Calcium channel blockers in treatment of hypertension

The Evolving Role of Calcium Channel Blockers in Hypertension Management: Pharmacological and Clinical Considerations

Worldwide, hypertension is the leading risk factor for cardiovascular disease and death. An estimated 122 million people, per the American Heart Association in 2023, have been diagnosed with this common condition. It is generally agreed that the primary goal in the treatment of hypertension is to reduce overall blood pressure to below 140/90 mmHg, with a more optimal goal of 130/80 mmHg. Common medications for treating hypertension include calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and diuretics. CCBs are one of the most widely studied agents and are generally recommended as first-line therapy alone and in combination therapies. This is largely based on the vast knowledge of CCB mechanisms and their minimal side effect profile. CCBs can be separated into two classes: dihydropyridine and non-dihydropyridine. Non-dihydropyridine CCBs act on voltage-dependent L-type calcium channels of cardiac and smooth muscle to decrease muscle contractility. Dihydropyridine CCBs act by vasodilating the peripheral vasculature. For many patients with only mild increases in systolic and diastolic blood pressure (e.g., stage 1 hypertension), the medical literature indicates that CCB monotherapy can be sufficient to control hypertension. In this regard, CCB monotherapy in those with stage 1 hypertension reduced renal and cardiovascular complications compared to other drug classes. Combination therapy with CCBs and angiotensin receptor blockers or angiotensin-converting enzyme inhibitors has been shown to be an effective dual therapy based on recent meta-analyses. This article is a review of calcium channel blockers and their use in treating hypertension with some updated and recent information on studies that have re-examined their use. As for new information, we tried to include some information from recent studies on hypertensive treatment involving calcium channel blockers.

Opioid-Related Genetic Polymorphisms of Cytochrome P450 Enzymes after Total Joint Arthroplasty: A Focus on Drug-Drug-Gene Interaction with Commonly Coprescribed Medications

Pharmacogenomic testing, together with the early detection of drug-drug-gene interactions (DDGI) before initiating opioids, can improve the selection of dosage and reduce the risk of adverse drug interactions and therapeutic failures following Total Joint Arthroplasty. The variants of CYP genes can mediate DDGI. Orthopedic surgeons should become familiar with the genetic aspect of opioid use and abuse, as well as the influence of the patient genetic makeup in opioid selection and response, and polymorphic variants in pain modulation.

Hypotensive effect of captopril on deoxycorticosterone acetate-salt-induced hypertensive rat is associated with gut microbiota alteration

The role of the gut microbiota in various metabolic diseases has been widely studied. This study aims to test the hypothesis that gut microbiota dysbiosis is associated with DOCA-salt-induced hypertension, while captopril, an antihypertensive drug, is able to rebalance the gut microbiota alterations caused by hypertension. Treatment with captopril resulted in an approximate 32 mmHg reduction in systolic blood pressure (162.57 vs. 194.61 mmHg) in DOCA-salt-induced hypertensive rats, although it was significantly higher than that in SHAM rats (136.10 mmHg). Moreover, the nitric oxide (NO) level was significantly increased (20.60 vs. 6.42 µM) while the angiotensin II (Ang II) content (42.40 vs. 59.47 pg/ml) was attenuated nonsignificantly by captopril treatment in comparison to those of DOCA-salt-induced hypertensive rats. The introduction of captopril significantly decreased the levels of tumor necrosis factor-α (TNF-ɑ) and interleukin-6 (IL-6). Hypertrophy and fibrosis in kidneys and hearts were also significantly attenuated by captopril. Furthermore, gut microbiota dysbiosis was observed in DOCA-salt-induced hypertensive rats. The abundances of several phyla and genera, including Proteobacteria, Cyanobacteria, Escherichia-Shigella, Eubacterium nodatum and Ruminococcus, were higher in DOCA-salt-induced hypertensive rats than in SHAM rats, while these changes were reversed by captopril treatment. Of particular interest, the genera Bifidobacterium and Akkermansia, reported as beneficial bacteria in the gut, were abundant in only hypertensive rats treated with captopril. These results provide evidence that captopril has the potential to rebalance the dysbiotic gut microbiota of DOCA-salt-induced hypertensive rats, suggesting that the alteration of the gut flora by captopril may contribute to the hypotensive effect of this drug.

Cellular and molecular effects of hyperglycemia on ion channels in vascular smooth muscle

Diabetes affects millions of people worldwide. This devastating disease dramatically increases the risk of developing cardiovascular disorders. A hallmark metabolic abnormality in diabetes is hyperglycemia, which contributes to the pathogenesis of cardiovascular complications. These cardiovascular complications are, at least in part, related to hyperglycemia-induced molecular and cellular changes in the cells making up blood vessels. Whereas the mechanisms mediating endothelial dysfunction during hyperglycemia have been extensively examined, much less is known about how hyperglycemia impacts vascular smooth muscle function. Vascular smooth muscle function is exquisitely regulated by many ion channels, including several members of the potassium (K+) channel superfamily and voltage-gated L-type Ca2+ channels. Modulation of vascular smooth muscle ion channels function by hyperglycemia is emerging as a key contributor to vascular dysfunction in diabetes. In this review, we summarize the current understanding of how diabetic hyperglycemia modulates the activity of these ion channels in vascular smooth muscle. We examine underlying mechanisms, general properties, and physiological relevance in the context of myogenic tone and vascular reactivity.

Regulation of Blood Pressure by Targeting CaV1.2-Galectin-1 Protein Interaction

BACKGROUND

L-type Ca_V1.2 channels play crucial roles in the regulation of blood pressure. Galectin-1 (Gal-1) has been reported to bind to the I-II loop of Ca_V1.2 channels to reduce their current density. However, the mechanistic understanding for the downregulation of Ca_V1.2 channels by Gal-1 and whether Gal-1 plays a direct role in blood pressure regulation remain unclear.

METHODS

In vitro experiments involving coimmunoprecipitation, Western blot, patch-clamp recordings, immunohistochemistry, and pressure myography were used to evaluate the molecular mechanisms by which Gal-1 downregulates Ca_V1.2 channel in transfected, human embryonic kidney 293 cells, smooth muscle cells, arteries from Lgasl1^-/- mice, rat, and human patients. In vivo experiments involving the delivery of Tat-e9c peptide and AAV5-Gal-1 into rats were performed to investigate the effect of targeting Ca_V1.2-Gal-1 interaction on blood pressure monitored by tail-cuff or telemetry methods.

RESULTS

Our study reveals that Gal-1 is a key regulator for proteasomal degradation of Ca_V1.2 channels. Gal-1 competed allosterically with the Ca_Vβ subunit for binding to the I-II loop of the Ca_V1.2 channel. This competitive disruption of Ca_Vβ binding led to Ca_V1.2 degradation by exposing the channels to polyubiquitination. It is notable that we demonstrated that the inverse relationship of reduced Gal-1 and increased Ca_V1.2 protein levels in arteries was associated with hypertension in hypertensive rats and patients, and Gal-1 deficiency induces higher blood pressure in mice because of the upregulated Ca_V1.2 protein level in arteries. To directly regulate blood pressure by targeting the Ca_V1.2-Gal-1 interaction, we administered Tat-e9c, a peptide that competed for binding of Gal-1 by a miniosmotic pump, and this specific disruption of Ca_V1.2-Gal-1 coupling increased smooth muscle Ca_V1.2 currents, induced larger arterial contraction, and caused hypertension in rats. In contrasting experiments, overexpression of Gal-1 in smooth muscle by a single bolus of AAV5-Gal-1 significantly reduced blood pressure in spontaneously hypertensive rats.

CONCLUSIONS

We have defined molecularly that Gal-1 promotes Ca_V1.2 degradation by replacing Ca_Vβ and thereby exposing specific lysines for polyubiquitination and by masking I-II loop endoplasmic reticulum export signals. This mechanistic understanding provided the basis for targeting Ca_V1.2-Gal-1 interaction to demonstrate clearly the modulatory role that Gal-1 plays in regulating blood pressure, and offering a potential approach for therapeutic management of hypertension.

Solubility and Thermodynamic Analysis of Antihypertensive Agent Nitrendipine in Different Pure Solvents at the Temperature Range of 298.15 to 318.15°K

The aim of the present study was to ascertain the solubility of nitrendipine (NP), an antihypertensive drug in six different pure solvents such as water, ethyl acetate (EA), ethanol, isopropyl alcohol (IPA), polyethylene glycol-400 (PEG-400), and Transcutol at temperature from 298.15 to 318.15 K under atmospheric pressure (p) of 0.1 MPa. Experimental solubility data of NP was fitted with Apelblat and ideal models. The mole fraction solubility of NP was found maximum in PEG-400 (6.85 × 10-2 at 318.15 K) followed by Transcutol (4.65 × 10-2 at 318.15 K), EA (1.68 × 10-2 at 318.15 K), ethanol (2.83 × 10-3 at 318.15 K), IPA (2.69 × 10-3 at 318.15 K), and water (1.29 × 10-7 at 318.15 K). The dissolution activity of NP was observed as an endothermic, spontaneous, and an entropy-driven in most of studied pure solvents. The solubility data of NP obtained in the present study could be useful in purification, recrystallization, and dosage forms design of NP.

The tobacco-specific carcinogen-operated calcium channel promotes lung tumorigenesis via IGF2 exocytosis in lung epithelial cells

Nicotinic acetylcholine receptors (nAChRs) binding to the tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) induces Ca²⁺ signalling, a mechanism that is implicated in various human cancers. In this study, we investigated the role of NNK-mediated Ca²⁺ signalling in lung cancer formation. We show significant overexpression of insulin-like growth factors (IGFs) in association with IGF-1R activation in human preneoplastic lung lesions in smokers. NNK induces voltage-dependent calcium channel (VDCC)-intervened calcium influx in airway epithelial cells, resulting in a rapid IGF2 secretion via the regulated pathway and thus IGF-1R activation. Silencing nAChR, α1 subunit of L-type VDCC, or various vesicular trafficking curators, including synaptotagmins and Rabs, or blockade of nAChR/VDCC-mediated Ca²⁺ influx significantly suppresses NNK-induced IGF2 exocytosis, transformation and tumorigenesis of lung epithelial cells. Publicly available database reveals inverse correlation between use of calcium channel blockers and lung cancer diagnosis. Our data indicate that NNK disrupts the regulated pathway of IGF2 exocytosis and promotes lung tumorigenesis.

The binding of tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) to nicotinic acetylcholine receptors (nAChRs) induces calcium signalling. Here the authors show that NKK-induced calcium influx in airway epithelial cells triggers IGF2 secretion and tumourigenesis.

Design, synthesis and evaluation of 9-hydroxy-7H-furo[3,2-g]chromen-7-one derivatives as new potential vasodilatory agents

Two new 9-hydroxy-7H-furo[3,2-g]chromen-7-one derivatives were designed, synthesized and evaluated for their in vitro vasodilatory activity. The structures of two compounds were elucidated by infrared, ¹H NMR, and mass spectral data. The in vitro pharmacological evaluation indicated that both of them possessed well vasodilatory activity compared with imperatorin. The molecule docking also showed two target compounds docked well with L-calcium channel (PDB code: 3G43). The result suggested that they would be potential vasodilatory agents for hypertension.

Clinical approach in treatment of resistant hypertension

Resistant hypertension, defined as failure to achieve target blood pressure despite the use of optimal or maximum doses of at least 3 agents, one of which is a diuretic, or requiring 4 or more medications to achieve blood pressure goal, is likely to affect up to 20% of all patients with hypertension. Apparent resistant hypertension may be caused by medication nonadherence, substances that either interfere with antihypertensive mediations or cause blood pressure elevation, and under- or inappropriate medication treatment. Certain patient characteristics are associated with the presence of resistant hypertension and include chronic kidney disease, diabetes, obesity, and presence of end-organ damage (microalbuminuria, retinopathy, left-ventricular hypertrophy). Secondary causes of resistant hypertension are not uncommon and include obstructive sleep apnea, chronic kidney disease, primary aldosteronism, renal artery stenosis, pheochromocytoma, and Cushing's disease. Initial medication management usually includes adding or increasing the dose of a diuretic, which is effective in lowering the blood pressure of a large number of patients with resistant hypertension. Additional management options include maximizing lifestyle modification, combination therapy of antihypertensive agents depending on individual patient characteristics, adding less-commonly used fourth- or fifth-line antihypertensive agents, and referral to a hypertension specialist.

Single‐ or Double‐Blind Treatment With Balsamodendron tnukul and Nifedipine in Hypertensive Patients

This study assessed and compared the effects of Balsamodendron mukul (an extract of the gum of a small tree) and nifedipine (a calcium-channel-blocking reference drug) on blood pressure, lipids, lipoproteins, and phospholipids in randomly selected patients with essential hypertension. Fifty-seven newly diagnosed hypertensive patients were randomly divided into three groups. They received either single-blind B. mukul (1.5 g/d) or single-blind nifedipine (10 mg/d) double-blind therapy with nifedipine (10 mg/d) and B. mukul (1.5 g/d) for 6 weeks. These groups were compared with control subjects. On treatment with B. mukul, levels of systolic blood pressure, diastolic blood pressure, plasma total cholesterol, low-density lipoprotein cholesterol, very low-density lipoprotein cholesterol, triglycerides, free fatty acids, and phospholipid levels were significantly reduced, and high-density lipoprotein cholesterol levels were significantly elevated, as compared with untreated hypertensive patients. Combined therapy with B. mukul and nifedipine was more beneficial than the treatment with B. mukul alone. Our study suggests that B. mukul may be an effective antihypertensive and hypolipidemic agent.

Does hormone replacement therapy affect the use of prescription medicines in postmenopausal women: experience from the Estonian Postmenopausal Hormone Therapy Trial [ISRCTN35338757]

OBJECTIVE

To determine how postmenopausal hormone therapy (HRT) is related to the use of other prescription medication.

DESIGN

Follow up of a randomised controlled trial with a blind subtrial of hormone therapy versus placebo and a nonblind subtrial of open label hormone therapy versus nontreatment.

POPULATION

A total of 1823 postmenopausal women aged 50-64 at the time of sampling participated in the trial from 1999 to 2004.

METHODS

Use of prescription medication was identified by records in the central computerised database of the Estonian Health Insurance Fund.

MAIN OUTCOME MEASURES

The use of 21 classes of prescription medication was compared in the hormone therapy arms and placebo or nontreatment trial arms. The influence of women's socio-economic characteristics on the intensity of concomitant medication use was also examined.

RESULTS

The proportion of women using any prescription medication besides hormone therapy did not differ between the arms. However, the type of prescribed drugs varied between the arms. After combining data from both hormone therapy arms, for women using HRT the combined hazard ratio was 1.26 (95% CI: 1.05-1.53) for the use of calcium channel blockers, 1.48 (95% CI: 1.10-1.99) for local vaginal treatment, 0.70 (95% CI: 0.50-0.99) for hypnotics and sedatives and 0.77 (95% CI: 0.60-0.99) for selective serotonin reuptake inhibitors (SSRIs). Women who were older, who had a higher body mass index, who were unemployed and who lived outside the capital used more prescription drugs in comparison with others.

CONCLUSIONS

Hormone therapy did not increase the overall use of prescription medication other than hormone therapy, but the types of drugs used in hormone therapy and nontherapy arms varied, with increased use of calcium channel blockers for hypertension and local vaginal treatments for vaginal candidiasis and decreased use of hypnotics, sedatives and SSRIs in the HRT arms.

Saga of Renin-Angiotensin System and Calcium Channels in Hypertensive Diabetics: Does it Have a Therapeutic Edge?

Current understanding of the genesis of diabetic vascular disease suggests that vascular complications, such as atherosclerosis and hypertension, are associated with changes in structural and functional parameters. Experimental and epidemiological data suggest that activation of the renin-angiotensin-aldosterone system plays an important role in the development of micro- and macro-vascular complications. Most of the negative cardiovascular actions of angiotensin II are mediated through AT1 receptors, whereas the AT2 receptors mediate largely beneficial effects. Hence, compared to angiotensin converting enzyme inhibitors (ACEIs), selective AT1 receptor blockers (ARBs) should provide additional end organ protection via AT2 receptors activation. Although ACEIs are useful therapeutically, they are being currently displaced by ARBs. Enhanced calcium ion channel activity is reported in vascular smooth muscles from diabetic animal models. Clinical benefits of calcium channel blockers (CCBs) in diabetic hypertensive patients are controversial, but there is increasing experimental evidence for the beneficial effects of dihydropyridine-type CCBs. Although the treatment of hypertension in diabetics reduces cardiovascular and microvascular complications, the ideal strategy for treating hypertension in diabetics has not been well defined and warrants a combination approach. Only limited clinical data regarding the use of ARBs in combination with CCBs in diabetics are available. The experimental data suggest that combination of a CCB and an AT1 receptor blocker, or a hypothetical dual blocker of AT1 receptors as well as of calcium channels would be an ideal regimen. There is, however, no conclusive clinical evidence to support the combined use of these drugs. This review highlights the available experimental data that support the therapeutic benefits of this combination.

Amlodipine ameliorates myocardial hypertrophy by inhibiting EGFR phosphorylation

The effects of long-acting calcium channel blockers on pressure overload-induced cardiac hypertrophy have been little studied in experimental animals and the underlying mechanisms are not fully understood. We previously reported that cardiomyocyte hypertrophy could be induced via phosphorylation of the epidermal growth factor receptor (EGFR). In this study, we investigated whether amlodipine attenuates cardiac hypertrophy by inhibiting EGFR phosphorylation. We found that amlodipine dose-dependently inhibited epinephrine-induced protein synthesis and EGFR phosphorylation in cultured neonatal rat cardiomyocytes. Our in vivo study revealed that amlodipine could ameliorate myocardial hypertrophy induced by transverse aortic constriction (TAC) in C57/B6 mice. One week after TAC, amlodipine treatment (3 mg/kg/day) significantly reduced the heart-to-body weight ratio (6.04 +/- 0.16 mg/g vs. 6.90 +/- 0.45 mg/g in untreated TAC mice, P < 0.01). These results indicate that amlodipine ameliorates cardiomyocyte hypertrophy via inhibition of EGFR phosphorylation.

Localization of intracellular calcium release in cells injured by venom from the ectoparasitoid Nasonia vitripennis (Walker) (Hymenoptera: Pteromalidae) and dependence of calcium mobilization on G-protein activation

Venom from the ectoparasitic wasp Nasonia vitripennis induces cellular injury that appears to involve the release of intracellular calcium stores via the activation of phospholipase C, and culminates in oncotic death. A linkage between release of intracellular Ca2+ and oncosis has not been clearly established and was the focus of this study. When BTI-TN-5B1-4 cells were treated with suramin, an uncoupler of G-proteins, venom-induced swelling and oncotic death were inhibited in a dose-dependent manner for at least 24 h. Suramin also blocked increases in free cytosolic [Ca2+], arguing that venom induces calcium mobilization through G-protein signaling pathways. Endoplasmic reticulum (ER) was predicted to be the source of intracellular calcium release, but labeling with the fluorescent probe ER-tracker revealed no indication of organelle swelling or loss of membrane integrity as would be expected if the Ca(2+)-ATPase pump was disabled by crude venom. Incubation of cell monolayers with calmodulin or nitrendipine, modulators of ER calcium release channels, neither attenuated nor augmented the effects of wasp venom. These results suggest that wasp venom stimulates calcium release from ER compartments distinct from RyRs, L-type Ca2+ channels, and the Ca(2+)-ATPase pump, or calcium is released from some other intracellular store. A reduction of mitochondrial membrane potential delta psi(m) appeared to precede a rise in cytosolic free Ca2+ as evidenced by fluorescent microscopy using the calcium-sensitive probe fluo-4 AM. This argues that the initial insult to the cell resulting from venom elicits a rapid loss of (delta psi(m)), followed by unregulated calcium efflux from mitochondria into the cytosol. Mobilization of calcium in this fashion could stimulate cAMP formation, and subsequently promote calcium release from NAADP-sensitive stores.

The evaluation of the N-type channel blocking properties of cilnidipine and other voltage-dependent calcium antagonists

Sympathetic neurotransmission in tissues with intact sympathetic nerve arborization is extensively dependent on calcium influx via N-type calcium-channels. It was the objective of the present study to assess and compare the claimed sympatholytic effect of the 1,4-dihydropyridine compound cilnidipine with other voltage-dependent calcium-channel (VDCC) antagonists. We studied these compounds by means of three different models. In the rabbit isolated thoracic aorta, the alleged sympatholytic properties displayed by these compounds were evaluated in the noradrenaline spillover model. Additionally, the influence of cilnidipine on stimulation-induced constrictor responses was studied in the rat isolated tail artery (male Wistar rats, 250-300 g) in addition to its effect on noradrenaline-induced contractions. Finally, we studied the influence of cilnidipine and other calcium-channel blockers on stimulation-induced chronotropic responses, in order to address N- or L-type selectivity, in the pithed rat model (male Wistar rats, 260-320 g). Furthermore, we evaluated their effect on noradrenaline-induced tachycardia. In the isolated rabbit thoracic aorta preparation omega-conotoxin GVIA (0.1 microM) nearly abolished the sympathetic outflow caused by stimulation, whereas nifedipine (0.1 microM) and amlodipine (1 microM) did not influence the evoked noradrenaline release. Cilnidipine (1 microM) significantly attenuated the response by nearly 18% and mibefradil (1 microM) by c. 42%. The stimulation-induced constrictor response (prejunctional effect) in the rat isolated tail artery could be blocked by omega-conotoxin GVIA (0.5 and 1 microM). Cilnidipine (10 nm and 0.1 microM) significantly attenuated responses to stimulation by maximally 20%, whereas it did not influence the constrictor response to noradrenaline (postjunctional effect). The mean heart rate in the pithed rat model amounted to 309.3 +/- 3.6 beats/min (bpm). Electrical stimulation of the cardio-accelerator nerves (C7-Th1) resulted in an increase by 106.7 +/- 2.2 bpm. All antagonists studied, except for nifedipine, attenuated the chronotropic response to stimulation (P < 0.05). The rank order of sympatholytic efficacy was: omega-conotoxin GVIA (84.8%), mibefradil (75.1%), cilnidipine (43.0%) and amlodipine (34.8%). Noradrenaline (10 nmol/kg) increased the heart rate by 117.8 +/- 2.7 bpm. This chronotropic response was influenced equally well by the calcium-channels blockers as observed in the stimulation (prejunctional) experiment. In conclusion, the N-type channel blocking properties and thus sympatholytic effect of cilnidipine could be demonstrated in some (vascular) but not all (cardiac) models studied. At the level of the vasculature cilnidipine reduced the neurotransmitter release to electrical stimulation in both the noradrenaline spillover model and in the model of the rat isolated tail artery, respectively. For amlodipine and nifedipine no sympatholytic activity could be demonstrated. In the pithed rat model, we were unable to demonstrate a selective N-type blocking effect for the VDCC-antagonists.

Treatment of hypertension in older patients: an updated look at the role of calcium antagonists

Hypertension is common in adults aged 60 years or older. Apart from age, hypertension is the most powerful predictor of cardiovascular end-organ damage and its associated morbidity and mortality. Although diastolic blood pressure is regarded as an important risk factor, it is now clear that systolic blood pressure, especially prevalent among older adults, is a better predictor of cardiovascular morbidity and mortality. Fewer than 30% of hypertensive patients have blood pressure levels controlled to <140/90 mm Hg as recommended by current guidelines. Controlled trials have demonstrated the benefits of lowering blood pressure for all hypertensive individuals, including those aged 65 years or older. Calcium antagonists of the dihydropyridine subclass, which include nifedipine, amlodipine, felodipine, and nitrendipine, as well as other drug classes, are potent antihypertensive agents that may be suitable for treatment of hypertension in older adults. However, as with all antihypertensive agents, adverse effects may limit their use; peripheral edema is particularly troublesome for dihydropyridines. Newer dihydropyridine calcium antagonists expected to be approved for use soon, including lercanidipine and lacidipine, have been associated with efficacy comparable to currently available calcium antagonists but with a lower incidence of adverse effects, especially ankle edema. Antihypertensive agents with improved tolerability profiles offer the potential for improved blood pressure control.

Phosphatidylinositol promotes cholesterol transport and excretion

Administration of phosphatidylinositol (PI) to New Zealand White rabbits increases HDL negative charge and stimulates reverse cholesterol transport. Intravenously administered PI (10 mg/kg) associated almost exclusively with the HDL fraction in rabbits. PI promoted an increase in the hepatic uptake of plasma free cholesterol (FC) and a 21-fold increase in the biliary secretion of plasma-derived cholesterol. PI also increased cholesterol excretion into the feces by 2.5-fold. PI directly affects cellular cholesterol metabolism. In cholesterol-loaded macrophages, PI stimulated cholesterol mass efflux to lipid-poor reconstituted HDL. PI was about half as effective as cAMP at stimulating efflux, and the effects of cAMP and PI were additive. In cultured HepG2 cells, PI-enriched HDL also enhanced FC uptake from HDL by 3-fold and decreased cellular cholesterol synthesis and esterification. PI enrichment had no effect on the selective uptake of cholesterol esters or on the internalization of HDL particles. PI-dependent metabolic events were efficiently blocked by inhibitors of protein kinase C and the inositol signaling cascade. The data suggest that HDL-PI acts via cell surface ATP binding cassette transporters and signaling pathways to regulate both cellular and intravascular cholesterol homeostasis.