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What is the plasma cofactor required by diuretics for direct vascular relaxant effect in vitro?

OBJECTIVE: To determine the plasma cofactor which is required by diuretics (hydrochlorothiazide, chlorthalidone, indapamide, and furosemide) for direct vasorelaxant effects in vitro. DESIGN: A randomized, double-blind, vehicle-control design was used to avoid experimenter bias. METHODS: We plotted concentration-response curves for responses to hydrochlorothiazide, chlorthalidone, indapamide, and furosemide of male Wistar rat aortic rings in the presence of different bath solutions containing various plasma factors. RESULTS: Plasma was found both to make possible and facilitate the vasodilator action of the diuretics tested by an action on the membrane and to decrease the action by binding the diuretics. The diuretics retained their vasorelaxant properties in Krebs solution alone, 30 min after having been incubated in a 50:50 solution of Krebs solution and plasma for 1 h. All four diuretics exerted significant vasorelaxant actions in Krebs solution-plasma, Krebs solution-serum, and Krebs solution plus human or bovine albumin (40 g/l) media. No vasorelaxant action was found in Krebs solution alone, Krebs solution plus denatured plasma, Krebs solution plus egg albumin, and Krebs solution plus insulin. CONCLUSION: Albumin is the main cofactor required by the diuretics tested for direct relaxant action in vitro, and these findings may explain some of the contradictory evidence concerning this action in the literature.

Animals↗

Vascular factors and cognition: toward a prevention of dementia?

High blood pressure is a known risk factor for stroke and dementia. However, very little is known about the prevention of dementia by lowering blood pressure. Perindopril pROtection aGainst REcurrent Stroke Study (PROGRESS) was designed to determine the effects of an angiotensin-converting enzyme (ACE) inhibitor-based blood pressure-lowering regimen on the risk of stroke among individuals with a prior stroke or transient ischaemic attack (TIA). One of the important aims of the study was to test the hypothesis that treatment would reduce the incidence of dementia and cognitive decline. A total of 6105 patients were randomized to active treatment or placebo. Active treatment comprised perindopril for all participants, and indapamide for those with neither a specific indication for, nor a contraindication to, a diuretic. Dementia was diagnosed according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Cognitive decline was defined as a drop of 3 points or more on the Mini-Mental State Examination (MMSE) between baseline and final follow-up. During a median follow-up of 3.9 years, dementia was diagnosed in 410 patients and cognitive decline in 610. Active treatment reduced the risk of cognitive decline (risk reduction [RR] 19%; 95% confidence interval [CI], 4-32; P = 0.01] but there was no clear reduction in the risk of dementia (RR, 12%; 95% CI, -8-28; P = 0.2]). The RR for cognitive outcomes preceded by a recurrent stroke was 34% (95% CI, 3-55; P = 0.03) for dementia and 45% (95% CI, 21-61; P = <0.001) for cognitive decline. Among individuals with a history of stroke or TIA, blood pressure-lowering treatment reduced the risk of cognitive decline by about one fifth. Cognitive decline and dementia associated with recurrent stroke during follow-up were each reduced by between one third and one half. These findings provide further support for the recommendation that blood pressure lowering with perindopril and indapamide be considered for all patients with cerebrovascular disease.

Aged↗

Reversal of left ventricular hypertrophy: what have recent trials taught us?

Regression of left ventricular hypertrophy (LVH) is an important intermediate target for antihypertensive therapy. Thus, several trials and meta-analyses have attempted to compare the effects of different antihypertensive agents on LVH, but flawed study designs and methodologic problems have limited the utility of these studies. PRESERVE (Prospective Randomized Enalapril Study Evaluating Regression of Ventricular Enlargement), LIVE (LVH: Indapamide Sustained Release Versus Enalapril) and LIFE (Losartan Intervention For Endpoint reduction in hypertension) represent a new generation of large well designed trials with the power to compare different antihypertensive drugs. These studies have shown that treatment regimens based on enalapril and a nifedipine gastrointestinal therapeutic system are of similar efficacy (PRESERVE), that indapamide sustained release (SR) is superior to enalapril (LIVE), and that a regimen based on losartan is superior to a regimen based on atenolol (LIFE) in reversing hypertensive LVH. LIVE incorporated on-treatment echocardiographic quality control, with centralized readers blinded for both treatment and sequence of recording. The findings of these rigorous studies, to some extent in disagreement with results of previous meta-analyses, support the notion that antihypertensive drugs need to be judged on their individual effects on important intermediate endpoints such as LVH in well designed and adequately sized studies. However, extrapolation of the results of these studies in terms of class effects could be misleading and should be made with caution.

Antihypertensive Agents↗

Rationale and design of the ADVANCE study: a randomised trial of blood pressure lowering and intensive glucose control in high-risk individuals with type 2 diabetes mellitus. Action in Diabetes and Vascular Disease: PreterAx and DiamicroN Modified-Release Controlled Evaluation.

RATIONALE: Individuals with type 2 diabetes mellitus have an increased risk of vascular disease, which is reduced by lowering the blood pressure of patients with hypertension. However, the association between blood pressure and vascular risk appears to be continuous across a broad range of values of blood pressure, and it is likely that blood pressure-lowering will confer similar benefits in nonhypertensive individuals. Intensive glucose-lowering in these patients have also been shown to reduce microvascular disease, but the effects on macrovascular outcomes remain uncertain. OBJECTIVES: To determine the effects on macrovascular and microvascular disease of first, lowering blood pressure using a very-low-dose angiotensin-converting enzyme (ACE) inhibitor-diuretic combination compared with placebo; and second, intensive glucose control targeting a glycated haemoglobin A1c concentration of 6.5% or less compared with usual glucose control, in high-risk hypertensive and non-hypertensive individuals with type 2 diabetes. DESIGN: A 2 x 2 factorial randomised, controlled trial with a scheduled period of treatment and follow-up of 4.5 years. SETTING: The study will be conducted in approximately 200 centres in Australasia, Asia, Europe and North America. PARTICIPANTS: The study will include 10000 adults with type 2 diabetes at increased risk of vascular disease. Individuals will be eligible irrespective of baseline blood pressure, baseline glucose concentration or requirement for background ACE inhibitor treatment. INTERVENTIONS: After 6 weeks receiving the active perindopril-indapamide combination, eligible individuals will be randomly allocated to receive continued very-low-dose perindopril-indapamide combination or matching placebo; and to an intensive modified-release gliclazide-based glucose control regimen, or usual guidelines-based treatment. STUDY OUTCOMES: The primary outcomes are, first, the composite of non-fatal stroke, non-fatal myocardial infarction or cardiovascular death and, second, the composite of new or worsening nephropathy or diabetic eye disease. Secondary outcomes include cause-specific cardiovascular end-points in addition to dementia and all-cause mortality.

Adult↗

[Functional status of the circulatory system in during dynamics of treating arterial hypertension in patients with vibration disease].

AIM: To develop medicinal approaches to correction of hemodynamic disturbances in vibration disease (VD) associated with arterial hypertension. MATERIAL AND METHODS: The study compared hypotensive and hypodynamic efficiency of amlodipin, diltiazem, enalapril, perindopril and indapamide in 74 VD patients with arterial hypertension (SAP 140-179 mm Hg, DAP 90-109 mm Hg; mean age 54.8 years, mean exposure to vibration 26.8 years). Before and after the treatment course the patients were examined with ultrasound by the following parameters: left ventricular contractility, left and right ventricular diastolic function, left atrial function. RESULTS: Amlodipin reduced left ventricular volume both in systole and diastole as well as maximal intramyocardial tension without significant change in contractility, raised a contraction reserve of the left atrium, improved ventricular relaxation. Diltiazem potentiates contractility of the left ventricle and atrium without marked impact on relaxation and tension of the myocardium. Enalapril and perindopril cause positive hemodynamic shifts. Perindopril vs enalapril was more effective in easing intramyocardial systolic tension of the left ventricular wall and in improving the diastolic function. Indapamid vs calcium antagonists and ACE inhibitors had a weaker effect on arterial pressure, no significant effect on left ventricular contraction, peripheral hemodynamics. Left atrial function was hyperactive. This was observed also in response to the other drugs. CONCLUSION: Amlodipin produced in patients with VD and AH more positive hemodynamic effects, reduced isotonic hyperfunction of the left ventricle, improves diastolic function of the ventricles. Amlodipin and perindopril are more promising prognostically in relation to reduction of left ventricular myocardial mass.

Antihypertensive Agents↗

New treatment guidelines for a patient with diabetes and hypertension.

Guidelines for medical treatment are becoming increasingly popular and many guidelines have been produced by various societies in diabetes, hypertension, and renal disease as well as general medicine. By their nature, they are outdated considering the rapid and efficient publication of many papers related to the treatment of hypertension in diabetes. Increased blood glucose causes vascular damage and abnormal vascular structure all over the body, an abnormal structure that is especially vulnerable to high blood pressure, even within the so-called normal range. There is now more and more evidence, especially in diabetics, that blood pressure should be as low as possible. In this context, it is important to stress that the so-called J-shaped relationship between blood pressure and mortality may not be so relevant. Major epidemiological studies came from the Framingham and the Multiple Risk Factor Intervention Trial (MRFIT) Diabetic Cohort. The MRFIT Cohort showed that cardiovascular mortality was increased by a factor of 2-4 in diabetic patients, and there was a clear association between systolic blood pressure and complications without any threshold value. It could be suggested that since diabetes is an important cardiovascular risk factor, a lower value (130/85 mmHg) than for non-diabetics (140/90 mmHg) should be proposed. The tight blood pressure control arm of the United Kingdom Prospective Diabetes Study was <150/85 mmHg (achieved 144/82 mmHg) and the aim in the less tight control arm was <180/105 mmHg (achieved 154/87 mmHg). In the tight control group, 29% needed three or more antihypertensive drugs. In the Hypertension Optimal Treatment study, the frequency of major cardiovascular disease events in the group with target <80 mmHg (achieved 144/81 mmHg) was 11.9/1000 patients/year, which was significantly lower than the event rate (24.4/1000 patients/year) in the group with target <90 mmHg (achieved 148/85 mmHg). A reduction in the frequency of diabetic nephropathy by angiotensin-converting enzyme (ACE) inhibitor treatment in normotensive lean microalbuminuric type 2 diabetic patients has been shown. However, it is impossible from the present data to draw any conclusions with respect to effect on the main composite endpoint of ACE inhibition in microalbuminuric type 2 diabetic patients without previous cardiovascular events or without hypertension. Recent published studies have also demonstrated beneficial effects with angiotensin receptor blockers (ARBs) in hypertensive patients with type 2 diabetes and nephropathy. Diuretics form a very important basis for antihypertensive treatment, also often in combination with agents that inhibit the renin-angiotensin system. Several studies show that treatment with the diuretic indapamide reduces the level of microalbuminuria in patients with type 2 diabetes. Diuretics were used as an adjunctive to reduce blood pressure in all studies; it is therefore understandable that many guidelines suggest that diuretics form part of the treatment of hypertension in diabetics. Many studies of an epidemiological nature and follow-up studies in diabetic patients show that blood pressure control is of vital concern in the prevention of diabetic complications, and indeed the usual criteria for good blood pressure control may not be stringent enough in diabetic patients. Many classes of antihypertensives may be used, but it appears that diuretics, such as indapamide sustained release (SR), constitute an important proposal in all treatment strategies.

Albuminuria↗

[Antihypertensive therapy in the nineties].

The risk for cardiovascular complications is already substantially increased in persons with borderline elevation of arterial pressure (141-159/90-94 mmHg and transiently below). It increases progressively with higher grades of hypertension. The main aim of treatment is thus a significant improvement in survival for the patient. Persons with raised blood pressure (BP) have often additional cardiovascular risk factors such as deranged carbohydrate metabolism, dyslipidemia, left ventricular hypertrophy, smoking and others. Treatment of hypertensive patients should thus not only normalize BP but should at the same time reduce associated risk factors or at least not increase them. Conventional antihypertensive treatment based on thiazides in high doses or beta-blocking agents led to marked reduction of strokes and heart failure, but did not satisfactorily reduce coronary heart disease or sudden cardiac death. It has been suspected that other cardiac risk factors are insufficiently influenced or eventually even deteriorated by conventional therapy, thus counteracting partly a beneficial effect of lowered BP. Beta-blockers however have at least a secondary preventive effect after myocardial infarction. Newer antihypertensive drugs such as ACE-inhibitors, calcium antagonists and alpha 1-blockers reduce left ventricular hypertrophy and are at least neutral with regard to metabolism of lipids and carbohydrates. The non-thiazide diuretic indapamide and the serotonin (S2-) blocker ketanserin likewise are neutral with regard to glucose and lipid metabolism. The efficacy of these new drugs regarding long term survival is as yet undetermined. Persisting borderline or established hypertension should as a rule always be approached with basic non-pharmacologic measures: loss of overweight, reduction of alcohol intake, exercise, avoidance of high salt foods, abstention from smoking and withdrawal of BP-raising drugs. If antihypertensive medication is indicated, potential first line drugs are ACE-inhibitors, calcium antagonists, beta-blockers, thiazides at low dose, indapamide, ketanserin, the alpha 1-blocker prazosin and others; initially as monotherapy, if needed in combinations of 2 or 3. Older patients or those will with additional disturbances such as diabetes, hypercholesterolemia, nephropathy, heart failure, ischemic heart disease, arrhythmias, claudication, asthma and others need problem-adjusted modifications of treatment.

Antihypertensive Agents↗

[Pharmacological cost-efficacy of various schemes of combined antihypertensive therapy in elderly patients].

AIM: To validate optimal cost-effective pharmacological policy in combined therapy of elderly hypertensive patients. MATERIAL AND METHODS: In 150 patients of a day hospital aged 55-74 years with at least stage II arterial hypertension of 4-40 years of duration a study was made of the cost efficacy of their combined treatment. The patients received lisinopril, metoprolol, nifedipin, enalapril, hypothiaside, indapamid. Clinical efficacy was assessed by the following criteria: a fall in systolic arterial pressure to at least 139 mm Hg or at least by 20% of the baseline, a fall in diastolic pressure to at least 89 mm Hg or 10% of the baseline. Economic parameters included cost of the disease, cost/effect values. RESULTS: Combination egilok+hypothiaside was the cheapest but the least effective. Diroton+indap combination was cheaper than less effective combination cordipin-retard+hypothiaside and renitek-hypothiaside. Pharmacological and cost efficacy of diroton+indap combination was the highest. CONCLUSION: Combination of lisinopril with indapamid was most adequate as to its cost and effect and can be used as a medication of the first line in elderly hypertensive patients.

Aged↗

[The place of diuretics in the treatment of chronic heart failure. Part I].

In series of papers the authors analyze the literature data concerned with clinical pharmacology of four main classes of diuretics and their use in long-term treatment of congestive chronic heart failure (CHF). Part I is devoted to basic clinical pharmacology of three main classes of diuretics -- loop, thiazide and potassium-sparing. The site of action in nephron, mechanisms and duration of action different loop and thiazide diuretics with emphasis to furosenide, torasemide, hydrochlorothiazide, metolazone and indapamide as well as contraindications and limitations for their use in the complex treatment of CHF are considered in detail. In long-term comparative studies showed long acting loop diuretic torasemide improved symptomatology and functional class of NYHA in patients with CHF in compared with furosenide. Thiazide-like diuretic indapamide does also act as vasodilator and decreases afterload of left ventricle of heart. But indapanide should be used with special caution because of their capacity to prolong the Q-T interval, which associates with polymorphic ventricular tachycardia, or torsades de poites.

Diuretics↗

[Effects of antihypertensive therapy on the renal function in spontaneously hypertensive rats (SHR) with renal ablation].

To determine whether pharmacological control of blood pressure could affect the renal function and its deterioration in SHR with renal ablation, we studied effects of oral administration of captopril (50 mg/kg/day) and ramipril (10 mg/kg/day), angiotensin converting enzyme inhibitors (ACEI), nilvadipine (10 mg/kg/day) and benidipine (3-6 mg/kg/day), calcium channel blockers (CCB), and indapamide (10 mg/kg/day), a non-thiazide diuretic, for 2 and 12 weeks on systolic blood pressure (SBP), blood urea nitrogen (BUN) and serum creatinine (Scr), endogenous creatinine clearance (Ccr), and urinary protein excretion (UP) in SHR subjected to 5/6 nephrectomy a week before. Three weeks after the surgery, SBP (mmHg) in the untreated group was 253 +/- 8.9 (n = 11), captopril group 156 +/- 8.9 (n = 7, p less than 0.05), ramipril group 176 +/- 12 (n = 7, p less than 0.05), nilvadipine group 146 +/- 8.8 (n = 7, p less than 0.05), and benidipine group 197 +/- 8.5 (n = 7, p less than 0.05). Monotherapy with indapamide (206 +/- 4.8, n = 7, p less than 0.05) induced only a slight decrease in the SBP. Thirteen weeks after the surgery, SBP in the untreated group was 270 +/- 6.9 (n = 14), in the captopril group 191 +/- 4.8 (n = 7, p less than 0.05), in the ramipril group 160 +/- 9.5 (n = 7, p less than 0.05), in the nilvadipine group 177 +/- 13.2 (n = 7, p less than 0.05), and in the benidipine group 150 +/- 4.9 (n = 7, p less than 0.05). BUN was lower in the captopril and nilvadipine groups but not in the other treatment groups compared with the untreated group. Scr was lower in the ACEI groups. Ccr was higher in the ACEI and benidipine groups. UP was lower in all treatment groups. These results indicate that the similar reduction of SBP by ACEI and CCB has the potential to preserve renal function and to lessen renal damage in this model. Furthermore, they also suggest that ACEI have the potential to ameliorate renal function in this model. However, it remains to be determined why, despite the similar effects on SBP, deterioration of renal function in this model was prevented only by treatment with the ACEI, but not with the CCB.

Animals↗

Sodium, large arteries, and diuretic compounds in hypertension.

Clinical and experimental data have shown that antihypertensive drugs do not cause the same change in arterial compliance for an equipotent blood pressure reduction. However, there is not clear data on the effect of sodium and diuretics on the visco-elastic properties of the hypertensive arterial wall. Cross-sectional epidemiologic studies suggest that, at any given value of age and blood pressure, pulse wave velocity is lower in the presence of decreased sodium intake. Longitudinal studies indicate that, in hypertensive subjects, low sodium intake is associated with a larger brachial artery diameter than is high sodium intake. In hypertension in the elderly and in severe hypertension with end-stage renal disease, sodium overload causes a reduction in arterial compliance and distensibility unrelated to blood pressure changes. In animal studies, the diuretic compounds cycletanine and indapamide were shown to increase systemic and carotid compliance independently of blood pressure changes. In contrast, a crossover study of hypertensive subjects showed that the diuretic agent hydrochlorothiazide did not change arterial compliance and pulse wave velocity, whereas the calcium entry blocker, felodipine, improved these parameters. Nevertheless, indapamide decreased the pulse pressure on stroke volume ratio, a parameter used as a marker of aortic distensibility. Taken together, such studies indicate that sodium may act on the arterial wall independently of blood pressure changes. The contribution of counter regulatory mechanisms, possibly related to the renin-angiotensin and sympathetic nervous systems, might explain the differences between the clinical and experimental changes observed with diuretic compounds. Of the various antihypertensive agents, diuretics seem to have the least effect on the arterial system.

Animals↗

Torsade de pointes and sudden death associated with diabetic autonomic diarrhoea--a case report.

A 68-year-old diabetic and hypertensive woman presented with chronic autonomic diarrhoea, syncope and palpitations which were associated with QT prolongation and recurrent episodes of torsade de pointes. She was on glibenclamide, indapamide and probucol (for type V hyperlipidaemia). Despite intravenous infusions of potassium, lignocaine and amiodarone, the unstable rhythm persisted. However, intravenous magnesium sulphate with small doses of intravenous propranolol terminated the torsade de pointes. She was stabilised but following discharge she relapsed, and upon re-admission, succumbed to intractable ventricular fibrillation. Early recognition and aggressive treatment of this condition is emphasised. Multiple aggravating factors ie autonomic diarrhoea resulting in severe potassium and magnesium depletion, kaliuretic effect of indapamide, probable QT prolongation associated with diabetic autonomic neuropathy and probucol; probable underlying coronary artery disease and heightened emotional and sympathetic discharge could have contributed to this very unstable ventricular arrhythmia and sudden death.

Aged↗

Mechanism of alpha-2 adrenergic modulation of canine cardiac Purkinje action potential.

We reported recently that stimulation of postjunctional alpha-2 adrenergic receptors prolongs the action potential durations (APD) of isolated canine Purkinje fibers. With standard microelectrode techniques, we examined the ionic mechanism through which alpha-2 adrenergic stimulation prolonged Purkinje APD, by measuring the effects of inhibitors of the various plateau currents on the alpha-2-mediated prolongation of APD. The alpha-2-specific agonist UK 14,304 (0.1 microM) prolonged the Purkinje APD at 50% repolarization and the APD at 90% repolarization, and these effects were inhibited by yohimbine (0.1 microM). The Purkinje APD at 50% repolarization and the APD at 90% repolarization were prolonged significantly with the transient outward potassium current inhibitor 4-aminopyridine (1 mM), the rapid component of delayed rectifier potassium current inhibitor d-sotalol (10 microM), the slow component of delayed rectifier potassium current inhibitor indapamide (0.1 microM) and the chloride current inhibitor mefenamic acid (10 nM) and were shortened significantly with the calcium current inhibitor nifedipine (0.3 microM). Prolongation of Purkinje APD at 50% repolarization and APD at 90% repolarization by UK 14,304 remained intact in the presence of d-sotalol, indapamide, mefenamic acid and nifedipine. All of these UK 14,304 effects were significantly reversed by yohimbine. Only in the presence of 4-aminopyridine did UK 14,304 fail to prolong Purkinje APD. The phase 1 magnitudes of Purkinje action potentials were also significantly inhibited by UK 14,304. This effect was completely abolished only in the presence of 4-aminopyridine. These results suggest that inhibition of the 4-aminopyridine-sensitive transient outward potassium current is the major ionic mechanism by which alpha-2 adrenergic stimulation prolongs Purkinje APD.

Action Potentials↗

Studies on the phototoxic effects of oral antidiabetics and diuretics.

A number of sulphonamide derived oral antidiabetics (chlorpropamide, glibenclamide, glipizide, gliquidone, glymidine, tolazamide and tolbutamide) and diuretics (bemetizide, bendroflumethiazide, benzylhydrochlorothaizide, bumetanide, butizide, chlortalidone, furosemide, hydrochlorothiazide, hydroflumethiazide, indapamide, piretanide, polythiazide, trichlormethiazide and xipamide) were investigated for phototoxicity in a cell culture model. Cell death dependent on UVA fluence and test substance concentration was observed in the presence of the oral antidiabetics glibenclamide and gliquidone, as well as the diuretics bemetizide, bendroflumethiazide, benzylhydroxhlorothiazide, bumetanide, butizide, hydrochlorothiazide, hydroflumethiazide, piretanide, polythiazide and trichlormethiazide. Bendroflumethiazide was phototoxic at 5 x 10(-5) mol/l and higher concentrations, bemetizide, benzylhydrochlorothiazide, bumetanide and hydroflumethiazide were phototoxic at 2.5 x 10(-4) mol/l and higher concentrations, and the oral antidiabetics glibenclamide and gliquidone as well as the diuretics butizide, hydrochlorothiazide, piretanide, polythiazide and trichlormethiazide were phototoxic at 5 x 10(-4) mol/l and higher concentrations. The oral antidiabetics chlorpropamide, glipizide, glymidine, tolazamide and tolbutamide as well as the diuretics chlortalidone, furosemide, indapamide and xipamide did not induce phototoxicity in this assay.

Carcinoma in Situ↗

Sequential monotherapy of hypertension.

In most cases, the antihypertensive therapy for an individual patient is selected through a process of trial and error. This study determined if, by treating each hypertensive patient sequentially, with six antihypertensive drugs, one from each of the major classes, one could decide on the best possible drug for control of hypertension. In a randomized open-label crossover study, 19 patients (16 male and 3 female), 28-70 years of age with a sitting diastolic blood pressure of 95-110 mm Hg were given atenolol, captopril, clonidine, indapamide, prazosin, and verapamil in a sequential manner. Each drug was started at the minimum recommended or lower dose and titrated upwards every 2 weeks, if well tolerated, until blood pressure was controlled (diastolic BP < 90 mm Hg). If blood pressure was controlled, the drug was continued for another 2 weeks. A washout period of at least 2 weeks was allowed between drugs. Both systolic and diastolic blood pressures were reduced significantly with all of the six drugs. In 18 of the 19 patients, blood pressure was controlled with at least one of six drugs, frequently with the lowest dose. The authors conclude that if hypertension is not controlled with the lowest recommended dose of a drug, other antihypertensive drugs should be tried sequentially rather than increasing the dose or adding a second drug.

Adult↗

Water vapor absorption into amorphous hydrophobic drug/poly(vinylpyrrolidone) dispersions.

Water vapor absorption isotherms were measured for three amorphous hydrophobic drug/poly(vinylpyrrolidone) (PVP) dispersions in the concentration range 10-90% w/w PVP. Experimental isotherms were compared to predicted isotherms calculated using each individual component isotherm multiplied by its weight fraction. Indomethacin (IMC)/PVP, ursodeoxycholic acid (UDCA)/PVP and indapamide (IDP)/PVP amorphous dispersions all exhibited experimental isotherms reduced relative to predicted isotherms indicating that dispersion formation altered the water vapor absorption properties of the individual components. For all three drug/PVP systems, deviation from predicted water uptake was greatest close to the 1:1 drug:PVP monomer composition, indicating that intermolecular interaction in amorphous dispersions affects the water uptake properties of the individual components. Using dry glass transition temperature (T(g)) data, the extent of drug/PVP interaction was shown to be greatest in the IDP/PVP system, which could explain why the largest reduction in water vapor absorption was found in this system. The plasticizing effect of absorbed water varied according to dry dispersion PVP content in all systems and the resulting nonideal changes in free volume, calculated using the Vrentas model, were greatest close to the 1:1 drug:PVP monomer composition. A three-component Flory-Huggins model successfully predicted isotherms for IMC/PVP compositions from 60 to 90% w/w PVP and identified an IMC-PVP interaction parameter chi in the range 1.27-1.49, values that suggest poor homogeneity of mixing in the dry system. These data indicate that amorphous dispersion formation causes both chemical and physical changes in the individual amorphous components that can have a significant effect on their water vapor absorption properties.

Absorption↗

Mechanisms of adrenergic control of sino-atrial node discharge.

Among the mechanisms proposed for the increase in discharge of sino-atrial node (SAN) by norepinephrine (NE) are an increase in the hyperpolarization-activated current I(f) and in the slow inward current I(Ca,L). If I(f) is the primary mechanism, cesium (a blocker of I(f)) should eliminate the positive chronotropic effect of NE. If I(Ca,L), is involved, [Ca(2+)](o) should condition NE effects. We studied the electrophysiological changes induced by NE in isolated guinea pig SAN superfused in vitro with Tyrode solution (both SAN dominant and subsidiary pacemaker mechanisms are present) as well as with high [K(+)](o), higher Cs(+) or Ba(2+) (only the dominant pacemaker mechanism is present). In Tyrode solution, NE (0.5-1microM) increased the SAN rate and adding Cs(+) (approximately 12 mM) caused a decaying voltage tail during diastole in subsidiary pacemakers. NE enhanced the Cs(+)-induced tail, and increased the rate but less than in Tyrode solution. In higher [Cs(+)](o) (15- 18 mM), Ba(2+) (1 mM) or Ba(2+) plus Cs(+) (10 mM) dominant action potentials (not followed by a tail) were present and NE accelerated them as in Tyrode solution. In high [K(+)](o), NE increased the rate in the absence and presence of Cs(+), Ba(2+) or Ba(2+) plus Cs(+). In these solutions, NE increased the overshoot and maximum diastolic potential of dominant action potentials (APs) and increased the rate by steepening diastolic depolarization and shifting the threshold for upstroke to more negative values. High [Ca(2+)](o) alone increased the rate and NE enhanced this action, whereas low [Ca(2+)](o) reduced or abolished the increase in rate by NE. In SAN quiescent in high [K(+)](o) plus indapamide, NE induced spontaneous discharge by decreasing the resting potential and initiating progressively larger voltage oscillations. Thus, NE increases the SAN rate by acting primarily on dominant APs in a manner consistent with an increase of I(Ca,L) and I(K) and under conditions where I(f) is either blocked or not activated. NE INITIATES spontaneous discharge by inducing voltage oscillations unrelated to I(f).

Action Potentials↗

The effect of chronic antihypertensive therapy on the index of left ventricular mass in patients with essential hypertension.

M-mode echocardiography was used in 80 patients with essential hypertension to study changes in the index of left ventricular mass during treatment over 3 years with reserpine, prazosin, indapamide and atenolol, separately or in combination. Forty patients completed a follow-up period of 36 months, while 5 patients died during this period. In all 5 groups, the index of left ventricular mass decreased significantly from the baseline after 1 and 3 years of treatment, except in those patients receiving prazosin in which there was no significant difference in the index of left ventricular mass between 1 and 3 years of treatment. Our results confirm that effective treatment of blood pressure results in a significant reduction in the index of left ventricular mass. Furthermore, this reduction was seen with all modes of treatment and suggests that it was reduction of blood pressure rather than any specific pharmacological property of the drugs that was of major importance.

Adult↗