Combined Renin Inhibition/Beta-Blockade

Condition(s) targeted: Hypertension

Intervention: Aliskiren (Drug); Extended-release metoprolol (Drug)

Phase: N/A

Status: Not yet recruiting

Sponsored by: The Rogosin Institute

Official(s) and/or principal investigator(s):
Jon D Blumenfeld, M.D., Principal Investigator, Affiliation: The Rogosin Institute

Overall contact:
Caitlin A Powers, N.P., Phone: 212-746-9114, Email: cpowers@mail.rockefeller.edu

Antihypertensive drug treatment is effective in only about 50% of patients. One mechanism responsible for treatment failure is a drug related stimulation of the renin-angiotension-aldosterone-system (RAAS). Several classes of medications that treat hypertension by blocking the RAAS system have been developed. However, the kidney responds to these drug treatments by producing greater amounts of renin. This high level of renin can reduce the effectiveness of some of these medications, ultimately causing the blood pressure to rise. This is one reason why blood pressure can be difficult to control in a certain percentage of patients.

The hypothesis to be tested in the proposed study is that beta-adrenergic blockade (β-blockade), when superimposed upon aliskerin, a drug that competitively inhibits plasma renin activity (PRA) but stimulates the release of renin by the kidneys (plasma renin concentration [PRC]), can suppress the reactive increase in PRC that occurs during aliskerin monotherapy.

The primary aim of this study is to measure plasma renin concentration (PRC) and plasma renin activity (PRA) levels during renin inhibition with aliskiren and combined renin inhibition/β-blocker treatment to determine whether the addition of a β-blocker attenuates the rise in plasma renin concentration (PRC). A secondary aim is to determine whether combined treatment further suppresses PRA and blood pressure.

Official title: Renin System Responses to Combined Renin Inhibition and Beta Adrenergic Blockade

Study design: Treatment, Non-Randomized, Open Label, Single Group Assignment

Primary outcome: Plasma renin concentration

Secondary outcome:

Plasma renin activity

Blood pressure

Detailed description: The renin-angiotensin-aldosterone system (RAAS) plays a central role in the maintenance of normal blood pressure (BP) homeostasis. Derangements in the regulation of this system, predominantly due to the failure to appropriately suppress renin secretion by the kidney, contribute to the pathogenesis of hypertension and its cardiovascular, renal and cerebrovascular complications.

Several classes of antihypertensive medications that interrupt the RAAS have been developed. These include agents that block angiotensin II (Ang II) binding to the AT1 receptor (Ang II receptor blockers [ARB], inhibit conversion of Ang I to Ang II (angiotensin converting enzyme [ACE] inhibitors), and suppress renal secretion of renin (beta-adrenergic receptor blocker). These agents effectively lower BP, particularly in the hypertensive patient with an unsuppressed plasma renin activity (PRA) level, and significantly improve survival in cardiovascular diseases in which PRA levels are often elevated (e. g., heart failure, myocardial infarction).

Renin secretion is regulated, in part, by feedback inhibition due to Ang II binding to the juxtaglomerular cell (JG). Interruption of Ang II generation or its receptor binding during treatment with an ACE inhibitor or ARB, respectively, stimulates renin secretion because feedback inhibition is attenuated and renal perfusion pressure is reduced. The consequent, reactive rise in PRA that occurs during treatment with these drugs can limit their antihypertensive efficacy because Ang I and subsequently, Ang II levels increase.

These observations reinforce the theoretical and practical importance of pharmacologic suppression of renin secretion to prevent the reactive rise in PRA that occurs during treatment with ACE inhibitors and ARBs. β-blockers suppress renin secretion by inhibiting β1-adrenergic receptors located on JG cells. PRA and Ang II levels are highly correlated and these decrease commensurately during treatment with a β-blocker.

Aliskiren is an orally active, non-peptide renin inhibitor. Its antihypertensive efficacy is due to the competitive antagonism of the renin-mediated conversion of angiotensinogen to Ang I. During aliskiren treatment, PRA and Ang II levels decrease significantly. Unlike β-blockade, in which the PRA level decreases as a consequence of reduced renal secretion of renin, aliskiren treatment decreases PRA in response to the direct, competitive inhibition of renin. Although PRA decreases, the aliskiren-mediated decrease in plasma Ang II level stimulates renal renin secretion. Therefore, although aliskiren and β-blockers both decrease PRA levels, they have divergent effects on the plasma concentration of renin (PRC): β-blockers decrease it and aliskiren increases it. The reactive rise in PRC has potential implications regarding the antihypertensive efficacy of aliskiren — high PRC levels theoretically can overcome the competitive inhibition of renin by aliskiren, thereby increasing PRA, Ang II, and BP.

Aliskiren has been studied as monotherapy and in combination with other antihypertensive drugs, including hydrochlorothiazide, valsartan, and amlopidine. It has not been studied in the presence of a β-blocker. Proposals for future studies include pursuing whether or not there are hypertensives who are resistant to aliskiren, what the mechanism(s) is for the resistance and ways to overcome the resistance.

This is a prospective, open-label study of the effect of the sequential addition of a β-blocker (extended release metoprolol) to aliskiren on the levels of plasma renin activity and plasma renin concentration in subjects with uncomplicated hypertension.

Minimum age: 18 Years. Maximum age: 80 Years. Gender(s): Both.

Criteria:

Inclusion Criteria:

Twenty subjects with a history of hypertension with the following inclusion criteria will be enrolled:

- Age 18-80 years

- Stage 1 (systolic 140-159 mm Hg or diastolic 90-99 mmHg) or Stage 2 (systolic >160 mm

Hg or diastolic >100 mmHg) or current treatment with antihypertensive medication.

- PRA ≥0. 65 ng/ml/h. If PRA is below this level during the screening period, due to

treatment with a beta-blocker or central α2-receptor agonist, the subject may be enrolled and the PRA level re-checked after treatment is tapered off.

Exclusion Criteria:

- History of diabetes requiring pharmacologic treatment with an oral or parenteral

hypoglycemic agent, including insulin

- TIA, stroke or myocardial infarction

- History of asthma or COPD

- Cockcroft Gault estimated GFR <60 ml/min/1. 73 m2

- Previous adverse events during treatment with a β-blocker or aliskiren

- ALT level twice normal

- Secondary forms of hypertension (e. g., renovascular, primary aldosteronism)

- PRA<0. 65 ng/ml/h after discontinuation of antihypertensive medication

- Systolic BP>180 mm Hg, diastolic BP>105 mm Hg

- Pregnant or breastfeeding, or planning pregnancy during the study period

Caitlin A Powers, N.P., Phone: 212-746-9114, Email: cpowers@mail.rockefeller.edu

Weill Cornell Clinical and Translational Science Center, New York, New York 10021, United States

Related publications:

Staessen JA, Li Y, Richart T. Oral renin inhibitors. Lancet. 2006 Oct 21;368(9545):1449-56. Review. Erratum in: Lancet. 2006 Dec 16;368(9553):2124.

Starting date: March 2008
Ending date: March 2010
Last updated: February 24, 2008