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Eprosartan

A Review of its Use in Hypertension

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Summary

Astract

Eprosartan is an angiotensin II receptor antagonist (angiotensin II receptor blocker [ARB]) used in the treatment of hypertension. In large, randomized trials, eprosartan (with or without hydrochlorothiazide [HCTZ]) demonstrated superior antihypertensive efficacy to that of placebo and, when administered at comparable dosage regimens, had similar blood pressure-lowering effects to enalapril. Eprosartan was generally well tolerated in clinical trials and had a lower incidence of persistent dry cough than enalapril. Eprosartan has a neutral effect on metabolic parameters, such as serum lipid levels and glucose homeostasis, and a low propensity for pharmacokinetic drug interactions. The use of eprosartan or other ARBs in combination with HCTZ tends to reverse the potassium loss associated with thiazide diuretics.

Independent of its antihypertensive effects, eprosartan was associated with improved clinical outcomes (primary composite endpoint of all causes of mortality and all cardiovascular and cerebrovascular events, including all recurrent events) compared with nitrendipine in a randomized, secondary prevention trial in hypertensive patients with previous cerebrovascular events (MOSES trial). Eprosartan also reduced blood pressure and was associated with a modest improvement in cognitive function in a large observational study in patients ≥50 years of age with newly diagnosed hypertension (OSCAR study). In both of these trials, additional antihypertensive therapy, such as HCTZ, was permitted. Therefore, eprosartan is a useful treatment option in the management of a broad range of patients with hypertension, and its use with HCTZ provides a rational combination regimen.

Pharmacological Properties

Eprosartan is a highly selective angiotensin II type 1 (AT1) receptor antagonist, with 1000-fold higher affinity for AT1 than AT2 receptors and no selectivity for adrenergic, serotonergic or other receptor types. Eprosartan has a nonbiphenyl, nontetrazole chemical structure, which is different from that of other ARBs.

Favourable effects on biomarkers of endothelial function, oxidative stress, platelet activation and haemostatic variables were demonstrated in patients with hypertension who were treated with eprosartan. Reductions in cardiac hypertrophy and mortality were among the beneficial effects of eprosartan in stroke-prone spontaneously hypertensive rats fed a high-salt, high-fat diet. In a 6-week study in patients with hypertension, eprosartan 600 mg once daily was more effective than atenolol 50 mg once daily in reducing central systolic blood pressure (SBP), aortic pulse pressure and wave reflection, but atenolol was associated with a greater effect on aortic stiffness. Eprosartan had a neutral effect on metabolic parameters, such as serum lipid levels, electrolytes and glucose homeostasis, in clinical trials.

Orally administered eprosartan has an absolute bioavailability of ≈13%, with peak plasma concentrations achieved 1–2 hours after administration. The mean terminal elimination half-life of eprosartan is ≈20 hours after multiple-dose administration. Eprosartan is primarily eliminated as unchanged drug via biliary and renal excretion. The propensity for pharmacokinetic interactions with eprosartan is low, as it is not metabolized by the cytochrome P450 (CYP) enzyme system, nor is it an inhibitor of CYP isoenzymes.

Therapeutic Efficacy

Several large (n >100), randomized, double-blind, multicentre trials showed that eprosartan 400–800 mg/day for 8 or 9 weeks achieved significantly (p≤0.01) greater reductions in sitting diastolic blood pressure (DBP) [primary endpoint] and SBP than placebo in patients with mild to moderate hypertension. Moreover, a consistent antihypertensive effect was shown throughout the once-daily dosage interval with eprosartan in a study using ambulatory blood pressure monitoring, and another trial demonstrated the superiority of eprosartan over placebo for reducing SBP (primary endpoint) in patients with isolated systolic hypertension. Active-comparator trials in patients with mild to moderate hypertension showed that comparable dosages of eprosartan and enalapril had broadly similar anti-hypertensive efficacy. A further randomized trial in patients with severe hypertension showed significantly (p<0.05) greater reductions from baseline in sitting and standing SBP (secondary endpoints) with eprosartan than with enalapril, and both agents achieved marked reductions in sitting DBP (primary endpoint) and standing DBP, with no significant between-group differences for these parameters. Concomitant HCTZ was included or permitted in some of the clinical trial protocols.

Results of the MOSES trial in hypertensive patients with previous cerebrovascular events showed that, after a mean follow-up period of 2.5 years, eprosartan-based therapy was significantly (p<0.05) more effective than nitrendipine-based therapy in reducing the primary composite endpoint of all causes of mortality and all cardiovascular and cerebrovascular events, including all recurrent events. There were no statistically significant between-group differences for changes in blood pressure. In the large, 6-month, observational OSCAR study in patients aged ≥50 years with newly diagnosed hypertension (defined as SBP ≥140mmHg), eprosartan-based therapy was associated with statistically significant (p < 0.0001) improvements for both of the co-primary endpoints (changes from baseline in SBP/DBP and Mini-Mental State Examination score), indicating not only an antihypertensive effect, but also a modest improvement in cognitive status. Results should be interpreted with caution because of inherent limitations of the observational study design.

Tolerability

Pooled data from placebo-controlled trials in patients with hypertension indicate that eprosartan has a similar tolerability profile to that of placebo. The most frequently reported adverse events with eprosartan in clinical trials were headache and gastrointestinal complaints, such as nausea, diarrhoea or vomiting. Age, race, sex, eprosartan dosage or frequency of eprosartan administration (once or twice daily) did not appear to affect the frequency of adverse events. Eprosartan was rarely associated with clinically significant laboratory abnormalities in clinical trials. Long-term (up to 2 years’) administration of eprosartan with or without HCTZ generally had a similar tolerability profile to that observed in shorter placebo-controlled trials, although there was a general trend for a higher incidence of adverse events among patients receiving combined therapy. Eprosartan was associated with a significantly (p<0.05) lower incidence of persistent dry cough than enalapril in a large, randomized, double-blind trial.

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    Greg L. Plosker

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Correspondence to Greg L. Plosker.

Additional information

Various sections of the manuscript reviewed by: E. Agabiti-Rosei, Department of Medical and Surgical Sciences, Clinica Medica, University of Brescia, Brescia, Italy; A. de la Sierra, Hypertension Unit, Department of Internal Medicine, Hospital Clinic, University of Barcelona, Barcelona, Spain; J. Minami, Teshima Clinic, Kure, Hiroshima, Japan; H.A. Punzi, Trinity Hypertension Research Institute, Punzi Medical Center, Carrollton, Texas, USA; N.R. Robles, Department of Nephrology, Hospital Infanta Cristina, Badajoz, Spain.

Data Selection

Sources: Medical literature published in any language since 1980 on ‘eprosartan’, identified using MEDLINE and EMBASE, supplemented by AdisBase (a proprietary database). Additional references were identified from the reference lists of published articles. Bibliographical information, including contributory unpublished data, was also requested from the company developing the drug.

Search strategy: MEDLINE, EMBASE and AdisBase search terms were ‘eprosartan’ or ‘eprosartan/hydrochlorothiazide’ or ‘eprosartan combined with hydrochlorothiazide’. Searches were last updated 23 October 2009.

Selection: Studies in patients with hypertension who received eprosartan. Inclusion of studies was based mainly on the methods section of the trials. When available, large, well controlled trials with appropriate statistical methodology were preferred. Relevant pharmacodynamic and pharmacokinetic data are also included.

Index terms: Eprosartan, hypertension, pharmacodynamics, pharmacokinetics, therapeutic use, tolerability.

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Plosker, G.L. Eprosartan. Drugs 69, 2477–2499 (2009). https://doi.org/10.2165/11203980-000000000-00000

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