Leg edema with (S)-amlodipine vs conventional amlodipine given in triple therapy for hypertension: a randomized double blind controlled clinical trial

The therapeutic concordance approach reduces adverse drug reactions in patients with resistant hypertension

Background

Adverse drug reactions (ADRs) remain among the leading causes of therapy-resistant hypertension (TRH) and uncontrolled blood pressure (BP). We have recently reported beneficial results in BP control in patients with TRH adopting an innovative approach, defined as therapeutic concordance, in which trained physicians and pharmacists reach a concordance with patients to make them more involved in the therapeutic decision-making process.

Methods

The main scope of this study was to investigate whether the therapeutic concordance approach could lead to a reduction in ADR occurrence in TRH patients. The study was performed in a large population of hypertensive subjects of the Campania Salute Network in Italy (ClinicalTrials.gov Identifier: NCT02211365).

Results

We enrolled 4,943 patients who were firstly followed-up for 77.64 ± 34.44 months, allowing us to identify 564 subjects with TRH. Then, 282 of these patients agreed to participate in an investigation to test the impact of the therapeutic concordance approach on ADRs. At the end of this investigation, which had a follow-up of 91.91 ± 54.7 months, 213 patients (75.5%) remained uncontrolled while 69 patients (24.5%, p < 0.0001) reached an optimal BP control. Strikingly, during the first follow-up, patients had complained of a total of 194 ADRs, with an occurrence rate of 68.1% and the therapeutic concordance approach significantly reduced ADRs to 72 (25.5%).

Conclusion

Our findings indicate that the therapeutic concordance approach significantly reduces ADRs in TRH patients.

Ambulatory blood pressure response to S‐amlodipine in Korean adult patients with uncontrolled essential hypertension: A prospective, observational study

Although amlodipine is recommended as the first‐line therapy for the treatment of hypertension, its use is limited by its potential side effects. S‐amlodipine is expected to be able to minimize side effects of amlodipine with a similar antihypertensive effect by removing the malicious R‐chiral form. However, sustainable blood pressure control with S‐amlodipine has not been well established yet. The purpose of the current study was to evaluate ambulatory blood pressure (ABP) profiles before and after a 12‐week treatment of S‐amlodipine. Patients received once‐daily S‐amlodipine 2.5 or 5 mg. ABP during 24 hr and office blood pressure were measured at baseline and after the 12‐week treatment. Primary endpoints were changes of systolic and diastolic 24 hr ABP. After 12‐week S‐amlodipine treatment, mean systolic ABP (‐15.1 ± 16.2 mmHg, p < .001) and diastolic ABP (‐8.9 ± 9.8 mmHg, p < .001) were decreased significantly. Both daytime and night‐time mean systolic BP and diastolic BP were also significantly decreased after the 12‐week treatment. Global trough‐to‐peak ratio and smoothness index after 12‐week S‐amlodipine treatment were .75 and .79 for SBP and .65 and .61 for DBP, respectively. Age ≥65 years (hazard ratio [HR]: 3.13; 95% confidence interval [CI]: 1.67–14.3) and nonalcohol drinking (HR: 3.09; 95% CI: 1.34–7.17) were independent clinical factors for target ABP achievement. Adverse drug reactions (ADR) were developed in 16 (6.4%) patients, including two (.8%) cases of peripheral edema. In conclusion, this study demonstrated the efficacy and safety of S‐amlodipine in patients with uncontrolled essential hypertension.

Associations between systemic medications and development of wet age-related macular degeneration

PURPOSE

To examine whether systemic medications are associated with the subsequent development of wet age-related macular degeneration (AMD).

METHODS

A retrospective study of 259 562 individuals based on registry data, from January 1, 2001, to December 31, 2017. End-point event was the International Classification of Diseases (ICD)-10 diagnosis for wet AMD. Association between use of systemic medication covering 85 generic drugs categorized according to Anatomical Therapeutic Chemical (ATC) codes and the incidence of wet AMD was evaluated using multivariate Poisson regression model (adjusted for age, sex, diabetes, cancer and socioeconomic group) and nested case-control design.

RESULTS

The mean length of follow-up was 9.84 years. The number of cases with wet AMD was 2947 and incidence rate was 1.15 per 1000 person-years. After adjustment, we observed an increased risk for the development of wet AMD for patients exposed to amlodipine (IRR 1.33, 95% CI 1.16-1.53), or felodipine (1.24, 95% CI 1.02-1.50). Similarly, an increased risk of wet AMD was associated with the use of bicalutamide (2.14, 95% CI 1.14-4.02), estradiol (1.20, 95% CI 1.03-1.40) and atorvastatin (1.22, 95% CI 1.05-1.43). Of note, digoxin (0.72, 95% CI 0.57-0.91), and ramipril (0.80, 95% CI 0.65-0.99) users had a lower incidence of wet AMD.

CONCLUSIONS

Our findings suggest that the use of second-generation calcium channel blockers could be associated with an increased risk for wet AMD development. Of note, the incidence of wet AMD seemed to be lower in patients using ramipril and digoxin. More studies are needed to elucidate the associations further.

Telmisartan Plus S-Amlodipine Single-Pill Combination Therapy is Safe and Effective in Patients with Hypertension from Large-Scale Nationwide Surveillance Data in Korea (NOVEL) Study

INTRODUCTION

We investigate the safety and efficacy of telmisartan plus S-amlodipine single-pill combination in a real-world population.

METHODS

A total of 44,715 patients who had hypertension and received a telmisartan/S-amlodipine single-pill combination at least once were included for safety and efficacy evaluation from 2852 primary to tertiary hospitals in Korea from August 2013 to December 2019. They were followed up for 3-6 months in terms of safety and efficacy of blood pressure (BP) lowering.

RESULTS

A total of 44,715 patients were included for safety analysis and 41,579 for efficacy analysis. Mean duration of taking the drug was 175.86 ± 48.45 days. A total of 28,096 (62.8%) patients were on telmisartan 40 mg plus S-amlodipine 2.5 mg combination followed by 80/2.5 mg (8664, 19.4%) and 40/5 mg of the drug (7136, 16.0%). Adverse events, total adverse drug reactions, and serious adverse drug reactions were found in 808 patients (1.81%), 352 (0.79%), and 1 (0.002%), respectively. Dizziness and headache were most common (134 [0.30%] and 81 [0.18%]) among all adverse events. Total edema and leg edema were rarely reported, 38 (0.08%) and 25 (0.06%), respectively. Systolic BP (SBP) and diastolic BP (DBP) was lowered from 143.1 ± 16.1/88.1 ± 11.8 mmHg to 129.6 ± 11.4/80.1 ± 9.0 mmHg (difference - 13.5/- 7.9 mmHg, P < 0.0001 for both). Target BP goal attainment rate defined as SBP < 140 mmHg and DBP < 90 mmHg was 74.6% (95% confidence interval [CI] 74.2-75.0) and BP response rate (defined as SBP < 140 mmHg or ≥ 20 mmHg reduction; DBP < 90 mmHg or ≥ 10 mmHg reduction) was 94.5% (95% CI 94.3-94.7).

CONCLUSION

Telmisartan plus S-amlodipine single-pill combination was safe and effective in patients with hypertension in a large real-world population.

Effectiveness of Levoamlodipine Maleate for Hypertension Compared with Amlodipine Besylate: a Pragmatic Comparative Effectiveness Study

PURPOSE

Antihypertensive treatment is the most important method to reduce the risk of cardiovascular events in hypertensive patients. However, there is scant evidence of the benefits of levoamlodipine maleate for antihypertensive treatment using a head-to-head comparison in the real-world. This study aims to examine the effectiveness of levoamlodipine maleate used to treat outpatients with primary hypertension compared with amlodipine besylate in a real-world setting.

METHODS

This was a pragmatic comparative effectiveness study carried out at 110 centers across China in outpatients with primary hypertension treated with levoamlodipine maleate or amlodipine besylate, with 24 months of follow-up. The primary outcomes used for evaluating the effectiveness were composite major cardiovascular and cerebrovascular events (MACCE), adverse reactions, and cost-effectiveness.

RESULTS

Among the included 10,031 patients, there were 482 MACCE, 223 (4.4%) in the levoamlodipine maleate group (n = 5018) and 259 (5.2%) in the amlodipine besylate group (n = 5013) (adjusted hazard ratio = 0.90, 95%CI: 0.75-1.08, P = 0.252). The levoamlodipine maleate group had lower overall incidences of any adverse reactions (6.0% vs. 8.4%, P < 0.001), lower extremity edema (1.1% vs. 3.0%, P < 0.001) and headache (0.7% vs. 1.1%, P = 0.045). There was a nearly 100% chance of the levoamlodipine maleate being cost-effective at a willingness to pay threshold of 150,000 Yuan per quality-adjusted life years (QALYs) gained, resulting in more QALYs (incremental QALYs: 0.00392) and cost savings (saving 2725 Yuan or 28.8% reduction in overall costs) per patient.

CONCLUSION

In conclusion, levoamlodipine maleate could reduce cost by 29% with a similar MACCE incidence rate and lower occurrence of adverse reactions (especially edema and headache) compared with amlodipine besylate.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01844570 registered at May 1, 2013.

S-amlodipine improves endothelial dysfunction via the RANK/RANKL/OPG system by regulating microRNA-155 in hypertension

S-amlodipine has been broadly used to treat hypertension, but its protective effects and underlying mechanism remain controversial. The purpose of our study was to investigate the mechanism by which S-amlodipine improves endothelial dysfunction. Specifically, we investigated if S-amlodipine regulates RANK/RANKL/OPG and micro-RNA 155 (miR-155) levels. Spontaneous hypertensive rats (SHR) were randomly divided into two groups: SHR (n = 12) and S-amlodipine (n = 12). We found that left ventricular ejection fraction (LVEF) increased significantly in the S-amlodipine group compared to the SHR group. After 10 weeks of S-amlodipine treatment, tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) levels were significantly lower and eNOS and NO production was significantly higher in the S-amlodipine group compared to the SHR group. In human umbilical vein endothelial cells (HUVECs), miR-155, RANK, and RANKL levels were significantly decreased, while OPG mRNA levels were significantly increased in the S-amlodipine group. HUVECs were transfected with miR-155 mimics or an inhibitor to determine the relationship between miR-155 and RANK/RANKL/OPG and NF-κB signaling. OPG mRNA levels following miR-155 inhibition were significantly higher compared to levels following treatment with miR-155 mimics. S-amlodipine significantly inhibited RANKL expression and NF-κB phosphorylation, and there were no significant differences in response to the NF-κB inhibitor (Bay110785). RANKL expression and NF-κB phosphorylation significantly decreased in the miR-155 inhibitor group. Furthermore, OPG protein expression significantly increased in response to miR-155 inhibition and S-amlodipine treatment (all p < 0.05). Our results indicate that S-amlodipine inhibits inflammation and protects against endothelial dysfunction, likely via regulating the RANK/RANKL/OPG pathway, which appears to be downstream of miR-155.

Amlodipine-Induced Pedal Edema and Its Relation to Other Variables in Patients at a Tertiary Level Hospital of Kathmandu, Nepal

Background: Vasodilatory edema is a frequently encountered side effect among hypertensive patients using antihypertensive drugs. This dose-dependent adverse effect is seen more commonly with amlodipine, so low-dose combination therapy is often used and preferred in practice. Pedal edema following use of amlodipine is scarcely studied in Nepalese population so far. Objectives: To find out the prevalence of amlodipine-associated pedal edema and its relation with other variables among patients presenting to a tertiary care center of Kathmandu, Nepal. Methods: A prospective cross-sectional study was conducted among hypertensive patients using amlodipine in combination with or without other antihypertensive medications under regular follow-up in an outpatient department of internal medicine of Shree Birendra Hospital, Kathmandu, Nepal, during the 7-month period from September 2017 to March 2018. The prevalence of pedal edema and its relation with amlodipine dose, duration, and other factors were studied using χ² test and logistic regression using SPSS version 22. Results: A total of 505 patients were observed during the study period, with the mean age of the population being 61.5 ± 13.4 years. Among the cases studied, edema was present in 79 (15.6%) cases. Use of amlodipine longer than 5 years was 21.65 (confidence interval [CI] = 9.575-48.970, P ˂ .001) times more likely to exhibit pedal edema; similarly, there was 2.149 (CI = 1.209-3.820, P = .009) times higher risk of having pedal edema in hypertensive individuals with other comorbidities. Increasing the dose of amlodipine has increased the likelihood of having pedal edema, but it is not statistically significant (odds ratio = 2.804, CI = 0.423-18.584, P = .285). Conclusion and Relevance: Significant number of hypertensive patients using amlodipine developed pedal edema. Likelihood of vasodilatory edema increases with the presence of comorbidities, higher dose, along with longer duration of amlodipine use.

Combination treatment of captopril and prazosin to treat patients with gestational hypertension

Gestational hypertensive disorder is a complication of pregnancy, which adversely affects mother-child health. Captopril and prazosin are two agents that are frequently applied for the treatment of patients with gestational hypertension. However, the cooperative efficacy of captopril and prazosin has been not investigated in a previous study. In the present study, the comprehensive treatment of captopril and prazosin for the treatment of patients with gestational hypertension was investigated. A total of 324 patients with gestational hypertension were recruited to analyze the therapeutic effects of captopril and prazosin in patients with gestational hypertension. The duration of the treatment, dose-limiting toxicities and maximum tolerated dose of captopril and prazosin were examined in this cohort. Furthermore, the levels of blood pressure and proteinuria were also examined in patients with gestational hypertension who received treatment with captopril and/or prazosin with placebo as a control. Serum levels of vasodilation-converting enzyme and α-adrenergic receptor were also examined prior to and during the 4-week post-treatment period. It was observed that the most common treatment-emergence adverse events were hypertension and proteinuria following 4-week treatments. The data revealed that captopril or prazosin treatments significantly ameliorated gestational hypertension and symptoms compared with placebo (P<0.01). Notably, the combination of captopril and prazosin treatments significantly ameliorated hypertension and proteinuria and reduced the expression levels of vasodilation-converting enzyme and α-adrenergic receptor (all P<0.01), which contributed to beneficial effects on complications and blood coagulation mechanism compared with either captopril or prazosin treatment. In conclusion, the present clinical study indicated that combination treatment of captopril and prazosin exhibited more efficient outcomes than the single agent by improving gestational hypertension, indicating that a comprehensive therapeutic regimen of captopril and prazosin may be a potential clinical opinion for patients with gestational hypertension.

S-Amlodipine: An Isomer with Difference-Time to Shift from Racemic Amlodipine

Calcium channel blockers are among the first-line drugs for treatment of hypertension (HTN). S-amlodipine (S-AM), an S-enantiomer of amlodipine, is available in India and in other countries like China, Korea, Russia, Ukraine, and Nepal. Being clinically researched for nearly two decades, we performed in-depth review of S-AM. This review discusses clinical evidence from total 42 studies (26 randomized controlled trials, 14 observational studies, and 2 meta-analyses) corroborating over 7400 patients treated with S-AM. Efficacy and safety of S-AM in HTN in comparison to racemic amlodipine, used as monotherapy and in combination with other antihypertensives, efficacy in angina, and pleiotropic benefits with S-AM, are discussed in this review.

Efficacy and Safety of S-Amlodipine 2.5 and 5 mg/d in Hypertensive Patients Who Were Treatment-Naive or Previously Received Antihypertensive Monotherapy

The aim of the present study was to evaluate the efficacy and safety of S-amlodipine 2.5 and 5 mg/d in patients with hypertension who were treatment-naive or previously received antihypertensive monotherapy. During the 8-week treatment period, all patients received S-amlodipine 2.5 mg/d for the first 4 weeks, followed by S-amlodipine 5 mg/d for the second 4 weeks. For efficacy assessments, ambulatory and office blood pressure (BP) measurements were performed during the baseline, fourth-week, and eighth-week visits. For safety assessments, all adverse events and abnormal laboratory findings were recorded. This study is registered with ClinicalTrials.gov (NCT03038451). Of 43 patients evaluated at the screening visit, 33 were enrolled. In the treatment-naive arm, significant reductions in both office and ambulatory systolic BP (SBP) and diastolic BP (DBP) were observed with S-amlodipine 2.5 mg/d and additional significant reductions were achieved with dose titration (S-amlodipine 5 mg/d). At the end of the study, the rate of the treatment-naive patients with BP under control (SBP/DBP <140/90 mm Hg) was 53% with S-amlodipine 2.5 mg and increased to 78% with S-amlodipine 5 mg. For the noninferiority evaluation, S-amlodipine 2.5 and 5 mg/d treatments were generally noninferior to both office and ambulatory BP levels achieved with the medications that the patients received before participating in the study. Five nonserious adverse events likely to be associated with the study drug were observed. No serious adverse event was encountered. Consequently, S-amlodipine can be suggested as an effective and safe treatment option for patients with hypertension.

Influence of Amlodipine Enantiomers on Human Microsomal Cytochromes P450: Stereoselective Time-Dependent Inhibition of CYP3A Enzyme Activity

Amlodipine (AML) is available as a racemate, i.e., a mixture of R- and S-enantiomers. Its inhibitory potency towards nine cytochromes P450 (CYP) was studied to evaluate the drug–drug interactions between the enantiomers. Enzyme inhibition was evaluated using specific CYP substrates in human liver microsomes. With CYP3A, both enantiomers exhibited reversible and time-dependent inhibition. S-AML was a stronger reversible inhibitor of midazolam hydroxylation: the K_i values of S- and R-AML were 8.95 µM, 14.85 µM, respectively. Computational docking confirmed that the enantiomers interact differently with CYP3A: the binding free energy of S-AML in the active site was greater than that for R-AML (−7.6 vs. −6.7 kcal/mol). Conversely, R-AML exhibited more potent time-dependent inhibition of CYP3A activity (K_I 8.22 µM, K_inact 0.065 min⁻¹) than S-AML (K_I 14.06 µM, K_inact 0.041 min⁻¹). R-AML was also a significantly more potent inhibitor of CYP2C9 (K_i 12.11 µM/S-AML 21.45 µM) and CYP2C19 (K_i 5.97 µM/S-AML 7.22 μM. In conclusion, results indicate that clinical use of S-AML has an advantage not only because of greater pharmacological effect, but also because of fewer side effects and drug–drug interactions with cytochrome P450 substrates due to absence of R-AML.