IN FOCUS
IN FOCUS
Other drugs that reduce blood pressure Alpha blockers . In drug-drug interaction studies , sildenafil ( 25 mg , 50 mg , or 100 mg ) and the alpha-blocker doxazosin ( 4 mg or 8 mg ) were administered simultaneously to patients with benign prostatic hyperplasia ( BPH ) stabilized on doxazosin therapy . In these study populations , mean additional reductions of supine systolic and diastolic blood pressure of 7 / 7 mmHg , 9 / 5 mmHg , and 8 / 4 mmHg , respectively , were observed . Mean additional reductions of standing blood pressure of 6 / 6 mmHg , 11 / 4 mmHg , and 4 / 5 mmHg , respectively , were also observed . There were infrequent reports of patients who experienced symptomatic postural hypotension . These reports included dizziness and light-headedness , but not syncope .
Amlodipine . When sildenafil 100 mg oral was co-administered with amlodipine , 5 mg or 10 mg oral , to hypertensive patients , the mean additional reduction on supine blood pressure was 8 mmHg systolic and 7 mmHg diastolic .
Monitor blood pressure when co-administering blood pressure lowering drugs with REVATIO ® ( sildenafil ).
USE IN SPECIFIC POPULATIONS
Pregnancy Pregnancy Category B There are no adequate and well-controlled studies of sildenafil in pregnant women . No evidence of teratogenicity , embryotoxicity , or fetotoxicity was observed in pregnant rats or rabbits dosed with sildenafil 200 mg / kg / day during organogenesis , a level that is , on a mg / m 2 basis , 32- and 68-times , respectively , the recommended human dose ( RHD ) of 20 mg three times a day . In a rat pre- and postnatal development study , the no-observed-adverse-effect dose was 30 mg / kg / day ( equivalent to 5-times the RHD on a mg / m 2 basis ).
Labor and Delivery The safety and efficacy of REVATIO during labor and delivery have not been studied .
Nursing Mothers It is not known if sildenafil or its metabolites are excreted in human breast milk . Because many drugs are excreted in human milk , caution should be exercised when REVATIO is administered to a nursing woman .
Pediatric Use In a randomized , double-blind , multi-center , placebo-controlled , parallelgroup , dose-ranging study , 234 patients with PAH , aged 1 to 17 years , body weight greater than or equal to 8 kg , were randomized , on the basis of body weight , to three dose levels of REVATIO , or placebo , for 16 weeks of treatment . Most patients had mild to moderate symptoms at baseline : WHO Functional Class I ( 32 %), II ( 51 %), III ( 15 %), or IV ( 0.4 %). One-third of patients had primary PAH ; two-thirds had secondary PAH ( systemicto-pulmonary shunt in 37 %; surgical repair in 30 %). Sixty-two percent of patients were female . Drug or placebo was administered three times a day .
The primary objective of the study was to assess the effect of REVATIO on exercise capacity as measured by cardiopulmonary exercise testing in pediatric patients developmentally able to perform the test ( n = 115 ). Administration of REVATIO did not result in a statistically significant improvement in exercise capacity in those patients . No patients died during the 16-week controlled study .
After completing the 16-week controlled study , a patient originally randomized to REVATIO remained on his / her dose of REVATIO or , if originally randomized to placebo , was randomized to low- , medium- , or high-dose REVATIO . After all patients completed 16 weeks of follow-up in the controlled study , the blind was broken and doses were adjusted as clinically indicated . Patients treated with sildenafil were followed for a median of 4.6 years ( range 2 days to 8.6 years ). During the study , there were 42 reported deaths , with 37 of these deaths reported prior to a decision to titrate subjects to a lower dosage because of a finding of increased mortality with increasing REVATIO doses . For the survival analysis which included 37 deaths , the hazard ratio for high dose compared to low dose was 3.9 , p = 0.007 . Causes of death were typical of patients with PAH . Use of REVATIO , particularly chronic use , is not recommended in children .
Geriatric Use Clinical studies of REVATIO did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects . Other reported clinical experience has not identified differences in responses between the elderly and younger patients . In general , dose selection for an elderly patient should be cautious , reflecting the greater frequency of decreased hepatic , renal , or cardiac function , and of concomitant disease or other drug therapy .
Patients with Hepatic Impairment No dose adjustment for mild to moderate impairment is required . Severe impairment has not been studied .
Patients with Renal Impairment No dose adjustment is required ( including severe impairment CLcr < 30 mL / min ).
PATIENT COUNSELING INFORMATION
• Inform patients of contraindication of REVATIO with regular and / or intermittent use of organic nitrates .
• Inform patients that sildenafil is also marketed as VIAGRA for erectile dysfunction . Advise patients taking REVATIO not to take VIAGRA or other PDE-5 inhibitors .
• Advise patients to seek immediate medical attention for a sudden loss of vision in one or both eyes while taking REVATIO . Such an event may be a sign of NAION .
• Advise patients to seek prompt medical attention in the event of sudden decrease or loss of hearing while taking REVATIO . These events may be accompanied by tinnitus and dizziness .
Rx only Rev . June 2015
RVU751714-02 © 2015 Pfizer Inc . All rights reserved . June 2015
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Of significance , in the past 15 months , outcome trials of two more classes of anti-hyperglycemic agents have demonstrated reduced cardiovascular outcomes in patients with T2DM , again , with special cardio-protective properties , beyond glucose control . The EMPA-REG trial 4 showed the sodium glucose transporter-2 ( SGLT2 ) inhibitor , empagliflozin , to significantly reduce the primary outcome of myocardial infarction , stroke , and cardiovascular death , and the reductions in heart failure hospitalizations , cardiovascular and total deaths were particularly impressive . The MOA responsible for these benefits seen with empagliflozin are likely multifactorial . Other SGLT2 inhibitor cardiovascular trials , CANVAS with canagliflozin , DECLARE with dapagliflozin , and NCT01986881 with ertugliflozin , are underway to evaluate the potential for a class effect . More recently the LEADER 5 trial showed a significant reduction in the composite cardiovascular events ( cardiovascular death , non-fatal MI and stroke ) and a reduction of cardiovascular mortality with the GLP-1 RA , liraglutide , that has nearly 100 % homology to human GLP-1 . And in the SUSTAIN-6 trial , use of semaglutide reduced a composite of cardiovascular events and a reduction of nonfatal MI and stroke 6 . Also of note involving the thiazolidinedione pioglitazone , the Insulin Resistance Intervention After Stroke Trial ( IRIS ) trial dedicated to individuals with prediabetes and prior stroke showed subsequent CVD events to be reduced in the pioglitazone treated group 7 , as observed in secondary endpoint analyses from the PROACTIVE clinical trial of patients with T2DM .
One-third or more of cardiovascular patients having T2DM , and another third being pre-diabetic with impaired glucose tolerance or impaired fasting glucose , as well as the other characteristics of the metabolic syndrome ( i . e . HTN , dyslipidemia ). Therefore , it is critical , especially in the secondary prevention setting , where decisions become much more complex , cardiologists must not only collaborate with endocrinologists and other providers managing patients with diabetes , but must also get accustomed to decisions made by the endocrinologist / diabetologist and / or take greater responsibility for the management of diabetes , and understand the value that these newer therapies for glucose , cholesterol and BP control may have to be mutually coordinated for maximal reduction of cardiovascular outcomes guided by information gleaned from clinical trial results . Also endocrinologists / diabetologists need be especially suspicious of the likelihood of subclinical or clinical ASCVD and work with cardiologists in both the primary prevent and secondary prevention setting . The American Association of Clinical Endocrinologist ( AACE ) and the American Diabetes Association ( ADA ) both have annualized updated guidelines for management of blood glucose , HTN and dyslipidemia . The National Lipid Association ( NLA ) serves as a training ground for educational expertise in the complexities of lipid management .
Finally , to help in the effort to better combine forces between cardiologists and diabetologists , the ACC , in partnership with the American Diabetes Association , American College of Physicians , American Association of Clinical Endocrinologists , and Joslin Diabetes Center has created the first worldwide collaborative diabetes registry ( thediabetesregistry . org ) that is designed to track and improve the quality of care of diabetes and those with the metabolic syndrome across the continuum of primary and specialty care and encourage the participation of primary care physicians , endocrinologists , cardiologists , and other healthcare providers managing diabetes . In addition , the ACC seeks to promote physician education through article reviews and hot topic discussions via its clinical topic collection on diabetes and cardiometabolic disease on ACC . org . ■
Address correspondence to : Nathan D . Wong , PhD , FACC , FAHA , Heart Disease Prevention Program , C240 Medical Sciences , University of California , Irvine , email : ndwong @ uci . edu
REFERENCES :
1 . Wong ND , Patao C , Wong K , et al . Diab Vas Dis Res 2013 ; 10 : 505-513 . 2 . Gaede P , Lund-Andersen H , Parving HH , et al . Effect of a multifactorial intervention on mortality in type 2 diabetes . N Engl J Med 2008 ; 58 ): 580-91 . 3 . Wong ND , Zhao Y , Patel R , et al . Diabetes Care 2016 ; 2016 ; 39:668 – 676 . 4 . Wanner C , Inzucchi SE , Lachin JM , et al . EMPA-REG OUTCOME Investigators . N Engl J
Med 2016 ; 375 ( 4 ): 323-34 . 5 . Marso SP , Daniels GH , Brown-Frandsen K , et al . N Engl J Med 2016 ; 375:311-22 . 6 . Marso SP , Bain SC , Consoli A , ET AL . sUSTAIN-6 Investigators . N Engl J Med . 2016 Sep 15
( e-pub ahead of press ). 7 . Inzucchi SE , Viscoli CM , Young LH , et al . Diabetes Care 2016 ; 39 : 1684-92 .
ACC . org / CSWNInterventions CardioSource WorldNews : Interventions
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