Bloqueo del eje renina angiontensina aldosterona (RAAS) en la enfermedad renal diabética. Más allá del control de la hipertensión arterial / Renin angiotensin aldosterone system (RAAS) and its suppression in diabetic kidney disease. Control of arterial hypertension and beyond

La enfermedad renal diabética (ERD) es una comorbilidad con alta prevalencia a nivel mundial, siendo una de las complicaciones más frecuentes de la diabetes mellitus (DM). La ERD se relaciona con complicaciones cardiovasculares y progresión de la enfermedad renal crónica (ERC), por ello la identificación de factores modificables, como el control de la presión arterial, es uno de los pilares más importantes en el manejo integral. En esta revisión hacemos un recorrido sobre el papel de la hipertensión y el bloqueo del eje renina angiotensina aldosterona (RAAS) en el curso de la ERD y las estrategias terapéuticas orientadas a la reducción de la presión arterial (PA), el bloqueo RAAS y el impacto en resultados renales y cardiovasculares. El objetivo de este artículo es hacer una revisión de las intervenciones más importantes que actúan bloqueando el eje renina angiotensina aldosterona (RAAS) y determinar si estas medidas en los pacientes con ERD, solo tienen impacto en el control de la presión arterial o si también son estrategias de nefro y cardio-protección. Conclusión: La ERD es una de las complicaciones más frecuentes de la diabetes mellitus (DM). El control de la PA sigue siendo un pilar fundamental para lograr estos objetivos. Los bloqueadores del RAAS (iECAS y BRAs) son los antihipertensivos de elección con efecto terapéutico por el bloqueo RAAS y esto les permite tener además del control de la PA, efectos nefroprotectores y cardioprotectores importantes en pacientes con ERD, sobre todo cuando hay la presencia de albuminuria. Evaluamos que además de los inhibidores de la enzima convertidora de angiotensina (iECAs) y los bloqueadores del receptor de angiotensina (BRAs), vienen tomando importancia los antagonistas selectivos del receptor mineralocorticoide (ARM) como Finerenona.

Diabetic kidney disease (DKD) is a comorbidity with a high worldwide prevalence, and one of the most frequent complications of diabetes mellitus (DM). CKD is related to cardiovascular complications and the progression of chronic kidney disease (CKD), therefore the identification of modifiable factors, such as blood pressure control, is one of the most important pillars in comprehensive management. In this review, we will analyze the role of hypertension and the renin-angiotensin-aldosterone system (RAAS) and its suppression in the course of CKD, and therapeutic strategies aimed at reducing blood pressure (BP), RAAS blockade, and the impact on renal and cardiovascular outcomes. The objective of this article is to review the most important interventions that act by blocking the renin-angiotensin-aldosterone system (RAAS) and to determine if these measures in patients with CKD only have an impact on blood pressure control or if they are also nephron and cardio-protective strategies. Conclusion: DKD is one of the most frequent complications of diabetes mellitus (DM). BP control continues to be a fundamental pillar to achieve these objectives. RAAS blockers (iECAS and ARBs) are the first-line antihypertensive with a therapeutic effect due to RAAS blockade and this allows them to have, in addition to BP control, important nephroprotective and cardioprotective effects in patients with CKD, especially when there is albuminuria. We evaluated that in addition to angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), selective mineralocorticoid receptor antagonists (MRA) such as Finerenone are gaining importance.

Angiotensin receptor-neprilysin inhibitors and cardiac remodeling

The aim of this study was to determine how sacubitril/valsartan compared with valsartan in an outpatient setting affects left ventricular remodeling in heart failure with reduced ejection fraction and functional (or secondary) mitral regurgitation (SMR) due to the effect of dual inhibition of the renin-angiotensin system and neprilysin. The outpatient study included 90 patients with chronic SMR who were followed up for 12 months. They received sacubitril/valsartan or valsartan instead of the more commonly used angiotensin-converting enzyme inhibitor enalapril for heart failure, in addition to standard medical therapy for heart failure. The difference in NT-proBNP change between groups was the primary endpoint. Changes in effective regurgitation orifice area, left ventricular ejection fraction, left ventricular end-systolic and end-diastolic volume indices, left atrial volume index, E/e' index, and exercise tolerance on the 6-minute walk test were secondary endpoints. In the treatment efficacy analysis, NT-proBNP levels decreased significantly by 37% in the sacubitril/valsartan group and by 11% in the valsartan group (P<0.001). Ejection fraction and exercise tolerance (increase in walking distance in the 6-min test) increased in the sacubitril/valsartan group (P<0.05). Also, in this group, the effective area of the regurgitation orifice, the left atrial volume index, the E/e' index, and the indices of the end-systolic and end-diastolic volume of the left ventricle (P<0.05) decreased more pronouncedly. Compared with valsartan, treatment with sacubitril/valsartan led to a significant improvement in cardiac remodeling in patients with SMR and heart failure with reduced ejection fraction.

Use of Diuretics is Associated with Higher Risk of Sarcopenia in Older Adults with Hypertension

Abstract Background: Sarcopenia is a disease that involves skeletal muscle mass loss and is highly prevalent in the older adult population. Moreover, the incidence of sarcopenia is increased in patients with hypertension. Objectives: The study aimed to evaluate the association between the classes of the drugs used for arterial hypertension treatment and the presence or absence of sarcopenia. Methods: 129 older adults with hypertension were evaluated by the researchers who registered the participants medication for arterial hypertension treatment. Sarcopenia level was measured by anthropometric parameters, muscular strength, and functional capacity. The data were analyzed by one-way ANOVA followed by post-hoc test and Fisher's exact test; statistical significance was set at 0.05. Results: Age was not different between women with different levels of sarcopenia, but significant differences were observed between men with absent sarcopenia (66.8±4.2 years) and men with probable sarcopenia (77.0±10.2 years). Individuals with absent sarcopenia showed higher handgrip strength (men: 33.8±7.4, women: 23.2±4.6 Kgf) in comparison with those with sarcopenia (men with probable sarcopenia: 9.5±3.3 Kgf, women with probable, confirmed, and severe sarcopenia: 11.7±2.5, 12.2±3.0, 11.8±1.8 Kgf, respectively). The analysis showed an association between the type of medication and degree of sarcopenia; diuretics were significantly associated with probable sarcopenia, and angiotensin II receptor blockers (alone or in combination with diuretics) was associated with absence of sarcopenia. Conclusion: In conclusion, handgrip strength was a good method to diagnose sarcopenia, and diuretics were associated with increased risk of sarcopenia in older adults with hypertension.

Effects of antihypertensive drugs on renal function after percutaneous transluminal coronary angioplasty / 药学实践杂志

Objective To evaluate the effects of antihypertensive drugs on renal function after percutaneous transluminal coronary angioplasty. Methods A retrospective analysis was performed on 193 patients who underwent percutaneous transluminal coronary angioplasty and took antihypertensive drugs regularly. Those patients were admitted to Nanjing Drum Tower Hospital during January 2020 to December 2020. The patients were divided into ACEI/ARB group, β-blockers, calcium channel blockers and hydration control group. All patients received routine hydration during the perioperative period. The changes of serum creatinine (Scr), blood urea nitrogen (BUN), estimated glomerular filtration rate(eGFR) and endogenous creatinine clearance rate (Ccr) before and after operation were compared. Results The incidence of CIN was 0% in four groups. Compared with the preoperative, there was no significant change in Scr and Ccr in every group. Except for the hydration control group, the BUN levels in three treated groups were reduced after postoperative. Specifically, the BUN reduction in β-blockers group has statistically significant difference compared to the hydration control group and CCB group. In addition, eGFR levels were significantly reduced in the β-blockers group. Preoperative Scr and Ccr levels in patients with high blood pressure (SBP≥140 or DBP≥90) were significantly different from the patients with normal blood pressure (SBP<140 and DBP<90). Conclusion The use of ACEI/ARB and CCB before percutaneous transluminal coronary angioplasty had no effect on renal function in the short term. β-blockers can slightly reduce renal function, especially in patients with high blood pressure, who should receive special attention.

Improved histoarchitectural changes with angiotensin receptor blockers in early testicular and cauda toxicity in rats / Mejora de los cambios en la histoarquitectura con bloqueadores de receptores de angiotensina en la toxicidad precoz testicular y de cauda en ratas

SUMMARY: Reproductive dysfunction is a complication for many diseases and toxins. Its early diagnosis and treatment are immensely important. Here the morphological histoarchitecture changes in early testicular and cauda toxicity before and after treatment with angiotensin receptor blockers were evaluated. Low-grade testicular damage was induced using thioacetamide (TAA, 50 mg/kg/day) intraperitoneally for two weeks in rats. The rats were randomly divided into four groups (n = 8) treated daily orally for three weeks as follows: Normal control (distilled water), TAA (positive control), TAA+candesartan (0.2 mg/kg) and TAA+losartan (7.5 mg/kg). Serum testosterone and testicular malondialdehyde and glutathione were measured. The changes in histoarchitecture of testis and cauda epididymis were evaluated by hematoxylin and eosin for general structure, Masson's trichrome for collagen, periodic acid Schiff for basement membrane, and caspase-3 and proliferating cell nuclear antigen (PCNA) for immunohistochemical analysis. The TAA-rats showed decreases of serum testosterone and testicular glutathione, increases in testicular malondialdehyde, degenerative changes and apoptosis in germ cells, thickening of tubular basal lamina and increases in expression of caspase 3, and decreases in expression of PCNA. The ARBs (candesartan and losartan) significantly reversed these changes with non-significant differences in-between. Treatment with ARBs (candesartan and losartan) significantly reversed TAA-induced low-grade testicular and cauda toxicity in rats. This could be potentially useful for early treatment of male patients with occupational toxicant-induced reproductive dysfunction especially if they are using ARBs for other comorbidities.

RESUMEN: La disfunción reproductiva es una complicación por muchas enfermedades y toxinas. Su diagnóstico y tratamiento tempranos son inmensamente importantes. Aquí se evaluaron los cambios morfológicos en la histoarquitectura en la toxicidad precoz testicular y cauda antes y después del tratamiento con bloqueadores de receptores de angiotensina. Se indujo daño testicular de bajo grado usando tioacetamida (TAA, 50 mg / kg / día) por vía intraperitoneal durante dos semanas en ratas. Las ratas se dividieron aleatoriamente en cuatro grupos (n = 8) tratados diariamente por vía oral durante tres semanas de la siguiente manera: control normal (agua destilada), TAA (control positivo), TAA + candesartan (0,2 mg / kg) y TAA + losartán (7,5 mg / kg). Se midieron la testosterona sérica, el malondialdehído testicular y el glutatión. Los cambios en la histoarquitectura de los testículos y la epidermis de la cauda se evaluaron mediante Hematoxilina y Eosina para determinar la estructura general, con tricrómicro de Masson para el colágeno, ácido periódico de Schiff para la membrana basal y la caspasa-3 y el antígeno nuclear de células proliferantes (PCNA) para análisis inmunohistoquímico. Las ratas TAA mostraron disminución de la testosterona sérica y glutatión testicular, aumentos en el malondialdehído testicular, cambios degenerativos y apoptosis en células germinales, engrosamiento de la lámina basal tubular y aumentos en la expresión de la caspasa 3, y disminución en la expresión de PCNA. Los ARB (candesartán y losartán) revirtieron significativamente estos cambios con diferencias no significativas en el medio. El tratamiento con BRA (candesartán y losartán) revirtió significativamente la toxicidad testicular y cauda inducida por TAA en ratas. Esto podría ser potencialmente útil para el tratamiento temprano de pacientes con disfunción reproductiva inducida por tóxicos ocupacionales, especialmente si están usando BRA para otras comorbilidades.

Drug utilization study of antihypertensive drugs in a tertiary care hospital

Background: Hypertension is a major common disease and effects a million of people worldwide. And is risk factor for other diseases like cardiovascular diseases, stroke etc. The aim of our study was undertaken to study the utilization pattern of anti hypertensive drugs at a tertiary care hospital. The guidelines for the treatment of hypertension are put forward by the Joint National Committee (JNC) on detection, evaluation and treatment of blood pressure. The Indian guidelines endorsed by the cardiology society of India, the hypertension society of India, and Indian college of physicians closely follow the JNC guidelines.Methods: A prospective cross-sectional observational study was conducted on 100 patients in outpatient Department of General medicine of Government General Hospital, Mahabubnagar district, Telangana. The data collected was analysed from the prescription pattern of anti hypertensive drugs. The data collected were statistically analysed and presented as counts and percentages.Results: Out of 100 study subjects, males were 55% and females were 45% and maximum number of patients in age group are (51 to 60 years.). Among antihypertensive drugs commonly used in present study are Losartan (ARB’s)-64% and for two drug therapy are enalapril and amlodipine 22% and for three drug therapy are enalapril +atenolol+furosemide-14%. Average number of drugs prescribed is 6.15% per prescription. Percentages of medicines prescribed by generic drugs are85% and from the essential drug list are 95%.Conclusions: In this study usage of anti hypertensive drugs were prescribed rationally in tertiary care hospital. The study emphasizes that need for effective continuing medical education and also preventive measures in hypertensive individuals.

A study on management of hypertension in patients with type 2 diabetes mellitus in tertiary care teaching rural hospital

Background: This study was aimed to analyze the drug utilization pattern in the management of hypertension in diabetic patients.Methods: A prospective, observational and non interventional study was conducted in 100 diabetic hypertensive patients admitted in medicine wards at Dhiraj Hospital. Patients who signed informed consent form were only included in the study. All the data were recorded from patients’ case files and analyzed.Results: Of enrolled 100 patients, 69 (69%) were male and 31 (31%) were female and maximum number of the patients (42%) were found in the age group of 51-60 years. Out of 100 admitted patients, 75% patients were treated with single antihypertensive agent, 20% were treated with combination of two antihypertensive agents while only 5% were administered more than two antihypertensive agents. As a single antihypertensive agent, most commonly prescribed was ACE inhibitors (32%), Calcium Channel Blockers (23%), Angiotensin Receptor Blockers (12%) and ?1 blockers (8%).Conclusions: There was poor awareness among the patients regarding control of hypertension, regular follow up, medication adherence etc. However, two third of diabetic patients had achieved blood pressure target control and ACE inhibitor remained first choice of drug for hypertension in diabetes in this study.

Comparative study to evaluate efficacy and safety of azilsartan and telmisartan in patients with grade I-II essential hypertension

Background: Objectives of the study was to study the effect of Azilsartan 40mg once daily versus Telmisartan 40mg once daily in patients with Grade I-II essential hypertension.Methods: A prospective study was conducted at MGM Medical college and Hospital which included 80 patients in each group with Grade I–II essential hypertension. The sex, age, presenting illness, and family history of the patients were recorded. Investigations such as blood sugar, urine analysis, kidney function test, lipid profile, and ECG were performed before starting the treatment. Any adverse effects during the treatment were noted. Blood pressure was recorded at baseline and during follow-up. One group received Azilsartan 40mg once daily and another group Telmisartan 40mg once daily. Patients were followed-up every week for 5 weeks.Results: Patients receiving Azilsartan 40mg and Telmisartan 40mg showed a significant fall (P <0.05) in systolic (SBP) at the end of fifth week, when compared to baseline and diastolic blood pressure (DBP) significant fall at fourth and fifth week. The difference in fall in SBP and DBP was insignificant between the groups, after first, second and third week (P >0.05). Adverse effects such as Nasopharyngitis, Upper respiratory tract inflammation, Gastroenteritis, headache, dizziness, and fatigue were reported with both drugs.Conclusions: Reduction of blood pressure with Azilsartan and Telmisartan was similar, but fall in blood pressure from baseline was highly significant in both groups.

Renoprotection Provided by Dipeptidyl Peptidase-4 Inhibitors in Combination with Angiotensin Receptor Blockers in Patients with Type 2 Diabetic Nephropathy / 中华医学杂志(英文版)

Background@#Treatment with the dipeptidyl peptidase-4 inhibitors (DPP4i) and angiotensin receptor blockers (ARBs) in patients with type 2 diabetic nephropathy (DN) has not been well characterized. This study aimed to assess the renoprotection of this combined treatment in DN patients.@*Methods@#A total of 159 type 2 DN patients from 2013 to 2015 were enrolled retrospectively from a prospective DN cohort at the National Clinical Research Center of Kidney Diseases, Jinling Hospital (China). Fifty-seven patients received DPP4i and ARB treatment, and 102 patients were treated with ARBs alone. All patients were followed up for at least 12 months. Statistical analyses were performed using Stata version 12.0.@*Results@#There were no significant differences at baseline for age, sex, body mass index, duration of diabetes, fasting blood glucose (FBG), hemoglobin A1c (HbA1c), and estimated glomerular filtration rate (eGFR) between the two groups. Antihypertensive and antidiabetic medication use was similar in each group except calcium channel antagonists (P = 0.032). No significant changes in FBG and HbA1c were observed in the two groups after treatment. The eGFR decreased slower in the DPP4i + ARB group than in the ARB group at 12 months (Δ12 months: -2.48 ± 13.86 vs. -6.81 ± 12.52 ml·min·1.73m, P = 0.044). In addition, proteinuria was decreased further in the DPP4i + ARB group than in the ARB group after 24 months of treatment (Δ24 months: -0.18 [-1.00, 0.17] vs. 0.32 [-0.35, 0.88], P = 0.031). There were 36 patients with an eGFR decrease of more than 30% over 24 months. After adjusting for FBG, HbA1c, and other risk factors, DPP4i + ARB treatment was still associated with a reduced incidence of an eGFR decrease of 20% or 30%.@*Conclusions@#The combined treatment of DPP4i and ARBs is superior to ARBs alone, as evidenced by the greater proteinuria reduction and lower eGFR decline. In addition, the renoprotection of DPP4i combined with ARBs was independent of glycemic control.

Research progress of LCZ696 in patients with chronic heart failure / 中国综合临床

Chronic heart failure(CHF)is the performance of end-stage cardiovascular disease and the leading cause of death in recent years.With the rapid development of medical care,the mortality rate of heart failure is still high.This is one in the two major challenges in the cardiovascular field in the 21st century.The new drug LCZ696 is a dual inhibitors of angiotensin receptor blockers(ARB)and neprilysin(NEP),which may lead to new hope for patients with heart failure.In order to determine the efficacy and safety of LCZ696 in the treatment of heart failure,foreign countries have carried out some large-scale trials,such as PARAMOUT, PARADIGM,TITRATION and so on.The results of these studies reflected the superiority of LCZ696 compared with enalapril,valsartan and other drugs in the treatment of chronic heart failure.ARB/antiotensin converting enzyme inhibitors(ACEI)targets the angiotensin receptor to dilate blood vessels and inhibits the sympathetic nerve,but their effects on sodium withdrawal and diuresis are weak.The sacubitril in LCZ696 prevents natriuretic peptide from degrading,strengthens the natriuretic diuretic and further expansion of blood vessels.Thereby it improves water and sodium retention and cardiac function.It can play a better synergistic role combined with valsartan.

The factors influence the use of angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers (ACEI/ARB) in patients with acute myocardial infarction in Gansu, Ningxia, Qinghai and Xinjiang from 2001 to 2011 / 中华急诊医学杂志

Objective To investigate the rate of employing angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) therapy in patients with acute myocardial infarction (AMI) in Gansu,Ningxia,Qinghai and Xinjiang provinces from 2001 to 2011,in order to determine the factors affecting the use of ACEI/ARB.Methods The original data of this study were obtained from the China PEACE,a national retrospective study of AMI to evaluate clinical outcome of coronary heart disease from 31 provinces.A part of these data was selected from 8 cooperative hospitals (2 hospitals were tertiary class and 6 hospitals were secondary class) from Gansu,Ningxia,Qinghai and,Xinjiang provinces for further analyses.The clinical data of AMI patients in 2001,2006 and 2011 were collected to analyze the use of ACEI/ARB therapy in each of these years.Binary logistic regression analysis was used to identify factors influencing the use of ACEI/ARB.Results Of 311 eligible patients included,300 were categorized into Class Ⅰ AMI and 11 into Class Ⅱ a AMI according to Chinese guidelines.From 2001 to 2011,there wassignificant change in the use of ACEI/ARB in term of percentage in patients with Class Ⅰ AMI (69.57％,82.19％ and 60.77％,P =0.033),but such change did not occur in patients with Class Ⅱa AMI (40％,0％ and 60％,P =0.525).Among three specific years,the percentage of ACEIs employed was noticeably higher than that of ARBs.Binary logistic regression analysis showed that patients with hypertension (OR =2.3,95％ CI:1.3-4.1),heart failure (OR =1.95,95％ CI:1.7-5.8),smoking indulgence (OR =2.0,95％ CI:1.2-3.6) were more likely to be treated with ACEI/ARB,and patients with prior stroke (OR=0.3,95％CI:0.1-0.8),systolic blood pressure ＜90 mmHg (OR =0.1,95％CI:0-0.5)were less likely to be treated with ACEI/ARB.Conclusiorns In underdeveloped areas such as Gansu,Ningxia,Qinghai and Xinjiang provinces,the overall proportion of rational and necessary use of ACEI/ARB use in patients with AMI during hospitalization is still low.The rational use of ACEI/ARB lags behind the advance of medical condition progress,economic development and information availability,especially in patients with a history of stroke,low blood pressure.Patients with hypertension,heart failure,smoking indulgence were more likely to get ACEI/ARB therapy.The main reasons of this phenomenon were attributed to firstly the thorough understanding of standard medication guide to coronary heart disease to be lacking among some professionals,secondly,the side effects of these drugs to be unnecessary worried about among certain of doctors,and thirdly,low awareness of the pathogenesis of AMI disease and the lack of concerning for patients to be existent.

The factors influence the use of angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers (ACEI/ARB) in patients with acute myocardial infarction in Gansu, Ningxia, Qinghai and Xinjiang from 2001 to 2011 / 中华急诊医学杂志

Objective To investigate the rate of employing angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) therapy in patients with acute myocardial infarction (AMI) in Gansu,Ningxia,Qinghai and Xinjiang provinces from 2001 to 2011,in order to determine the factors affecting the use of ACEI/ARB.Methods The original data of this study were obtained from the China PEACE,a national retrospective study of AMI to evaluate clinical outcome of coronary heart disease from 31 provinces.A part of these data was selected from 8 cooperative hospitals (2 hospitals were tertiary class and 6 hospitals were secondary class) from Gansu,Ningxia,Qinghai and,Xinjiang provinces for further analyses.The clinical data of AMI patients in 2001,2006 and 2011 were collected to analyze the use of ACEI/ARB therapy in each of these years.Binary logistic regression analysis was used to identify factors influencing the use of ACEI/ARB.Results Of 311 eligible patients included,300 were categorized into Class Ⅰ AMI and 11 into Class Ⅱ a AMI according to Chinese guidelines.From 2001 to 2011,there wassignificant change in the use of ACEI/ARB in term of percentage in patients with Class Ⅰ AMI (69.57％,82.19％ and 60.77％,P =0.033),but such change did not occur in patients with Class Ⅱa AMI (40％,0％ and 60％,P =0.525).Among three specific years,the percentage of ACEIs employed was noticeably higher than that of ARBs.Binary logistic regression analysis showed that patients with hypertension (OR =2.3,95％ CI:1.3-4.1),heart failure (OR =1.95,95％ CI:1.7-5.8),smoking indulgence (OR =2.0,95％ CI:1.2-3.6) were more likely to be treated with ACEI/ARB,and patients with prior stroke (OR=0.3,95％CI:0.1-0.8),systolic blood pressure ＜90 mmHg (OR =0.1,95％CI:0-0.5)were less likely to be treated with ACEI/ARB.Conclusiorns In underdeveloped areas such as Gansu,Ningxia,Qinghai and Xinjiang provinces,the overall proportion of rational and necessary use of ACEI/ARB use in patients with AMI during hospitalization is still low.The rational use of ACEI/ARB lags behind the advance of medical condition progress,economic development and information availability,especially in patients with a history of stroke,low blood pressure.Patients with hypertension,heart failure,smoking indulgence were more likely to get ACEI/ARB therapy.The main reasons of this phenomenon were attributed to firstly the thorough understanding of standard medication guide to coronary heart disease to be lacking among some professionals,secondly,the side effects of these drugs to be unnecessary worried about among certain of doctors,and thirdly,low awareness of the pathogenesis of AMI disease and the lack of concerning for patients to be existent.

Telmisartan-induced sprue-like enteropathy: a case report and a review of patients using non-olmesartan angiotensin receptor blockers

Recent studies have identified sprue-like illness associated with the use of the antihypertensive agent olmesartan medoxomil. However, whether this condition is specific to the use of olmesartan or is associated with the use of drugs belonging to the class of “sartans” remains to be clarified. A 45-year-old woman with chronic kidney disease along with hypothyroidism and hypertension presented with chronic diarrhea and significant weight loss. Endoscopy of the upper gastrointestinal tract showed scalloping and grooving of the duodenum, and histopathological examination showed subtotal villous atrophy. She was on telmisartan for hypertension, which was discontinued. Subsequently, diarrhea ameliorated dramatically, and she regained weight. To our knowledge, this is the first study to report telmisartan-associated sprue-like enteropathy. Further, we have reviewed the cases of patients with sprue-like enteropathy caused by valsartan, irbesartan, and eprosartan.

Comparative study to evaluate efficacy & cost effectiveness of Olmesartan versus Telmisartan, in patients of stage I hypertension.

Background: Hypertension is one of the most common diseases in the world. It is an important and independent risk factor for atherosclerosis, heart failure, renal disease, and peripheral arterial disease. It is directly responsible for 57% of all stroke deaths and 42% of coronary heart disease deaths in India Objectives: To evaluate and compare efficacy and cost effectiveness in hypertensive patients receiving Olmesartan and Telmisartan in Stage I hypertension Material and methods: The present study was an open, prospective, randomized, parallel group comparative study conducted in 60 patients of stage I hypertension over a period of 16 weeks. Patients were randomly allocated to two, age and sex, matched groups of 30 patients each. Group I patients were started on Olmesartan at a dose of 20 mg & Group II patients were put on Telmisartan at a dose of 40 mg. The BP lowering efficacy and cost effective analysis of Olmesartan versus Telmisartan was calculated & compared. The data was entered in Microsoft excel and compiled. Statistical analysis was done using various tests. Results: Maximum patients in both the groups were in age group of 51-60 years. In group I there were 13 males and 17 females. In group II there were 14 males and 16 females. Both Olmesartan and Telmisartan are effective in lowering systolic & diastolic BP in supine & sitting positions & mean BP is also lowerer, more in Olmesartan group. By cost effective analysis Telmisartan was found more cost effective. Incremental cost effective ratio was found to be 218.35. Conclusion: Both Olmesartan and Telmisartan belong to the same antihypertensive drug class, effectively reduce systolic and diastolic blood pressure at various visits. Taking into account Total cost Telmisartan was more cost effective than Olmesartan. ICER was found to be 218.35.

Evidence-based medicine study on the effect of angiotensin converting enzyme inhibitors or angiotensin Ⅱ receptor blockers combined with low-dose spironolatone on diabetic nephropathy / 中华老年医学杂志

Objective To systemically review the efficacy and safety of low dose spironolatone combined with angiotensin convertig enzyme inhibitors (ACEI) or angiotensin Ⅱ receptor blockers (ARB) on diabetic nephropathy.Methods PubMed,the Cochrane library (Issue 4,2014),CBM,CNKI,VIP and WanFang Data were searched from inception to July 2014 for randomized controlled trials (RCTs) concerning ACEI or ARB combined with low-dose spironolatone in the treatment of diabetic nephropathy.Two reviewers screened literature according to the inclusion and exclusion criteria,extracted data,and assessed the methodological quality of included studies.Then Meta analysis was performed using RevMan 5.2 software.Results A total of 19 RCTs involving 1313 patients were included in this study.The results of Meta-analysis showed that compared with ACEI or ARB treatment alone,ACEI or ARB combined with low-dose spironolatone had lower urinary albumin excretion rate (UAER) [mean difference (MD) =21.03,95％ CI:18.51-23.56,P＜ 0.01] and proteinuria (MD=171.29,95％ CI:81.96-260.62,P＜0.01),and had no influence on plasma albumin (Alb) (MD=-0.25,95％ CI:-0.66-0.17,P＞0.05),meanwhile had lower serum creatinine (Scr) (MD=2.63,95％CI:0.92-4.34,P＜0.05),but had higher concentration of blood potassium (MD=-0.26,95％ CI:-0.37-0.14,P＜0.01).Conclusions ACEI or ARB combined with low-dose spironolactone can significantly reduce the urinary albumin level and delay the deterioration of renal function.Blood potassium concentrations in most patients are within the normal range,although it is increased after the treatment of ACEI or ARB combined with low-dose spironolactone.

Cardioprotective Effect of Fimasartan, a New Angiotensin Receptor Blocker, in a Porcine Model of Acute Myocardial Infarction

Cardioprotective effect of fimasartan, a new angiotensin receptor blocker (ARB), was evaluated in a porcine model of acute myocardial infarction (MI). Fifty swine were randomized to group 1 (sham, n=10), group 2 (no angiotensin-converting enzyme inhibitor [ACEI] or ARB, n=10), group 3 (perindopril 2 mg daily, n=10), group 4 (valsartan 40 mg daily, n=10), or group 5 (fimasartan 30 mg daily, n=10). Acute MI was induced by occlusion of the left anterior descending artery for 50 min. Echocardiography, single photon emission computed tomography (SPECT), and F-18 fluorodeoxyglucose cardiac positron emission tomography (PET) were performed at baseline, 1 week, and 4 weeks. Iodine-123 meta-iodobenzylguanidine (MIBG) scan was done at 6 weeks for visualization of cardiac sympathetic activity. Left ventricular function and volumes at 4 weeks were similar between the 5 groups. No difference was observed in groups 2 to 5 in SPECT perfusion defect, matched and mismatched segments between SPECT and PET at 1 week and 4 weeks. MIBG scan showed similar uptake between the 5 groups. Pathologic analysis showed similar infarct size in groups 2 to 5. Infarct size reduction was not observed with use of fimasartan as well as other ACEI and ARB in a porcine model of acute MI.

Importância da proteção cardiovascular durante o tratamento da hipertensão arterial: diferenças entre os agentes inibidores do sistema renina-angiotensina-aldosterona / Importance of cardiovascular protection during arterial hypertension treatment: differences among renin-angiotensin-aldosterone system inhibitors

A inibição do sistema renina-angiotensina-aldosterona (SRAA) demonstrou ser fundamental não somente no controle da hipertensão arterial, mas também na redução da progressão de doenças cardíacas, renais e vasculares, com impacto positivo na morbimortalidade. Diversas evidências revelam que o SRAA participa ativamente da origem da hipertensão arterial, com relação no desenvolvimento de obesidade, dislipidemia, resistência à insulina e doença crônica renal, além de ser o responsável pela homeostase eletrolítica. A ativação do SRAA se associa com níveis elevados de enzima conversora de angiotensina (ECA) e expressão aumentada de angiotensinogênio, fatores esses que levam ao aumento de angiotensina II, responsável por estresse oxidativo, vasoconstrição, hiperatividade do sistema nervoso simpático e aumento da reabsorção de sódio. O SRAA pode ser inibido em diferentes estágios e por mecanismos diversos, sendo que a forma como é inibido tem influência no prognóstico. E, dentre essas opções, há evidências claras do melhor benefício sobre a redução da mortalidade por todas as causas e da mortalidade cardiovascular com o uso dos inibidores da ECA (IECA) sobre os bloqueadores de receptores AT1 (BRA). Dentre os diferentes IECA, o perindopril, através de suas características específicas e benefícios clínicos comprovados em estudos randomizados de maior impacto, garante uma superioridade na proteção cardiovascular durante o tratamento dos pacientes hipertensos. Cabe destacar que os estudos que deram origem aos IECA tiveram a participação de pesquisadores brasileiros, com destaque para o Professor Sérgio Ferreira (Hospital das Clínicas da Universidade de São Paulo, Ribeirão Preto)

Renin-angiotensin-aldosterone system (RAAS) inhibition has demonstrated to be crucial not only to control arterial hypertension but also to reduce the progression of cardiac, renal and vascular diseases, with positive impact on morbidity-mortality. There is evidence revealing that RAAS participates actively on arterial hypertension origin, also taking part on obesity, dyslipidemia, insulin resistance and chronic renal disease, besides being responsible for electrolytic homeostasis. RAAS activation is associated with elevated levels of angiotensin conversion enzyme (ACE) and angiotensinogen overexpression, factors which increase angiotensin II, that induces oxidative stress, vasoconstriction, sympathy nervous systemhyperactivity and sodium reabsorption increase. RAAS may be inhibited in different stages and through different mechanisms, and the way it is inhibited is linked to prognosis. Among available options, there is clear evidence of a better benefit over all cause and cardiovascular mortality reduction when using ACE inhibitors (ACEI) over AT1 receptor blockers (ARB). Among different ACEI, perindopril, through its specific characteristics and clinical benefits proved on high level randomized trials guarantees a superior cardiovascular protection while treating hypertensive subjects. It's nice to highlight that Brazilian researches, mainly Professor Sérgio Ferreira (Hospital das Clínicas da Universidade de São Paulo, Ribeirão Preto), took part on the studies that discovered ACEIs.

Efficacy observation on Uremic Clearance Granule combined with ARB or ACEI for treating massive proteinuria in patients with diabetic nephropathy / 重庆医学

Objective To observe the effects of Uremic Clearance Granule combined with angiotensin receptor blockers (ARB) or angiotensin converting enzyme inhibitors (ACEI) in treating different period of diabetic nephropathy (DN ) .Methods 46 patients with DN were divided into the control group and the treatment group ,23 cases in each group .The two groups were given the rou-tine hypoglycemic therapy .The control group was treated with ACEI or ARB ,while the treatment group was given Uremic Clear-ance Granule 5 g each time ,four times daily for successive 4 weeks .Then the indexes of serum creatinine ,blood urea nitrogen ,cysta-tin-C ,microalbumin and 24 h urine total protein at 24 h before and after treatment were observed .Results The microalbumin and 24 h urine total protein after treatment in the two groups were reduced compared with before treatment (P0 .05) . In the patients with the stage Ⅳ of DN ,on the basis of ACEI or ARB adding Uremic Clearance Granule could significantly decrease the urine protein(P<0 .05) .Conclusion ACEI or ARB combined with Uremic Clearance Granule has definite effect for treating massive proteinuria of DN .

A system review: the effects of T-type CCB or ACEI /ARB for hypertensive patients with chronic kidney disease / 中国药学杂志

OBJECTIVE: To evaluate whether T-type CCBs are equivalent with or superior to ACEIs/ARBs on renal outcomes in hupertensive patients with chronic kidney disease. METHODS: Cochrane Library, Pubmed, EMbase and CNKI were searched for relevant randomized controlled trials (RCTs) from inception to May 2012. The meta-analysis was performed by Revman 5.1 software. RESULTS: Five RCTs (563 subjects) were included in the present study. T-type CCBs performed a pooled improvement in creatinine clearance and glomerular filtration rate similar to ACEIs/ARBs but were inferior to ACEIs/ARBs on reducing proteinuria excretion (three RCTs, 389 subjects, WMD 0.26 g·d-1, 95% CI 0.10 to 0.43), although T-type CCBs and ACEIs/ARBs showed stable anti-hypertensive effect. CONCLUSION: Our findings suggest that despite T-type CCBs do offer salutary effects on kidney outcomes and hypertension can be applied to treat hypertensive patients with chronic kidney disease, ACEIs /ARBs might be better choice for pressure control in this target population especially when proteinuria is the main issue of renal dysfunction.

Los antagonistas de los receptores de la angiotensina II a la luz de los estudios de mayor impacto / Los antagonistas de los receptores de la angiotensina II a la luz de los estudios de mayor impacto

Introducción: Los antagonistas de los receptores de la angiotensina II constituyen un grupo reciente de fármacos para el tratamiento de la hipertensión arterial (HTA), su utilidad se ha extendido además al manejo de la Insuficiencia cardiaca, la nefroproteccion y el infarto agudo de miocardio. Farmacología: Actúan sobre el sistema renina-angiotensina-aldosterona aunque de diferente forma, bloqueando la unión de la angiotensina II a los receptores tipo 1 de la angiotensina II presentes en numerosos tejidos (tejido muscular liso, glándula adrenal y miocardio) y, como consecuencia, inhiben su efecto vasopresor y liberador de aldosterona. Conclusiones: En la hipertensión arterial. Son la alternativa a los inhibidores de la enzima conversora de la angiotensina (IECA) cuando sea necesario utilizar un antihipertensivo del eje renina-angiotensina y el paciente no pueda o no deba utilizar un fármaco de dicho subgrupo. Como nefroprotectores. Si bien los Antagonistas de los receptores de la Angiotensina (ARA II) han disminuido los niveles de proteinuria en pacientes renales siguen siendo una alternativa a los IECA. En la insuficiencia cardiaca. Los IECA son el tratamiento inicial, mientras que los ARA II pueden ser útiles en pacientes que no los toleren. En el post infarto agudo de miocardio. Los IECA siguen siendo el tratamiento de elección y los ARA II la alternativa cuando el paciente no tolere los IECA.

Introduction: Angiotensin-receptor blockers constitute a recent group of medicaments for the treatment in hypertension, its usefulness has spread in addition to the managing of the cardiac Insufficiency, renal protection and acute myocardial infarction. Pharmacology: Alter renin-angiotensin-aldosterone system though of different form, blocking the unión of angiotensin II to its receptors (type 1) in numerous organs (muscle, adrenal gland and myocardium) and, its consequence, disable its vasopresor effect and aldosterone liberating. Conclusions: In hypertension. Angiotensin-receptor blockers are alternative to angiotensine-converting-enzime inhibitors when it is necessary to use these antihypertensives and the patient could not or should not use a medicament of the above mentioned subgroup. In renal protection. Though Angiotensin-receptor blockers have diminished the levels of proteinuria in renalpatients continued being an alternative to angiotensine-converting-enzime inhibitors. In cardiac insufficiency. Angiotensine-converting-enzime inhibitors are initial treatment, whereas Angiotensin-receptor blockers can be usefulin patients who do not tolerate them. In post-acute myocardial infarction. Angiotensine-converting-enzime inhibitors continued being treatment of choice and the alternative when patients do not tolerate these medicaments.