A multicenter, community-based study of doxazosin in the treatment of concomitant hypertension and symptomatic benign prostatic hyperplasia: the Hypertension and BPH Intervention Trial (HABIT)

Directed Evolution of P450 BM3 towards Functionalization of Aromatic O-Heterocycles

The O-heterocycles, benzo-1,4-dioxane, phthalan, isochroman, 2,3-dihydrobenzofuran, benzofuran, and dibenzofuran are important building blocks with considerable medical application for the production of pharmaceuticals. Cytochrome P450 monooxygenase (P450) Bacillus megaterium 3 (BM3) wild type (WT) from Bacillus megaterium has low to no conversion of the six O-heterocycles. Screening of in-house libraries for active variants yielded P450 BM3 CM1 (R255P/P329H), which was subjected to directed evolution and site saturation mutagenesis of four positions. The latter led to the identification of position R255, which when introduced in the P450 BM3 WT, outperformed all other variants. The initial oxidation rate of nicotinamide adenine dinucleotide phosphate (NADPH) consumption increased ≈140-fold (WT: 8.3 ± 1.3 min-1; R255L: 1168 ± 163 min-1), total turnover number (TTN) increased ≈21-fold (WT: 40 ± 3; R255L: 860 ± 15), and coupling efficiency, ≈2.9-fold (WT: 8.8 ± 0.1%; R255L: 25.7 ± 1.0%). Computational analysis showed that substitution R255L (distant from the heme-cofactor) does not have the salt bridge formed with D217 in WT, which introduces flexibility into the I-helix and leads to a heme rearrangement allowing for efficient hydroxylation.

Pharmacologic management of non-neurogenic functional obstruction in women

INTRODUCTION

Impaired bladder emptying in women without neurologic disease may be related to urethral obstruction and/or impaired bladder contractility. Mechanical obstruction generally requires surgical management and options are limited for impaired bladder contractility. However, functional obstruction from voiding dysfunction or primary bladder neck obstruction may present an opportunity for pharmacologic intervention.

AREAS COVERED

In this review, the authors extensively reviewed available literature regarding the use of off-label medications for functional bladder outlet obstruction in women. In addition, side effect profiles and pharmacology of these medications determined from on-label indications are reviewed. Specific medications reviewed include vaginal diazepam, baclofen, urethral botulinum toxin injection, and alpha-adrenergic blockers.

EXPERT OPINION

Alpha-blockers in particular have demonstrated promise in women with demonstrable or suspected bladder outlet obstruction with side effect profiles similar to those observed in men. However, lack of quality data hinders informed decision making with alpha-blockers or any of the other agents studied in women with non-neurogenic functional outlet obstruction. In the absence of well-designed, placebo-controlled multi-institutional trials, those prescribing these medications must be aware of special considerations and side effects associated with relatively unfamiliar treatments in the context of uncertain benefit.

Transforming growth factor beta1 mediates apoptotic activity of angiotensin II type I receptor blocker on prostate epithelium in vitro

BACKGROUND

The significant association of benign prostatic hyperplasia (BPH) and hypertension indicates a common pathophysiological factor for both diseases. Hyperactivity of the renin-angiotensin system (RAS) has been reported in BPH. Angiotensin II type I (AT1) receptor is the principal mediator of the RAS, and the antagonist, AT1 receptor blocker (ARB), can induce apoptosis in prostate epithelium cells and increase transforming growth factor beta1 (TGF-beta1) expression. We aimed to investigate the mechanism of inhibition of AT1 receptor in prostate epithelium cells and the role of TGF-beta1.

METHODS

Human prostate epithelium cell lines were treated with different concentrations of ARB (losartan) (0, 0.1, 1, 10, 100, and 1,000 microM) for 24-72 hr. Cell proliferation was analyzed by cell proliferation assay. The location of AT1 receptor was shown by immunocytohistochemistry and immunocytofluorescence study. Analysis of apoptosis was by use of terminal transferase TdT-mediated dUTP-biotin end labeling (TUNEL) and caspase 3/7 activity assay. Mitochondrial outer-membrane permeabilization was measured by JC-1 staining. The level of TGF-beta1 was determined by enzyme-linked immunosorbent assay.

RESULTS

Immunohistochemistry and immunofluorescence analysis showed AT1 receptor expressed in epithelium cells. Compared to control cultures, cultures treated with losartan for 24-72 hr showed a dose-dependent significant decrease in cell number, with apoptosis increased by 65.2%. Decreased cell number was reversed on treatment with anti-TGF-beta1 antibody. TUNEL staining showed increased apoptosis in prostate epithelium cells exposed to losartan. Caspase 3/7 activation was increased and mitochondrial membrane potential was downregulated. Expression of TGF-beta1 in cells treated with losartan was higher than that in untreated cells.

CONCLUSIONS

The apoptotic effect of blockade of AT1 receptor on human prostatic epithelium cells may be mediated through an autocrine the production of TGF-beta1. Furthermore, this finding may have implications for medication options. Inc.

Effects of dietary flaxseed lignan extract on symptoms of benign prostatic hyperplasia

A flaxseed lignan extract containing 33% secoisolariciresinol diglucoside (SDG) was evaluated for its ability to alleviate lower urinary tract symptoms (LUTS) in 87 subjects with benign prostatic hyperplasia (BPH). A randomized, double-blind, placebo-controlled clinical trial with repeated measurements was conducted over a 4-month period using treatment dosages of 0 (placebo), 300, or 600 mg/day SDG. After 4 months of treatment, 78 of the 87 subjects completed the study. For the 0, 300, and 600 mg/day SDG groups, respectively, the International Prostate Symptom Score (IPSS) decreased -3.67 +/- 1.56, -7.33 +/- 1.18, and -6.88 +/- 1.43 (mean +/- SE, P = .100, < .001, and < .001 compared to baseline), the Quality of Life score (QOL score) improved by -0.71 +/- 0.23, -1.48 +/- 0.24, and -1.75 +/- 0.25 (mean +/- SE, P = .163 and .012 compared to placebo and P = .103, < .001, and < .001 compared to baseline), and the number of subjects whose LUTS grade changed from "moderate/severe" to "mild" increased by three, six, and 10 (P = .188, .032, and .012 compared to baseline). Maximum urinary flows insignificantly increased 0.43 +/- 1.57, 1.86 +/- 1.08, and 2.7 +/- 1.93 mL/second (mean +/- SE, no statistical significance reached), and postvoiding urine volume decreased insignificantly by -29.4 +/- 20.46, -19.2 +/- 16.91, and -55.62 +/- 36.45 mL (mean +/- SE, no statistical significance reached). Plasma concentrations of secoisolariciresinol (SECO), enterodiol (ED), and enterolactone (EL) were significantly raised after the supplementation. The observed decreases in IPSS and QOL score were correlated with the concentrations of plasma total lignans, SECO, ED, and EL. In conclusion, dietary flaxseed lignan extract appreciably improves LUTS in BPH subjects, and the therapeutic efficacy appeared comparable to that of commonly used intervention agents of alpha1A-adrenoceptor blockers and 5alpha-reductase inhibitors.

High-dose terazosin therapy (5mg) in Korean patients with lower urinary tract symptoms with or without concomitant hypertension: a prospective, open-label study

PURPOSE

We determined the efficacy and safety of a relatively high dose of terazosin (5mg) in Korean patients with lower urinary tract symptoms (LUTS), with or without concomitant hypertension.

MATERIALS AND METHODS

From July to December 2006, 200 men who consecutively presented with LUTS were prospectively studied. Eight weeks after treatment, blood pressure (BP), uroflowmetry, and International Prostate Symptom Score (I-PSS) were assessed. For analysis purposes, patients were stratified according to concomitant hypertension. Of the 200 patients, 173 completed the scheduled eight-week treatment period.

RESULTS

At baseline, no differences were evident in the two groups in terms of I-PSS, Qmax, PVR and BP. After eight weeks of treatment-although I-PSS and uroflowmetry parameters were not significantly different in the two groups-systolic and diastolic BP in the non-hypertensive control group were higher than in the hypertensive group (p= 0.001 and p=0.0100, respectively). Changes in I-PSS, uroflowmetry parameters, and BPs measured at week eight post- treatment commencement did not significantly differ between the two groups. Moreover, the addition of 5mg of terazosin to antihypertensives did not cause a significant reduction in either systolic or diastolic BP in either group.

CONCLUSION

Adding terazosin to existing antihypertensive regimens did not seem to increase the incidence of adverse events. Our findings suggest that 5mg terazosin is effective and that it has an acceptable safety profile as an add-on therapy for patients with LUTS and concomitant hypertension.

Enantiomeric resolution of doxazosin mesylate and its process-related substances on polysaccharide chiral stationary phases

High-performance liquid chromatographic methods for separation of racemic doxazosin mesylate and its synthetic precursors on polysaccharide based stationary phases viz., amylose tris-(3,5-dimethylphenylcarbamate) (Chiralpak AD-H) and cellulose tris-(3,5-dimethylphenylcarbamate) (Chiralcel OD-H) were developed. The base line separation with Rs>1.50 was obtained using a mobile phase containing n-hexane-alcohol-0.1% diethylamine (ethanol, 1-propanol and 2-propanol) in various proportions. The effect of concentration of the alcoholic modifiers on the resolution was studied. A good separation was achieved on amylose based Chiralpak AD-H column when compared with cellulose based Chiralcel OD-H. The effects of structural features of the solutes and solvents on discrimination between the enantiomers were examined. The detection was carried out at 240 nm with UV detector while identification by polarimetric detector connected in series. The method was suitable not only for process development of doxazosin mesylate but also determination of enantiomeric purity of bulk drugs and pharmaceuticals.

Long-term follow-up study to evaluate the efficacy and safety of the doxazosin gastrointestinal therapeutic system in patients with benign prostatic hyperplasia with or without concomitant hypertension

OBJECTIVE

To assess the long-term efficacy and safety of extended-release doxazosin gastrointestinal therapeutic system (GITS) under routine clinical care conditions over 12 months in Korean men with benign prostatic hyperplasia (BPH) with and without coexisting hypertension.

PATIENTS AND METHODS

In this open-label, multicentre, uncontrolled, flexible-dose study, 475 men (> or =40 years old) with clinical evidence of BPH were enrolled from 40 centres. Patients were evaluated at baseline and at 1, 2, 6 and 12 months of treatment. The primary efficacy variable was the Clinicians Global Assessment of Change (CGAC; improved, no change, or worse). Secondary efficacy variables were International Prostate Symptom Score (IPSS), quality of life (QoL), maximum urinary flow rate (Q(max)), and postvoid residual (PVR) urine volume. Adverse events (AEs) and blood pressure (BP) were also recorded.

RESULTS

In all, 186 patients completed the study; based on the CGAC, most patients (155, 83.8%) improved and 31 (16.2%) had no change in symptoms. The mean (sd) change in the IPSS and QoL from baseline were -9.0 (6.8) and -1.6 (1.4), respectively (both P < 0.05). The Q(max) and PVR urine volume were significantly better than at baseline, with means of 10.5 (4.3) vs 13.7 (6.3), and 39.1 (37.0) vs 23.2 (33.7); P < 0.05). The decrease in systolic BP (SBP) and diastolic BP (DBP) from baseline in 52 hypertensive patients was significantly greater than in 134 normotensive patients, at (SBP/DBP) -9.5 (18.4)/-13.4 (10.9) vs -3.3 (12.5)/-1.4 (9.5); P < 0.05). A total of 47 AEs were reported in 41 of 475 patients (8.6%); the most common were dizziness (2.7%), erectile dysfunction (1.1%), dry mouth (1.1%), prostatic disorder (0.6%), and postural hypotension (0.4%).

CONCLUSIONS

After 12 months, treatment with doxazosin GITS resulted in an improvement in > 83% of patients based on the CGAC, with significant improvements in IPSS, QoL, Q(max,) and PVR urine volume. Doxazosin GITS was effective and well tolerated as long-term therapy for Korean patients with BPH.

Doxazosin GITS versus standard doxazosin in mild to moderate hypertension

BACKGROUND

The selective alpha 1-adrenoceptor antagonist doxazosin in both standard formulation and gastrointestinal therapeutic system (GITS) controlled-release formulation is effective for hypertension without having a negative impact on serum lipids. This study was designed to compare the relative efficacy of these two formulations of doxazosin on clinic and ambulatory blood pressure and serum lipids in patients with mild to moderate hypertension.

METHODS

Hypertensive patients aged 18-70 years (n = 335) were evaluated in a multi-center prospective randomized study. Following a 2-week placebo run-in phase, patients were randomized to receive doxazosin 2 or 4 mg, with dose titration, or doxazosin GITS 4 mg, no dose titration, for 9 weeks.

RESULTS

Both doxazosin formulations reduced clinic diastolic and systolic blood pressure from baseline (P < 0.0001). Doxazosin GITS and doxazosin 4 mg had similar blood pressure-lowering effects. Doxazosin GITS reduced sitting diastolic and systolic blood pressure compared with doxazosin 2 mg (P < 0.01 for both). A greater proportion of the doxazosin GITS group reached goal blood pressure (< or = 140/90 mm Hg) after 9 weeks compared with the doxazosin 2-mg group. All doses of doxazosin reduced 24-h and daytime (7:00 am to 10:00 pm) ambulatory blood pressure from baseline (all P < 0.01). Doxazosin GITS significantly reduced nighttime (10:00 pm to 7:00 am) ambulatory blood pressure from baseline. A neutral effect on serum lipids was observed with doxazosin.

CONCLUSIONS

Doxazosin GITS and doxazosin were effective in reducing clinic and ambulatory blood pressure. The GITS formulation reduced the need for dose titration. Both doxazosin formulations were well tolerated.

Clinical ease of using doxazosin in BPH patients with and without hypertension

Clinical studies have demonstrated that doxazosin therapy reduced blood pressure (BP) in patients with benign prostatic hyperplasia (BPH) who were hypertensive at baseline but not in patients who were physiologically or pharmacologically normotensive at baseline. In patients with BPH and uncontrolled hypertension, despite treatment with other antihypertensive drugs, the addition of doxazosin resulted in improved control with significant reductions in BP. The new formulation, doxazosin gastrointestinal therapeutic system (GITS), is initiated at a therapeutic dose, simplifying dose titration. Based on its efficacy and pharmacokinetic and tolerability profiles, doxazosin GITS is an effective and well-tolerated treatment for normotensive and hypertensive patients with BPH.

EFFECTS OF α 1 -ADRENERGIC RECEPTOR SUBTYPE SELECTIVE ANTAGONISTS ON LOWER URINARY TRACT FUNCTION IN RATS WITH BLADDER OUTLET OBSTRUCTION

PURPOSE

Antagonists of alpha 1-adrenergic receptors (alpha 1ARs) relieve obstructive and irritative symptoms in patients with bladder outlet obstruction. However, to our knowledge mechanisms underlying the relief of irritative symptoms remain unknown. Because bladder alpha 1dARs are up-regulated in some rats with bladder outlet obstruction, we investigated the effect of the alpha 1aAR antagonist 5-methyl urapidil (5MU) vs the alpha 1a/alpha 1dAR antagonist tamsulosin on urinary frequency in obstructed rats.

MATERIALS AND METHODS

Baseline frequency was measured using a chronic micturition recording system and then obstruction (40 rats) or sham obstruction surgery (11 rats) was performed. After 6 weeks frequency was reassessed, followed by subcutaneous implantation of osmotic pumps to deliver 5MU, tamsulosin or vehicle for 1 week. Upon the completion of drug treatment urinary frequency was again measured and the pressor response to the alpha 1AR agonist phenylephrine was documented.

RESULTS

Obstructed bladder mass was an average of 4.9 times greater than bladder mass in sham operated rats (p <0.001). Urinary frequency was elevated in obstructed rats with a bladder mass of greater than 500 mg vs all rats with a bladder mass of under 255 mg (p = 0.01). Of rats with a bladder mass of greater than 500 mg frequency was decreased in those treated with tamsulosin (p = 0.03) but not in those treated with 5MU. Tamsulosin and 5MU inhibited the pressor response to phenylephrine.

CONCLUSIONS

Urinary frequency is increased in rats with a bladder mass of greater than 500 mg. The combined alpha 1a/alpha 1dAR antagonist tamsulosin decreases urinary frequency more than the alpha 1aAR selective antagonist 5MU. This finding supports the hypothesis that the alpha 1dAR is important for mediating irritative symptoms.

Patients with uncontrolled hypertension or concomitant hypertension and benign prostatic hyperplasia

At optimal doses, individual antihypertensive agents lower blood pressure (BP) by an average of 10 mmHg. Many patients with hypertension, including those with stage 3 hypertension, target organ damage, or those at high risk for cardiovascular events and/or adverse effects of high-dose monotherapy, are likely to require combination antihypertensive drug treatment to achieve the recommended systolic/diastolic BP (< 140/90 mmHg). Two studies, a placebo-controlled, double-blind trial (n = 70) and a community-based, open-label trial (n = 491) investigated the antihypertensive efficacy of doxazosin, a long-acting selective alpha1-adrenoceptor blocker, as add-on therapy for uncontrolled hypertension with other antihypertensive medications and in patients with concomitant benign prostatic hyperplasia (BPH) and treated but inadequately controlled hypertension, respectively. The addition of doxazosin to baseline antihypertensive medication(s) significantly lowered BP and had a significantly positive effect on the serum lipid profile. In patients with concomitant BPH, doxazosin significantly improved all BPH symptom scores, regardless of initial symptom severity. Add-on doxazosin sufficiently reduced systolic/diastolic BP such that many patients whose hypertension was previously uncontrolled by other antihypertensive medications were able to reach goal BP (< 140/90 mmHg). Doxazosin as add-on therapy was well tolerated. In conclusion, doxazosin as add-on therapy improves BP control in hypertensive patients not at goal BP and improves lower urinary tract symptoms in patients with concomitant BPH.

Mechanistic insights into the role of α1-adrenergic receptors in lower urinary tract symptoms

Although alpha(1)AR antagonists have been used for more than two decades to treat lower urinary tract symptoms (LUTS), we have little understanding of the mechanistic basis of their efficacy and their role in the development of LUTS. It is clear that alpha(1)ARs play a critical role in bladder dysfunction and recent data suggest that alpha(1)AR subtype switching may play a key role in this pathophysiology, providing support for use of alpha(1)(d)AR-selective antagonists in treating irritative symptoms. This review seeks to summarize current levels of understanding in this field and discusses new concepts that suggest increased levels of complexity involving cross-talk in multiple receptor systems. Effective therapeutic modalities likely will involve increased subtype selective alpha(1)AR antagonists and other pharmacodynamic factors.

Knockout of the alpha 1A/C-adrenergic receptor subtype: the alpha 1A/C is expressed in resistance arteries and is required to maintain arterial blood pressure

alpha 1-adrenergic receptors (ARs) play a major role in blood pressure regulation. The three alpha 1-AR subtypes (A/C, B, and D) stimulate contraction of isolated arteries, but it is uncertain how different subtypes contribute to blood pressure regulation in the intact animal. We studied the role of the alpha 1A/C subtype by using gene knockout. alpha 1A/C knockout (KO) mice were viable and overtly normal. The LacZ reporter gene replaced alpha 1A/C coding sequence in the KO, and beta-galactosidase staining was present in resistance arteries and arterioles, but not in the thoracic aorta or its main branches. By tail cuff manometer and arterial catheter in conscious mice, alpha 1A/C KO mice were hypotensive at rest, with an 8-12% reduction of blood pressure dependent on alpha 1A/C gene copy number. A61603, an alpha 1A/C-selective agonist, caused a pressor response that was lost in the KO and reduced but significant in heterozygous mice with a single copy of the alpha 1A/C. A subtype-nonselective agonist [phenylephrine (PE)] caused a pressor response in KO mice, but the final arterial pressure was only 85% of wild type. The baroreflex was reset in the KO, and heart rate variability was decreased. After baroreflex blockade with atropine, PE increased blood pressure but did not change heart rate. Cardiac and vascular responses to the beta-AR agonist isoproterenol were unchanged, and the arterial lumen area was not altered. We conclude that the alpha 1A/C-AR subtype is a vasopressor expressed in resistance arteries and is required for normal arterial blood pressure regulation. alpha 1A/C-selective antagonists might be desirable antihypertensive agents.

A randomized, double-blind, placebo-controlled trial to determine the effectiveness of botanically derived inhibitors of 5-alpha-reductase in the treatment of androgenetic alopecia

BACKGROUND

Androgenetic alopecia (AGA) is characterized by the structural miniaturization of androgen-sensitive hair follicles in susceptible individuals and is anatomically defined within a given pattern of the scalp. Biochemically, one contributing factor of this disorder is the conversion of testosterone (T) to dihydrotestosterone (DHT) via the enzyme 5-alpha reductase (5AR). This metabolism is also key to the onset and progression of benign prostatic hyperplasia (BPH). Furthermore, AGA has also been shown to be responsive to drugs and agents used to treat BPH. Of note, certain botanical compounds have previously demonstrated efficacy against BPH. Here, we report the first example of a placebo-controlled, double-blind study undertaken in order to examine the benefit of these botanical substances in the treatment of AGA.

OBJECTIVES

The goal of this study was to test botanically derived 5AR inhibitors, specifically the liposterolic extract of Serenoa repens (LSESr) and beta-sitosterol, in the treatment of AGA.

SUBJECTS

Included in this study were males between the ages of 23 and 64 years of age, in good health, with mild to moderate AGA.

RESULTS

The results of this pilot study showed a highly positive response to treatment. The blinded investigative staff assessment report showed that 60% of (6/10) study subjects dosed with the active study formulation were rated as improved at the final visit.

CONCLUSIONS

This study establishes the effectiveness of naturally occurring 5AR inhibitors against AGA for the first time, and justifies the expansion to larger trials.

Alpha adrenoceptor antagonists in the year 2000: is there anything new?

Selective alpha1-adrenergic blockade is now a well accepted and widely used therapeutic treatment for patients presenting with symptomatic bladder outlet obstruction thought to be associated with benign prostatic hyperplasia. This review summarizes the recent developments in this field relating to the subject of receptor subtype selectivity and the potential relevance of this to clinical usefulness of existing drug therapy. Whilst a number of unanswered questions remain as to the exact mechanisms of both drug action and side-effect profile, nevertheless it is clear that existing clinically available alpha1-antagonists provide a safe, effective and generally well tolerated therapy for patients with lower urinary tract symptoms thought to be associated with benign prostatic obstruction. The implications of the ALLHAT study are discussed.