Electrochemical screening of selected β-blockers at a polarized liquid-liquid interface

This paper describes the electrochemical behavior of five β-blockers at the polarized liquid-liquid interface formed between aqueous solution (sodium chloride solution or Britton-Robinson buffers) and bis(triphenylphosphoranylidene)ammonium tetrakis(4-chlorophenyl)borate (BTPPATPBCl) dissolved in 1,2-dichloroethane (the organic phase). All measurements reported in this work were conducted using cyclic voltammetry (CV). The effects of the concentration of analytes, the pH of the aqueous phase, and applied electrochemical parameters on the analytical performance of the studied system are studied and discussed. The linear dynamic ranges (LDRs) of the studied β-blockers were in the range of 5-200 μmol L-1 and the lowest limit of detection (LOD) value was determined for pindolol (LOD = 1.96 μM μmol L-1). The highest LOD value was 4.96 μmol L-1 found for nebivolol. In addition, physicochemical parameters such as the formal Galvani potential difference (Δaqorgϕ), formal Gibbs free energies of the ion transfer reaction (ΔaqorgG') and partition coefficients (log P'aq/org) for all studied molecules were determined. The latter were compared and correlated with the available literature values of log Poctanol. Finally, a standard addition method was used to determine the concentration of nebivolol in pharmaceutical preparations using a platform based on the electrified liquid-liquid interface.

Nanosized ethosomal dispersions for enhanced transdermal delivery of nebivolol using intradermal/transfollicular sustained reservoir: in vitro evaluation, confocal laser scanning microscopy, and in vivo pharmacokinetic studies

Nebivolol (NBV), a BCS class II anti-hypertensive drug, suffers from limited solubility and oral bioavailability. Nanosized ethosomes were adopted as an approach to solubilize and deliver NBV transdermally, as a substitute to oral route. Ethosomal dispersions were prepared employing thin film hydration method. Formulation variables were adjusted to obtain entrapment efficiency; EE > 50%, particle size; PS < 100 nm, zeta potential; ZP > ±25 mV, and polydispersity index; PDI < 0.5. The optimized ethosomal dispersion (OED) showed accepted EE 86.46 ± 0.15%, PS 73.50 ± 0.08 nm, ZP 33.75 ± 1.20 mV, and PDI 0.31 ± 0.07. It also showed enhanced cumulative amount of NBV permeated at 8 h (Q8) 71.26 ± 1.46% and 24 h (Q24) 98.18 ± 1.02%. TEM images denoted spherical vesicles with light colored lipid bi-layer and dark core. Confocal laser scanning microscopy showed deeply localized intradermal and transfollicular permeation of the fluorolabelled OED (FL-OED). Nanosized FL-OED (<100 nm) can permeate through hair follicles creating a drug reservoir for enhanced systemic absorption. OED formulated into transdermal patch (OED-TP1) exhibited accepted physicochemical properties including; thickness 0.14 ± 0.01 mm, folding endurance 151 ± 0.07, surface pH 5.80 ± 0.15, drug content 98.64 ± 2.01%, mucoadhesion 8534 ± 0.03, Q8 87.61 ± 0.11%, and Q24 99.22 ± 0.24%. In vivo pharmacokinetic studies showed significantly enhanced bioavailability of OED-TP1 by 7.9 folds compared to oral Nevilob® tablets (p = 0.0002). It could be concluded that OED-TP1 can be a promising lipid nanocarrier TDDS for NBV and an efficacious alternative route of administration for hypertensive patients suffering from dysphagia.

METASTATIC NODULAR MELANOMA DEVELOPING ON NEVUS SPILUS DURING INTAKE OF BETA BLOCKERS (BISOPROLOL/NEBIVOLOL) AND ACE INHIBITORS (PERINDOPRIL). POTENTIAL LINKS TО THE DRUG RELATED NITROSOGENESIS/CARCINOGENESIS, DUNNING-KRUGER EFFECT AND GENETIC WEAPONS OF THE NEW GENERATION

Drug-induced Nitrosogenesis/Carcinogenesis turns out to be a ubiquitous, pervasive, large-scale, poorly controllable concept for the academic community, which underlies the long-term, permanent modification of the human genome by contact with nitrosamines/NDSRIs, which ultimately leads to the generation of diverse cancers, but also melanoma in particular. The discovery of a (currently) unclassifiable number of nitroso derivatives/genome modifiers in the most commonly distributed drugs worldwide (in about 300 preparations according to the FDA/includes beta blockers/bisoprolol/nebivolol and ACE inhibitors/perindopril), their forced tolerability, attributed as a necessity or lack of alternative also to the present (but also to future periods), and their proven carcinogenicity (already 70 years ago), suggest a kind of creepy form of experiment to which public health is subjected worldwide. The creation of a universal nitroso-comfort of pharmaceutical companies and the regulation of a permanent intake of carcinogens in drugs for years to come, but also decades back, suggest possible cartel agreements between the regulation/distribution unit and that of production cycles. These "agreements" are becoming increasingly evident and in all likelihood position nitrosogenesis from a until recently unknown element, to a pathogenetic factor of paramount importance. Melanoma could be viewed precisely as the controlled end gene-modified product of drug-mediated nitrosogenesis/carcinogenesis, proven to be a locoregional (but not only) phenomenon hundreds if not thousands of times. The dilemma stays: Are the nitrosamines in drugs genetic weapons, ethnic bioweapons for silent war ? The nitrosogenesis concerning melanoma leads to the logical conclusion that cancer is in fact a largely controlled set event or, according to others, a forced necessity of evolutionary globalization processes to purge the population in certain regions. In favor of this statement indicative are namely: 1) lack of regulatory control/results of such conducted, 2) complete information veil for the end user regarding contamination with carcinogens/nitrosamines in certain batches or all batches of drugs, 3) misinformation and lack of transparency regarding the concept of nitrosogenesis also for the academic community, as well as 4) the impunity to pharmaceutical conglomerates after criminal negligence/controlled criminogenicity proven thousands of times by the FDA/EMA leading to regulatory controlled drug mediated genocide of the human population in certain areas on a daily basis. And most important of all: 5) the lack of refusal to eliminate these drugs, i.e. - the imposition of forced tolerance at any cost. It is extremely unfortunate that the mentioned and identified grotesque/situation, its tolerance on a global scale, lead to a misjudgement of the significance of real tumor inducers within the global health map//statistics as well as melanoma. The focus of prevention is being displaced, while the incidence of cancer in general and that of melanoma is skyrocketing. Nitrosamines could be defined as the newest, modern, until recently invisible and unknown, but -controllable form of genetic weapon to modify the human genome. Because of these very facts, the likelihood that clinicians and the academic community are in the frozen and permanent state of the Dunning-Kruger effect is very real. Certain globalization regulatory elements create problems and assignments that must be solved ˝competently˝ by incompetent, fully regulatable compartments. As their state of competence depends again and entirely on ˝their incompetence˝. Until now. After the formalization of the concept of Nitrosogenesis (as a form of genetic weapon) and melanoma for example, but not only, it remains to be seen whether universal incompetence will become a guarantee of competence and the survival. Or- will it remain again at the level of globalized, criminally conditioned, appointed and regulated from above "competent incompetence". The dilemmas to regulators and manufacturers remain open : Is it competent to take drugs that contain carcinogens/nitrosamines? Is it competent for this issue to continue for decades with impunity? Is it competent for regulators not to inform consumers about the presence of carcinogens/genome modifiers in medicines for decades? Is it competent for certain regions to be affected by nitrosamine contamination and not others? Is it competent not to reflect this in regional and global health bulletins on side effects? Is it competent to make thousands of times the profits from the modified genetic map business, regulated and legally initiated through the intake of carcinogens? Is it competent to have the concentration of carcinogens within polymedication exceeding many times the daily allowable doses of carcinogens and have no solution for this? Is it competent, when the intake of nitrosamines in medicines is associated with the generation of melanomas and heterogeneous cancers- to have no alternative to this or when one is available- to conceal it skillfully? Is it competent to determine carcinogenic activity based on mutagenic tests? Is it competent to be polyincompetent within a framework of mass (in)competence? We report systemically administered drugs for the treatment of high blood pressure from the group of beta blockers (bisoprolol/nebivolol) and ACE inhibitors (perindopril) that have been identified by regulators in the face of FDA as hypothetically contaminated with nitrosamines/NDSRIs with a carcinogenic potency between 4 and 5, respectively. Within this cumulative intake, (which according to the regulators was not at risk of developing cancerous forms), similar to other cases in the world literature, the patient developed a relatively short-term, metastatic nevus spilus-based nodular melanoma. The paper analyses not only the role of nitrosogenesis, but also that of two pregnancies and painful sunburns as potential cofactors for melanoma genesis. Academic attention is drawn to the potential impact of drug-mediated nitrosogenesis/carcinogenesis. Nitrosamines in the framework of polycontamination and polymedication could also be identified as one of the most effective, until recently unknown, modern generation genetic weapons for modifying the human genome and controlling cancer. Moreover, they could be controllably applied and skillfully targeted. At least until now. The officialization of carcinogens in more than 250 of the most common drugs and the clinico-pathological correlations concerning the development of cancer/melanoma in poorly controlled geographical regions represent a kind of in vivo prospective study to determine precisely the real carcinogenic role of nitrosamines to date.

Antihypertensive Efficacy Of Nebivolol And Low Dose Spironolactone In Patients With Resistant Hypertension

OBJECTIVE

Resistant hypertension is associated with increased mortality and morbidity. The optimal medical therapy is not fully elucidated in resistant hypertension. There are relatively few studies in the literature on the treatment of resistant hypertension. In this study, we compared the effectiveness of nebivolol 5 mg, a third generation beta-blocker, with spironolactone 25 mg in patients with resistant hypertension.

METHODS

A total of 81 patients with resistant hypertension were included in the study. The spironolactone group was composed of 38 patients while the nebivolol group was composed of 43 patients. Resistant hypertension was defined as having office blood pressure ≥ 140/90 mmHg while the patients were under 3 or more antihypertensive agents treatment which included diuretic agents. Office and ambulatory blood pressure at basal and after 8 weeks of treatment were recorded.

RESULTS

Office systolic blood pressure and diastolic blood pressure in 24-hour ambulatory blood  pressure monitoring were significantly lower when compared to basal values in both nebivolol and spironolactone groups. The decrease in 24-hour mean systolic and diastolic blood pressure in nebivolol group was 14.9 ± 19.8 mmHg and 9.3 ± 12.7 mmHg compared to 19.5 ± 16.4 mmHg and 13.7 ± 10.8 mmHg in the spironolactone group, respectively. The decrease in 24-hour mean systolic and diastolic blood pressure was not significantly different between the nebivolol and spironolactone groups (P = 0.338 and P = 0.153).

CONCLUSION

Nebivolol is an effective treatment option for resistant hypertension and the antihypertensive effect of nebivolol is similar to low-dose spironolactone.

A Novel, Sustainable, and Eco-Friendly Spectrophotometric and Chemometric Approach for Determination of Severely Overlapped Spectrum via Unified Regression Equation: Greenness and Whiteness Assessment

BACKGROUND

Nebivolol and valsartan (VAL) in combination with each other successfully control blood pressure and improve hypertension patient outcomes.

OBJECTIVE

To develop and validate innovative, simple, and sustainable spectrophotometric methods for the simultaneous analysis of nebivolol and valsartan.

METHOD

The new modified difference amplitude modulation (MD-AM) method uses only unified regression equation and does not require any resolution techniques. Other different approaches were also applied for the determination of the same mixture including univariate and multivariate spectrophotometric methods. The multivariate methods were PLS and PCR, whereas the univariate methods were derivative ratio (DD1), ratio difference (RD), constant center (CC), constant center spectrum subtraction (CC-SS), constant value coupled with amplitude difference (CV-AD), advanced concentration value (ACV), and amplitude difference (AD). The proposed methods use a green solvent; thus, the environmental impact of the presented procedures was evaluated qualitatively and quantitatively using six well-known evaluation tools.

RESULTS

All methods were applied successfully for the analysis of the studied drugs in their bulk powder, pharmaceutical dosage form Byvalson®, and in vitro release at intestinal pH (7.4) using a USP dissolution tester. Results obtained were compared statistically with the reported method and with each other using a one-way ANOVA statistical test, and no significant differences were found.

CONCLUSIONS

All green and white analytical chemistry evaluation tools results confirm the safety, sustainability, and cost-effectiveness of the approaches, indicating that the methods are regarded green and sustainable. Results were agreeable, encouraging their applicability in quality control laboratories for dosage form and making these methods an eco-friendly substitute for the analysis of this combined dosage form and for evaluating the dissolution profile.

HIGHLIGHTS

For the first time, a severely overlapped spectrum was determined using a unified regression equation without the need of extended part or zero contribution regions by the novel method MD-AM. The proposed methods are the first study of in vitro dissolution profiling of nebivolol hydrochloride (NEB) and VAL and the first sustainable and green methods applied without compromising the analytical criteria.

Nebivolol protects erectile functions compared to Metoprolol in hypertensive men with atherogenic, venogenic, psychogenic erectile dysfunction: A prospective, randomized, cross-over, clinical trial

INTRODUCTION

Both hypertension and β-blocker drugs used for treating hypertension (HT) can cause erectile dysfunction (ED). Nebivolol, unlike other β-blockers, may not cause impotence since it increases the release of Nitric Oxide (NO), which is the main mediator of erection. This study investigated the effect of Nebivolol and Metoprolol on erectile functions in hypertensive men.

MATERIALS AND METHODS

Married men whose blood pressure were >140/90 mmHg were included in the study. All patients were assessed for ED, and the cause of ED was then investigated. Nebivolol or Metoprolol was started for one month in all patients. After one-month drugless period, the β-blockers were switched. Blood pressures, pulses and sexual function tests were evaluated, and plasma NO levels were measured at the end of the treatments and during the drugless period.

RESULTS

There was no difference in antihypertensive efficacy between the two drugs (p = 0.828;0.194 for systolic and diastolic BP). Metoprolol caused a significant decrease in IIEF-5 score, whereas Nebivolol did not cause a decrease in IIEF-5 score on patients with psychogenic, arteriogenic, and venous failure related ED (respectively, p<0.001,0.004,0.005 for Metoprolol; p = 0.201,0.598,0.088 for Nebivolol). In the non-ED group, both drugs decreased the IIEF-5 score, but the decrease for Metoprolol (p = 0.001) was more than that for Nebivolol (p = 0.012). Plasma NO levels did not change with Metoprolol (p = 0.268) but increased with Nebivolol (p<0.001). There was a positive correlation between plasma NO values and IIEF-5 score used for the assessment of sexual functions (r = 0.284, p = 0.026).

CONCLUSION

Nebivolol may be advantageous in terms of preserving sexual functions because of increasing NO in eligible hypertensive male patients.

Photochemical degradation of nebivolol in different natural organic matter solutions under simulated sunlight irradiation: Kinetics, mechanism and degradation pathway

Nebivolol (NEB) is widely used for the treatment of hypertension and chronic heart failure and has become an ubiquitous emerging organic pollutant. It has been shown to undergo direct photolysis, but the role of DOM in its degradation kinetics and mechanism is not well understood. In this study, we studied the photochemical behavior of NEB in the presence of seawater DOM (SW-DOM) and freshwater DOM (SRNOM) under simulated sunlight irradiation. SW-DOM had a promotion effect on NEB photodegradation, whereas SRNOM retarded its photolytic transformation. After eliminating the influence of light screening, we found that the indirect photodegradation rate of NEB in the presence of SRNOM was lower than that in the presence of SW-DOM. Results show that the indirect photodegradation pathway occurred by reaction with triplet-excited DOM (³DOM*). The second-order rate constants for ³SW-DOM* and ³SRNOM* reaction with NEB are 3.7 × 10⁹ M^-1 s^-1 and 3.7 × 10⁸ M^-1 s^-1, respectively. The electron donating capacity of SRNOM is higher than that of SW-DOM, indicating that SRNOM may contain more activated phenolic moieties. SRNOM may thus have higher antioxidant activity, leading a higher inhibitory effect on NEB photodegradation. A total of six degradation products were identified in the absence and presence of DOM by HPLC-ESI-MS/MS. The substitution of F by OH-groups and further oxidation a OH-group in the lateral chain to a ketone, and cleavage of N-C bond by the attack of ³DOM* are here proposed as the main degradation pathways.

Photolytic degradation of the β-blocker nebivolol in aqueous solution

Nebivolol (NEB) is one of the top-sold prescription drugs belonging to the third generation of beta-blockers. However, so far, occurrence data in the environment are lacking. Within this study NEB has been found for the first time in effluent samples of wastewater treatment plants in Germany with an average concentration of 13 ng L^-1. Its photodegradation behavior in the environment and in technical processes is largely unknown. To fill this gap, three different UV treatment procedures (UV-C at 254 nm, UV-B at 312 nm and UV-A at 365 nm) were investigated in three different matrices: pure water, pure water in presence of the hydroxyl radical (OH) scavenger tert.-butanol and real wastewater. No elimination was observed during UV-A treatment. In contrast, NEB degradation during UV-B and UV-C treatment followed pseudo first order reaction kinetics, with highest removal rate during UV-C treatment in pure water (k = 7.8 × 10^-4 s^-1). The rate constant for UV-C irradiation decreased to 2.9 × 10^-4 s^-1 in the presence of the OH scavenger and in the presence of the wastewater matrix. The rate constant for the UV-B lamp was 4.4 × 10^-4 s^-1, Three transformation products were identified after UV-B and UV-C photolytic degradation using high resolution mass spectrometry. The main photoreaction is the substitution of the fluorine atoms of NEB by hydroxyl groups. A photolytic cleavage of the CF bond can be excluded as the high bond dissociation energy of aromatic CF bonds (525 kJ mol^-1), exceeds the energy of electromagnetic radiation applied in the present study (≥254 nm, i.e., max. 471 kJ E^-1). The quantum yields for NEB degradation for the UV-C lamp achieved in pure water, the OH scavenged system and wastewater matrix were Φ_deg = 0.53, 0.19 and 0.22, respectively. For UV-B Φ_deg was 0.023 ± 0.003, noticeable differences in quantum yield were not found. The photooxidation involves reactive oxygen species such as superoxide and singlet oxygen. These oxidative species may be formed upon reaction of photo-excited NEB with oxygen.

Lichenoid Eruption Associated with the Use of Nebivolol

Objective:

To report a case of lichenoid drug eruption (LDE) after starting antihypertensive treatment with nebivolol, a cardioselective β-blocker.

Case Summary:

Five weeks after starting treatment with nebivolol, a 62-year-old woman presented with erythematous papules on both extremities and skin lesions spreading over the back. She was not being treated with any other drugs. Because the administration of levocetirizine, topical methylprednisolone, and systemic prednisone was unsuccessful, the treatment was stopped and the lesions were biopsied. The histopathological features of the lesions were consistent with LDE. After withdrawal of nebivolol and subsequent readministration of topical methylprednisolone and systemic prednisone, the skin lesions resolved within 12 days. Assessment of the causality revealed a probable relationship between nebivolol and the lichenoid eruptions.

Discussion:

Although β-blockers can be associated with LDE, as of July 7, 2006, this has not been previously reported with nebivolol. T cells invading the dermis are considered to be responsible for epidermal destruction associated with LDE, as has been described for lichenoid forms of chronic graft versus host disease and idiopathic lichen ruber planus.

Conclusions:

Nebivolol can cause LDE, as has been reported with other β-blockers. The underlying mechanism appears to be T cell–mediated. Cross-reactivity with other β-blockers cannot be excluded; therefore, the risk of recurrent LDE should be weighed carefully against the clinical benefit before switching to another β-blocker.

The Antihypertensive and Cardiac Hemodynamic Effects of Nebivolol

Acute, subacute, and chronic treatment with nebivolol, a novel β1-selective adrenergic antagonist, significantly lowered systolic and diastolic blood pressure and heart rate in patients with essential hypertension. No orthostatism and bradycardia were reported. A comparison between a normal control group and 23 hypertensive patients revealed that the ratio between the preejection period (PEP) and the left ventricular ejection time (LVET) of the systolic time inter vals (STI) was significantly increased in the hypertensive patients, owing to a prolongation of the PEPc (PEP corrected for heart rate). Treatment with ne bivolol 5 mg once a day significantly improved the PEP/LVET, in acute condi tions from 0.42 ± 0.023 to 0.39±0.018, after one month of treatment from 0.40 ± 0.013 to 0.36 ± 0.013 and after one year of treatment from 0.41 ± 0.012 to 0.36 ± 0.010, owing to a significant shortening of the PEP c. There was no correlation between changes of blood pressure and changes of STI.

Diastolic dysfunction is an early finding in hypertension and may well be reflected in the prolongation of the PEPc. The improvement of left ventricu lar performance, as measured with STI, suggests that treatment with nebivolol may favorably influence the underlying diastolic dysfunction and be of therapeutic value for hypertensive patients with left ventricular damage.

Economic benefits associated with beta blocker persistence in the treatment of hypertension: a retrospective database analysis

OBJECTIVES

To assess the association between medical costs and persistence with beta blockers among hypertensive patients, and to quantify persistence related medical cost differences with nebivolol, which is associated with improved tolerability, versus other beta blockers.

METHODS

Adults who initiated hypertension treatment with a beta blocker were identified from the MarketScan * claims database (2008-2012). Patients were classified based on their first beta blocker use: nebivolol, atenolol, carvedilol, metoprolol, and other beta blockers. Patients with compelling indications for atenolol, carvedilol or metoprolol (acute coronary syndrome and congestive heart failure) were excluded. Patients enrolled in health maintenance organization or capitated point of service insurance plans were also excluded. Persistence was defined as continuous use of the index drug (<60 day gap). The average effect of persistence on medical costs (2012 USD) was estimated using generalized linear models (GLMs). Regression estimates were used to predict medical cost differences associated with persistence between nebivolol and the other cohorts.

RESULTS

A total of 587,424 hypertensive patients met the inclusion criteria. Each additional month of persistence with any one beta blocker was associated with $152.51 in all-cause medical cost savings; continuous treatment for 1 year was associated with $1585.98 in all-cause medical cost savings. Patients treated with nebivolol had longer persistence during the 1 year study period (median: 315 days) than all other beta blockers (median: 156-292 days). Longer persistence with nebivolol translated into $305.74 all-cause medical cost savings relative to all other beta blockers.

LIMITATIONS

The results may not be generalizable to hypertensive patients with acute coronary syndrome or congestive heart failure.

CONCLUSIONS

Longer persistence with beta blockers for the treatment of hypertension was associated with lower medical costs. There may be greater cost savings due to better persistence with nebivolol than other beta blockers.

Acute and 14-day hepatic venous pressure gradient response to carvedilol and nebivolol in patients with liver cirrhosis

BACKGROUND AND OBJECTIVE

Alternative drug therapies are needed for the treatment of portal hypertension. The aim of this randomized study was to evaluate and compare the effects of carvedilol and nebivolol on the hepatic venous pressure gradient (HVPG) response in the patients with liver cirrhosis.

MATERIAL AND METHODS

In total, 20 cirrhotic patients were randomized into 2 groups and treated with carvedilol (n=10) or nebivolol (n=10). HVPG was measured at baseline, 60 minutes after the administration of carvedilol (25 mg) or nebivolol (5 mg), and after 14 days of carvedilol (25 mg) or nebivolol (5 mg) administered daily. RESULTS. Carvedilol significantly reduced HVPG from 22.2 mm Hg (SD, 4.4) to 15.2 mm Hg (SD, 3.7) after 60 minutes and to 16.4 mm Hg (SD, 2.9) after 14 days (P<0.01). Nebivolol reduced HVPG from 19.7 mm Hg (SD, 2.5) to 15.7 mm Hg (SD, 2.6) and 16.7 mm Hg (SD, 3.2), respectively (P<0.02). Carvedilol effectively decreased HVPG in a greater proportion of the patients after an acute probe (88% vs. 57%) and after 14 days of the treatment (88% vs. 28%, P<0.05) in comparison with nebivolol.

CONCLUSION

Carvedilol and nebivolol reduce HVPG in cirrhotic patients; however, the effect of carvedilol on the HVPG reduction might be superior to that of nebivolol, especially after 14 days of treatment.

Significant deterioration of anti-atherogenic efficacy of nebivolol in a double (apolipoprotein E and endothelial nitric oxide synthase) knockout mouse model of atherosclerosis in comparison to single (apolipoprotein E) knockout model

Anti-atherogenic action of nebivolol in apolipoprotein E (apoE)-single knockout mouse model can be explained by its beneficial effect on endothelium, especially on endothelial nitric oxide synthase (eNOS). We, therefore, decided to use apoE and eNOS-double knockout mouse model to confirm that mechanism of nebivolol beneficial action. In apoE-single knockout mice, lesion area measured by "cross-section" of aortic roots was 79,244 ± 6,143 μm(2) in the control group versus 65,347 ± 6,152 μm(2) in nebivolol-treated group (P<0.05). However, in apoE and eNOS-double knockout mice, lesion area measured by "cross-section" of aortic roots was 92,319 ± 8,876 μm(2) in the control group versus 98,609 ± 9,164 μm(2) in nebivolol-treated group (P>0.05). The comparison between apoE-single knockout mice and apoE & eNOS-double knockout mice without treatment also showed statistically significant difference: 81,232 ± 8,264 μm(2) versus 92,319 ± 8,876 μm(2) (P<0.05). This is the first report that describes the effect of nebivolol on atherogenesis in apoE and eNOS-double knockout mice, proving directly the necessity of the presence of eNOS in endothelium for nebivolol to show its an anti-atherogenic potency.

Nebivolol potentiates the efficacy of PDE5 inhibitors to relax corpus cavernosum and penile arteries from diabetic patients by enhancing the NO/cGMP pathway

INTRODUCTION

The efficacy of oral pharmacotherapy for erectile dysfunction (ED) (i.e., type 5 phosphodiesterase[PDE5] inhibitors) is significantly reduced in diabetic patients. Nebivolol is a selective β1-blocker used for treatinghy pertension that has been shown to increase the efficacy of sildenafil to reverse ED in diabetic rats.

AIM

To evaluate the effects of nebivolol on the efficacy of the PDE5 inhibitors, sildenafil, tadalafil, and vardenafil to relax human corpus cavernosum (HCC) and vasodilate human penile resistance arteries (HPRA) from diabetic patients with ED (DMED). The influence of nebivolol on the capacity of these three PDE5 inhibitors to stimulate cyclic guanosine monophosphate (cGMP) production in HCC was also evaluated.

METHODS

HCC and HPRA were obtained from organ donors without ED (NEND; n = 18) or patients with diabetes undergoing penile prosthesis implantation (DMED; n = 19). Relaxations of HCC strips and HPRA to sildenafil,tadalafil, and vardenafil were evaluated in organ chambers and wire myographs. cGMP content in HCC was determined by ether extraction and quantification by ELISA.

MAIN OUTCOME MEASURES

Effects of nebivolol on PDE5 inhibitor-induced relaxation of HCC, vasodilation ofHPRA and cGMP accumulation in HCC.

RESULTS

Treatment with nebivolol (1 μM) significantly potentiated sildenafil-, tadalafil- and vardenafil-induced relaxations of HCC and vasodilations of HPRA from both NEND and DMED. Enhancement of relaxant capacity by nebivolol resulted in reversion of the impairment of PDE5 inhibition-induced responses in DMED and it was accompanied by enhancing the ability of PDE5 inhibitors to increase cGMP in HCC restoring reduced cGMP levelsin HCC from DMED.

CONCLUSIONS

Nebivolol potentiated the capacity of PDE5 inhibitors to relax vascular structures of erectile tissue from diabetic patients by enhancing the nitric oxide (NO)/cGMP pathway in these tissues. These effects suggest a potential therapeutic utility of nebivolol as an adjunct to PDE5 inhibitors for the treatment of ED associated with diabetes.

[Postregistration study of comparative assessment efficacy of the use of fixed combination of nebivolol and amlodipine for the treatment of patients with moderate and high degree of arterial hypertension]

AIM

of the study was to assess efficacy of the use of fixed combination of nebivolol and amlodipine in patients with moderate and high degree of arterial hypertension (AH).

MATERIAL AND METHODS

Patients with diagnosis of primary AH (n=124) were divided into 2 groups by random sample method. Patients of group 1 (n=62) received of fixed combination of nebivolol and amlodipine, while those of group 2 (n=62) received free combination of nebivolol and amlodipine. Study drugs were administered both as initial therapy and replacement of preceding treatment. Duration of observation was 3 months with visits after first 2 weeks and in 1, 2, and 3 months after enrollment.

RESULTS

Starting from 2nd week visit of fixed combination of nebivolol and amlodipine treated patients had significantly lower levels of systolic and diastolic AP. Already after 2 weeks of combined two-component therapy 60% of group 1 and 52% of group 2 patients achieved target AP. Target AP was achieved by the end of month 1 by 86 and 71%, of month 2 - by 93 and 78% of patients in groups 1 and 2, respectively. In 3 months almost all patients had target AP, but in 1.6% of group 1 and 2.3% of group 2 patients this level was achieved after addition of a thiazide diuretic. Patients receiving of fixed combination of nebivolol and amlodipine achieved noromosyslolia more quickly compared with patients who received free combination of nebivolol and amlodipine.

CONCLUSION

Combined therapy with fixed combination of nebivolol and amlodipine appears to be one of effective approaches to treatment of patients with moderate and high degree AH.

Economic impact of switching from metoprolol to nebivolol for hypertension treatment: a retrospective database analysis

OBJECTIVE

To estimate the real-world economic impact of switching hypertensive patients from metoprolol, a commonly prescribed, generic, non-vasodilatory β1-blocker, to nebivolol, a branded-protected vasodilatory β1-blocker.

METHODS

Retrospective analysis with a pre-post study design was conducted using the MarketScan database (2007-2011). Hypertensive patients continuously treated with metoprolol for ≥6 months (pre-period) and then switched to nebivolol for ≥6 months (post-period) were identified. The index date for switching was defined as the first nebivolol dispensing date. Data were collected for the two 6-month periods pre- and post-switching. Monthly healthcare resource utilization and healthcare costs pre- and post-switching were calculated and compared using Wilcoxon test and paired t-test. Medical costs at different years were inflated to the 2011 dollar.

RESULTS

In total, 2259 patients (mean age: 60 years; male: 52%; cardiovascular [CV] disease: 37%) met the selection criteria. Switching to nebivolol was associated with statistically significant reductions in the number of all-cause hospitalization (-33%; p < 0.01), CV-related hospitalizations (-60%; p < 0.01), and outpatient visits (-7%; p < 0.01). Monthly inpatient costs were reduced by $111 (p < 0.01), while monthly drug costs increased by $52 (p < 0.01). No statistically significant differences were found in overall costs and costs of outpatient or ER visits. Sensitivity analyses, conducted using various lengths of medication exposure, controlling for spill-over effect or excluding patients with compelling indications for metoprolol, all found some level of reduction in resource utilization and no significant difference in overall healthcare costs.

CONCLUSIONS

This real-world study suggests that switching from metoprolol to nebivolol is associated with an increase in medication costs and significant reductions in hospitalizations and outpatient visits upon switching, resulting in an overall neutral effect on healthcare costs. These results may be interpreted with caution due to lack of a comparator group and confounding control caused by design and limitations inherent in insurance claims data.

[Special characteristics of progression of myocardial remodeling in patients with various forms of unstable angina]

AIM

To study special characteristics and prognostic value of cardiac remodeling in patients with unstable angina (UA).

MATERIAL

Throughout 2 years we performed repetitive echocardiographic examinations of 166 patients with Braunwald class IB and IIB-IIIB UA for assessment of left ventricular (LV) structural-functional changes.

RESULTS

More severe form of remodeling (eccentric hypertrophy) was significantly more frequent in patients with IIB-IIB class UA. However in IB class UA during first year after episode of UA we noted rapid progression of remodeling mainly at the account of transition from concentric hypertrophy. Tissue Doppler study revealed more severe type of diastolic dysfunction (type 2 - pseudonormalization) in patients with class IIB-IIIB UA. Changes of some echocardiographic parameters correlated with severity of subsequent remodeling of the heart, development of chronic heart failure (CHF), myocardial infarction, and recurrent episodes of UA. In UA rate of unfavorable outcomes was related to degree of ischemic myocardial remodeling. We established a number of early EchoCG markers of LV remodeling increases of endsystolic dimension and volume, myocardial stress, lowering of ratios of diastolic peaks of filling and relaxation (/ and E`/A`) - preceding the development of systolic, diastolic dysfunction and CHF.

IMPLICATION

The use of complex therapy with acetylsalicylic acid in patients with UA, perindopril, nebivolol and simvastatin is justified for prevention LV remodeling and lowering of rate of acute ischemia recurrence and CHF development.

β1-Adrenergic blockers exert antioxidant effects, reduce matrix metalloproteinase activity, and improve renovascular hypertension-induced cardiac hypertrophy

Hypertension induces left-ventricular hypertrophy (LVH) by mechanisms involving oxidative stress and unbalanced cardiac matrix metalloproteinase (MMP) activity. We hypothesized that β1-adrenergic receptor blockers with antioxidant properties (nebivolol) could reverse hypertension-induced LVH more effectively than conventional β1-blockers (metoprolol) when used at doses that exert similar antihypertensive effects. Two-kidney one-clip (2K1C) hypertension was induced in male Wistar rats. Six weeks after surgery, hypertensive and sham rats were treated with nebivolol (10 mg kg(-1)day(-1)) or metoprolol (20 mg kg(-1)day(-1)) for 4 weeks. Systolic blood pressure was monitored weekly by tail-cuff plethysmography. LV structural changes and fibrosis were studied in hematoxylin/eosin- and picrosirius-stained sections, respectively. Cardiac MMP levels and activity were determined by in situ zymography, gel zymography, and immunofluorescence. Dihydroethidium and lucigenin-derived chemiluminescence assays were used to assess cardiac reactive oxygen species (ROS) production. Nitrotyrosine levels were determined in LV samples by immunohistochemistry and green fluorescence and were evaluated using the ImageJ software. Cardiac protein kinase B/Akt (AKT) phosphorylation state was assessed by Western blot. Both β-blockers exerted similar antihypertensive effects and attenuated hypertension-induced cardiac remodeling. Both drugs reduced myocyte hypertrophy and collagen deposition in 2K1C rats. These effects were associated with lower cardiac ROS and nitrotyrosine levels and attenuation of hypertension-induced increases in cardiac MMP-2 levels and in situ gelatinolytic activity after treatment with both β-blockers. Whereas hypertension increased AKT phosphorylation, no effects were found with β-blockers. In conclusion, we found evidence that two β1-blockers with different properties attenuate hypertension-induced LV hypertrophy and cardiac collagen deposition in association with significant cardiac antioxidant effects and MMP-2 downregulation, thus suggesting a critical role for β1-adrenergic receptors in mediating those effects. Nebivolol is not superior to metoprolol, at least with respect to their capacity to reverse hypertension-induced LVH.

Nebivolol reduces central blood pressure in stage I hypertensive patients: experimental single cohort study

CONTEXT AND OBJECTIVES

Assessment of central blood pressure (BP) has grown substantially over recent years because evidence has shown that central BP is more relevant to cardiovascular outcomes than peripheral BP. Thus, different classes of antihypertensive drugs have different effects on central BP despite similar reductions in brachial BP. The aim of this study was to investigate the effect of nebivolol, a β-blocker with vasodilator properties, on the biochemical and hemodynamic parameters of hypertensive patients.

DESIGN AND SETTING

Experimental single cohort study conducted in the outpatient clinic of a university hospital.

METHODS

Twenty-six patients were recruited. All of them underwent biochemical and hemodynamic evaluation (BP, heart rate (HR), central BP and augmentation index) before and after 3 months of using nebivolol.

RESULTS

88.5% of the patients were male; their mean age was 49.7 ± 9.3 years and most of them were overweight (29.6 ± 3.1 kg/m2) with large abdominal waist (102.1 ± 7.2 cm). There were significant decreases in peripheral systolic BP (P = 0.0020), diastolic BP (P = 0.0049), HR (P < 0.0001) and central BP (129.9 ± 12.3 versus 122.3 ± 10.3 mmHg; P = 0.0083) after treatment, in comparison with the baseline values. There was no statistical difference in the augmentation index or in the biochemical parameters, from before to after the treatment.

CONCLUSIONS

Nebivolol use seems to be associated with significant reduction of central BP in stage I hypertensive patients, in addition to reductions in brachial systolic and diastolic BP.

Efficacy and safety of nebivolol and valsartan as fixed-dose combination in hypertension: a randomised, multicentre study

BACKGROUND

The fixed-dose combination of any two antihypertensive drugs from different drug classes is typically more effective in reducing blood pressure than a dose increase of component monotherapy. We assessed the efficacy and safety of a fixed-dose combination of a vasodilating β blocker (nebivolol) and an angiotensin II receptor blocker (valsartan) in adults with hypertension.

METHODS

We did an 8-week, phase 3, multicentre, randomised, double-blind, placebo-controlled, parallel-group trial at 401 US sites. Participants (age ≥18 years) with hypertension but with blood pressure less than 180/110 mm Hg were randomly assigned (2:2:2:2:2:2:2:1) by a 24-h interactive web response system in blocks of 15 to 4 weeks of double-blind treatment with nebivolol and valsartan fixed-dose combination (5 and 80 mg/day, 5 and 160 mg/day, or 10 and 160 mg/day), nebivolol (5 mg/day or 20 mg/day), valsartan (80 mg/day or 160 mg/day), or placebo. Doses were doubled in weeks 5-8; results are reported according to the final dose. Participants and research staff were masked to treatment allocation. The primary and key secondary endpoints were changes from baseline to week 8 in diastolic and systolic blood pressure, respectively. The primary statistical comparison was between the highest fixed-dose combination dose and the highest monotherapy doses; lower doses were then compared if this comparison was positive (Hochberg method for multiple testing). Efficacy analyses were by intention to treat. Safety assessments included monitoring of adverse events. Continuous efficacy parameters were analysed using an ANCOVA model; binary outcomes were analysed using a logistic regression model. This study is registered with ClinicalTrials.gov, NCT01508026.

FINDINGS

Between Jan 6, 2012, and March 15, 2013, 4161 patients were randomly assigned (277 to placebo and 554-555 to each active comparator group), 4118 of whom were included in the primary analysis. At week 8, the fixed-dose combination 20 and 320 mg/day group had significantly greater reductions in diastolic blood pressure from baseline than both nebivolol 40 mg/day (least-squares mean difference -1·2 mm Hg, 95% CI -2·3 to -0·1; p=0·030) and valsartan 320 mg/day (-4·4 mm Hg, -5·4 to -3·3; p<0·0001); all other comparisons were also significant, favouring the fixed-dose combinations (all p<0·0001). All systolic blood pressure comparisons were also significant (all p<0·01). At least one treatment-emergent adverse event was experienced by 30-36% of participants in each group.

INTERPRETATION

Nebivolol and valsartan fixed-dose combination is an effective and well-tolerated treatment option for patients with hypertension.

FUNDING

Forest Research Institute.

Nebivolol protects against myocardial infarction injury via stimulation of beta 3-adrenergic receptors and nitric oxide signaling

Nebivolol, third-generation β-blocker, may activate β3-adrenergic receptor (AR), which has been emerged as a novel and potential therapeutic targets for cardiovascular diseases. However, it is not known whether nebivolol administration plays a cardioprotective effect against myocardial infarction (MI) injury. Therefore, the present study was designed to clarify the effects of nebivolol on MI injury and to elucidate the underlying mechanism. MI model was constructed by left anterior descending (LAD) artery ligation. Nebivolol, β3-AR antagonist (SR59230A), Nitro-L-arginine methylester (L-NAME) or vehicle was administered for 4 weeks after MI operation. Cardiac function was monitored by echocardiography. Moreover, the fibrosis and the apoptosis of myocardium were assessed by Masson's trichrome stain and TUNEL assay respectively 4 weeks after MI. Nebivolol administration reduced scar area by 68% compared with MI group (p<0.05). Meanwhile, nebivolol also decreased the myocardial apoptosis and improved the heart function after MI (p<0.05 vs. MI). These effects were associated with increased β3-AR expression. Moreover, nebivolol treatment significantly increased the phosphorylation of endothelial NOS (eNOS) and the expression of neuronal NOS (nNOS). Conversely, the cardiac protective effects of nebivolol were abolished by SR and L-NAME. These results indicate that nebivolol protects against MI injury. Furthermore, the cardioprotective effects of nebivolol may be mediated by β3-AR-eNOS/nNOS pathway.

Real-world adherence and persistence associated with nebivolol or hydrochlorothiazide as add-on treatment for hypertension

OBJECTIVE

To compare adherence and persistence associated with nebivolol and hydrochlorothiazide (HCTZ) as add-on hypertension treatments.

RESEARCH DESIGN AND METHODS

Adults with ≥1 hypertension diagnosis (ICD-9-CM 401-405) who used nebivolol or HCTZ as their first add-on antihypertensive therapy between 1/1/2008 and 9/30/2010 were identified from a large claims database. Patients had continuous enrollment for ≥1 year preceding (baseline period) and following (study period) the first qualifying prescription fill, and did not use nebivolol or HCTZ during the baseline period. A random sample of HCTZ patients meeting selection criteria were selected in a 3:1 ratio to nebivolol patients.

MAIN OUTCOME MEASURES

The probability of receiving each drug, adjusted for baseline patient demographics, significantly different comorbidities, and costs was estimated using a logistic model. Inverse propensity score weights were used to balance confounding factors for between-cohort comparisons. Adherence (estimated using the medication possession ratio [MPR]) and persistence (estimated as days from initiation to the first >30 day gap in the index drug supply) at 6, 9, and 12 months were compared using weighted t tests.

RESULTS

Baseline characteristics of nebivolol (n = 722) and HCTZ (n = 2166) patients were well balanced after weighting. At 12 months, nebivolol patients had a significantly higher MPR than HCTZ patients (0.76 vs. 0.70, P < 0.001), and medication persistence was 28 days longer (273 vs. 245 days, P < 0.001). Between-group differences were also significant at 6 and 9 months.

CONCLUSIONS

When used as an add-on therapy for hypertension, nebivolol was associated with significantly higher rates of adherence and persistence compared with HCTZ, after adjusting for baseline differences between treatment groups. These results may be impacted by limitations inherent in insurance claims data, such as the lack of clinical information.

[Cardiovascular diseases and osteoporosis: what is common?]

The review analyzes the possible effect of cardiac drugs on the course of osteoporosis (OP). The fact that atherosclerosis and OP share the mechanisms of development, among which the enhanced activity of the sympathetic part of the autonomic nervous system and endothelial dysfunction are most important, is beyond question now. In this connection, beta-adrenoblockers, nebivolol in particular, attract attention. Nebivolol is known to be a selective beta1-adrenoblocker that has an additional vasodilator property, by stimulating the synthesis of nitric oxide. This may serve to increase bone mineral density and slow down the progression of OP. At the same time, most investigations in this area are retrospective therefore final conclusions call for randomized prospective studies that will be able to evaluate more objectively the effect of cardiac drugs on the prevention of OP or its progression delay.

[Nephroprotective properties of third-generation beta-adrenoblockers]

Experimental and clinical data on the nephroprotector properties of third-generation beta-adrenoblockers nebivolol and carvedilol are reviewed. These properties are related to the antihypertensive effect and ability of drugs to suppress oxidative stress in glomerules, proximal renal tubules, and surrounding interstitial tissue.

Assessment of effect of irbesartan and nebivolol on the left atrium volume and deformation in the patients with mild-moderate hypertension

BACKGROUND

We aimed to assess the effects of irbesartan and nebivolol on the left atrium (LA) volume and deformation in the patients with mild-moderate hypertension.

PATIENTS AND METHODS

The study comprised of 160 patients (mean age: 55.6±9.6 years), who had Stage 1 or 2 hypertension according to the European Society of Cardiology (ESC) and have not been receiving antihypertensive therapy. The patients were assigned to treatment groups; irbesartan (n=80) and nebivolol (n=80). The patients were clinically and echocardiographically reevaluated on the 6th and 12th months after the onset of treatment.

RESULTS

There was no difference between the two treatment groups in terms of baseline demographic, clinical and echocardiographic characteristics. Moreover, no difference was observed between the treatment groups on the 6th and 12th months. Intragroup analyses revealed that systolic blood pressure (SBP) and diastolic blood pressure (DBP) significantly decreased in time and diastolic function parameters were improved. However, whilst significant increase was observed in conduit volume, decrease was observed in other volumes of the LA in the irbesartan and nebivolol groups. This significant change was observed on the 6th month in both treatment groups. LA global peak systolic strain (LAGLSs), LA global peak systolic strain rate (LAGLSRs), LA global peak strain rate during early ventricular diastole (LAGLSRe) and LA global peak strain rate (LAGLSRa) during late ventricular diastole (LAGLSRa) values began to be significantly increased after 6 months of treatment in both treatment groups.

CONCLUSIONS

We found that nebivolol, which is a new generation beta blocker, is effective as irbesartan with proven efficacy in improving LA volume and LA myocardial performance in patients with mild-moderate hypertension. Moreover, we determined that strain and strain rate, which are the new echocardiographic parameters, are effective as LA volumes in assessing LA functions.

Effect of nebivolol treatment on atherosclerotic plaque components in apoE-knockout mice

Nebivolol, a third generation beta1-blocker was previously found to reduce the size of atherosclerotic lesions. The aim of this study was to assess the effect of orally administered nevibolol on the components of the atherosclerotic plaque in apoE-deficient mice. The quantitative evaluation of cross-sectioned plaques stained by histological and immunohistochemical techniques revealed that treatment with nebivolol (2.0 μol per kg b.w.) for 4 months caused a decrease in the necrotic core area (by 46%, p=0.03), density of CD68+ macrophages (by 41%, p=0.008) and CD3+ lymphocytes (by 16%, p=0.03), collagen content (by 49%, p=0.008) and the activity area of metalloproteinases (by 48%, p=0.008), as well as an increase in the smooth muscle content of the fibromuscular cap (by 46%, p=0.008). These effects suggest that nebivolol suppresses the inflammatory/immune processes in the plaque and enhances its stability.

Nebivolol attenuates prooxidant and profibrotic mechanisms involving TGF-β and MMPs, and decreases vascular remodeling in renovascular hypertension

Nebivolol and metoprolol are β1-adrenergic receptor blockers with different properties. We hypothesized that nebivolol, but not metoprolol, could attenuate prooxidant and profibrotic mechanisms of hypertension and therefore protect against the vascular remodeling associated with hypertension. Hypertension was induced in male Wistar rats by clipping the left renal artery. Six weeks after surgery, hypertensive and sham rats were treated with nebivolol (10 mg kg(-1) day(-1)) or metoprolol (20 mg kg(-1) day(-1)) for 4 weeks. Systolic blood pressure was monitored weekly. Morphologic changes in the aortic wall were studied in hematoxylin/eosin and picrosirius red sections. Aortic NAD(P)H activity and superoxide production were evaluated by luminescence and dihydroethidium, respectively, and TBARS levels were measured in plasma. Aortic nitrotyrosine staining was evaluated to assess peroxynitrite formation. TGF-β levels and p-ERK 1/2 expression were determined by immunofluorescence and Western blotting, respectively. Matrix metalloproteinase (MMP) activity and expression were determined by in situ zymography, gel zymography, Western blotting, and immunofluorescence, and TIMP-1 was assessed by immunohistochemistry. Both β1-receptor antagonists exerted very similar antihypertensive effects. However, while metoprolol had no significant effects, nebivolol significantly attenuated vascular remodeling and collagen deposition associated with hypertension. Moreover, nebivolol, but not metoprolol, attenuated hypertension-induced increases in aortic NAD(P)H oxidase activity, superoxide production, TBARS concentrations, nitrotyrosine levels, TGF-β upregulation, and MMP-2 and -9 expression/activity. No effects on p-ERK 1/2 and TIMP-1 expression were found. These results show for the first time that nebivolol, but not metoprolol, attenuates prooxidant and profibrotic mechanisms involving TGF-β and MMP-2 and MMP-9, which promote vascular remodeling in hypertension.

The effect of nebivolol on P wave duration and dispersion in patients with Behçet's disease; a prospective single-arm controlled study

OBJECTIVE

Behçet's disease (BD) is a chronic multi-system disease presenting with recurrent oral and genital ulceration, and relapsing uveitis. Left ventricular diastolic dysfunction, ventricular arrhythmia and sudden cardiac death have been documented in BD. P wave dispersion (PD) has been reported to be associated with inhomogeneous and discontinuous propagation of sinus impulses. PD has been reported to be longer in patients with BD. Nebivolol, besides its selective beta1-blocking activity, causes an endothelium dependent vasodilatation through nitric oxide release. In this study, we searched for the effects of nebivolol on P wave duration and dispersion in patients with BD.

METHODS

This study was designed as prospective single-arm controlled study. We prospectively studied 35 Behçet's patients who were diagnosed according to the International Study Group criteria. Patients received 5 mg nebivolol per day for 3 months. The patients were evaluated with 12-leads electrocardiography at baseline and after for 3-month therapy. The difference between maximum and minimum P wave durations was defined as PD. The paired samples t test, Wilcoxon test were used for statistical analysis.

RESULTS

A significant decrease was observed in PD after therapy period (62.85±21.62 vs. 44.28±18.03 msec, p=0.001). No adverse effects were observed in treatment period.

CONCLUSION

BD is associated with prolonged P wave duration and dispersion. We have shown for the first time that nebivolol causes a significant decrease in maximum P wave duration and PD in patients with BD. However, further comprehensive studies are needed to determine the long-term effects of nebivolol.

Effects of nebivolol on liver fibrosis induced by bile duct ligation in Wistar rats

AIM

To study the effect of nebivolol on liver fibrosis induced by common bile duct ligation (BDL) in rats.

MATERIALS AND METHODS

After BDL, Wistar rats were divided into three groups (n=24): SO, sham-operated animals; BDL, BDL rats without treatment; BDL+N, BDL rats treated with nebivolol for five weeks. Alanine aminotransferase, aspartate aminotransferase, gamma glutamyltransferase, total bilirubin and albumin levels were assessed. Liver samples collected were stained with hematoxylin-eosin, Masson's trichrom and reticulin.

RESULTS

Mortality reached 37.5% in the BDL group, whereas no deaths were observed in the SO and BDL+N groups. The BDL group showed hepatic damage as evidenced by elevation in serum biochemical parameters and fibrosis scores. These pathophysiological changes were attenuated in the BDL+N group. However, there was no significant difference between these two groups.

CONCLUSION

Nebivolol improved the survival rate of animals with BDL, but was unable to significantly improve liver function or reduce liver fibrosis.

The β-blocker Nebivolol Is a GRK/β-arrestin biased agonist

Nebivolol, a third generation β-adrenoceptor (β-AR) antagonist (β-blocker), causes vasodilation by inducing nitric oxide (NO) production. The mechanism via which nebivolol induces NO production remains unknown, resulting in the genesis of much of the controversy regarding the pharmacological action of nebivolol. Carvedilol is another β-blocker that induces NO production. A prominent pharmacological mechanism of carvedilol is biased agonism that is independent of Gα_s and involves G protein-coupled receptor kinase (GRK)/β-arrestin signaling with downstream activation of the epidermal growth factor receptor (EGFR) and extracellular signal-regulated kinase (ERK). Due to the pharmacological similarities between nebivolol and carvedilol, we hypothesized that nebivolol is also a GRK/β-arrestin biased agonist. We tested this hypothesis utilizing mouse embryonic fibroblasts (MEFs) that solely express β₂-ARs, and HL-1 cardiac myocytes that express β₁- and β₂-ARs and no detectable β₃-ARs. We confirmed previous reports that nebivolol does not significantly alter cAMP levels and thus is not a classical agonist. Moreover, in both cell types, nebivolol induced rapid internalization of β-ARs indicating that nebivolol is also not a classical β-blocker. Furthermore, nebivolol treatment resulted in a time-dependent phosphorylation of ERK that was indistinguishable from carvedilol and similar in duration, but not amplitude, to isoproterenol. Nebivolol-mediated phosphorylation of ERK was sensitive to propranolol (non-selective β-AR-blocker), AG1478 (EGFR inhibitor), indicating that the signaling emanates from β-ARs and involves the EGFR. Furthermore, in MEFs, nebivolol-mediated phosphorylation of ERK was sensitive to pharmacological inhibition of GRK2 as well as siRNA knockdown of β-arrestin 1/2. Additionally, nebivolol induced redistribution of β-arrestin 2 from a diffuse staining pattern into more intense punctate spots. We conclude that nebivolol is a β₂-AR, and likely β₁-AR, GRK/β-arrestin biased agonist, which suggests that some of the unique clinically beneficial effects of nebivolol may be due to biased agonism at β₁- and/or β₂-ARs.

[Nebivolol in treatment of multiple cerebral aneurysms]

INTRODUCTION

We examined the effect of nebivolol on blood pressure control after subarachnoidal hemorrhage in three patients with multiple aneurysms.

PATIENTS AND METHODS

Endovascular intervention was applied to treat the bleeding aneurysms of all patients, and the silent aneurysms were followed-up. In all patients nebivolol was used as long-term anti-hypertensive medication.

RESULTS

With nebivolol treatment the blood pressure in our patients was maintained in the normal range with no unexpected shoot-ups. The size of the silent aneurysms did not increase and the endovascularly treated aneurysms demonstrated acceptable morphology on follow-up catheter-angiography.

DISCUSSION

After endovascular treatment of the bleeding aneurysm, strict blood pressure control is essential in those with multiple aneurysms to prevent the rupture of silent aneurysms. Antihypertensive medications with a 24-hour effect are preferable. Nebivolol seemed to be an appropriate medication for this purpose in all of our patients.

Effects of nebivolol on aortic compliance in patients with diabetes and maximal renin angiotensin system blockade: the EFFORT study

The beneficial effects of nebivolol on arterial stiffness and endothelial dysfunction are well documented in untreated hypertensive patients and differ from nonvasodilatory β-blockers. This study tests the hypothesis that the addition of nebivolol in predominantly African American patients with type 2 diabetes already receiving maximally tolerated doses of renin-angiotensin system (RAS) blockers will further improve large artery compliance. Patients with type 2 diabetes and hypertension on maximal RAS blockade (n=70) were randomized to nebivolol or metoprolol succinate daily. Doses were titrated until systolic blood pressure (SBP) was <130 mm Hg. Radial artery applanation tonometry and pulse wave velocity (PWV) analysis were used to derive central aortic pressures and hemodynamic indices at repeated visits at intervals during a 6-month period. Both metoprolol succinate and nebivolol groups demonstrated reductions in brachial SBP (-8.2±4.3 mm Hg [P=.01] and -7.8±3.7 [P=.002], respectively) and aortic DBP (-2.4±1.8 [P=.039] and -4.0±2.9 mm Hg [P=.013], respectively). Aortic SBP decreased in the nebivolol group only (125.3±8 to 121.6±8.2, P=.025). There were no between group differences in aortic SBP, DBP, augmentation index, or PWV reduction. A significant increase in hemoglobin A1c was observed only in the metoprolol group. In patients with well-controlled type 2 diabetes and hypertension treated with maximally tolerated RAS blockade, nebivolol does not offer significant reductions in aortic BP over metoprolol succinate but maintains a stable metabolic profile.

The influence of angiotensin-(1-7) peptidomimetic (AVE 0991) and nebivolol on angiotensin I metabolism in aorta of apoE-knockout mice

The detrimental role of over activation of renin-angiotensin system (RAS) in atherogenesis is widely recognized. Recently, we have demonstrated that Ang-(1-7) peptidomimetic - AVE0991, as well as known beta-adrenolytic agent nebivolol, exert anti-atherogenic actions in mouse model of atherosclerosis - apoE-knockout mice. Here, using LC-ESI-MS ex vivo system, we tested whether prolonged treatment of apoE-knockout mice by these drugs can influence RAS in aorta of apoE-knockout mice in regard to generation of most active metabolites of Ang I-Ang II and Ang-(1-7). As compared to wild type animals there was increased generation of Ang II in aorta of apoE-knockout mice, while the formation of Ang-(1-7) did not differ between both groups. Either treatment with AVE0991 or nebivolol resulted in significant attenuation of Ang II production in aorta of apoE-knockout mice. In conclusion, for the first time we directly demonstrated that there is increase in ability of aortic tissue to generate Ang II in mouse model of atherosclerosis of apoE knockout mice, and that such effect could be efficiently attenuated either by treatment of nebivolol or Ang-(1-7) peptidomimetic - AVE0991. The exact mechanism(s) responsible for interference of both drugs with RAS require further investigation.

Further data on beta-blockers and cancer risk: observational study and meta-analysis of randomized clinical trials

BACKGROUND

The aim of the present paper is to provide some further data on the relationship between β-blocker treatment and the incidence of cancer, using two different approaches (epidemiological study and meta-analysis of clinical trials).

METHODS

In a consecutive series of 1340 diabetic patients starting insulin therapy, 112 cases of cancer during a mean follow-up of 75.9 months were identified as first hospital admission or death. For each case, the controls were chosen randomly from those members of the cohort matched for age, sex and BMI. The main predefined analysis was the comparison of cases and controls for length of exposure to β-blockers and proportion of patients exposed using a conditional logistic regression which takes into account the matching structure. For the meta-analytic sub-study, an extensive search of Medline and the Cochrane Library (any date up to December 31st, 2011) was performed for all trials in which a β-blocker was used. Mantel-Haenszel Odds Ratios (MH-OR) with 95% confidence intervals for incident malignancies were calculated using a random effect model.

RESULTS

After adjusting for mean daily dose of glargine and metformin, and ischemic heart disease, exposure to β-blockers was associated with a reduced overall risk of cancer (HR 0.33 [0.13; 0.83], p = 0.019; HR for each month of exposure 0.87 [0.77; 0.98], p = 0.025). In the meta-analysis sub-study, performed on nine trials, β-blockers were associated with a non-significant trend toward lower risk of cancer (MH-OR 0.93 [0.86; 1.01], p = 0.070).

STUDY LIMITATION

Limitations of the observational study are the small sample size that limits the statistical power of analyses, that it was performed on diabetic patients only, and that diagnoses of malignancies were derived from administrative data.

CONCLUSIONS

In conclusion, this research seem to confirm a possible beneficial effect of β-blockers against the risk of cancer development.

Placebo effect and efficacy of nebivolol in patients with hypertension not controlled with lisinopril or losartan: a phase IV, randomized, placebo-controlled trial

BACKGROUND

Most patients with hypertension require more than one antihypertensive to achieve blood pressure (BP) control.

OBJECTIVE

The purpose of this trial was to assess the efficacy and tolerability of add-on nebivolol, a vasodilatory β-blocker, in patients with untreated or poorly controlled hypertension, receiving stable therapy with lisinopril (an angiotensin-converting enzyme inhibitor) or losartan (an angiotensin II receptor blocker).

STUDY DESIGN

This was a phase IV double-blind, placebo-controlled trial conducted from August 2008 to March 2010 (ClinicalTrials.gov identifier: NCT00734630). Patients entered a 2-week, single-blind, placebo-only washout phase, followed by a 3- to 4-week open-label lead-in phase (lisinopril, 10-20 mg/day, or losartan, 50-100 mg/day), and a 12-week randomized, double-blind add-on treatment phase with placebo or nebivolol (5-40 mg/day).

SETTING

This study was conducted at 76 outpatient centers in the United States.

PATIENTS

Participants were men and women aged 18-85 years with a diagnosis of primary hypertension and seated trough systolic BP (SBP) at screening in the range of 170-200 mmHg if untreated, 155-180 mmHg if taking 1 antihypertensive medication, or 140-170 mmHg if taking 2 antihypertensive medications.

INTERVENTION

The intervention was 12 weeks' treatment with nebivolol 5-40 mg/day added to a background therapy of lisinopril 10-20 mg/day or losartan 50-100 mg/day.

MAIN OUTCOME MEASURES

Primary and secondary efficacy parameters were changes from baseline in seated trough cuff SBP and diastolic BP (DBP) at Week 12, respectively. Tolerability was assessed by monitoring treatment-emergent adverse events (TEAEs).

RESULTS

A total of 491 patients were randomized to receive nebivolol (n=258) or placebo (n=233). Efficacy analyses were conducted for 256 nebivolol and 232 placebo patients (intent-to-treat population); completion rates were 88.8% and 85.8%, respectively. Mean baseline SBP/DBP values were 163.1/98.2 mmHg (nebivolol) and 162.4/96.8 mmHg (placebo). Nebivolol was associated with a non-significant mean±SD reduction in SBP (-10.1±16.9 mmHg) versus placebo (-7.3±15.9 mmHg, P=0.093) and significant mean DBP reduction (-7.8±10.1 mmHg vs -3.5±10.6 mmHg, P<0.001). Subgroup analysis suggested a significant effect on DBP for patients receiving background losartan treatment (-8.1±9.2 mmHg vs -3.1±9.4 mmHg, P<0.001), but not for those receiving lisinopril (-7.6±10.8 mmHg vs -3.8±11.6 mmHg, P=0.076). A total of 28% nebivolol-treated and 22% placebo-treated patients reported a TEAE, the most frequent being upper respiratory tract infection (4.3% and 2.1%, respectively), bradycardia (2.7% and 0%), headache (2.3% and 2.1%), and nasopharyngitis (2.3% and 0.9%).

CONCLUSION

These data suggest that nebivolol, when added to lisinopril or losartan, results in an additional BP reduction; however, only the effect on DBP reached statistical significance. A subanalysis suggests that the effect on DBP may be stronger in losartan-treated than lisinopril-treated patients. A relatively strong placebo effect may limit data interpretation. Nebivolol was well tolerated, as there was no difference in TEAEs between nebivolol and placebo.

FUNDING

This trial (NCT00734630) was funded by Forest Laboratories, Inc.

Comparative Effects of a New Cardioselective Beta-Blocker Nebivolol and Nifedipine Sustained-Release on 24-Hour Ambulatory Blood Pressure and Plasma Lipoproteins

This double-blind, parallel-group study compared the effects of nebivolol, a novel cardioselective beta-blocker, with those of nifedipine sustained-release on 24-hour ambulatory blood pressure and plasma lipoprotein levels. After a washout period of 8 weeks, 51 patients with mild to moderate essential hypertension were randomized to double-blind treatment with either nebivolol 5 mg once a day (n = 26) or nifedipine sustained-release 20 mg bid (n = 25) over a period of 12 weeks. Both treatments produced similar and significant (P = .0001) reduction in office blood pressure as well as in 24-hour, work, awake, and sleep ambulatory blood pressure. The clinical response (diastolic blood pressure less than 90 mmHg or decreased by greater than or equal to 10 mmHg) rate was 69% for nebivolol and 59% for nifedipine, respectively. Moreover, the nebivolol and nifedipine treatment-induced decreases in mean 24-hour ambulatory blood pressure were similar to the decreases in clinic blood pressure. Furthermore, the percentages of "blood pressure loads" (awake greater than 140/90 mmHg and asleep greater than 120/80 mmHg) were lowered significantly (P = .0001), from 60% to 29% with nebivolol and from 60% to 39% with nifedipine. Mean ambulatory heart rate was reduced (P = .0001) from 79 +/- 7 to 68 +/- 7 beats/minute during nebivolol therapy and from 80 +/- 9 to 79 +/- 7 (not significant) with nifedipine. Total plasma cholesterol and low-density lipoprotein levels decreased significantly (P less than .05) by 5 and 8%, respectively, after nebivolol treatment, and each decreased by 3% after nifedipine treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Nebivolol induces distinct changes in profibrosis microRNA expression compared with atenolol, in salt-sensitive hypertensive rats

Nebivolol is a selective β1-blocker with nitric oxide-enhancing effects. MicroRNAs are small noncoding RNA molecules that downregulate gene expression. We compared the effects of nebivolol and atenolol, a first generation β1-selective blocker, on left ventricular hypertrophy, fibrosis, and function and microRNA expression in a rodent model of hypertension. Dahl salt-sensitive rats received either low-salt chow (control) or AIN-76A high-salt (8% NaCl) diet and randomized to vehicle (high-salt), nebivolol (20 mg/kg per day), or atenolol (50 mg/kg per day) for 8 weeks. High-salt induced left ventricular hypertrophy and fibrosis and decreased the expression of miR-27a, -29a, and -133a. Nebovolol attenuated deterioration of left ventricular systolic function, remodeling, and fibrosis more than atenolol, despite similar effects on heart rate and blood pressure. Nebivolol, but not atenolol, prevented the decrease in miR-27a and -29a induced by high-salt. Nebivolol and atenolol equally attenuated the decrease in miR-133a. In vitro overexpression of miR-27a,-29a, and -133a inhibited cardiomyocyte hypertrophy and reduced collagen expression. Both miR-27a and -29a target Sp1, and miR-133a targets Cdc42. Pharmacological inhibition of Sp1 and Cdc42 decreased myocardial fibrosis and hypertrophy. Our data support a differential microRNAs expression profile in salt-induced hypertension. Nebivolol substantially attenuated cardiac remodeling, hypertrophy, and fibrosis more than atenolol. These effects are related to attenuation of the hypertension-induced decrease in miR-27a and -29a (with a subsequent decrease in Sp1 expression) and miR-133a (with a subsequent decrease in Cdc42).

Effect of nebivolol on endothelial dysfunction in patients with Behçet's disease; a prospective single-arm controlled study

OBJECTIVE

Behçet's disease (BD) is a systemic vasculitis, capable of involving all types of vessels. Endothelial dysfunction (ED) has been previously documented in BD. Previous studies showed that nebivolol might improve endothelial functions in endothelial dysfunction. The aim of our study is to assess the effects of nebivolol on endothelial dysfunction in patients with Behçet's disease.

METHODS

This study was designed as prospective single-arm controlled study. We prospectively studied 35 Behçet's patients who were diagnosed according to the International Study Group criteria. Patients received 5 mg nebivolol per day for 3 months. Endothelial dysfunction was evaluated by brachial artery flow-mediated dilatation (FMD) method using high-resolution vascular ultrasound device at baseline and after for 3-month therapy. The paired samples t test, Wilcoxon test, Pearson, Spearman correlation analyses were used for statistical analysis.

RESULTS

A significant improvement was observed in FMD after therapy period (4.23±1.19 vs 7.95±2.21%, p<0.001). The correlation analysis showed a negative correlation between post-treatment high-sensitive C-reactive protein and FMD (r=-0.435, p=0.009). No adverse effects were observed in treatment period.

CONCLUSION

Nebivolol improved endothelial dysfunction in Behçet's patients. However, further comprehensive studies are needed to determine the long-term effects of nebivolol.

Nebivolol monotherapy for patients with systolic stage II hypertension: results of a randomized, placebo-controlled trial

BACKGROUND

Elevated systolic blood pressure (SBP) is an independent risk factor for cardiovascular events and mortality.

OBJECTIVE

The goal of this study was to assess whether nebivolol (NEB), a vasodilatory β(1)-selective blocker, is a safe and efficacious monotherapy for individuals with systolic stage II hypertension.

METHODS

In this multicenter trial, 18- to 64-year-olds who had not used antihypertensive treatment for at least 4 weeks and had SBP/diastolic blood pressure (DBP) of 160 to 180/90 to 110 mm Hg were randomized to receive double-blind medication for 6 weeks (NEB, n = 290; placebo [PBO], n = 142). Depending on response, the starting dose (5 mg/d) could be increased directly to 20 mg/d. Primary parameters were baseline-end point changes in trough seated SBP and DBP (intent-to-treat [ITT] population); the Hochberg method was used to control the type I error (α = 0.05). Responder analysis was also performed. Safety and tolerability assessment included monitoring of adverse events (AEs).

RESULTS

Mean age at baseline (ITT) was 50.7 years, and the mean SBP/DBP values were 167/101 mm Hg; 202 (47.3%) participants were women, 276 (63.9%) had body mass index ≥30 kg/m(2), 152 (35.2%) were black, and 161 (37.3%) were Hispanic. Completion rates were 79.7% (PBO) and 90.3% (NEB). After 2 weeks of treatment, 92% and 95% participants in the NEB and PBO groups, respectively, had SBP in the range of 130 to 180 mm Hg and were titrated to the 20-mg/d NEB dose or its matching PBO tablet. After 6 weeks of treatment, the NEB group experienced significant mean reductions compared with the PBO group for both SBP (-18.2 vs -12.3 mm Hg; P < 0.001) and DBP (-12.3 vs -5.7 mm Hg; P < 0.001), down to mean SBP/DBP values of 149/89 mm Hg and 155/95 mm Hg, respectively, and had a significantly higher percentage of individuals who achieved BP control (SBP/DBP <140/90 mm Hg, 30.6% vs 17.3%; P = 0.004). Post hoc analyses suggest that NEB was not efficacious in reducing SBP in black participants. Mean changes in pulse rate were -12.8 beats/min for the NEB group and -1.6 beats/min for the PBO group (P < 0.001). Rates of discontinuations due to an AE (NEB vs PBO) were 1.4% in both groups, rates of any treatment-emergent AEs were 19.7% versus 19.0%, and rates of serious AEs were 0.3% versus 2.1%. The most common AEs (NEB vs PBO) were headache (2.1% vs 2.8%) and hypertension (0.7% vs 2.1%).

CONCLUSIONS

NEB monotherapy was an efficacious and well-tolerated treatment option for these study individuals with systolic stage II hypertension, but most of them would need combination therapy to achieve BP control.

[Effect of monotherapy with nebivolol, bisoprolol, carvedilol on the state of vegetative nervous system and sexual function in men with arterial hypertension]

Aim of the study was to assess effect of monotherapy with nebivolol, bisoprolol, carvedilol for 2 months on sexual function in men with arterial hypertension (AH). Men with 1-2 degree of AH (n=75, age 35-55 years, mean age 48+/-3,5 years) received monotherapy with these drugs for 2 months. Registration of parameters of heart rate variability (HRV), Dopplerography of penile arteries, and the Vasilchenko questionnaire were implemented at the end of 4 months of placebo period and after 2 months of therapy with a study drug. Therapy with bisoprolol, carvedilol, and nebivolol was associated with significant elevation of parasympathetic part of vegetative nervous system tone, improvement of systolic blood flow in cavernous and dorsal arteries. Analysis of data obtained by Vasilchenko questionnaire demonstrated improvement of psychic and erectile components of sexual function. Thus bisoprolol, carvedilol, and nebivolol did not worsen sexual function of men with AH, improved spectral parameters of HRV and vascular blood flow in arteries of cavernous bodies.

Role of nitric oxide in the effect of nebivolol on isolated tracheal muscle of guinea pig

BACKGROUND

The use of beta blockers is limited by their ability to produce bronchospasm in asthmatics. Third generation beta-blockers like Nebivolol may show better tolerability because they may augment the release of nitric oxide (NO) from endothelial cells. However the involvement of NO in the respiratory effect of Nebivolol remains controversial. The present study, carried out on isolated tracheal muscle strips of guinea pigs, was designed to explore this controversy.

METHOD

Varying concentration of histamine ranging from 10(-7) M to 10(-3) M were used to plot a concentration response curve on the isolated tracheal muscle strips of guinea pig and was used as a control. The same concentration response curve was plotted in presence of a fixed concentration of Nebivolol 10(-6) M and then again in presence of a fixed concentration of L-Nitro Arginine Methyl Ester (L-NAME) 10(-4) M and Nebivolol 10(-6) M together in a series of experiments using six sets of isolated tracheal muscle strips in each case.

RESULTS

Nebivolol did not produce any significant shift in the concentration response curve while in the presence of L-NAME, Nebivolol shifted the histamine concentration response curve upwards and to the left.

CONCLUSION

Nebivolol does not augment the histamine induced contraction of respiratory smooth muscle of guinea pig but in the presence of Nitric Oxide inhibitor L-NAME a significant augmentation of the same curve occurs, indicating a role of NO in the sparing of respiratory smooth muscle by Nebivolol.

Vasodilatory mechanisms of beta receptor blockade

Beta-blockers are widely prescribed for the treatment of a variety of cardiovascular pathologies. Compared to traditional beta-adrenergic antagonists, beta-blockers of the new generation exhibit ancillary properties such as vasodilation through different mechanisms. This translates into a more favorable hemodynamic profile. The relative affinities of beta-adrenoreceptor antagonists towards the three beta-adrenoreceptor isotypes matter for predicting their functional impact on vasomotor control. This review will focus on the mechanisms underlying beta-blocker-evoked vasorelaxation with a specific emphasis on agonist properties of beta(3)-adrenergic receptors.

Protective effects of nebivolol against anthracycline-induced cardiomyopathy: a randomized control study

BACKGROUND

We aimed to evaluate the effect of prophylactic nebivolol use on prevention of antracycline-induced cardiotoxicity in breast cancer patients.

METHODS

In this small, prospective, double-blind study, we randomly assigned 45 consecutive patients with breast cancer and planned chemotheraphy to receive nebivolol 5mg daily (n=27) or placebo (n=18). Echocardiographic measurements and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels were obtained at baseline and at 6-month of chemotherapy.

RESULTS

Both studied groups had comparable echocardiographic variables and NT-pro-BNP levels at baseline. At 6-month, the left ventricular (LV) end-systolic and end-diastolic diameters increased in the placebo group (LVESD: 29.7 ± 3.4 to 33.4 ± 4.5mm; LVEDD: 47.2 ± 3.8 to 52.0 ± 4.6mm, p=0.01 for both) but remained unchanged in the nebivolol group (LVESD: 30.4 ± 3.5 to 31.0 ± 3.6mm, p=0.20; LVEDD: 47.0 ± 4.4 to 47.1 ± 4.0mm, p=0.93). The placebo group also had lower LVEF than the nebivolol group (57.5 ± 5.6% vs. 63.8 ± 3.9%, p=0.01) at 6-month. NT-pro-BNP level remained static in the nebivolol group (147 ± 57 to 152 ± 69 pmol/l, p=0.77) while it increased in the placebo group (144 ± 66 to 204 ± 73 pmol/l, p=0.01).

CONCLUSIONS

Prophylactic use of nebivolol treatment may protect the myocardium against antracycline-induced cardiotoxicity in breast cancer patients.

Nebivolol does not protect against 5/6 ablation/infarction induced chronic kidney disease in rats - comparison with angiotensin II receptor blockade

AIMS

Nitric oxide (NO) deficiency contributes to chronic kidney disease progression. Nebivolol, a beta adrenergic receptor antagonist, may enhance endogenous NO. Here, we investigated whether Nebivolol attenuates hypertension and renal injury after 5/6 ablation/infarction (A/I). Efficacy was compared to the AT1 receptor antagonist Olmesartan.

MAIN METHODS

Kidney disease and hypertension were induced by right kidney ablation and ~2/3 infarction of the left kidney. Rats were treated orally with vehicle (placebo), Nebivolol (5mg/kg b.i.d.), or Olmesartan (2.5mg/kg/day) for 6 weeks after A/I.

KEY FINDINGS

With placebo, glomerular sclerosis and tubulointersititial fibrosis developed with increased blood pressure and proteinuria, and a fall in NO(x) excretion. Olmesartan prevented these changes, but Nebivolol had no effect on these measures but lowered heart rate. Neither treatment reduced systemic oxidative stress (urinary hydrogen peroxide and TBARS). Compared to controls, renal cortex abundance of nNOSα decreased and nNOSβ increased in rats after 5/6 A/I, with no changes in eNOS. Neither treatment restored nNOSα; however, both reduced nNOSβ. Activity of DDAH was decreased by 5/6 A/I but restored by both treatments despite no increase in DDAH protein abundance. Kidney cortex abundance of manganese SOD fell after 5/6 A/I and was restored by treatment with Olmesartan but not Nebivolol. Extracellular and copper/zinc SOD abundances were not changed.

SIGNIFICANCE

In conclusion, Nebivolol showed no benefit after 6 weeks in rapidly progressing, ANG II-dependent 5/6 A/I model of chronic kidney disease. This contrasts to the protection seen with 6 month treatment of Nebivolol in the slowly progressing 5/6 ablation model.

Beta3-adrenoreceptor stimulation ameliorates myocardial ischemia-reperfusion injury via endothelial nitric oxide synthase and neuronal nitric oxide synthase activation

OBJECTIVES

This paper examined whether nebivolol protects the heart via nitric oxide (NO) synthase and NO-dependent signaling in an in vivo model of acute myocardial infarction.

BACKGROUND

Beta(3)-adrenergic receptor (AR) activation promotes endothelial nitric oxide synthase (eNOS) activity and NO bioavailability. We hypothesized that specific beta(3)-AR agonists would attenuate myocardial ischemia-reperfusion (MI/R) injury via eNOS activation and increased NO bioavailability.

METHODS

Mice were subjected to 45 min of myocardial ischemia in vivo followed by 24 h of reperfusion (R). Nebivolol (500 ng/kg), CL 316243 (1 μg/kg), BRL-37344 (1 μg/kg), or vehicle (VEH) was administered at the time of R. Myocardial area-at-risk (AAR) and infarct size (INF)/AAR was measured at 24 h of R. Cardiac tissue and plasma were collected to evaluate eNOS phosphorylation, neuronal nitric oxide synthase (nNOS), inducible nitric oxide synthase expression, and nitrite and nitrosothiol levels.

RESULTS

Nebivolol (500 ng/kg) reduced INF/AAR by 37% (p < 0.001 vs. VEH) and serum troponin-I levels from 41 ± 4 ng/ml to 25 ± 4 ng/ml (p < 0.05 vs. VEH). CL 316243 and BRL-37344 reduced INF by 39% and 42%, respectively (p < 0.001 vs. VEH). Nebivolol and CL 316243 increased eNOS phosphorylation at Ser-1177 (p < 0.05 vs. VEH) and increased nitrite and total nitrosylated protein levels. Nebivolol and CL 316243 significantly increased myocardial nNOS expression. Nebivolol failed to reduce INF after MI/R in beta(3)-AR (-/-), eNOS(-/-), and in nNOS(-/-) mice.

CONCLUSIONS

Our results indicate that beta(3)-AR agonists protect against MI/R injury. Furthermore, the cardioprotective effects of beta(3)-AR agonists are mediated by rapid eNOS and nNOS activation and increased NO bioavailability.

Persistence with nebivolol in the treatment of hypertension: a retrospective claims analysis

OBJECTIVE

Examine drug persistence by evaluating the hazard of discontinuation and of switching to different antihypertensive drugs in patients initiating treatment with a recently approved β-blocker, nebivolol, versus other β-blockers.

METHODS

This retrospective analysis included all patients diagnosed with hypertension in the MarketScan Database (January 2007 - December 2008) with at least two medical claims and no prior β-blocker prescriptions within 6 months of the initial prescription date. Multivariate Cox proportional hazard models (adjusted for baseline differences in demographics, previous use of other antihypertensive medications, initial doses and supply of medication, and number of distinct prescriptions at baseline) were used to assess the hazard of discontinuation, defined as the first prescription gap of ≥30 days, and to assess the hazard of switching to another antihypertensive drug, defined as a prescription fill for another antihypertensive drug within 15 days before and 30 days after discontinuation of the initial β-blocker.

RESULTS

Of the 173,200 patients included in the study population, the adjusted hazard of discontinuation for nebivolol-initiated patients was 8-20% lower than that of patients who initiated treatment with atenolol (hazard ratio [HR] 0.82, p < 0.001), metoprolol (HR 0.91, p < 0.001), carvedilol (HR 0.92, p < 0.001), or other β-blockers (HR 0.80, p < 0.001). The adjusted hazard of nebivolol-treated patients switching to a different antihypertensive medication was 12-22% lower than that of the other four β-blocker cohorts (atenolol: HR 0.80, p < 0.001; metoprolol: HR 0.86, p < 0.001; carvedilol: HR 0.88, p < 0.001; other β-blockers: HR 0.78, p < 0.001). Sensitivity analyses defined discontinuation as prescription gaps of ≥45 days and ≥60 days and showed a lower hazard of discontinuation among patients initiating nebivolol than among patients initiating all other drug cohorts (p < 0.001).

LIMITATIONS

Comparisons of non-randomized treatment groups may be confounded by unobserved differences in patients' baseline characteristics.

CONCLUSIONS

Initiation with nebivolol was associated with greater persistence than initiation with atenolol, carvedilol, metoprolol, or other β-blockers.