|Systematic (IUPAC) name|
|Licence data||EMA: , US FDA:|
|Bioavailability||Low (approximately 2.5%)|
C09 (with HCT)
|(what is this?)|
Aliskiren (INN) (trade names Tekturna, US; Rasilez, UK and elsewhere) is the first in a class of drugs called direct renin inhibitors. Its current licensed indication is essential (primary) hypertension. While used for high blood pressure, other better studied medications are typically recommended due to concerns of higher side effects and less evidence of benefit.
In December 2011, Novartis halted a clinical trial of the drug after discovering increased incidence of nonfatal stroke, kidney complications, high blood potassium, and low blood pressure in people with diabetes and kidney impairment.
As a result, in April 20, 2012:
- A new contraindication was added to the product label concerning the use of aliskiren with angiotensin receptor blockers (ARBs) or angiotensin-converting enzyme inhibitors (ACEIs) in patients with diabetes because of the risk of kidney impairment, low blood pressure, and high levels of potassium in the blood.
- A warning to avoid use of aliskiren with ARBs or ACEIs was also added for patients with moderate to severe kidney impairment (i.e., where glomerular filtration rate is less than 60 ml/min).
While used for high blood pressure, other better studied medications are typically recommended. Prescrire has stated that aliskiren is potentially more harmful than beneficial and thus list it as of 2014 as a drug to avoid.
Mechanism of action
Renin, the first enzyme in the renin–angiotensin–aldosterone system, plays a role in blood pressure control. It cleaves angiotensinogen to angiotensin I, which is in turn converted by angiotensin-converting enzyme (ACE) to angiotensin II. Angiotensin II has both direct and indirect effects on blood pressure. It directly causes arterial smooth muscle to contract, leading to vasoconstriction and increased blood pressure. Angiotensin II also stimulates the production of aldosterone from the adrenal cortex, which causes the tubules of the kidneys to increase reabsorption of sodium, with water following, thereby increasing plasma volume, and thus blood pressure. Aliskiren binds to the S3bp binding site of renin, essential for its activity. Binding to this pocket prevents the conversion of angiotensinogen to angiotensin I. Aliskiren is also available as combination therapy with hydrochlorothiazide.
- High blood potassium level (particularly when used with ACE inhibitors in diabetic patients)
- Low blood pressure (particularly in volume-depleted patients)
- Diarrhea and other GI symptoms
- Elevated uric acid, gout, and kidney stones
- Pregnancy: Other drugs such as ACE inhibitors, also acting on the renin-angiotensin system, have been associated with fetal malformations and neonatal death.
- Breastfeeding: During animal studies, the drug has been found present in milk.
- Aliskiren has been shown to increase the likelihood of adverse cardiovascular outcomes in patients with diabetes and kidney or heart disease.
Aliskiren is a minor substrate of CYP3A4 and, more importantly, P-glycoprotein:
- It reduces furosemide blood concentration.
- Atorvastatin may increase blood concentration, but no dose adjustment is needed.
- Due to possible interaction with ciclosporin, the use of ciclosporin and aliskiren at the same time is contraindicated.
- Caution should be exercised when aliskiren is administered with ketoconazole or other moderate P-glycoprotein inhibitors (itraconazole, clarithromycin, telithromycin, erythromycin, or amiodarone).
- Recommendations have been made to stop prescribing aliskiren-containing medicines to patients with diabetes (type 1 or type 2) or with moderate to severe kidney impairment who are also taking an ACE inhibitor or ARB. Such patients should consider alternative antihypertensive treatment as necessary.
Rationale for design
Many drugs control blood pressure by interfering with angiotensin or aldosterone. However, when these drugs are used chronically, the body increases renin production, which drives blood pressure up again. Therefore, doctors have been looking for a drug to inhibit renin directly. Aliskiren is the first drug to do so.
- "First Hypertension Drug to Inhibit Kidney Enzyme Approved". CBC. 2007-03-06. Retrieved 2007-03-14.[dead link]
- "Towards better patient care: drugs to avoid in 2014". Prescrire International 23 (150): 161–165. June 2014.
- Healthzone.ca: Blood-pressure drug reviewed amid dangerous side effects
- Parving, Hans-Henrik; Brenner, M.D., Ph.D., Barry M.; McMurray, M.D., John J.V.; de Zeeuw, M.D., Ph.D., Dick; Haffner, M.D., Steven M.; Solomon, M.D., Scott D.; Chaturvedi, M.D., Nish; Persson, M.D., Frederik; Desai, M.D., M.P.H., Akshay S.; Nicolaides, M.D., Maria; Richard, M.Sc., Alexia; Xiang, Ph.D., Zhihua; Brunel, M.D., Patrick; Pfeffer, M.D., Ph.D. last15=for the ALTITUDE Investigators, Marc A. (2012). "Cardiorenal End Points in a Trial of Aliskiren for Type 2 Diabetes". NEJM 367 (23): 2204–13. doi:10.1056/NEJMoa1208799. PMID 23121378.
- Gradman A, Schmieder R, Lins R, Nussberger J, Chiang Y, Bedigian M (2005). "Aliskiren, a novel orally effective renin inhibitor, provides dose-dependent antihypertensive efficacy and placebo-like tolerability in hypertensive patients". Circulation 111 (8): 1012–8. doi:10.1161/01.CIR.0000156466.02908.ED. PMID 15723979.
- Straessen JA, Li Y, and Richart T (2006). "Oral Renin Inhibitors". Lancet 368 (9545): 1449–56. doi:10.1016/S0140-6736(06)69442-7. PMID 17055947.
- "Chemistry & Biology : Structure-based drug design: the discovery of novel nonpeptide orally active inhibitors of human renin". ScienceDirect. Retrieved 2010-01-20.
- Baldwin CM, Plosker GL.. doi:10.2165/00003495-200969070-00004. Drugs 2009; 69(7):833-841.
- Drugs.com: Tekturna
- Cardiorenal end points in a trial of aliskiren for type 2 diabetes, N Engl J MED. 2012;367(23):2204-2213
- European Medicines Agency recommends new contraindications and warnings for aliskiren-containing medicines.
- Ingelfinger JR (June 2008). "Aliskiren and dual therapy in type 2 diabetes mellitus". N. Engl. J. Med. 358 (23): 2503–5. doi:10.1056/NEJMe0803375. PMID 18525047.
- PharmaXChange: Direct Renin Inhibitors as Antihypertensive Drugs
- Prescribing Information for Tekturna
- aliskiren at the US National Library of Medicine Medical Subject Headings (MeSH)
- Chemical synthesis