Pretreatment body mass index affects achievement of target blood pressure with sodium-glucose cotransporter 2 inhibitors in patients with type 2 diabetes mellitus and chronic kidney disease

Emerging Pharmacological Approaches for the Treatment of Arterial Hypertension

Despite the availability of several drug classes for the treatment of hypertension, the current approaches to high blood pressure (BP) are not fully satisfying the needs of this patient population. As a result, in recent years, many clinical trials have investigated novel pharmacological approaches for lowering high BP. As overactivity of the renin-angiotensin-aldosterone system is often present in hypertensive patients, especially those with resistant hypertension, several studies have focused on novel strategies to counteract this phenomenon by the use of non-steroidal inhibitors of the mineralocorticoid receptors, aldosterone synthase inhibitors or RNA-targeting therapies to inhibit the hepatic synthesis of angiotensinogen. The latter approach in particular might offer the additional advantage of reducing the daily pill burden of these patients, hence mitigating the common occurrence of non-adherence to treatment. Because obesity and diabetes are common risk factors for hypertension (a high percentage of individuals with resistant hypertension being obese), numerous investigations have analyzed the BP-lowering effects of those agents, such as glucagon-like peptide-1 receptor agonists and sodium-glucose co-transporter-2 inhibitors, which have been shown to reduce body weight and improve cardiovascular outcomes in these patients. Available evidence suggests that these drug classes can indeed afford a clinically meaningful BP decrease and, potentially, reduce the treatment burden. In conclusion, even though the rates of uncontrolled hypertension remain high, several novel therapeutic options are in the offing. As these emerging treatments will compound with many already available agents, future efforts should be directed at better phenotyping patients to tailor the most suitable approach for each one.

The effects of SGLT2 inhibitors on metabolic phenotype and FGF-21 expression from the adipose tissue and the liver are less pronounced in ob/ob mice

BACKGROUND

the metabolic effects of sodium-glucose cotransporter-2 inhibitors (SGLT2i), such as lipolysis and ectopic fat reduction, seem related to the synthesis of fibroblast growth factor-21 (FGF-21), and FGF-21 analogs are now under investigation for the treatment of obesity complications such as metabolic dysfunction-associated steatotic liver disease. However, FGF-21 levels are paradoxically higher in obesity, indicating a hormone-resistant state that may hinder the benefits of SGLT2i.

METHODS

To define if a different energy status influences the response to SGLT2i, we evaluated the effects of dapagliflozin administration on nine-week-old C57BL/6J wild-type and B6.V-LEP ob/ob mice as a model of genetic obesity. Blood glucose, body weight and food intake were evaluated, and the FGF-21 expression was determined in subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and brown adipose tissue (BAT). In the liver, FGF-21 gene expression, protein concentration and triglyceride content were evaluated.

RESULTS

glucose plasma levels and body weight were higher in ob/ob than in lean mice. After four weeks of treatment, dapagliflozin reduced blood glucose levels and body weight in both animal models, but weight loss was more significant in lean mice. The baseline expression of FGF-21 was higher in both SAT, VAT and the liver of ob/ob mice, whereas it was almost undetectable in BAT in both animal groups. After the treatment period, dapagliflozin was shown to increase FGF-21 expression in VAT only in lean animals, while the expression was unaffected in ob/ob mice. Similar effects were observed in the liver analyses, along with no variation in triglyceride content.

CONCLUSIONS

SGLT2i administration results in less pronounced metabolic effects in ob/ob mice than in lean mice. This data suggests a less sensitive response in obesity, probably due to a chronic stimulation leading to abnormalities of the SGLT2i-FGF-21 axis which should be considered in managing patients affected by genetic obesity.

Obstructive sleep apnea -related hypertension: a review of the literature and clinical management strategy

Obstructive Sleep Apnea (OSA) and hypertension have a high rate of co-occurrence, with OSA being a causative factor for hypertension. Sympathetic activity due to intermittent hypoxia and/or fragmented sleep is the most important mechanisms triggering the elevation in blood pressure in OSA. OSA-related hypertension is characterized by resistant hypertension, nocturnal hypertension, abnormal blood pressure variability, and vascular remodeling. In particular, the prevalence of OSA is high in patients with resistant hypertension, and the mechanism proposed includes vascular remodeling due to the exacerbation of arterial stiffness by OSA. Continuous positive airway pressure therapy is effective at lowering blood pressure, however, the magnitude of the decrease in blood pressure is relatively modest, therefore, patients often need to also take antihypertensive medications to achieve optimal blood pressure control. Antihypertensive medications targeting sympathetic pathways or the renin-angiotensin-aldosterone system have theoretical potential in OSA-related hypertension, Therefore, beta-blockers and renin-angiotensin system inhibitors may be effective in the management of OSA-related hypertension, but current evidence is limited. The characteristics of OSA-related hypertension, such as nocturnal hypertension and obesity-related hypertension, suggests potential for angiotensin receptor-neprilysin inhibitor (ARNI), sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucose-dependent insulinotropic polypeptide receptor/ glucagon-like peptide-1 receptor agonist (GIP/GLP-1 RA). Recently, OSA has been considered to be caused not only by upper airway anatomy but also by several non-anatomic mechanisms, such as responsiveness of the upper airway response, ventilatory control instability, and reduced sleep arousal threshold. Elucidating the phenotypic mechanisms of OSA may potentially advance more personalized hypertension treatment strategies in the future. Clinical characteristics and management strategy of OSA-related hypertension. OSA obstructive sleep apnea, BP blood pressure, ABPM ambulatory blood pressure monitoring, CPAP continuous positive airway pressure, LVH left ventricular hypertrophy, ARB: angiotensin II receptor blocker, SGLT2i Sodium-glucose cotransporter 2 inhibitors, ARNI angiotensin receptor-neprilysin inhibitor, CCB calcium channel blocker, GIP/GLP-1 RA glucose-dependent insulinotropic polypeptide receptor and glucagon-like peptide-1 receptor agonist.