Chronotherapy in the news again?
@medscape.com discusses the story so far with the new ONAM study www.medscape.com/viewarticle/...
@drlabos.bsky.social feat Scott Garrison and moi
#Hypertension
Yes, MRAs can cause mild hyponatremia. Usually not a major issue but can be a factor. I have not seen severe hyponatremia (eg <125) and use a lot.
Aldosterone deficient mice are mildly hyponatremic (inconsistently)
Primary aldosteronism is associated with mild hypernatremia
Tolerate if really needed, but taper as BP falls after spironolactone takes effect- usually weeks to 3 months
42% sensitivity is what you want in a screening test, right? [sarcasm]
Hypertension Secrets has been translated into multiple languages, including Lithuanian!
Get your copy here: shop.elsevier.com/books/hypert...
@edgarvlermamd.bsky.social @drjmluther.bsky.social
The CPC from last @ahascience.bsky.social #HypertensionSessions now published in @ahajournals.bsky.social
www.ahajournals.org/doi/10.1161/...
thanks to @drjmluther.bsky.social and all the education editors for the invite
We hope it makes for an educational read!
New 2025 AHA/ACC Hypertension Guideline dropped!
www.jacc.org/doi/10.1016/...
#hypertension #medsky #nephsky
#LaskerLaureate Rustom Jal Vakil was born #OTD in 1911. He won a #LaskerAward in 1957 for his studies on the use of reserpine in the treatment of #hypertension. ow.ly/bFTR50FunRI 🧪
almost always lower dose 12.5-25, occasionally higher 50-100mg.
hyperkalemia/CKD > gynecomastia > dysmenorrhea of course can be limiting
Yes you should be able to reduce medications after adding Spironolactone.
I withdraw based on other adverse med effects (edema = CCB; K = thiazide/RAASi)
I use this figure in my talks on Resistant HTN...(observational, but holds up imo)
pubmed.ncbi.nlm.nih.gov/11991219/
New PA Endo guideline is also out by experts @anandvaidya17.bsky.social #Cardiosky @hswapnil.medsky.social doi.org/10.1210/clin...
The first #ERA25 simultaneous pub
CONFIDENCE trial of empagliflozin + finerenone in N = 579
Greater reduction in ACR and BP
Note the impressive GFR dip
www.nejm.org/doi/full/10....
Bring back methyldopa too!
Standardized treatment in advance-HTN included thiazide + ARB for all.
Upcoming Launch-HTN uses standard background meds so will be a mix of real world regimens.
Longer term open label followup is ongoing too.
I'm gonna guess Geriatrics
Plenary at @hypertensioncanada.bsky.social with @drjmluther.bsky.social on new drugs
He starts of with the really old drugs!
#CHC25
*in rodents
Phase 2 trial of the new antihypertensive agent, ultra-long-acting (q6 month), subq, small interfering RNA against angiotensinogen (Zilebesiran), hit JAMA!
h/t @drjmluther.bsky.social
jamanetwork.com/journals/jam...
1/
Hyponatremia define here as <135, and also while all patients on a thiazide. Suspect clinically significant hypoNa is much less common.
#NephJC
I do not have any inside info- doesn't look like it is being studied in the US, likely due to lack of patent protection. But it appears much less selective than newer agents. It is just R-fadrazole.
the bigger issue is - don't block cortisol synthesis, which ramps up ACTH and revs up the steroid pathway and further augments DOC accumulation.
#NephJC
btw @kidneyboy.bsky.social this pathway needs to be taught to our Neph fellows so they can think this problem out like you're doing
Indapamide 2.5mg or if previously on HCTZ continue that dose (if I recall correctly).
Plus Olmesartan 40mg in all.
If previously on 3 drugs then Amlodipine 10mg or max tolerated dose used.
#NephJC
absolutely.
Not sure the numbers are sig different, but I think your rationale is correct. The dose would have been pushed up to 100mg only in the most resistant #NephJC
Theoretically:
- it targets the primary issue in many patients- unregulated aldosterone production.
-avoid effect of further elevated Aldo during MRA treatment
Obvs -avoid gynecomastia and off-target effects of Spiro.
For other MRAs it has always been difficult to push dose high enough.
#NephJC
I would classify Osilodrostat as a nonselective inhibitor. It impaired Cort-stim response in those doses. also Lowered BP - would not include with selective ASIs.
Osilodrostat is now approved for treatment of Cushing's (Cortisol inhibition) at much higher dose than used in these trials.
#NephJC
That is why they added the Cystatin-C measurement to help clarify.
I do expect some hemodynamic effect with treatment of uncontrolled HTN into a lower range, though.
#NephJC
correct. Aldo usually increases with MRA treatment.
Renin increases during both ASI and MRA.
Plasma Aldo provides a snapshot in time.
24hr urine Aldo may give a better measure of coverage.
#NephJC
At very high dose, ASIs increase DOC.
Less potent MR agonist - BP reduction and Renin increase is still evident.
CYP11B1 inhibition also increases ACTH, DOC.
Lower dose for each ASI is chosen in part to limit DOC response.
#NephJC
Baxdrostat HALO study failed to reach primary endpoint - I don't know why but VERY large placebo drop in AOBP.
Trial design or conduct error. I don't think it was the drug.
#NephJC
