Antihypertensive utility of perindopril in a large, general practice-based clinical trial

Comparative Solid-State Stability of Perindopril Active Substance vs. Pharmaceutical Formulation

This paper presents the results obtained after studying the thermal stability and decomposition kinetics of perindopril erbumine as a pure active pharmaceutical ingredient as well as a solid pharmaceutical formulation containing the same active pharmaceutical ingredient (API). Since no data were found in the literature regarding the spectroscopic description, thermal behavior, or decomposition kinetics of perindopril, our goal was the evaluation of the compatibility of this antihypertensive agent with the excipients in the tablet under ambient conditions and to study the effect of thermal treatment on the stability of perindopril erbumine. ATR-FTIR (Attenuated Total Reflectance Fourier Transform Infrared) spectroscopy, thermal analysis (thermogravimetric mass curve (TG-thermogravimetry), derivative thermogravimetric mass curve (DTG), and heat flow (HF)) and model-free kinetics were chosen as investigational tools. Since thermal behavior is a simplistic approach in evaluating the thermal stability of pharmaceuticals, in-depth kinetic studies were carried out by classical kinetic methods (Kissinger and ASTM E698) and later with the isoconversional methods of Friedman, Kissinger-Akahira-Sunose and Flynn-Wall-Ozawa. It was shown that the main thermal degradation step of perindopril erbumine is characterized by activation energy between 59 and 69 kJ/mol (depending on the method used), while for the tablet, the values were around 170 kJ/mol. The used excipients (anhydrous colloidal silica, microcrystalline cellulose, lactose, and magnesium stearate) should be used in newly-developed generic solid pharmaceutical formulations, since they contribute to an increased thermal stability of perindopril erbumine.

Efficacy and Safety of Fixed-Dose Perindopril Arginine/Amlodipine in Hypertensive Patients Not Adequately Controlled with Amlodipine 5 mg or Perindopril tert-Butylamine 4 mg Monotherapy

OBJECTIVES

To assess the blood pressure-lowering efficacy and tolerability of perindopril/amlodipine fixed-dose combinations in Chinese patients with mild-to-moderate essential hypertension not adequately controlled with monotherapy alone.

METHODS

In 2 separate double-blind studies, patients received a 4-week run-in monotherapy of amlodipine 5 mg or perindopril 4 mg, respectively. Those whose blood pressure was uncontrolled were then randomized to receive the fixed-dose combination of perindopril 5 mg/amlodipine 5 mg (Per/Amlo group) or remain on the monotherapy for 8 weeks. Patients who were uncontrolled at the week 8 (W8) visit were up-titrated for the Per/Amlo combination, or received additional treatment if on monotherapy, for a further 4 weeks. The main efficacy assessment was at 8 weeks.

RESULTS

After 8 weeks, systolic blood pressure (SBP; primary criterion) was statistically significantly lower in the Per/Amlo group (vs. Amlo 5 mg, p = 0.0095; vs. Per 4 mg, p < 0.0001). Uncontrolled patients at W8 who received an up-titration of the Per/Amlo combination showed a further SBP reduction. These changes were mirrored by reassuring reductions in diastolic blood pressure. The fixed-dose combinations were well tolerated.

CONCLUSIONS

Single-pill combinations of perindopril and amlodipine provide hypertensive patients with a convenient and effective method of reducing blood pressure.

Combination therapy in the extended cardiovascular continuum: a focus on perindopril and amlodipine

The progression of cardiovascular disease could be regarded as following atherosclerosis-related and age-related pathways. The starting points for these pathways are different--risk factors or aortic ageing--but they conclude in the same way: end-stage heart disease. Together these interlinked pathways form the extended cardiovascular continuum. Renin-angiotensin-aldosterone system (RAAS) inhibitors have been shown to interrupt or slow the progression of cardiovascular disease along one pathway, the cardiovascular atherosclerotic continuum. Cardiovascular protection with RAAS inhibitors varies; different RAAS inhibitors offer different levels of protection. Similarly, calcium channel blockers (CCBs) also have clearly shown protective effect of cardiovascular system, especially as it regards cerebrovascular disease risk. The AngloScandinavian Cardiac Outcomes Trial (ASCOT) showed that a combination of the angiotensin-converting enzyme (ACE) inhibitor perindopril and CCB amlodipine offered better cardiovascular protection in at-risk hypertensive patients than beta-blocker and thiazide. By attenuating the deleterious effects of cardiovascular disease at multiple stages of the extended cardiovascular continuum on top of lowering blood pressure (BP), perindopril and amlodipine could interrupt and slow the progression of cardiovascular disease. These antihypertensive agents have complementary vascular effects that enhance cardiovascular protection and reduce side-effects. Evidence from ASCOT shows that antihypertensive and vascular effects of amlodipine with and without perindopril have translated into real-life clinical benefits. A strategy using ACE inhibitors and CCBs, such as perindopril and amlodipine, to target multiple stages in both pathways of cardiovascular disease could effectively reduce cardiovascular risk and lower BP.

Angiotensin-converting enzyme inhibition in cardiovascular disease: evidence with perindopril

Perindopril is a long-acting, once-daily lipophilic angiotensin-converting enzyme inhibitor with high tissue angiotensin-converting enzyme affinity, lowering angiotensin II and potentiating bradykinin. Its efficacy, safety and tolerability are well established in the treatment of hypertension and heart failure. Moreover, large morbidity-mortality trials, such as the EUropean trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease (EUROPA) and Perindopril pROtection aGainst REcurrent Stroke Study (PROGRESS), have shown that antihypertensive treatment with perindopril reduces and prevents cardiovascular disease in a large range of patients with vascular diseases, whether hypertensive or not. Thus, the outcome of these and other trials support the concept of cardiovascular protective properties of angiotensin-converting enzyme inhibition with perindopril in addition to the obvious blood-pressure-lowering effect. Considering its properties and the gathered clinical evidence on efficacy and tolerability, perindopril fulfils the criteria of the latest guidelines for hypertension and cardiovascular disease management and should therefore be considered as a first-line antihypertensive agent, forming a consistent part of the comprehensive strategy against hypertension and related cardiovascular complications.

RAAS inhibition and mortality in hypertension

The renin-angiotensin-aldosterone system (RAAS) regulates the body's hemodynamic equilibrium, circulating volume, and electrolyte balance, and is a key therapeutic target in hypertension, the world's leading cause of premature mortality. Hypertensive disorders are strongly linked with an overactive RAAS, and RAAS inhibitors, like angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs), are routinely used to treat high blood pressure (BP). BP reduction is one of the main goals of current European hypertension guidelines. Oral ACE inhibitors, the oldest category of RAAS inhibitor, were commercially released over 30 years ago in the early 1980s, over a decade before the first ARBs became available. The introduction of ACE inhibitors heralded major changes in the way hypertension and cardiovascular disease were treated. Although the decision of the medical community to replace older ACE inhibitors with more modern ARBs in the 1990s was debatable, it did nevertheless allow scientists to learn more about the angiotensin receptors involved in RAAS stimulation. This and much else of value have been discovered since RAAS inhibitors first became available, but some surprising gaps in our knowledge exist. Until recently, the effect of RAAS inhibition on mortality in hypertension was unknown. This question was recently addressed by a meta-analysis of randomized controlled trials in populations who received contemporary antihypertensive medication. The results of this meta-analysis have helped elucidate the long-term consequences of treatment with RAAS inhibitors on mortality in hypertension. This article will consider the differences between RAAS inhibitors in terms of pharmacological and clinical effects and analyze the impact of the main types of RAAS inhibitor, ACE inhibitors and ARBs, on mortality reduction in hypertensive patients with reference to this latest meta-analysis.

Difference in blood pressure response to ACE-Inhibitor monotherapy between black and white adults with arterial hypertension: a meta-analysis of 13 clinical trials

Background

Among African-Americans adults, arterial hypertension is both more prevalent and associated with more complications than among white adults. Hypertension is also epidemic among black adults in sub-Saharan Africa. The treatment of hypertension among black adults may be complicated by lesser response to certain classes of anti-hypertensive agents.

Methods

We systematically searched literature for clinical trials of ACE-inhibitors among hypertensive adults comparing blood pressure response between whites and blacks. Meta-analysis was performed to determine the difference in systolic and diastolic blood pressure response. Further analysis including meta-regressions, funnel plots, and one-study-removed analyses were performed to investigate possible sources of heterogeneity or bias.

Results

In a meta-analysis of 13 trials providing 17 different patient groups for evaluation, black race was associated with a lesser reduction in systolic (mean difference: 4.6 mmHg (95% CI 3.5-5.7)) and diastolic (mean difference: 2.8 mmHg (95% CI 2.2-3.5)) blood pressure response to ACE-inhibitors, with little heterogeneity. Meta-regression revealed only ACE-inhibitor dosage as a significant source of heterogeneity. There was little evidence of publication bias.

Conclusions

Black race is consistently associated with a clinically significant lesser reduction in both systolic and diastolic blood pressure to ACE-inhibitor therapy in clinical trials in the USA and Europe. In black adults requiring monotherapy for uncomplicated hypertension, drugs other than ACE-inhibitors may be preferred, though the proven benefits of ACE-inhibitors in some sub-groups and the large overlap of response between blacks and whites must be remembered. These data are particularly important for interpretation of clinical drug trials for hypertensive black adults in sub-Saharan Africa and for the development of treatment recommendations in this population.

Management of hypertension with the fixed combination of perindopril and amlodipine in daily clinical practice: results from the STRONG prospective, observational, multicenter study

BACKGROUND

Current clinical guidelines recognize that the use of more than one agent is necessary to achieve target BP in the majority of patients. The ASCOT-BPLA trial demonstrated that the free combination of amlodipine and perindopril effectively controlled BP and was better than a beta-adrenoceptor antagonist (beta-blocker)/diuretic combination in reducing total mortality and cardiovascular outcomes.

OBJECTIVE

To evaluate the efficacy and tolerability of a fixed combination of perindopril and amlodipine in the clinical setting.

STUDY DESIGN

The STRONG (SafeTy & efficacy analysis of coveRsyl amlodipine in uncOntrolled and Newly diaGnosed hypertension) study was a prospective, observational, multicenter trial.

SETTING

This was a naturalistic, real-world, clinic-based, outpatient study involving 336 general practitioners/primary care physicians in 65 cities in India.

PATIENTS

Adults aged 40-70 years with newly diagnosed/untreated stage 2 hypertension (BP >/=160/100 mmHg), hypertension uncontrolled with monotherapy (BP >140/90 mmHg), or hypertension inadequately managed with another combination therapy.

INTERVENTION

Fixed combination perindopril 4 mg/amlodipine 5 mg once daily for 60 days.

MAIN OUTCOMES MEASURE

The primary outcomes were the mean change in BP from baseline and the proportion of patients achieving adequate BP control (</=140/90 mmHg, or </=130/80 mmHg in patients with diabetes mellitus) in the intent-to-treat (ITT) population. Secondary analyses included incidence of adverse events (ITT) and treatment adherence rate (completers).

RESULTS

In total, 1250 patients comprised the ITT population: 32.6% with newly diagnosed hypertension; 40.5% with hypertension uncontrolled with monotherapy; and 26.9% with hypertension inadequately managed with another combination therapy. Mean SBP/DBP decreased significantly from baseline (167.4 +/- 15.2/101.4 +/- 9.1 mmHg) over 60 days (-41.9 +/- 34.8/-23.2 +/- 21.8 mmHg; p < 0.0001). Target BP was achieved in 66.1% of patients in the total population, 68.3% of untreated patients, 68.4% of patients uncontrolled with monotherapy, and 59.9% of patients inadequately managed with combination therapy. In 161 patients with SBP >180 mmHg at baseline (newly diagnosed: n = 50; uncontrolled on monotherapy: n = 53; inadequately managed on combination therapy: n = 58), BP was reduced by 63.2 +/- 32.5/29.0 +/- 21.9 mmHg (p < 0.0001) at day 60. The fixed combination was safe and well tolerated. All 1175 patients completing the 60-day study (94%) adhered to their treatment regimen.

CONCLUSION

Fixed combination perindopril/amlodipine was found to be an effective and well tolerated antihypertensive treatment, with an excellent rate of treatment adherence in the clinical setting. Fixed combination perindopril/amlodipine is expected to be useful in the management of hypertension in primary healthcare, with a positive impact on treatment adherence.

Dose-dependent antihypertensive efficacy and tolerability of perindopril in a large, observational, 12-week, general practice-based study

BACKGROUND

Current guidelines recommend the use of full therapeutic dosages of antihypertensive agents, or combination therapy, to improve BP control of hypertensive patients in primary healthcare.

OBJECTIVE

The aim of this study was to assess the dose-dependent antihypertensive efficacy and safety of perindopril 4 and 8 mg/day in the clinical setting.

STUDY DESIGN AND SETTING

The CONFIDENCE study was a prospective, observational, multicenter trial. This was a real-world, clinic-based, outpatient study involving 880 general practitioners/primary-care clinics and 113 specialists in Canada.

PATIENTS

The study included untreated or inadequately managed patients with hypertension (i.e. seated BP ≥ 140/90 mmHg, or ≥ 130/80 mmHg in the presence of diabetes mellitus, renal disease, or proteinuria) without coronary artery disease (CAD).

INTERVENTION

Treatment consisted of perindopril 4 mg/day, uptitrated to 8 mg/day as required for BP control at visit 2, for 12 weeks. Among the patients already being treated at baseline, perindopril either directly replaced all previous ACE inhibitors or angiotensin II type 1 receptor antagonists (angiotensin receptor blockers [ARBs]), or was added to antihypertensive treatment with calcium channel blockers (CCBs), diuretics, or β-adrenoceptor antagonists (β-blockers).

MAIN OUTCOMES MEASURES

The primary outcomes were the mean changes in BP from baseline following treatment with perindopril 4 and 8 mg/day as well as the proportion of patients achieving BP control (BP <140/90 mmHg, or <130/80 mmHg in diabetic patients) in the intent-to-treat (ITT) population. Secondary analyses included the incidence of adverse events and compliance.

RESULTS

A total of 8298 hypertensive patients entered the study: 56% with newly diagnosed hypertension and 44% with uncontrolled hypertension. Mean SBP/DBP decreased significantly from baseline (152.5  ±  10.8/89.5  ±  9 mmHg) over 12 weeks (-18.5/-9.7 mmHg; p < 0.001). At visit 2, 23% of patients were uptitrated to perindopril 8 mg/day, which resulted in an additional mean 10.1/5.3 mmHg BP reduction; this reduction was even greater (15.1/5.7 mmHg) among a separate group of severely hypertensive patients (i.e. SBP >170 mmHg or DBP >109 mmHg at baseline). Target BP was achieved in 54% of the ITT population. Both perindopril 4 mg/day and perindopril 8 mg/day were well tolerated and compliance was high throughout the study.

CONCLUSION

In the clinical outpatient setting, perindopril was found to be an effective dose-dependent and well tolerated antihypertensive treatment, with good compliance. Uptitration to the full therapeutic dosage of perindopril is an efficient approach for the management of a broad range of hypertensive patients without CAD.

Association between adherence to calcium-channel blocker and statin medications and likelihood of cardiovascular events among US managed care enrollees

Background

Prior studies have found that patients taking single-pill amlodipine/atorvastatin (SPAA) have greater likelihood of adherence at 6 months than those taking 2-pill calcium-channel blocker and statin combinations (CCB/statin). This study examines whether this adherence benefit results in fewer cardiovascular (CV) events.

Methods

A retrospective cohort study was conducted using administrative claims data from the IMS LifeLink: US Health Plan Claims database, identifying adults already taking CCB or statin (but not both) who had an index event of either initiating treatment with SPAA or adding CCB to statin (or vice versa) between April 1, 2004 to August 31, 2005. Inclusion criteria included age 18+ years, continuously enrolled for minimum of 6 months prior and 18 months following treatment initiation, >1 diagnosis of hypertension, and no prescription claims for SPAA or added CCB or statin for 6 months prior. Exclusion criteria included >1 claim with missing or invalid days supplied, age 65+ years and not enrolled in Medicare Advantage, or history of prior CV events, cancer diagnosis, or chronic renal failure. The primary outcome measure was the rate of CV events (myocardial infarction, heart failure, angina, other ischemic heart disease, stroke, peripheral vascular disease, or revascularization procedure) from 6 to 18 months following index date, analyzed at three levels: 1) all adherent vs. non-adherent patients, 2) SPAA vs. dual-pill patients (regardless of adherence level), and 3) adherent SPAA, adherent dual-pill, and non-adherent SPAA patients vs. non-adherent dual-pill patients.

Results

Of 1,537 SPAA patients, 56.5% were adherent at 6 months, compared with 21.4% of the 17,910 CCB/statin patients (p < 0.001). Logistic regression found SPAA patients more likely to be adherent (OR = 4.7, p < 0.001) than CCB/statin patients. In Cox proportional hazards models, being adherent to either regimen was associated with significantly lower risk of CV event (HR = 0.77, p = 0.003). A similar effect was seen for SPAA vs. CCB/statin patients (HR = 0.68, p = 0.02). In a combined model, the risk of CV events was significantly lower for adherent CCB/statin patients (HR = 0.79, p = 0.01) and adherent SPAA patients (HR = 0.61, p = 0.03) compared to non-adherent CCB/statin patients.

Conclusions

Patients receiving SPAA rather than a 2-pill CCB/statin regimen are more likely to be adherent. In turn, adherence to CCB and statin medications is associated with lower risk of CV events in primary prevention patients.

Antihypertensive efficacy of perindopril 5-10 mg/day in primary health care: an open-label, prospective, observational study

BACKGROUND AND OBJECTIVES

Optimal control of hypertension reduces the risk of long-term cardiovascular complications, and current guidelines recommend blood pressure (BP) targets of <140/90 mmHg for patients. Despite this, the BP of many patients with hypertension in primary health care remains poorly controlled. The ACE inhibitor perindopril has proven BP-lowering efficacy as well as protective effects against cardiovascular events among patients with additional cardiovascular risk factors. The PREFER study assessed the antihypertensive efficacy and safety of perindopril 5-10 mg/day among hypertensive patients who were unresponsive to treatment with other ACE-inhibitor-based regimens.

METHODS

The PREFER study was an open-label, prospective, observational study conducted in primary health-care centres throughout Romania. Patients selected for the study (n = 824; mean + or - SD age 60.3 + or - 9.8 years) had uncontrolled hypertension (i.e. seated BP > or =140/90 mmHg, or > or = 130/80 mmHg in patients with diabetes mellitus or at high cardiovascular risk) despite receiving ACE inhibitors either alone or in free combination with other antihypertensive classes. At study entry, current ACE inhibitor treatment was replaced by perindopril 5 mg/day. Patients were followed up monthly for 3 months and the dosage of perindopril could be increased to 10 mg/day in cases of failure to achieve BP control. No other change in antihypertensive therapy was permitted.

RESULTS

Replacing the previous ACE inhibitor with perindopril 5-10 mg/day resulted in decreases of 26.2 mmHg (from 162.6 + or - 15.6 to 136.4 + or - 14.6 mmHg [p < 0.001]) in systolic BP and of 12.6 mmHg (from 96.9 + or - 17.2 to 84.3 + or - 12.8 mmHg [p < 0.001]) in diastolic BP. Mean pulse pressure (PP) was reduced by 13.6 mmHg (from 65.7 to 52.1 mmHg) with greater decreases seen in patients aged >70 years or with isolated systolic hypertension. BP control was achieved in 48.1% of the previously uncontrolled population. Antihypertensive efficacy was observed across patient subgroups regardless of the severity of hypertension at baseline and number of cardiovascular risk factors. Patient compliance with treatment was high throughout the study.

CONCLUSIONS

Perindopril 5-10 mg/day lowers BP and PP and improves BP control among hypertensive patients who were previously unresponsive to other ACE inhibitor-based regimens.

[Angiotensin converting enzyme inhibitors and calcium antagonists: a synergistic action for a better prevention of cardiovascular events]

Treatment of hypertension increasingly requires association of drugs. Among them, the association of calcium antagonists with angiotensin converting enzyme inhibitors is a new tempting approach since the two pharmaceutical classes have synergistic effects on blood pressure lowering and target organ protection whereas their effect is antagonistic for adverse events. Numerous large randomized clinical trials have validated this treatment strategy, and new fixed association are being developed. They apply to hypertensive patients, but also to coronary artery disease patients and more generally speaking to high cardiovascular risk subjects.

Perindopril for control of blood pressure in patients with hypertension and other cardiovascular risk factors: an open-label, observational, multicentre, general practice-based study

BACKGROUND AND OBJECTIVES

Hypertension, one of the major treatable cardiovascular (CV) risk factors, usually occurs in association with other major risk factors. As well as providing rapid blood pressure (BP) goal attainment, antihypertensive therapy should also provide reductions in CV events and mortality in a wide range of patients. For this, higher dosages and combinations of antihypertensive agents are often required. ACE inhibitors are recommended as first-line agents for control of hypertension in patients with additional CV risk factors. The PEACH (Perindopril's Effect At Controlling Hypertension) study was a community-based study performed to evaluate the effectiveness and safety of high-dose perindopril in patients with mild-to-moderate hypertension and additional risk factors for CV disease.

METHODS

This was an open-label, multicentre observational study conducted in Canadian general practice clinics. The study assessed the efficacy and tolerability of perindopril given once daily for 10 weeks uptitrated to the maximal recommended dose of perindopril as required for BP control in newly diagnosed or previously treated patients with uncontrolled mild to moderate hypertension and >or=1 additional risk factor. Patients not achieving target BP after 2 weeks of therapy were uptitrated from perindopril 4 mg to perindopril 8 mg once daily. Efficacy endpoints included reduction in systolic (SBP) and diastolic (DBP) BP and BP control. Tolerability assessments included adverse effects and physicians' assessment of tolerability. The number of missed doses was also recorded.

RESULTS

Overall, 2220 patients with hypertension and >or=1 other risk factor were prescribed perindopril at 291 centres; 51.9% were male, 78.3% Caucasian, 12.8% Asian, 36.2%>or=65 years of age and 34.5% had uncontrolled BP despite previous antihypertensive treatment. Compared with previously treated patients, treatment-naive patients had fewer risk factors, and a higher proportion were Asian (p<0.05 for all comparisons). Most patients (76%) had 1-2 risk factors. Perindopril produced significant SBP/DBP reductions at 2 and 10 weeks (-15.8/-8.0 and -21.1/-11.0 mmHg, respectively). Overall, at week 10, BP control rate was 53.6%, better than at week 2 in the overall cohort and in all subgroups. Uptitration to high-dose perindopril to achieve BP control was required in 46% of patients with one additional risk factor compared with 64% of patients with >or=4 additional risk factors. These results demonstrate that the more risk factors the patient has, the greater the need for high-dose perindopril to achieve BP control. Perindopril was well tolerated as indicated by the high proportion of physicians (95.9%) reporting 'good' to 'excellent' tolerability at week 10.

CONCLUSION

In this community-based clinical practice trial, up to 10 weeks' perindopril therapy, uptitrated to the maximal recommended dose as required for BP control, significantly reduced SBP/DBP in patients with mild-to-moderate hypertension and additional CV risk factors. Patients with more risk factors were more likely to require high-dose perindopril.

Optimizing the treatment of hypertension and stable coronary artery disease: clinical evidence for fixed-combination perindopril/amlodipine

BACKGROUND

Optimized management of hypertension and coronary artery disease (CAD) improves cardiovascular risk and outcomes, and prevents complications. This article reviews evidence for the fixed combination of the angiotensin-converting enzyme (ACE) inhibitor perindopril and the calcium channel blocker amlodipine.

METHODS

A literature search was performed in PubMed/MEDLINE to identify articles published in English between 1988 and March 2008 describing clinical trials, particularly outcome trials, or mechanisms of therapeutic action relevant to the use of combination therapy in patients with hypertension or stable coronary artery disease with an ACE inhibitor (perindopril) and a calcium channel blocker (amlodipine).

FINDINGS

Clinical trials indicate that this combination may have a positive impact on cardiovascular mortality and morbidity in hypertensive individuals. The two complementary mechanisms of action appear to work in synergy, leading to more efficient blood pressure lowering, improved fibrinolytic function, and reduction of secondary effects. This also represents a simplified management strategy for stable CAD. Perindopril has proven efficacy in the prevention of cardiovascular events and mortality in CAD patients, while amlodipine is widely used in the symptomatic management of CAD. Both aspects of guideline-recommended management of CAD are therefore addressed in a single tablet.

CONCLUSIONS

The clinical evidence for fixed-combination perindopril/amlodipine indicates it as a credible option for the optimization of the management of hypertension and CAD.

Effects of perindopril in hypertensive patients with or without type 2 diabetes mellitus, and with altered insulin sensitivity

Impaired insulin sensitivity and hypertension are risk factors for atherosclerosis, which in turn leads to a variety of cardiovascular diseases. In both conditions, the risks of morbidity and mortality appear to be further increased. Impaired insulin sensitivity is also a precursor for diabetes. The renin-angiotensin-aldosterone system (RAAS) is implicated in the development of both hypertension and insulin resistance. Antihypertensive agents that act by blocking the RAAS, such as angiotensin-converting enzyme (ACE) inhibitors, may improve insulin sensitivity and therefore prevent the deleterious consequences of insulin resistance, including type 2 diabetes. ACE inhibitors appear to improve insulin sensitivity in patients with hypertension and insulin resistance, including diabetes. This review assesses the literature surrounding the use of the ACE inhibitor perindopril in patients with hypertension and varying degrees of insulin resistance, including the effects of perindopril in preventing the development of diabetes and subsequent cardiovascular morbidity and mortality.

Cardiovascular Events in Hypertension Trials of Angiotensin‐Converting Enzyme Inhibitors

Angiotensin-converting enzyme inhibitors are widely-prescribed drugs for hypertension and are supported by clinical trials in which they reduce cardiovascular events. In the high-risk patients in the Heart Outcomes Prevention Evaluation, the Perindopril Protection Against Recurrent Stroke Study, and European Trial of Reduction of Cardiac Events With Perindopril in Stable Coronary Artery Disease, ramipril and perindopril showed impressive benefits. One reason trandolapril did somewhat less well in the Prevention of Events With Angiotensin-Converting Enzyme Inhibition trial may be that its patients were very well treated with other effective modalities. In the Antihypertensive and Lipid Lowering to Prevent Heart Attack Trial, lisinopril-treated patients had a slightly lower incidence of myocardial infarction, despite much poorer control of blood pressure, perhaps because a second-line diuretic was prohibited by protocol. Although angiotensin-converting enzyme inhibitors can cause cough and angioedema (more common among blacks), angiotensin receptor blockers are currently more expensive and have fewer outcome trials to support their use.

Perindopril arginine: benefits of a new salt of the ACE inhibitor perindopril

BACKGROUND

The efficacy of the angiotensin-converting enzyme (ACE) inhibitor perindopril in the treatment of hypertension, stable coronary artery disease, and heart failure is well established. The reduced stability of the current salt, perindopril-tert-butylamine, in extreme climatic conditions has prompted research into more stable compounds. This article presents stability and bioequivalence results for a new L-arginine salt of perindopril.

METHODS

Drug stability studies were performed on nonsalified perindopril, perindopril-tert-butylamine, and perindopril arginine in closed and open containers. The bioequivalence of perindopril arginine was tested in 36 healthy male volunteers in an open-label, randomized, two-period, crossover pharmacokinetic study. A consumer study was carried out in 120 patients to assess preference for a simplified packaging using a high-density polyethylene canister designed for distribution to all climatic zones.

RESULTS AND DISCUSSION

Perindopril arginine is 50% more stable than perindopril-tert-butylamine, which increases the shelf life from 2 to 3 years. At the revised dosage (perindopril arginine 5-10 mg/day corresponds to perindopril-tert-butylamine 4-8 mg/day), the new salt is equivalent in terms of pharmacokinetics, efficacy, safety, and acceptability. The consumer studies indicate a preference for the new packaging, with 62% of patients nominating the canister as better than the blister packs.

CONCLUSION

The new perindopril arginine salt is equivalent to perindopril-tert-butylamine and more stable, and can be distributed to climatic zones III and IV without the need for specific packaging. The patient preference for the new packaging could have positive implications for compliance.

Perindopril: the evidence of its therapeutic impact in hypertension

INTRODUCTION

Effective antihypertensive therapy reduces the risk of cardiovascular and cerebrovascular disease and death. Perindopril, a long-acting angiotensin-converting enzyme (ACE) inhibitor, is an established antihypertensive agent administered as a once-daily tablet.

AIMS

To review recent evidence for the use of perindopril in the treatment of hypertension.

EVIDENCE REVIEW

Evidence shows that perindopril alone or in combination with other antihypertensive agents can achieve clinically significant reductions in blood pressure after 12 weeks of treatment. There is strong evidence from large randomized studies that perindopril-based therapy reduces the risk of cardiovascular outcomes, including mortality, in patients with coronary artery disease and those who have had a prior stroke or transient ischemic attack. There is also some evidence that these effects are greater than those achieved by blood pressure reduction alone, suggesting other drug-related effects including improvements in endothelial function. Recent results have also shown that an amlodipine ± perindopril regimen prevented more major cardiovascular events than an atenolol-based regimen in patients with hypertension, as a result of better control of blood pressure. Economic evidence from one major study shows that, for most patients, the incremental cost per quality-adjusted life-year gained with perindopril 8 mg was lower than the threshold value of €20 000 (73-92% of patients) in Europe or £20 000 (94% of patients) in the UK.

CLINICAL VALUE

There is strong evidence supporting the use of perindopril-based therapy for the treatment of hypertension and reduction in the risk of cardiovascular disease, stroke, and death in a wide range of patients with stable coronary artery disease or hypertension.

ACE inhibition in hypertension: focus on perindopril

Ongoing developments in our understanding of cardiovascular disease, together with the introduction of new drugs to treat these conditions, has led to much debate over the optimal management of hypertension. The ALLHAT study showed no major differences in cardiovascular outcome among three major classes of antihypertensive drugs. Indeed, large meta-analyses have substantiated this view, and most experts would agree that BP reduction matters more than the choice of antihypertensive agent. However, recently published data from the ASCOT-BPLA trial for hypertensive patients at moderate risk of cardiac events have caused some experts to re-evaluate this view. The recent Blood Pressure Lowering Treatment Trialists' Collaboration publication confirmed this change. In the ASCOT-BPLA trial, antihypertensive therapy based on amlodipine+perindopril significantly reduced total and cardiovascular mortality as well as other clinically relevant outcomes in comparison with a traditional strategy based on atenolol and a thiazide diuretic, despite both regimens producing nonsignificantly different reductions in brachial BP. These findings suggest that amlodipine/perindopril may exert a beneficial effect by acting on other parameters such as central BP or BP variability. ACE inhibitors have been shown to have antiatherosclerotic and antithrombogenic effects, to improve endothelial dysfunction, and to prevent cardiac remodeling in patients with coronary heart disease. In this regard, perindopril, which has relatively high affinity for ACE and true 24-hour duration of action, is one of the most extensively studied ACE inhibitors. More recent data suggest that ACE inhibitors reduce arterial stiffness, an independent risk factor for cardiovascular events, and have a beneficial effect on central aortic BP, thus providing a possible explanation for the findings of ASCOT-BPLA and confirming that ACE inhibitors are an appropriate first choice for patients with hypertension.

Angiotensin-converting enzyme inhibitor use in the year 2005

The angiotensin-converting enzyme (ACE) inhibitor drug class is one with considerable staying power. ACE inhibitors are not only well established antihypertensive agents but also are compounds that fairly regularly provide end-organ protection. Several of the ACE inhibitors are entangled in an active debate regarding class effect. Class effect for ACE inhibitors is a hopelessly confused term because its definition is not standardized and is subject to interpretation that in many cases is self-serving. For the most part, ACE inhibitor side effects are readily identifiable, and management strategies put in place can be logical and sequential. The future of this drug class remains bright. Other drug classes, such as angiotensin receptor blockers, have narrowed-but not entirely closed-the outcomes gap that exists between these two drug classes.

The ASCOT trial: clarifying the role of ACE inhibition in the reduction of cardiovascular events in patients with hypertension

Hypertension remains one of the primary causes of preventable death in developed countries. Universally accepted clinical practice guidelines based on well designed trials are needed to ensure standardized treatment for these patients. It has been hypothesized that agents such as calcium channel antagonists and ACE inhibitors may be more effective than beta-adrenoceptor antagonist (beta-blocker)- or diuretic-based regimens. However, until recently, there have been limited data on the efficacy of 'newer' antihypertensive regimens, particularly combination therapy, relative to standard therapeutic options. The ASCOT-BPLA (Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm), a prospective, randomized, controlled trial in >19 250 patients with hypertension, highlights the benefit of a combined amlodipine plus perindopril regimen over an atenolol plus diuretic-based combination in terms of significant reductions (p < 0.05) in all-cause mortality, total cardiovascular events and procedures, and fatal and nonfatal stroke. The ASCOT-BPLA trial underlines the cardiovascular benefit of ACE inhibitors, specifically perindopril, beyond that provided by BP reduction, and potentially reflects a mechanistic feature of the ACE inhibitors. It also suggests that the combination of amlodipine plus perindopril may provide broad-spectrum cardiovascular protection, as well as reduce the incidence of new-onset diabetes mellitus and renal impairment, in addition to its efficacy in lowering BP. The ASCOT-BPLA trial provides evidence of the need to reconsider traditional prescribing recommendations in patients with hypertension, particularly conclusions reached in the US after the publication of the ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial) study. The recently published National Institute for Health and Clinical Excellence (NICE) guidelines in the UK emphasize the efficacy of ACE inhibitors as first-line agents for hypertensive patients <55 years of age and recommend ACE inhibitor therapy at any stage of hypertension management.

Clinical experience with perindopril in elderly hypertensive patients: a subgroup analysis of a large community trial

OBJECTIVE

To evaluate the effectiveness and safety of perindopril in a subgroup of 3010 elderly (> or =65 years) hypertensive patients, who participated in a large US general practice-based community trial.

METHODS

All patients received open-label perindopril 4 mg once a day for 6 weeks. After 6 weeks the dosage was either maintained (group I) or increased to 8 mg/day (group II) based on the physician's assessment of blood pressure (BP) response. Patients were then followed for another 6 weeks for a total study duration of 12 weeks.

RESULTS

Demographic and baseline clinical characteristics revealed a higher proportion of women, longer duration of hypertension and higher baseline systolic BP (SBP) among elderly than young (<65 years, n = 7332) hypertensive patients. A clinically relevant BP reduction of similar magnitude was obtained in elderly and young patients with perindopril monotherapy. At week 12, the mean reduction in BP from baseline was 18.4/8.7 mm Hg in the elderly and 17.5/11.3 mm Hg in the young. Elderly patients with hypertension not responding adequately to the 4 mg/day dosage at week 6 had a BP reduction of 6.3/3.6 mm Hg (group II). Up-titration to an 8 mg/day dosage for another 6 weeks gave an additional 8.9/3.5 mm Hg reduction resulting in a total reduction of 15.2/7.1 mm Hg from baseline. A similar magnitude of increase in response to up-titration of perindopril was seen in young patients. BP control (<140/90 mm Hg) on perindopril monotherapy was achieved in 41.4% of elderly and 51.9% of young patients. In both age groups, up-titration to an 8.0 mg/day dosage in group II patients increased BP control by approximately 5-fold at week 12 (28.2% in the elderly and 36.4% in the young). A similar increased response on BP reduction and BP control (<140/90 mm Hg) with up-titration was seen in elderly subgroups of African American and diabetic patients. The 7th Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure recommended target goal of <130/80 mm Hg was achieved with perindopril monotherapy in 15.6% of hypertensive diabetic patients. Perindopril reduced BP effectively and safely in very elderly (> or =75 years) hypertensive patients. Perindopril was well tolerated in elderly patients including high-risk groups. The incidence of cough (7-10%), the most common symptom, was similar in all age groups. The low incidence of postural hypotension (< or =0.2%) observed in the elderly and very elderly further supports the good tolerance and safety profile of the drug. Data analysis from this study suggests that community physicians, in general, are less aggressive in controlling BP in the elderly and more inclined to treat or control diastolic BP than SBP.

CONCLUSION

Perindopril treatment is effective and well tolerated in elderly patients with hypertension.

Clinical Experience with Perindopril in Patients Nonresponsive to Previous Antihypertensive Therapy: A Large US Community Trial

A subgroup analysis of a large US community trial was conducted to evaluate the antihypertensive efficacy and safety of perindopril, an angiotensin-converting enzyme inhibitor (ACEI), in 3159 patients who lacked blood pressure (BP) control at entry with previous antihypertensive therapy. Patients received 4 mg perindopril daily for 6 weeks. Based on physicians' assessment of BP response, the patients were then either maintained on 4 mg daily (group 1) or the dose was increased to 8 mg daily (group 2) for an additional 6 weeks. The mean baseline sitting BP was 158.2/92.9 mm Hg. Perindopril monotherapy produced a significant BP decrease from baseline of 11.6/6.5 mm Hg and 14.9/8.4 mm Hg at weeks 6 and 12, respectively. In group 1 patients, the majority of BP decrease occurred at week 6 (17.3/9.5 mm Hg) and was maintained until the end of week 12 (18.2/10.1 mm Hg). In group 2 patients, the BP decrease on the 4-mg dose was modest at week 6 by 5.2/3.1 mm Hg. However, further dose up-titration of perindopril to 8 mg resulted in a clinically significant BP decrease of 11.9/6.8 mm Hg from baseline to week 12. Significant antihypertensive effects of perindopril were also demonstrated in the special patient populations of elderly (>or=65 years), black, isolated systolic hypertension, patients with concomitant cardiovascular diseases, and patients nonresponsive to other ACEI therapy. Overall, BP control (<140/<90 mm Hg) was achieved in 40.0% of patients at week 12. Perindopril was well tolerated with cough and angioedema reported in 8.5% and 0.4% patients, respectively. Physicians assessed therapeutic response to perindopril as satisfactory in 73.8% patients who were nonresponsive to previous antihypertensive therapy. These results suggest that, in a community-based practice, perindopril monotherapy (4-8 mg/d) is an effective and safe therapeutic option in patients nonresponsive to previous antihypertensive therapy.