A randomized controlled trial on the blood pressure–lowering effect of amlodipine and nifedipine‐GITS in sustained hypertension

A Randomized Controlled Trial on the Efficacy and Safety of a Calcium-Channel Blocker and an Angiotensin-Converting Enzyme Inhibitor in Chinese and European Patients with Hypertension

BACKGROUND

In a post hoc analysis of a multinational, randomized trial, we investigated whether the efficacy and safety of nifedipine-gastrointestinal therapeutic system (GITS) and ramipril differed between Chinese and European patients with hypertension.

METHODS

Previously treated (after 2-week washout) and untreated patients with clinic blood pressure (BP) ≥ 140/90 mmHg (systolic/diastolic), daytime ambulatory BP ≥ 135/85 mmHg and standard deviation of home systolic BP > 7 mmHg, and/or daytime BP > 12 mmHg were randomly assigned to treatment based on nifedipine-GITS 30 mg or ramipril 10 mg for 12 months. Clinic, ambulatory and home BP were measured at baseline, 10 weeks and 12 months after randomization.

RESULTS

A total of 67 Chinese and 101 European patients were analyzed and they differed in age (50.9 vs. 54.6 years, respectively), body mass index (24.5 vs. 27.0 kg/m2), clinic diastolic BP (87.9 vs. 92.5 mmHg), heart rate (75.0 vs. 70.8 beats/minute), and nighttime diastolic BP (79.3 vs. 75.9 mmHg) (all P < 0.05). However, within each ethnicity, patients were comparable for clinical characteristics between the nifedipine-GITS and ramipril groups (P > 0.05). In both the Chinese and European patients, BP was similarly reduced with nifedipine-GITS and ramipril, except that daytime systolic/diastolic BP reductions were 7.4/4.1 mmHg greater in the ramipril than nifedipine-GITS group in Chinese (P = 0.02). The safety profile differed between the Chinese and European patients (P for drug*ethnicity interaction ≤ 0.05) for all adverse events (lower incidence on nifedipine-GITS in Chinese), ankle edema (higher on nifedipine-GITS in Europeans), and dry cough (higher on ramipril in Chinese).

CONCLUSION

In the Chinese and European patients with hypertension, nifedipine-GITS and ramipril had similar BP lowering efficacy, but different safety profile and tolerability.

CLINICAL TRIALS REGISTRATION

Identifier at clinicaltrials.gov NCT02499822 (Registration date: 16 July 2015).

Alcohol consumption and ambulatory blood pressure-lowering effect in male patients on clinic blood pressure-guided antihypertensive treatment

In the present analysis, we investigated the association between alcohol consumption and ambulatory blood pressure (BP) control in male patients after 8 weeks of antihypertensive therapy with two dihydropyridine calcium channel blockers. The study participants were hypertensive (clinic systolic/diastolic BP of 140-179/90-109 mmHg and 24-hour ambulatory systolic/diastolic BP ≥ 130/80 mmHg) patients enrolled in a randomized controlled trial and treated with amlodipine 5-10 mg or nifedipine gastrointestinal therapeutic system (GITS) 30-60 mg once daily. Alcohol consumption was classified as non-drinkers and drinkers. Non-dipping was defined as a BP drop from daytime to nighttime <10%. At baseline, the 131 alcohol drinkers, compared with 141 non-drinkers, had a significantly higher nighttime systolic/diastolic BP (129.3 ± 13.5/83.8 ± 9.5 vs. 125.7 ± 12.3/80.9 ± 8.2 mmHg, P ≤ 0.02), night-to-day ratio for both systolic (89.1 ± 8.5 vs. 87.0 ± 7.1%, P = 0.03) and diastolic BP (88.7 ± 8.8 vs. 86.5 ± 7.9%, P = 0.04) and prevalence of non-dippers for systolic (45.0% vs. 33.3%, P = 0.048) and diastolic BP (42.0% vs. 29.8%, P = 0.04). However, they had similar clinic and 24-hour and daytime ambulatory BP at baseline (P ≥ 0.07). Antihypertensive treatment significantly (P ≤ 0.001) reduced clinic and ambulatory systolic and diastolic BP from baseline in both alcohol drinkers and non-drinkers at 4 and 8 weeks of follow-up. However, in patients with a non-dipping pattern at baseline, the proportion of dippers for systolic/diastolic BP at 8 weeks of follow-up (36.5% vs. 58.5%) was significantly lower in 67 alcohol drinkers than in 52 non-drinkers (P = 0.035). Alcohol drinkers had higher nighttime BP and a higher prevalence of non-dippers than non-drinkers. Clinic blood pressure-guided antihypertensive treatment was insufficient in controlling nighttime BP or changing the non-dipping to dipping pattern in alcohol drinkers with sustained clinic and ambulatory hypertension. Alcohol drinkers had higher nighttime systolic and diastolic blood pressure than non-drinkers at baseline. Clinic blood pressure-guided antihypertensive treatment was insufficient in changing the non-dipping to dipping pattern in alcohol drinkers with sustained clinic and ambulatory hypertension.

Seasonal variation in ambulatory blood pressure control in patients on clinic blood pressure-guided antihypertensive treatment

BACKGROUND

We investigated seasonal variation in ambulatory blood pressure control in hypertensive patients on clinic blood pressure-guided antihypertensive treatment.

METHODS

The study participants were hypertensive patients enrolled in an 8-week therapeutic study. Antihypertensive treatment was initiated with long-acting dihydropyridine calcium channel blockers amlodipine 5 mg/day or the gastrointestinal therapeutic system (GITS) formulation of nifedipine 30 mg/day, with the possible up-titration to amlodipine 10 mg/day or nifedipine-GITS 60 mg/day at 4 weeks of follow-up.

RESULTS

The proportion of up-titration to higher dosages of antihypertensive drugs at 4 weeks of follow-up was higher in patients who commenced treatment in autumn/winter ( n  = 302) than those who commenced treatment in spring/summer ( n  = 199, 24.5 vs. 12.0%, P  < 0.001). The control rate of clinic blood pressure, however, was lower in autumn/winter than in spring/summer at 4 (56.7 vs. 70.7%, P  = 0.003) and 8 weeks of follow-up (52.5 vs. 74.9%, P  < 0.001). At 8 weeks, patients who commenced treatment in autumn/winter, compared with those who commenced treatment in spring/summer, had a significantly ( P ≤0.03) smaller daytime (mean between-season difference -3.2/-2.8 mmHg) but greater nighttime SBP/DBP reduction (3.6/1.6 mmHg). Accordingly, at 8 weeks, the prevalence of nondippers was significantly ( P  < 0.001) higher in spring/summer than in autumn/winter for both SBP (54.8 vs. 30.0%) and DBP (53.4 vs. 28.8%).

CONCLUSION

Clinic blood pressure-guided antihypertensive treatment requires a higher dosage of medication in cold than warm seasons, which may have led to over- and under-treatment of nighttime blood pressure, respectively.

Comparative Bioequivalence and Food Effect of Two Formulations of 30-mg Nifedipine Controlled-Release Tablets in Healthy Chinese Adults

Nifedipine is a potent antihypertensive medication classified as a dihydropyridine calcium channel blocker. The objective of this trial was to assess the bioequivalence of a 30-mg nifedipine controlled-release tablet and a reference drug in a cohort of healthy Chinese individuals. Two independent open-label, randomized, single-dose, crossover studies were conducted, 1 under fasting conditions (N = 44, with 1 participant dropping out midway) and the other under fed conditions (N = 44, with 4 participants dropping out midway). Plasma concentrations of nifedipine were determined using liquid chromatography-mass spectrometry, and pharmacokinetic (PK) parameters were calculated using noncompartmental analysis with Phoenix WinNonlin 8.0 software. In both fasting and fed studies, reasonable bioequivalence was observed for the PK parameters of both the test product and the reference drug. A good safety profile was demonstrated for both the test product and reference drug, with no serious adverse events reported, and both were similarly well tolerated. An important observation with food coadministration was that systemic exposure to nifedipine (based on area under the curve, AUC0-∞) was reduced by approximately 12%. The bioequivalence of the test product and reference drug under fasting/fed conditions in healthy subjects in China was demonstrated by the study results.

Personalized Antihypertensive Treatment Optimization With Smartphone-Enabled Remote Precision Dosing of Amlodipine During the COVID-19 Pandemic (PERSONAL-CovidBP Trial)

BACKGROUND

The objective of the PERSONAL-CovidBP (Personalised Electronic Record Supported Optimisation When Alone for Patients With Hypertension: Pilot Study for Remote Medical Management of Hypertension During the COVID-19 Pandemic) trial was to assess the efficacy and safety of smartphone-enabled remote precision dosing of amlodipine to control blood pressure (BP) in participants with primary hypertension during the COVID-19 pandemic.

METHODS AND RESULTS

This was an open-label, remote, dose titration trial using daily home self-monitoring of BP, drug dose, and side effects with linked smartphone app and telemonitoring. Participants aged ≥18 years with uncontrolled hypertension (5-7 day baseline mean ≥135 mm Hg systolic BP or ≥85 mm Hg diastolic BP) received personalized amlodipine dose titration using novel (1, 2, 3, 4, 6, 7, 8, 9 mg) and standard (5 and 10 mg) doses daily over 14 weeks. The primary outcome of the trial was mean change in systolic BP from baseline to end of treatment. A total of 205 participants were enrolled and mean BP fell from 142/87 (systolic BP/diastolic BP) to 131/81 mm Hg (a reduction of 11 (95% CI, 10-12)/7 (95% CI, 6-7) mm Hg, P<0.001). The majority of participants achieved BP control on novel doses (84%); of those participants, 35% were controlled by 1 mg daily. The majority (88%) controlled on novel doses had no peripheral edema. Adherence to BP recording and reported adherence to medication was 84% and 94%, respectively. Patient retention was 96% (196/205). Treatment was well tolerated with no withdrawals from adverse events.

CONCLUSIONS

Personalized dose titration with amlodipine was safe, well tolerated, and efficacious in treating primary hypertension. The majority of participants achieved BP control on novel doses, and with personalization of dose there were no trial discontinuations due to drug intolerance. App-assisted remote clinician dose titration may better balance BP control and adverse effects and help optimize long-term care.

REGISTRATION

URL: clinicaltrials.gov. Identifier: NCT04559074.

Application of metabolomics in the diagnosis of non-alcoholic fatty liver disease and the treatment of traditional Chinese medicine

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease around the world, and it often coexists with insulin resistance-related diseases including obesity, diabetes, hyperlipidemia, and hypertension, which seriously threatens human health. Better prevention and treatment strategies are required to improve the impact of NAFLD. Although needle biopsy is an effective tool for diagnosing NAFLD, this method is invasive and difficult to perform. Therefore, it is very important to develop more efficient approaches for the early diagnosis of NAFLD. Traditional Chinese medicine (TCM) can play a certain role in improving symptoms and protecting target organs, and its mechanism of action needs to be further studied. Metabolomics, the study of all metabolites that is thought to be most closely associated with the patients' characters, can provide useful clinically biomarkers that can be applied to NAFLD and may open up new methods for diagnosis. Metabolomics technology is consistent with the overall concept of TCM, and it can also be used as a potential mechanism to explain the effects of TCM by measuring biomarkers by metabolomics. Based on PubMed/MEDLINE and other databases, this paper retrieved relevant literature NAFLD and TCM intervention in NAFLD using metabolomics technology in the past 5 years were searched, and the specific metabolites associated with the development of NAFLD and the potential mechanism of Chinese medicine on improving symptoms were summarized.

Evaluation of commonly used cardiovascular drugs in inhibiting vonoprazan metabolism in vitro and in vivo

As a novel acid-suppressing drug, vonoprazan shows the potential to replace traditional proton-pump inhibitors. With its widespread use, some adverse effects that require further study have emerged due to drug–drug interactions. Our study is the first experiment that evaluated the drug–drug interactions of eleven common cardiovascular drugs that inhibit vonoprazan metabolism in vitro and in vivo. Rat liver microsome incubation and molecular simulation docking were applied to explore the inhibition mechanism. Amlodipine and nifedipine showed inhibitory effects on vonoprazan metabolism in both rat and human liver microsomes in the first evaluation part in vitro. The inhibition mechanism analysis results demonstrated that amlodipine and nifedipine might inhibit the metabolism of vonoprazan by a mixed type of competitive and non-competitive inhibition. However, the pharmacokinetic data of the vonoprazan prototype revealed that amlodipine affected vonoprazan in vivo while nifedipine did not. Thus, more attention should be paid when amlodipine is prescribed with vonoprazan. Furthermore, the changes in its carboxylic acid metabolites MI hinted at a complex situation. Molecular simulation suggested the CYP2B6 enzyme may contribute more to this than CYP3A4, and further inhibitory experiments preliminarily verified this speculation. In conclusion, the use of vonoprazan with cardiovascular drugs, especially amlodipine, should receive particular attention in clinical prescriptions.

Comparative efficacy of generic nifedipine versus brand-name amlodipine for hypertension management in Taiwan

The control rate of hypertension remains concerning, indicating the requirement for better management strategies. The calcium channel blockers brand‐name amlodipine and nifedipine with extended‐release formulations demonstrate similar clinical efficacy. However, the efficacy of generic nifedipine remains obscure. We compared the efficacy of generic nifedipine and brand‐name amlodipine in terms of cardiovascular (CV) outcomes. Patients prescribed generic nifedipine (SRFC CYH) or brand‐name amlodipine besylate (Norvasc, Pfizer) between August 1, 2017, and July 31, 2018, were enrolled; patients with CV events within 3 months were excluded. CV outcomes included CV death, nonfatal myocardial infarction (MI), nonfatal ischemic stroke, hospitalization for heart failure, and composite endpoints of 3P‐ and 4P‐major adverse cardiac events (MACE). A total of 1625 patients treated with nifedipine (SRFC CYH) and 16 587 patients treated with Norvasc were included. After propensity score matching, there were 995 and 4975 patients in the nifedipine CYH and Norvasc groups, respectively. At a mean follow‐up period of 30.3 ± 6.4 months, nifedipine CYH was comparable to Norvasc in terms of CV death (P = .107), nonfatal MI (P = .121), nonfatal ischemic stroke (P = .453), hospitalization for heart failure (P = .330), 3P‐MACE (P = .584), and 4P‐MACE (P = .274). Cox regression analysis revealed that nifedipine CYH and Norvasc had similar efficacy in terms of 3P‐MACE (hazard ratio, 0.970; 95% confidence interval, 0.601–1.565, P = .900) and 4P‐MACE (hazard ratio, 0.880; 95% confidence interval, 0.628–1.233, P = .459). In conclusion, Nifedipine SRFC CYH and Norvasc have comparable clinical efficacy for hypertension management.

24-Hour Blood Pressure Control with Amlodipine: A Review of the Current Scenario

Introduction Hypertension is the leading cause of cardiovascular diseases and premature death worldwide. Antihypertensive therapy using calcium channel blockers (CCBs) is one of the preferred choices to treat blood pressure (BP) and control blood pressure variability (BPV). In contrast to clinic BP, 24-hour ambulatory BP monitoring (ABPM) has evolved into an accurate and reproducible tool for the assessment and management of hypertension. Amlodipine, a longer acting dihydropyridine CCB is effective for 24 hours BP control and also minimizing BPV. The present article is the comprehensive review highlighting the efficacy of amlodipine in controlling 24-hour BP and minimizing BPV from the review of recent studies.

Materials and Methods The literature search was done using PubMed, Google Scholar, and MEDLINE databases. The studies to be included for review, were identified through the keywords: “amlodipine,” “ambulatory BP monitoring (ABPM),”“blood pressure variability (BPV),” “CCBs,” and filtering articles published in English language only.

Results Pharmacological evidence suggests that amlodipine has the ability to block all the subtypes of CCBs such as L-, N-, P-, Q-, R-, and T-type. Various clinical studies reported that amlodipine is a powerful, well-tolerated, and safe antihypertensive agent which is widely used either alone or as a key component of combination therapy for control of 24 hours BP.

Conclusion Overall, amlodipine is a proven and effective antihypertensive drug and helpful in controlling 24-hour BP, minimizing BP variability and hence reducing the risk of cardiovascular complications.

Nifedipine or amlodipine? The choice for hypertension during pregnancy: a systematic review and meta-analysis

BACKGROUND

There is a lack of sufficient evidence regarding efficacy and safety of amlodipine on treating hypertension during pregnancy.

OBJECTIVE

To compare antihypertensive efficacy, pregnancy outcome and safety of amlodipine with nifedipine on hypertension during pregnancy.

METHODS

A systematic search of PubMed, Embase, Cochrane Library, clinicaltrials.gov, Chinese National Knowledge Infrastructure, Wanfang Database and China Biology Medicine disc of randomized controlled trials (RCTs) up to April l5, 2021 was conducted on RCTs comparing amlodipine to nifedipine for the treatment of hypertension during pregnancy. Screening, data extraction, and quality assessment were done by two independent reviewers. To estimate relative effects from all available evidence, a meta-analysis was conducted.

RESULTS

Seventeen RCTs were included. Amlodipine was found the efficacy is slightly superior to nifedipine on treating hypertension during pregnancy (RR 1.06, 95% CI 1.01 to 1.10) with a decreased risk for maternal side effects (RR 0.42, 95% CI 0.29 to 0.61). Subgroup analysis found amlodipine can get a better control on SBP (RR - 11.68, 95% CI - 17.98 to - 5.37) and DBP (RR - 7.44, 95% CI - 13.81 to - 1.06) compared with intermediate-/long-acting nifedipine. In addition, there was no difference between amlodipine and nifedipine on pregnancy outcomes including caesarean section, premature labour, placental abruption, FGR, fetal distress, neonatal asphyxia.

CONCLUSIONS

Given the results of this systematic review and meta-analysis, amlodipine can be effectively and safely used for hypertension during pregnancy.

Serum uric acid change in relation to antihypertensive therapy with the dihydropyridine calcium channel blockers

PURPOSE

We investigated serum uric acid changes in relation to the achieved clinic and ambulatory blood pressure after 8 weeks of antihypertensive therapy with two dihydropyridine calcium channel blockers.

MATERIALS AND METHODS

The study participants were patients with clinic and ambulatory hypertension, enrolled in a randomised controlled trial that compared amlodipine (5-10 mg, n = 215) and nifedipine gastrointestinal therapeutic system (GITS, 30-60 mg, n = 203). Hyperuricaemia was defined as a serum uric acid concentration of ≥420 µmol/L in men and ≥360 µmol/L in women. Analysis of covariance and multiple regression analyses were performed to study the associations between serum uric acid changes and the achieved clinic and ambulatory blood pressure during follow-up.

RESULTS

At baseline, 67 (16.0%) of the 418 patients had hyperuricaemia. Antihypertensive treatment reduced clinic and 24-h daytime and night-time systolic/diastolic blood pressure by a mean (±standard error [SE]) change of -17.4 ± 0.6/-8.6 ± 0.4 mm Hg and -13.7 ± 0.5/-8.3 ± 0.3 mm Hg, -13.8 ± 0.6/-8.4 ± 0.4 mm Hg, and -12.7 ± 0.7/-8.0 ± 0.4 mm Hg, respectively. Antihypertensive treatment reduced serum uric acid by a mean (±SE) change of -9.3 ± 2.8 μmol/L. The serum uric acid changes differed according to the achieved clinic and ambulatory blood pressure, and were statistically significant (mean ± SE -20.6 ± 6.6 to -10.7 ± 2.9 μmol/L, p ≤ 0.04) at the systolic/diastolic ranges of 130-139/≥90 mm Hg in clinic pressure, and <130/75-84 mm Hg, <145/80-84 mm Hg and <120/65-69 mm Hg in 24-h, daytime and night-time ambulatory pressure.

CONCLUSION

Our study showed that antihypertensive therapy with a dihydropyridine calcium channel blocker was associated with reduced serum uric acid, especially when 24-h ambulatory systolic blood pressure was controlled.

Treatment effect of lacidipine and amlodipine on clinic and ambulatory blood pressure and arteria stiffness in a randomised double-blind trial

PURPOSE

In a randomised, double-blind trial, we investigated effects of lacidipine on clinic and ambulatory blood pressure (BP) and arterial stiffness in patients with mild-to-moderate hypertension, as compared with amlodipine.

MATERIALS AND METHODS

Previously untreated and treated patients (n = 269, 50-80 years of age) with clinic hypertension (a clinic systolic/diastolic BP 140-180/<110 mmHg and <160/100 mmHg, respectively) were randomly assigned to double-dummy treatment with lacidipine (4-6 mg/day) or amlodipine (5-7.5 mg/day) for 20 weeks. The primary efficacy variable was the change in 24-h ambulatory systolic BP at 20 weeks of treatment. Arterial stiffness was measured as brachial-ankle pulse wave velocity (PWV).

RESULTS

After 20 weeks of treatment, 24-h systolic BP decreased from 141.3 ± 14.0 and 138.3 ± 12.8 mmHg at baseline, respectively, in the lacidipine (n = 134) and amlodipine groups (n = 135), by a least square mean (±SE) change of 15.2 ± 1.3 and 15.5 ± 1.3 mmHg, respectively, with a between-group difference (95% confidence interval [CI]) of 0.3 mmHg (-3.4 to 4.1, p = 0.86). Similar results were observed for other ambulatory BP components and clinic BP. Clinic and ambulatory pulse rate did not significantly change in either group (p ≥ 0.21). PWV decreased significantly (p < 0.001) from baseline in both groups, with a non-significant between-group difference of 0.24 m/s (p = 0.45). The incidence rate of adverse events was 30.3% (n = 40) and 27.5% (n = 36) in the lacidipine and amlodipine groups, respectively (p = 0.61). No serious adverse event occurred in the trial.

CONCLUSIONS

Lacidipine effectively lowers clinic and ambulatory BP in patients with mild-to-moderate hypertension and significantly improves arterial stiffness, similarly as amlodipine.