Direct Renin Inhibition Effects on Atherosclerotic Biomarkers

Phase 4

Completed

• Conditions: Coronary Artery Disease; Type 2 Diabetes Mellitus
• Interventions: Drug: Aliskiren; Drug: Amlodipine

• Registration Number: NCT00818779
• Lead Sponsor: Texas Tech University Health Sciences Center

Brief Summary

The investigators aim to assess if a new blood pressure medication, aliskiren, reduces various biomarkers of heart disease found in the blood in patients with a history of both heart disease and type 2 diabetes. The primary hypothesis is that aliskiren will reduce these biomarkers compared to a calcium channel blocker.

Detailed Description

Agents that attenuate the renin angiotensin system (RAS), i.e. angiotensin converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARB), have shown to have therapeutic benefit in a variety of cardiovascular disorders. ACE-Is are considered standard of care for secondary prevention of CAD by the AHA/ACC. Based on the HOPE study, the beneficial effects of ACE-Is in patients at high risk for cardiovascular outcomes may be beyond mere blood pressure control. In addition to their effects on blood pressure, aldosterone, and sodium and water absorption, blockade of the RAS with ACE-Is or ARBs alter key biomarkers of vascular inflammation, vascular endothelial function, and fibrinolytic balance. These surrogate biomarkers are thought to play a role in the progression of atherosclerosis. Biomarkers of vascular inflammation include vascular and intracellular cell adhesion molecule (VCAM and ICAM respectively) and c-reactive protein (CRP). Markers of endothelial function include endothelin-1 (ET-1) and the vasodilator nitric oxide (NO). Plasminogen activator inhibitor-1 (PAI-1) is a prothrombotic marker associated with plaque proliferation and atherosclerosis progression.

ACE-Is block the conversion of angiotensin 1 (Ang 1) to angiotensin 2 (Ang 2). "ACE escape" may attenuate the influence of ACE-Is despite proven benefits in clinical trials.

Aliskiren is the first direct renin inhibitor approved by the FDA for the treatment of hypertension. It is a very specific and potent inhibitor of human renin. As such it may offer an advantage over ACE-I and ARB therapy as it blocks the rate limiting step of the RAS. It does not show a compensatory increase in RAS activity noted with ARBs or non-ACE production of Ang 2 as seen with ACE-Is. Aliskiren appears to have additive blood pressure lowering effects when added to ACE-I or ARB therapy.

A very commonly prescribed antihypertensive, the dihydropyridine calcium channel blocker amlodipine, has a synergistic effect on lowering BP when used with an ACE-I. It has been shown to have mixed effects on atherosclerotic biomarkers in a variety of subjects. Type 2 diabetes affects many of the atherosclerotic markers described above and as such can be a confounding variable in research involving these biomarkers.

With the addition of a new therapeutic agent that affects the RAS, its different pharmacodynamic effects on the RAS compared to ACE-I and ARB therapy, and that Ang 2 levels are not fully blocked by ACE-I therapy, it is critical to better understand how the new class of direct renin inhibitors may influence atherosclerotic biomarkers in patients with a variety of cardiovascular disorders. The objectives of this application are to determine whether the direct renin inhibitor, aliskiren, affects atherosclerotic biomarkers in patients with stable coronary artery disease and diabetes currently receiving standard ACE-I therapy and if aliskiren has a more favorable effect on these markers compared to the calcium antagonist amlodipine.

Large clinical trials have proven the benefit of RAS blockade in reducing cardiovascular morbidity and mortality. The significance of this research is that more information is needed to better understand how antihypertensive agents, particularly those that block the RAS, reduce cardiovascular disease beyond blood pressure reduction alone. Research that elucidates how agents may reduce atherosclerosis is very important to help better target drug therapy to a condition that is the leading cause of death in this country.

Study Timeline

• Study Start: 2008-01
• Study First Submitted: 2009-01-06
• Study First Submitted QC: 2009-01-07
• Study First Posted: 2009-01-08
• Primary Completion: 2011-08
• Study Completion: 2011-08
• Results First Submitted: 2012-06-18
• Results First Submitted QC: 2012-10-18
• Results First Posted: 2012-11-19
• Status Verified: 2017-10
• Last Update Submitted: 2017-10-31
• Last Update Posted: 2017-12-05

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 38

Inclusion Criteria

• Diagnosis of type 2 diabetes
• Diagnosis of coronary artery disease
• Currently receiving therapy with an ACE-Inhibitor or Angiotensin Receptor Blocker
• Currently receiving antiplatelet therapy and statin therapy
• Baseline blood pressure > 100/75 mm Hg
• BMI 25-35 kg/m2

Exclusion Criteria

• Concurrent calcium channel blocker therapy
• Documented peripheral edema
• Hyperkalemia
• Serum creatinine > 2.0
• Diagnosed with proteinuria
• Diagnosed with liver dysfunction or serious rheumatological disorder

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Aliskiren	Aliskiren	Aliskiren 150-300 mg once daily
Amlodipine	Amlodipine	5-10 mg amlodipine once daily

Primary Outcome Measures

Name	Time	Method
Plasminogen Activator Inhibitor 1	6 weeks (change from baseline)	Plasminogen Activator Inhibitor 1 is a biomarker found in serum that indirectly assesses blood clotting activity. Lower PAI-1 levels are thought to be better than higher levels. The primary outcome is mean change from baseline and can include negative numbers as a result.

Secondary Outcome Measures

Name	Time	Method
Serum Level of Nitric Oxide	6 week (change from baseline)	Surrogate biomarker of cardiovascular risk
Serum Level of Vascular Cell Adhesion Molecule	6 week (change from baseline)	Surrogate biomarker cardiovascular risk
Serum Level of C-reactive Protein	6 week (change from baseline)	Surrogate biomarker of cardiovascular risk
Serum Level of Intracellular Cell Adhesion Molecule	6 week (change from baseline)	Surrogate biomarker of cardiovascular risk

Trial Locations

Locations (1)

Texas Tech University Health Sciences Center; 🇺🇸 Lubbock, Texas, United States