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The cardiologist perspective
Introduction
(RAS)
Introduction
(ARBs)
Introduction
(ARBs)
ARBs are an important drug class in hypertension & heart failure
therapy + protection from diabetic nephropathy.
8 are clinically available [azilsartan, eprosartan, candesartan,
irbesartan, losartan, olmesartan, telmisartan, valsartan].
As a class, ARBs are chemically similar but vital pharmacokinetic
and pharmacodynamic differences exist between them.
ARBs differ in the magnitude and duration of the antihypertensive
response as well as in added protection of reducing
cardiovascular risks: this has important implications in clinical
practice
Differences in the
Pharmacokinetic parameters
Pharmacokinetic differences
Telmisartan has the longest half-life of
clinically available ARBs
Angiotensin Receptor Blockers - Advantages of the new Sartans, July 2013, VOL. 61
Plasma half-life
Telmisartan has the longest half-life of
clinically available ARBs
Telmisartan, with a
terminal 24-hour half-life,
may be the most effective
ARB in controlling early
morning surge in BP.
Burnier, Brunner. Lancet 2000;355:637645, Brunner. J Hum Hypertens 2002;16 (Suppl 2):S13S16, U.S. Pharm. 2004;10:HS19-HS25.,
Volume of distribution
Telmisartan has the largest volume of
distribution of clinically available ARBs
Lipophilicity
Telmisartan is 5 times more lipophilic
than Losartan
ARBs
Partition
coefficient
Telmisartan
3.20
Irbesartan
1.48
Candesartan
-0.96
Valsartan
-0.95
Losartan
(active metabolite)
-2.45
Trough/peak ratios
Trough-to-peak ratio is a widely used measure
of the duration of antihypertensive efficacy.
SBP
JNC VI recommendation
DBP
>50%
>50%
35%
51%
Telmisartan 40 mg
66%
~100%
Telmisartan 80 mg
92%
~100%
Losartan 50 mg
Renal excretion
Lowest renal excretion of clinically available ARBs*
Differences in the
Pharmacodynamic
parameters
Surmountable vs
Insurmountable
Losartan
Telmisartan
Insurmountable Binding
Telmisartan binds insurmountably to the AT1 receptor
Control
100
Telmisartan 10 nM
Telmisartan 100 nM
Telmisartan 1000 nM
75
50
25
-10
-9
-8
-7
-6
-5
-4
ARBs
Dissociation
half-life
Telmisartan
87 min
Candesartan
66 min
Losartan
2.5 min
Angiotensin II
12 min
Br J Cardiol 2010;17:s3-s5
Drug interactions
Comparison of the class as a whole reveals that
losartan has the highest potential for drug
interactions due to its involvement with the
hepatic cytochrome P450 enzyme system.
Br J Cardiol 2010;17:s3-s5
Decrease in BP difference in
ARBs
Greater reductions in trough blood pressure
Song, White. Formulary 2001;36:487499 ,Sharma et al. Clin Nephrol 2005;63:250257, BUMC PROCEEDINGS 2003;16:123126
*P<0.05 vs Losartan
Cice et al. XLI ERA. 2004
U.S. Pharm. 2004;10:HS19-HS25. , Song, White. Formulary 2001;36:487499 ,Sharma et al. Clin Nephrol 2005;63:250257
Compared to
other AT(1)
receptor blockers
Telmisartan may
have further
additional
beneficial effects
in patients with
metabolic
syndrome
*
* P<0.05 vs Losartan
ELITE
VALHeFT
CHARM
TELMAR
ONTARGET
TRANSCEND
Conclusion
Summary
2.
3.
4.
5.
Better distribution
Activates
PPAR-gamma
No modification
of dosage
Telmisartan is indicated for cardiovascular prevention beyond that of blood pressure-lowering alone.
Beevers et al. BMJ 2001;322:912916
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