugs and visits increased with more intensive treatment. The increase in treatment costs was partly but not fully offset by a nonsignificant reduction in the cost of CV hospitalizations. For patients with diabetes there were no significant differences in total cost between the target groups. The cost of avoiding a major CV event was negative in the base case analysis, SEK -10 360 (CI: -78 195, 75 630), and SEK 18 450 (CI: -88 789, 192 980) in a sensitivity analysis. For patients on ASA, costs were slightly but significantly higher than for patients on placebo. The estimates of the cost of avoiding a major CV event varied between SEK 41 600 and SEK 477 400, with very wide confidence intervals.

CONCLUSIONS

The treatment cost increases as the target for hypertension treatment is lowered. In patients with diabetes, intensive treatment to a lower target is cost-effective. Because of the nonsignificant difference in events, no conclusion can be made for all patients in the study. Furthermore, no conclusive evidence was found regarding the cost-effectiveness of adding ASA to the treatment of hypertension.

The effect of nonsteroidal anti-inflammatory drugs on blood pressure in patients treated with different antihypertensive drugs

Hypertension and arthritis are both common diseases in the older age group and require pharmacologic treatment. Nonsteroidal anti-inflammatory drugs (NSAIDs) alter renal function if given in high enough doses, reducing renal blood flow and the glomerular filtration rate and causing sodium retention. In salt sensitive subjects, this retention of sodium will cause blood pressure to rise. Salt sensitivity is more common in elderly patients, in diabetics, and in people with renal failure. When most antihypertensive drugs are used, people become salt sensitive, as shown by the additive effect of salt restriction or diuretics on blood pressure response. The responses to dihydropyridine and possibly other calcium channel blocking drugs are not affected to any major extent by sodium intake or by diuretics. Studies are described which indicate that indomethacin elevates blood pressure in elderly people treated with enalapril, but not in people whose blood pressure is controlled with amlodipine or felodipine. It is unclear whether the various NSAIDs have different effects on blood pressure. It is proposed that if the same analgesic effect is achieved with the same amount of cyclooxygenase inhibition, the response will be similar. Aspirin, used in a prophylactic dose, does not inhibit to this extent and does not elevate blood pressure. If elderly people require NSAIDs, it would appear that dihydropyridine calcium channel blocking drugs are more effective at lowering and maintaining blood pressure control and should be one of the drugs used. If patients are on other antihypertensive agents, it is important to monitor blood pressure when a NSAID is added to therapy.

Influence of antihypertensive treatment with perindopril, pindolol or felodipinon plasma leptin concentration in patients with essential hypertension

Leptin - produced predominantly by adipocytes - is presumably also involved in pathogenesis of essential hypertension (EH). In the present study, we addressed the question whether and to what extent antihypertensive monotherapy does influence leptinemia in patients with mild or moderate EH. Forty-two EH patients were enrolled in this randomized, open-labeled study. In all subjects, plasma concentrations of leptin, insulin, glucose, cholesterol, triglycerides and creatinine were estimated twice - before and one month after initiation of monotherapy with perindopril, pindolol or felodipin, respectively. Plasma leptin concentration, in the afternoon and midnight, was significantly higher in patients with essential hypertension than in normotensive healthy subjects (p < 0.01). Therapy with perindopril or felodipin did not influence the daily profile of leptinemia or insulinemia, respectively. However, pindolol monotherapy showed a marked (p < 0.01) suppressive effect on the daily profile of leptinemia, but did not influence insulinemia.

CONCLUSIONS

First, patients with essential hypertension are characterized by higher plasma leptin levels as compared with normotensive healthy subjects; second, suppressive effect of pindolol on leptinemia may be of pathophysiological relevance in the course of weight gain during beta-blocker therapy.

Effects of aging and AT-1 receptor blockade on NO synthase expression and renal function in SHR

In an earlier study, we found increased NO production and NO synthase (NOS) expression in renal and vascular tissues of prehypertensive and adult spontaneously hypertensive rats (SHR). This study was designed to determine the effects of aging and AT-1 receptor blockade (losartan 30 mg/kg/day beginning at 8 weeks of age) on NO system in this model. Compared to the Wistar Kyoto (WKY) control rats, untreated SHR showed severe hypertension, elevated urinary NO metabolite (NO(chi)) excretion, marked upregulations of renal and vascular eNOS and iNOS proteins, normal renal function and heart weight at 9 weeks of age. Hypertension control with either AT-1 receptor or calcium channel blockade (felodipine 5 mg/kg/day) mitigated upregulation of NOS isoforms in the young SHR. With advanced age (63 weeks), the untreated SHR showed increased proteinuria, renal insufficiency, cardiomegaly, reduced urinary NO(chi) excretion and depressed renal and vascular NOS protein expressions as compared to the corresponding WKY group. AT-1 receptor blockade prevented proteinuria, renal insufficiency, cardiomegaly, and renal and vascular NOS deficiency. Thus, in young SHR, hypertension results in compensatory upregulation of renal and vascular NOS, which can be attenuated by vigorous antihypertensive therapy. With advanced age, untreated SHR exhibit cardiomegaly, renal dysfunction and marked reductions of eNOS and iNOS compared with the aged WKY rats. Hypertension control with AT-1 receptor blockade initiated early in the course of the disease prevents target organ damage and preserves renal and vascular NOS.

Smooth blood pressure control obtained with extended-release felodipine in elderly patients with hypertension: evaluation by 24-hour ambulatory blood pressure monitoring

OBJECTIVE

To assess, by smoothness index (SI), distribution of the antihypertensive effect of extended-release (ER) felodipine over 24 hours in elderly patients with hypertension.

METHODS

After a 4-week washout phase, 35 elderly patients (mean age 69 +/- 4 years) with mild-to-moderate hypertension received 2 weeks' treatment with ER felodipine 5mg once daily. The dosage of ER felodipine was doubled to 10 mg/day and given for a further 2 weeks in non-responders (sitting clinic blood pressure > 140/90mm Hg). The study had an open-label design with no placebo control. After each period, clinic and ambulatory blood pressures were measured. Trough-to-peak (T/P) ratio was computed by dividing the blood pressure (BP) change at trough (22 to 24 hours after drug intake) by the change at peak (2 adjacent hours with a maximal BP reduction between the second and eighth hour after drug intake). SI was calculated as the ratio between the average of the 24, hourly, treatment-induced BP changes and its standard deviation.

RESULTS

After the initial 2-week treatment period, clinic and 24-hour ambulatory BP values were higher in non-responders (145 +/- 11/87 +/- 8 and 135 +/- 17/80 +/- 6mm Hg, respectively) than in responders (133 +/- 6/81 +/- 3 and 130 +/- 9/77 +/- 7mm Hg). In non-responders, clinic and 24-hour BP values were lowered after a further 2 weeks of treatment with ER felodipine 10 mg/day (128 +/- 11/78 +/- 6 and 128 +/- 12/75 +/- 5mm Hg). SI was high in responders (0.8 +/- 0.8/0.7 +/- 0.7 for systolic/diastolic BP) and low in non-responders (0.5 +/- 0.6/0.3 +/- 0.6) during the first 2-week treatment period. It increased in non-responders after an additional 2 weeks of treatment with ER felodipine 10 mg/day (1.0 +/- 0.8/0.7 +/- 0.6). Median T/P ratios were 0.73 and 0.61 (systolic BP and diastolic BP) in responders and 0.41 and 0.61 in non-responders after 2 weeks of treatment. At variance with SI, T/P ratios did not increase in non-responders after doubling the dosage of ER felodipine (0.34 and 0.18). ER felodipine did not increase 24-hour heart rate. A total of nine adverse events were recorded in six patients (17%), but no patients withdrew from the study.

CONCLUSION

ER felodipine 5 to 10 mg/day smoothly and safely reduces 24-hour ambulatory BP in elderly patients with hypertension.