Hypertension - Role of Azilsartan ( Case based & Evidence based)

1. Resistant Hypertension, complications, Target organ damage
2. newly diagnosed stage-1 hypertension, rationale of use of ARB and
comparison of Azilsartan with other ARBs
3. Hypertension with bronchial asthma
4. Hypertension with Diabetes Mellitus with proteinuria
5. Hypertension , Diabetes and IHD
6. Gestational Hypertension , rationale of use of drugs
7. Hypertension , Diabetes , ACS
8. Hypertension, Diabetes and Syndrome X
9. Hypertension and special situations drtoufiq19711@yahoo.com

Case scenario
• Mr. J. K 35 years old business man
presented with headache , neck pain and
dizziness for last 15 days. He is smoker and
dyslipidemic. His B. P is 155/95 mm Hg on
both arms and pulse 80 b/min. What are the
management startagies?
drtoufiq19711@yahoo.com

Considering points
• Stage of hypertension? 155/95 mm Hg
• 1. Role of life style modifications?
• 2. Role of diets ?
• 3. first line of antihypertensives?

Classification and Management
BP
classification
SBP*
mmHg
DBP*
mmHg
Lifestyle
modification
Initial drug therapy
Without compelling
indication
With compelling
indications
Normal <120 and <80 Encourage
Prehypertension 120–
139
or 80–
89
Yes No antihypertensive
drug indicated.
Drug(s) for
compelling
indications. ‡
Stage 1
Hypertension
140–
159
or 90–
99
Yes Thiazide-type diuretics
for most. May
consider ACEI, ARB,
BB, CCB, or
combination.
Drug(s) for the
compelling
indications.‡
Other
antihypertensive
drugs (diuretics,
ACEI, ARB, BB,
CCB) as needed.
Stage 2
Hypertension
>160 or >100 Yes Two-drug combination
for most† (usually
thiazide-type diuretic
and ACEI or ARB or
BB or CCB).
*Treatment determined by highest BP category.
†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.
‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

Case continued
• Pt was being treated with beta blockers (
Atenolol 50 mg once daily). After 10 days
patient came for follow-up. Now,
• Pulse-70 b/min
• BP- 140/95 mm Hg
• and he feels better but complained of
erectile dysfuntion.

What should be the next management?
• Considering
• 1. symptoms decreased
• 2. BP not controlled yet
• 3. Erectile Dysfuntion

• His drug beta blockers were stopped and
switched to calcium channel blockers (
Amlodipine 5 mg daily) and advised to
follow up after 15 days.

During follow-up
• Pulse- 80 b /min
• BP- 135/85 mm Hg
• But patient now complained of ankle edema
• What should be the next plan?

Considering points
• To control BP properly
• Ankle edema
• Shiftinng to another group of
drugs/cilnidipine
• Or add another drug to combat edema

Options
• Switch to another groups
• Add on ACEi/ ARB
• Add on Diuretics
• Time of follow up

EVOLUTION OF HYPERTENSION
MANAGEMENT
JNC I
1977
JNC II
1980
JNC III
1984
JNC IV
1988
JNC V
1993
JNC VI
1997
JNC VII
2003
High Dose
diuretic
High Dose
diuretic
Lower
Dose
diuretic
Or
-blocker
Lower
Dose
diuretic
Or
-blocker
Or
ACEI
Or
CCB
Lower
Dose diuretic
Or
-blocker
Or
ACEI
Or
CCB
-blocker
Or
 /  blocker
• Individulised
Therapy
•Single-agent
titration preferred
•Loe-dose combo
therapy as a
secondary option
•Focus on
Systolic BP
Control
•Thiazide-
type diuretics
preferred as
initial drug
treatment
•Emphasis on
combination
therapy
High-dose Monotherapy Low-dose Combination

is better than other ARBs in BP control
Ref. William B. White et al.(2011), Effect of ARB.. (Hypertension. 2003;42:1206-1252)

is unique in sustainable BP control
Ref. William B. White et al.(2011), Effect of ARB.. (JNC-7, Hypertension. 2003;42:1206-1252)

is unique considering AT1 affinity
Ref. Vasc Health Risk Manag. 2012; 8: 133–143. (www.ncbi.nlm.nih.gov/pmc/articles/PMC3295635/)

is also better than Ramipril in BP control
Ref. Gitt et al.; licensee BioMed Central Ltd. 2013

Preferable for Patients on Hemodialysis
Ref. 1Department of Nephrology, Saitama Medical University, Saitama, Japan 2Ikebukuro Hospital, Saitama, Japan
Pre-dialytic SBP in the morning at home and during night were all
significantly reduced by 3 months’ administration of azilsartan:
(167.3±10.3 to 145.3±9.6 (pre-dialytic); 167.1±11.0 to 151.8±10.4
(home);150.5±13.1 to 134.0±10.3(night); mmHg). Switching from
olmesartan to azilsartan safely decreased home-measured BP in
hemodialysis patients.

Preferable for Diabetic Hypertensive
Ref. Journal of Hypertension-2016
A study revealed that Azilsartan lowers SBP by a greater
magnitude than Olmesartan or Valsartan at maximally approved
doses in patients with prediabetes mellitus and T2DM. These
findings have important clinical implications for this high-risk
patient group.

offers very minimum adverse events
44
45
46
47
48
49
50
51
52
53
Placebo Azilsartan Valsartan Olmesartan
%ofpatients
Ref. William B. White et al.(2011), Effect of ARB.. (Hypertension. 2003;42:1206-1252)

Ref. Center for Drug Evaluation and Research . Silver Spring, MD: NDA 200-796: Azilsartan medoxomil, Clinical Pharm & Biopharma Review(s) 2010.
Peak Plasma Concentration (Cmax) : 1.5-3 hrs
Bioavailability : 60% (does not alter with food intake)
Elimination Half-life : 12 hrs (round-the-clock action)
Metabolism : CYP2C9 (less drug interaction)
Use in kidney patients : No need of dosage adjustment
Use in liver disease : No need of dosage adjustment
offers superb pharmacokinetic profile

%Bioavailability
Ref.www.slideshare.net/moshiurmurad/current-status-of-arbs-in-bdppt
0
10
20
30
40
50
60
Losartan Valsartan Olmesartan Azilsartan
offers highest bioavailability among ARBs

Ref. Vasc Health Risk Manag. 2012; 8: 133–143.
the latest ARB with improved efficacy
1. Compared to other ARBs, azilsartan may increase the target BP control
& response rate by 8%–10%
2. Control BP in a UNIFORM way round-the-clock
3. Better than any other ARB/ACE I (Olmesartan/Ramipril)
4. Side effect & tolerability profile is similar to placebo
5. Excellent pharmacokinetic profile

Conclusion
• Hypertension is easy to diagnose and easy to treat
• Aim of the management is to save the target organ from the
deleterious effect
• Pharmacological armament of antihypertensive drugs so rich
that we have wide range of options. And this makes the
physicians comfortable in varied situations. Conversely one
needs to be judicious regarding the choice of the drug
• Besides pharmacology we have other choices and one has to be
acquainted with that choice
• Primary prevention of hypertension should be highlighted and it
should get more priority than it is getting now.

Hypertension - a worldwide epidemic
It’s a disease which is responsible for 3 million death annually
About 15-20% of Bangladeshi population is suffering from
Hypertension
HTN is very poorly controlled - < 25% in developed & < 10% in
developing countries
Early diagnosis & management can prevent end organ damage from
HTN
Target goal of BP in hypertensive patients:-
< 140/90 mm Hg
< 130/80 mm Hg for patients with DM & renal disease
Lifestyle modification is the universal “Vaccine” against Hypertension
Conclusion

Hypertension - Role of Azilsartan ( Case based & Evidence based)

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