Use of losartan in the treatment of hypertensive patients with a history of cough induced by angiotensin-converting enzyme inhibitors

Therapeutic approaches of uncomplicated arterial hypertension in patients with COPD

The concomitant presence of systemic arterial hypertension and chronic obstructive pulmonary disease (COPD) is frequent. Indeed, arterial hypertension is the most common comorbid disease in COPD patients. Since many antihypertensive drugs can act on airway function the treatment of arterial hypertension in COPD patients appears complex. Moreover, in these patients, a combined therapy is required for the adequate control of blood pressure. Currently, available data are inconsistent and not always comparable. Therefore the aim of this review is to analyze how antihypertensive drugs can affect airway function in order to improve the clinical management of hypertensive patients with COPD. Thiazide diuretics and calcium channel blockers appear the first-choice pharmacological treatment for these patients.

The cough reflex is upregulated by lisinopril microinjected into the caudal nucleus tractus solitarii of the rabbit

We have previously shown that cough potentiation induced by intravenous administration of the AT1 receptor antagonist losartan is lower than that induced by the ACE inhibitor lisinopril in anesthetized and awake rabbits. Since losartan and lisinopril cross the blood-brain barrier, their central action on the cough reflex can be hypothesized. Mechanical stimulation of the tracheobronchial tree and citric acid inhalation were used to induce cough reflex responses in pentobarbital sodium-anesthetized, spontaneously breathing rabbits. Bilateral microinjections (30-50 nl) of losartan (5mM), lisinopril (1mM), bradykinin (0.05 mM), HOE-140 (0.2mM, a bradykinin B2 receptor antagonist) and CP-99,994 (1mM, an NK1 receptor antagonist) were performed into the caudal nucleus tractus solitarii, the predominant site of termination of cough-related afferents. Lisinopril, but not losartan increased the cough number. This effect was reverted by HOE-140 or CP-99,994. Cough potentiation was also induced by bradykinin. The results support for the first time a central protussive action of lisinopril mediated by an accumulation of bradykinin and substance P.

Tolerability of angiotensin-receptor blockers in patients with intolerance to angiotensin-converting enzyme inhibitors: a systematic review and meta-analysis

BACKGROUND

Between 5% and 20% of patients treated with angiotensin-converting enzyme inhibitors (ACE inhibitors) develop intolerance. Angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]) can be used as an alternative treatment.

OBJECTIVE

In this study we aimed to evaluate the tolerability of ARBs in patients with intolerance to ACE inhibitors.

DATA SOURCES

The electronic databases PubMed, MEDLINE/EMBASE via Dialog, CENTRAL, and ISI Web of Knowledge were searched.

STUDY SELECTION

Randomized controlled trials (RCTs) evaluating ARBs in patients with intolerance to ACE inhibitors were selected.

DATA SYNTHESIS

Risk ratio (RR) and 95% confidence intervals (CIs) were estimated assuming the random effects method. We found 11 RCTs comparing ARBs with ACE inhibitors, diuretics, or placebo, and one RCT comparing high-dose versus low-dose ARB.

RESULTS

ARBs had fewer cough events versus ACE inhibitors (RR 0.37; 95% CI 0.28, 0.48). ARBs had drug discontinuation (RR 0.99; 95% CI 0.84, 1.17) and cough risk (RR 1.01; 95% CI 0.74, 1.39) rates similar to placebo. Angioedema risk with ARBs was also similar to placebo (RR 1.62; 95% CI 0.17, 15.79). Compared with placebo, hypotension (RR 2.63; 95% CI 1.77, 3.92), renal dysfunction (RR 2.07; 95% CI 1.45, 2.95) and hyperkalemia (RR 3.37; 95% CI 1.60, 7.11) were more frequent with ARBs.

CONCLUSIONS

ACE inhibitor rechallenge should be discouraged in patients with previous intolerance to ACE inhibitors due to a higher risk of cough. ARBs had cough and angioedema incidences similar to placebo. Despite a significantly higher incidence of hypotension, renal dysfunction and hyperkalemia, discontinuation of ARBs was similar to placebo.

Drug allergy: an updated practice parameter

Adverse drug reactions (ADRs) result in major health problems in the United States in both the inpatient and outpatient setting. ADRs are broadly categorized into predictable (type A and unpredictable (type B) reactions. Predictable reactions are usually dose dependent, are related to the known pharmacologic actions of the drug, and occur in otherwise healthy individuals, They are estimated to comprise approximately 80% of all ADRs. Unpredictable are generally dose independent, are unrelated to the pharmacologic actions of the drug, and occur only in susceptible individuals. Unpredictable reactions are subdivided into drug intolerance, drug idiosyncrasy, drug allergy, and pseudoallergic reactions. Both type A and B reactions may be influenced by genetic predisposition of the patient

Structural insight on the activity of type 1 angiotensin II peptide antagonists using MD simulations

Angiotensin II (AngII) is an octapeptide hormone, which plays a very important role in the blood pressure control mechanism. The excess production of this hormone is one of the main causes of hypertension illness. The antagonists for AngII At1 receptor constitute some of the most effective antihypertension drugs. In this work, both tested type1 AngII antagonists as well as new modeled antagonists (obtained by substitution of nonspecific amino acids by noncode residues (Sarcosine (Sar) and several Calpha, Calpha-dialkylglycines)) were simulated in dimethyl sulfoxide (DMSO) using molecular dynamics (MD). A number of common structural characteristics were identified on the active (and potentially active) simulated analogs, which seem to be correlated with their antagonistic activity. Two of the designed analogs were proposed as possible antagonists.

Discontinuation of antihypertensive drugs among newly diagnosed hypertensive patients in UK general practice

OBJECTIVES

To evaluate antihypertensive drug discontinuation among newly diagnosed hypertensive patients.

METHODS

This was a population-based cohort study using the UK General Practice Research Database (GPRD). Patients newly diagnosed with hypertension between 1991 and 2001 and subsequently treated with antihypertensive drugs were included. Overall antihypertensive drug discontinuation was evaluated from a patient's first-ever antihypertensive prescription. Class-specific discontinuations were evaluated from a patient's first-ever prescriptions of angiotensin-converting enzyme (ACE) inhibitors (ACE-I), alpha antagonists, angiotensin-2 antagonists (AIIA), beta blockers, calcium-channel blockers (CCB), miscellaneous, potassium-sparing diuretics, and thiazides. Discontinuation occurred when no antihypertensive prescription was issued within 90 days following the most recent prescription expiration.

RESULTS

The study population comprised 109 454 patients, with 223 228 antihypertensive drug-class episodes contributing to the class-specific analysis. Overall antihypertensive drug discontinuation was 20.3% [95% confidence interval (CI): 20.0, 20.5%] at 6 months and 28.5% (95% CI: 28.2, 28.7%) at 1 year, with a median time to discontinuation of 3.07 years. The median time to antihypertensive class discontinuation was longest for AIIAs (2.90 years) followed by ACE-I (2.24), CCB (1.86), beta blockers (1.50), thiazides (1.50), alpha antagonists (1.35), potassium-sparing diuretics (0.40), and miscellaneous (0.39). One-year discontinuation ranged from 29.4% (95% CI: 28.0, 30.7) for AIIAs to 64.1% (95% CI: 62.1, 66.3) for potassium-sparing diuretics. Forty-four percent who discontinue their first-ever antihypertensive drug class failed to switch to a different drug class within 90 days of discontinuation.

CONCLUSION

It is important that general practitioners (GPs) monitor patients closely in the first year following antihypertensive drug initiation, due to the high early risk of discontinuation, and the low percentage of patients who switch to a different antihypertensive drug class after a drug-class discontinuation. AIIA, followed by ACE-I and CCB, had the lowest risk of discontinuation among antihypertensive drug classes.

Indications for and utilization of ACE inhibitors in older individuals with diabetes. Findings from the National Health and Nutrition Examination Survey 1999 to 2002

BACKGROUND

Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) improve cardiovascular outcomes in high-risk individuals with diabetes. Despite the marked benefit, it is unknown what percentage of patients with diabetes would benefit from and what percentage actually receive this preventive therapy.

OBJECTIVES

To examine the proportion of older diabetic patients with indications for ACE or ARB (ACE/ARB). To generate national estimates of ACE/ARB use.

DESIGN AND PARTICIPANTS

Survey of 742 individuals> or =55 years (representing 8.02 million U.S. adults) self-reporting diabetes in the 1999 to 2002 National Health and Nutrition Examination Survey.

MEASUREMENTS

Prevalence of guideline indications (albuminuria, cardiovascular disease, hypertension) and other cardiac risk factors (hyperlipidemia, smoking) with potential benefit from ACE/ARB. Prevalence of ACE/ARB use overall and by clinical indication.

RESULTS

Ninety-two percent had guideline indications for ACE/ARB. Including additional cardiac risk factors, the entire (100%) U.S. noninstitutionalized older population with diabetes had indications for ACE/ARB. Overall, 43% of the population received ACE/ARB. Hypertension was associated with higher rates of ACE/ARB use, while albuminuria and cardiovascular disease were not. As the number of indications increased, rates of use increased, however, the maximum prevalence of use was only 53% in individuals with 4 or more indications for ACE/ARB.

CONCLUSIONS

ACE/ARB is indicated in virtually all older individuals with diabetes; yet, national rates of use are disturbingly low and key risk factors (albuminuria and cardiovascular disease) are being missed. To improve quality of diabetes care nationally, use of ACE/ARB therapy by ALL older diabetics may be a desirable addition to diabetes performance measurement sets.

Cough and angioedema from angiotensin-converting enzyme inhibitors: new insights into mechanisms and management

PURPOSE OF REVIEW

Angiotensin-converting enzyme inhibitors are widely prescribed for hypertension and heart failure. These drugs are commonly associated with cough, and are less commonly associated with angioedema, which may be potentially life threatening. This review describes data that extend our understanding of the mechanisms of these reactions, and provides guidance about clinical management.

RECENT FINDINGS

For patients who develop angioedema from angiotensin-converting enzyme inhibitors, recent data are reassuring that the majority of such patients can tolerate angiotensin-II receptor blockers. These data support earlier conclusions that most patients with angiotensin-converting enzyme inhibitor-induced cough can tolerate angiotensin-II receptor blockers. Limited case reports suggest that in acute angioedema induced by angiotensin-converting enzyme inhibitors, patients refractory to standard treatment may benefit from the infusion of fresh frozen plasma.

SUMMARY

Although data are incomplete, it appears that angiotensin-converting enzyme inhibitors cause cough and angioedema through a cascade of effects that begins with the accumulation of kinins, and then involves arachidonic acid metabolism and nitric oxide generation. Most patients who develop either cough or angioedema from angiotensin-converting enzyme inhibitors can tolerate angiotensin-II receptor blocking agents.

NO-Sartans: A New Class of Pharmacodynamic Hybrids as Cardiovascular Drugs

The aim of this work was to develop lead pharmacodynamic hybrids, NO-sartans, possessing the characteristics of a typical AT1-antagonist and of a "slow NO donor", by adding NO-donor side chains to losartan. These new compounds, 2a and 2b, displayed vasorelaxing effects, due to the release of NO, and antagonized the vasocontractile effects of angiotensin II, with potency values similar to that of losartan. In vivo, the antihypertensive effects of 2a were similar to those of losartan and captopril.

Use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high-risk clinical and ethnic groups with diabetes

BACKGROUND

Diabetes causes 45% of incident end-stage renal disease (ESRD). Risk of progression is higher in those with clinical risk factors (albuminuria and hypertension), and in ethnic minorities (including blacks, Asians, and Latinos). Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) slow the progression of diabetic nephropathy, yet little is known about their use among patients at high risk for progression to ESRD.

OBJECTIVES

To examine the prevalence of ACE or ARB (ACE/ARB) use overall and within patients with high-risk clinical indications, and to assess for ethnic disparities in ACE/ARB use.

DESIGN

Observational cohort study.

SETTING

Kaiser Permanente Northern California (KPNC) Diabetes Registry, a longitudinal registry that monitors quality and outcomes of care for all KPNC patients with diabetes.

PATIENTS

Individuals (N= 38887) with diabetes who were continuously enrolled with pharmacy benefits during the year 2000, and had self-reported ethnicity data on survey.

INTERVENTIONS AND MEASUREMENTS

Pharmacy dispensing of ACE/ARB.

RESULTS

Forty-one percent of the cohort had both hypertension and albuminuria, 30% had hypertension alone, and 12% had albuminuria alone. Fourteen percent were black, 11% Latino, 13% Asian, and 63% non-Latino white. Overall, 61% of the cohort received an ACE/ARB. ACE/ARB was dispensed to 74% of patients with both hypertension and albuminuria, 64% of those with hypertension alone, and 54% of those with albuminuria alone. ACE/ARB was dispensed to 61% of whites, 63% of blacks, 59% of Latinos, and 60% of Asians. Among those with albuminuria alone, blacks were significantly (P =.0002) less likely than whites to receive ACE/ARB (47% vs 56%, respectively). No other ethnic disparities were found.

CONCLUSIONS

In this cohort, the majority of eligible patients received indicated ACE/ARB therapy in 2000. However, up to 45% to 55% of high-risk clinical groups (most notably individuals with isolated albuminuria) were not receiving indicated therapy. Additional targeted efforts to increase use of ACE/ARB could improve quality of care and reduce ESRD incidence, both overall and in high-risk ethnic groups. Policymakers might consider use of ACE/ARB for inclusion in diabetes performance measurement sets.

Comparison of quality of life and cough on eprosartan and enalapril in people with moderate hypertension

The objective of this study was to compare quality of life and incidence of dry persistent cough among patients treated with eprosartan and enalapril for mild-moderate hypertension. This was a randomised 26-week double-blind controlled trial carried out in clinics in nine countries of North America, Europe and South Africa. A total of 529 patients aged 18 and over with diastolic blood pressure between 95 mm Hg and 114 mm Hg were studied. Treatment comprised of eprosartan or enalapril monotherapy for 12 weeks with the option of hydrochlorothiazide addition for the remaining 14 weeks. The primary outcome measures were cough and the Psychological General Wellbeing Index (PGWB) total and subscales (anxiety, self-control, depression, general health, positive wellbeing and vitality). The results were that 17.8% of enalapril patients and 13.2% of eprosartan patients withdrew from randomised treatment. Those on enalapril were twice as likely to have gained a definite or possible cough by study end point as those on eprosartan (7.6% vs 3.2%) P = 0.099. At monotherapy end point the differences were greater (9.9% vs 2.1%) and of statistical significance, P = 0.001. Patients treated with enalapril, however, had small but significant improvements in measures of self-control and total PGWB compared with those on eprosartan. The effect sizes of 0.2 or less indicated that there were small differences. In conclusion eprosartan was associated with fewer coughs than enalapril but it performed less well on some aspects of quality of life.

Quality of life and cough on antihypertensive treatment: a randomised trial of eprosartan, enalapril and placebo

The objective of this study was to compare the quality of life and incidence of dry cough with the angiotensin II antagonist eprosartan, the ACE-inhibitor enalapril, and placebo, in hypertensive patients with a history of ACE-inhibitor cough. The study was a multicentre, randomised, double-blind, parallel group controlled trial. A total of 136 patients judged to have ACE-inhibitor cough during single-blind enalapril treatment which was lost during a subsequent placebo washout phase, were randomised to receive either eprosartan 300 mg twice daily, or enalapril 20 mg once daily, or placebo for 6 weeks. Self-completion questionnaires assessing quality of life and cough were examined at baseline and end of study. At study end point 23% of patients in the enalapril group and 5% in the eprosartan and placebo groups reported cough (which included definite, probable and possible coughs) (P = 0.02). After adjusting for multiple comparisons, the eprosartan group was not significantly different from either placebo or enalapril. There were no significant differences in the Psychological General Wellbeing Index (PGWB). In conclusion the incidence of self-reported cough on eprosartan was similar to that on placebo, and lower than on enalapril but this difference was not significant when adjustments were made for multiple comparisons. There were no differences in quality of life.

Effects of candesartan on cough and bronchial hyperresponsiveness in mildly to moderately hypertensive patients with symptomatic asthma

BACKGROUND

Candesartan, an AT(1) receptor antagonist, has been reported to have no association with persistent cough in subjects with hypertension, but there has been no study on the safety of its administration to hypertensive patients with symptomatic asthma. The aim of this study was to compare the adverse effects of candesartan and calcium antagonists on cough, pulmonary function, and bronchial hyperresponsiveness in these patients.

METHODS AND RESULTS

Sixty mildly to moderately hypertensive patients with bronchial asthma received either candesartan (n=30) or the calcium antagonists nifedipine or manidipine (n=30) for 6 months. The candesartan group included 5 subjects with a history of ACE inhibitor-induced cough. There were no differences between the 2 groups in patient characteristics, ACE gene polymorphism, pulmonary function, or bronchial hyperresponsiveness to methacholine. Control of hypertension was the primary end point; new cough detected by self-administrated questionnaire and an increase in cough frequency by visual analog scale were the second end point. No patient complained of persistent cough. Neither mean visual analog scale score nor pulmonary functions changed during this study. Bronchial hyperresponsiveness had a tendency to improve in the candesartan group, but there was no difference between the 2 groups.

CONCLUSIONS

Incidence, frequency, and severity of persistent cough, pulmonary functions, and bronchial hyperresponsiveness did not change in either the candesartan or calcium antagonist group. It is suggested that candesartan is as effective and safe as calcium antagonists in the treatment of hypertension associated with symptomatic asthma.

Patient-reported adherence to guidelines of the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

OBJECTIVES

To compare antihypertensive drug compliance with treatment guidelines established by the Sixth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI), and to identify patient adherence to antihypertensive drugs and factors affecting prescribing patterns.

METHODS

Patients filling antihypertensive drug prescriptions in metropolitan New York area pharmacies were enrolled. Pharmacy externs collected patient-reported demographics, medical and drug histories, and blood pressure measurements. Compliance with JNC VI guidelines was assessed.

RESULTS

Eight hundred twenty-one patients from 102 pharmacies participated. Blood pressure was controlled in 61% of patients at the time of the study. The most prescribed class of antihypertensive agents was angiotensin-converting enzyme inhibitors, followed by diuretics and beta-blockers. Over the study period, compliance with JNC VI guidelines decreased significantly from 85% to 64% (p<0.05). Thirty-seven percent of patients reported consistent adherence to their antihypertensive regimens. Patients' education level was the only factor found to correlate positively with the appropriateness of antihypertensive agents prescribed.

CONCLUSION

Compliance with JNC VI guidelines decreased over time, and patient adherence to drug therapy was suboptimal. Continuing-education efforts to reinforce optimal blood pressure management are necessary.

Therapeutic trials comparing angiotensin converting enzyme inhibitors and angiotensin II receptor blockers

Two independent pharmacologic methods of specifically interfering with the renin-angiotensin-aldosterone system have been brought to the marketplace: angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). These agents have the potential not only to be very widely used for a broad variety of clinical indications but also to compete against each other as treatments for hypertension, heart failure, renal impairment, and other conditions. Many short-term comparative studies of these two classes of drugs have now been completed. Most have focused on surrogate endpoints, such as blood pressure, renal function, or cough. These studies have generally concluded that ARBs are better tolerated but that the two drug classes otherwise have similar efficacy. The largest clinical trial comparing ARBs and ACE inhibitors thus far completed, Evaluation of Losartan in the Elderly (ELITE 2), failed to confirm the results of a smaller study; it did not demonstrate a significant improvement in outcomes (death or hospitalization for heart failure) with an ARB used alone, despite better tolerability. Many longer-term outcome studies with survival endpoints are under way, but most will compare the combination against an ACE inhibitor alone. These studies will define the optimal use of these agents in medicine for decades to come.

Spectrum of use for the angiotensin-receptor blocking drugs

The renin-angiotensin system (RAS) plays an important role in regulating blood pressure, and maintaining fluid and electrolyte balance. Angiotensin II is the principal mediator of the RAS and has been implicated in the development of hypertension as well as other forms of cardiovascular and renal disease. Angiotensin II-receptor antagonists are a new class of drugs that inhibit the RAS by selectively blocking the AT(1) receptor. These compounds therefore provide more specific and thorough blockade of the RAS by inhibiting the deleterious actions of angiotensin II at the receptor level, irrespective of how this peptide is formed. The increased specificity of action of angiotensin II-receptor antagonists may also circumvent unwanted side-effects normally associated with angiotensin-converting enzyme (ACE) inhibitors (eg, cough and angioedema) as these agents do not interfere with the metabolism of other peptides (eg, bradykinin, substance P, etc.). There is still some concern with angiotensin II-receptor antagonists and the long-term effects of hyper-stimulation of the unopposed AT(2) receptor that is caused by elevated levels of angiotensin II. However, it appears that stimulation of the AT(2) receptor may actually contribute to the beneficial effects of angiotensin II-receptor antagonists by counteracting the effects mediated by the AT(1) receptor. Angiotensin II-receptor antagonists display great therapeutic promise in the field of cardiovascular medicine and are currently being exploited as new antihypertensive agents. These drugs have demonstrated safety, efficacy, and tolerability; however, morbidity and mortality data are still lacking. Nonetheless, it is likely that angiotensin II-receptor antagonists will become part of the medical arsenal against cardiovascular and renal disease, thus consideration should be given to their future use as first-line antihypertensive agents.