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SALLAU Manasseh
Cardiopulmonary
Sytolic/diastolic dysfunction
Decreased cardiac output (↓ stroke volume)
Tachycardia
Arrhythmias
Pulmonary congestion/edema
Dyspnea
Systemic Vasculature
↑ Systemic vascular resistance
↑ Blood volume
↑ Systemic edema
RATIONALE FOR DRUG THERAPY IN MI
Improve Myocardial Oxygen Supply/Demand Ratio
Pain Management
Analgesics
Isoleucine
Leucine
Proline
Tyrosine
Histidine
Arginine
CARDIOVASCULAR EFFECTS OF ANGIOTENSIN II
When angiotensin II is formed, it acts via it receptors found
on different part of the body to cause different effects.
ANGIOTENSIN II RECEPTORS AND THEIR LOCATION IN
THE BODY
The actions of Ang II are mediated by angiotensin receptors,
AT1 and AT2.
Two more angiotensin receptors have been described, AT3
and AT4, but their role is still unknown (Dihn, D.T. et al.,
2001).
AT1 receptors are mainly found in the heart, adrenal glands,
brain, liver and kidneys. Their main role is to regulate blood
pressure as well as fluid and electrolyte balance.
AT2 receptors are highly expressed in the developing fetus
but they decline rapidly after birth (Dihn, D.T. et al., 2001).
Most of the known actions of Ang II are mediated through
the AT1 receptors.
CARDIOVASCULAR EFFECTS OF ANGIOTENSIN II CON’T
Heart failure:
Hyperkalemia .
Eprosartan (Teveten).
Irbesartan (Avapro).
Telmisartan (Micardis).
Valsartan (Diovan).
Losartan (Cozaar).
The first one is the imidazole ring that binds to amino acids
in helix 7 (Asn295).
STRUCTURE ACTIVITY RELATIONSHIP OF ARBs CON’T
The second group is the biphenyl-methyl group that binds to amino acids in both
helices 6 and 7 (Phe301, Phe300, Trp253 and His256).
Losartan
The third one is the tetrazole group that interacts with amino acids in helices 4 and 5
(Arg167 and Lys199)
NOTE:
The tetrazole group has been successfully replaced by a carboxylic acid group as is the
case with telmisartan.
Telmisartan
STRUCTURE ACTIVITY RELATIONSHIP OF ARBs CON’T
Most of the ARBs have the same pharmacophore so the difference in their
biochemical and physiological effects is mostly due to different substituents.
Lipophilic substituents like the linear alkyl group at the 2-position on the
imidazole ring together with the biphenyl-methyl group, associate with
hydrophobic pockets of the receptor.
Losartan
Telmisartan
An acidic group like tetrazole, CO2H or NHSO2CF3 at the 1-position of the
biphenyl-methyl group will bind to a basic position in the receptor and are
required for potent antagonistic activity (Yanagiasawa H. et al., 1996).
STRUCTURE ACTIVITY RELATIONSHIP OF ARBs CON’T
In valsartan, the imidazole ring of losartan has been replaced with an
acylated amino acid.
Losartan Valsartan
Irbesartan Losartan
STRUCTURE ACTIVITY RELATIONSHIP OF ARBs CON’T
The structure of eprosartan is the one that differs most from the other ARBs,
the usual biphenyl-methyl group has been replaced by a carboxy benzyl group
that mimics more closely the phenolic moiety of Tyr4 group of Ang II.
Eprosartan
Losartan
This change results in a stronger binding to the receptor but the biochemical
and physiological effects are not significantly improved (Aulakh GK et al., 2007).
Telmisartan
STRUCTURE ACTIVITY RELATIONSHIP OF ARBs CON’T
It has been reported that imidazoles that have hydroxymethyl and carboxy
groups at the 4- and 5 position, possessed potent antagonistic activity, caused
by the hydrogen bonding and hydrophilicity of the hydroxymethyl group
(Yanagiasawa H. et al., 1996).
Losartan
Olmesartan
It has also been reported that a hydroxy group in the 4-position on the
imidazole ring, plays an important role in the binding affinity and
compensates for the disadvantage of lipophilicity of the bulky alkyl group
(Yanagiasawa H. et al., 1996).
STRUCTURE ACTIVITY RELATIONSHIP OF ARBs CON’T
These results show that a medium-sized hydroxy alkyl group,
such as CHMeOH and CMe2OH, is favorable for the substituent
of the 4-position on the imidazole ring. Furthermore, the
ionizable group is favorable for the binding affinity (Yanagiasawa
H. et al., 1996).
Candesartan Telmisartan
Irbesartan
Eprosartan
Losartan Olmesartan
Valsartan
DOSAGE/ADMINISTRATION AND PHARMACOKINETICS OF
ARBs
Drug Dose T1/2 Protein Bioavailability Renal/hepatic Food effects Daily
Equivalence (hrs) binding (%) clearance (%) dosage(mg)
(mg) (%)
Losartan 50 2 98.7 33 10/90 Minimal 50-100
( Cozaar)
EXP3174 - 6-9 99.8 - 50/50 - -
40-50%
Valsartan 80 6 95 25 30/70 decreased 80-320
(Diovan) by
All of the ARBs, except for telmisartan and olmesartan, are metabolized in
some way by the cytochrome P450 (CYP) enzyme 2C9, that is found in the
human liver.
Telmisartan is the only ARB that can cross the blood–brain barrier and can
therefore inhibit centrally mediated effects of Ang II, contributing to even better
blood pressure control (Aulakh GK, et al., 2007).
ARBs COMBINATION
Irbesartan+Hydrochlorthiazide ( CoAprovel).
Valsartan+Hydrochlorthiazide (Co-Diovan).
ARBs UNDER DEVELOPMENT
Pratosartan
Several new nonpeptide ARBs are undergoing clinical trials or are at pre-
clinical stages of development. Among these are embusartan (BAY 10-6734 or
BAY 10-6734), KRH-594, fonsartan (HR 720) and pratosartan (KT3-671).
(Aulakh GK. Et al., 2007).
The purpose of the oxo group is similar to that of the carboxylic acid groups
on other ARBs(Ogihara, T. et al., 2008).
ARBs UNDER DEVELOPMENT CON’T
NOTES:
The safety and efficacy of Co-Diovan have not been established in
children below the age of 18 years.
Several new nonpeptide ARBs are undergoing clinical trials or are at pre-
clinical stages of development. Among these are embusartan (BAY 10-6734),
KRH-594, fonsartan (HR 720) and pratosartan (KT3-671). (Aulakh GK. Et
al., 2007).
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