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Systole Diastole
Heart
Force of
at rest
Heart pumping
Causing strain
Beta-blockers
ACE Inhibitors
• First Generation
• Second Generation
• Third Generation - Amlodipine
N – type = Neuronal
The N-type currents are found primarily in neurons
where they initiate
neurotransmission by releasing norepinephrine from
peripheral sympathetic nerve endings
They are also present in Renal tissue
Heart H
Y
Leads to increase in : P
Sympathetic • Cardiac output
nerve Peripheral artery Vascular resistance E
Na+ retention
activity
(N-type Ca++ channels) Renin-Angiotensin System R
T
E
Leptin Kidney N
S
I
O
Obesity
Skeletal muscle Increased Insulin resistance N
Cardiovascular Therapeutics 27 (2009) 124–139
Sympathetic overactivity
(Activation of N-type Ca++ channels)
Excessive
Glutamate release Glomerular
via activation of
N-type Ca++ channels HT
Synthesized by Fujirebio Inc. (Japan) and is currently marketed in Japan, China &
Portugal under brand name – ATELEC, CINALONG & TENVASC
L-type
• Lowers Blood Pressure by inhibiting L-type calcium channels which
are directly associated with vascular tone
N-type
• Blocks N-type calcium channels which are related to sympathetic
nervous activity
25 Cellular inhibitory effects of
21 AMLODIPINE Dihydropyridines were noted on
20 rat ventricular myocytes
CILNIDIPINE
Cilnidipine had the highest selectivity
15 NIMODIPINE
for N-type channels
NISOLDIPINE
10 Ratio of IC50 (L-type & N-type
NICARDIPINE Ca++ channels)
5
0.43
• With Cilnidipine the IC50
0.082 0.01 0.34
0 ratio is 21
IC50 (L/N) ratio
• This is about 50 times more
than that of Amlodipine
(IC50 ratio: 0.43)
Renoprotective Effect
Neuroprotective Effect
Metabolic Syndrome
Other Benefits
CARDIOPROTECTIVE EFFECT
Journal of the American Society of Hypertension (2011) 1–7
Effects of the L/N-type calcium channel antagonist
cilnidipine on morning blood pressure control and peripheral
edema formation
Conclusion
• Cilnidipine had a greater effect on MHT, without causing
significant leg edema, when administered at bedtime.
• The sympathoinhibitory action and the resulting balanced
vasodilation of arteries and veins by the L/N-type calcium
channel blocker cilnidipine are clinically useful features for
treating hypertensive patients.
Cardioprotective Effect
The purpose of this study was to assess the effect of Cilnidipine and Amlodipine
on ambulatory BP levels
24 hours ambulatory BP monitoring was performed before and after the use of
Cilnidipine (n=55) and Amlodipine (n=55) as Once Daily
• Cilnidipine – 10 to 20 mg/day
0
SBP DBP
-5 Both the drugs significantly reduced the
clinical and 24-hours Systolic BP (SBP)
and Diastolic BP (DBP) (p < 0.005)
-10 -12 -12
However, there is 8% reduction
Diff. in BP
-35
3
2.5 1.9
1.6 1.7
2 AMLODIPINE
1.5
CILNIDIPINE
1
24HPR DAY PR NIGHT PR
0.5
0
-0.5
-1
-1.5
-2 -1.2 -1.2
-1.6
-2.5
The 24-h, daytime and night time PR showed significantly greater decreases in the
cilnidipine group compared to amlodipine.
Hoshide S. Hypertens Res. 2005 Dec;28(12):1003-8
Cardioprotective Effect
The 24-hr daytime & night time PR showed significantly greater decrease in
cilnidipine group compared to amlodipine group
Cardioprotective Effect
Increased pulse pressure, SBP and DBP are well known characteristics of
hypertension in elderly patients
Both SBP & DBP were significantly decreased in clinidipine treated group
The reductions in SBP & DBP were 46.8 ± 6.6 mmHg and 18.8 ± 4.2 mmHg
As a consequence of the decrease in SBP & DBP, pulse pressure was significantly
decreased
Cardioprotective Effect
MIBG (123I-metaiodobenzylguanidine)
• Radioactive isotope analog of Guanidine shares the same kinetics as
norepinephrine in the human body
• Decreased MIBG uptake is associated with unfavorable prognosis
Cilnidipine Amlodipine
CV events like Myocardial Infarction (MI), stroke & sudden death often occur
during morning
During this time of the day, over-activation of sympathetic nerve increases the
TPR & therefore, the resultant CV events
CCBs including Amlodipine are known to cause Pedal edema in upto 32% of patients
• This is primarily due to increased venular pressure after sympathetic nervous
system stimulation
Sympathetic nerves are found in the venules. Hence the drugs that block N-type
calcium channels may possibly cause venodilation
Arterial Dilation
Cardioprotective Effect
LVH is an independent risk factor for Ischemic Heart Disease (IHD), Arrhythmia,
sudden death & Congestive Heart Failure (CHF)
This results in less blood reaching the kidneys, leading to Renin Angiotensin-
Aldosterone System (RAAS) stimulation or sympathetic stimulation
However excessive SNS stimulation has unfavorable prognosis for heart failure
CCBs are not ideally suited for patients with heart failure
Cardioprotective Effect
Method
60 patients with mild Essential Hypertension were randomly allocated in
two groups to receive
• Cilnidipine (n = 30) - 10 mg
• Quinapril (n = 30) - 10 mg
-2
% Reduction in L V M I QUINAPRIL
-4
CILNIDIPINE
-6
-8 -7.6
-10
-10.6
-12
Results
• In both the groups SBP & DBP significantly decreased to similar levels
• Only in Cilnidipine group, the MIBG uptake increased significantly (p < 0.02)
The usefulness of Cilnidipine in patients with CHF was evaluated using MIBG
Myocardial Scintigraphy
Symptom improvement, BP, HR, MIBG kinetic differences were noted at six months
Salient Features
• The data suggests that higher the baseline heart rate, the more marked
will be the decrease in heart rate with the use of Cilnidipine
• This is the first large scale study (1008 patients) conducted in a multi-
centeric setting to evaluate the safety and efficacy of combination
therapy with an ARB and CCB - Cilnidipine
ACEIs slow the progression of CRI and are the preferred drugs
While Serum creatinine levels did not change, Cilnidipine, like Benazepril,
significantly reduced SBP, DBP & Albuminuria
250 110
100
200
90
150
80
100 70
50 60
Before 6 12 months Before 3 6 12 months
Methods:
28 proteinuric hypertensive outpatients received either:
• Amlodipine – 5 to 10 mg/day
• Cilnidipine – 10 mg/day
Investigations included – Urine Protein, Urine Albumin, Serum Creatinine
& Serum β2-Microglobulin
60
40 • Increase in Proteinuria
was suppressed in
20 Cilnidipine group
4
00 • BP reduction was similar
in both the groups
Proteinuria
Methods:
Conclusion:
• In patients with Diabetic Nephropathy, blocking N-type Ca++ channels
with Cilnidipine resulted in significant reduction in Albuminuria.
• Pharmacological profile –
Cilnidipine, as an antihypertensive,
is equivalent. to a Comb. of pure
L- type CCB + Small dose of α &
β- adrenergic receptor antagonist
Thus, the L/ N-type Ca++ channel blocker cilnidipine can be categorized as the
fourth – generation according to its effects on sympathetic function
NEUROPROTECTIVE EFFECT
To evaluate neuroprotective effect and
mechanisms of action of cilnidipine, a inhibitor
of L- and N-type calcium channels.
Cilnidipine does not result in decrease in the number of platelets and patients
have not demonstrated incidence of hematoma enlargement or re-bleeding
The study results shows that when Cilnidipine is given within 3 days of
hospitalization, it can reduce the amount of intravenous Nicardipine and may also
help to maintain the BP below 80% of its initial level
Number of subjects :77 patients (35 with DM and 42 without DM) received either:
• Amlodipine-2.5 to 7.5 mgs
• Cilnidipine-10 to 20 mgs
Investigations done : Serum Cholesterol, HDL-C, LDL-C, TG, Serum insulin, plasma
renin and aldosterone. Insulin resistance index (HOMA-R: homeostasis model
assessment insulin resistance index), Estimated GFR (eGFR) and the urinary
albumin/creatinine were calculated.
3 Mg/dL Triglyceride
280
2
240
1 200
160
0 120
DM (-) DM (-)
0
Total DM(-) DM(+) Total DM(-) DM(+)
Amlodipine Cilnidipine
Amlodipine Cilnidipine
eGFR
mL/min 1.73m2
100
+
++
80
60
40
Total DM(-) DM(+) Total DM(-) DM(+)
Amlodipine Cilndipine
Cilnidipine reduces excessive excitation of the sympathetic nervous system and the
release of norepinephrine from sympathetic nerve endings, and consequently
suppresses reflective tachycardia and stress-induced blood pressure elevation
As regards, renal function in the diabetic group, estimated glomerular filtration rate
was significantly higher with Cilnidipine than with Amlodipine
Using ABPM, amlodipine elevated daytime and nocturnal heart rate, while
cilnidipine reduced daytime and nocturnal heart rate
Highlights
HOMA-R* was significantly lower with cilnidipine than with amlodipine, indicating
that insulin resistance was improved by cilnidipine
Plasma renin activity was significantly lower with cilnidipine than with amlodipine
Cilnidipine which inhibits N-type calcium channels is more useful for patients with
hypertension and diabetes mellitus from its effects on glucose and lipid metabolism
and renal function
16 hypertensive patients were evaluated for lipid lowering effects with
Cilnidipine (5 to 10mg/d) for 3 months
Pts had ‘high’ lipid profile - >300mg/dl
70 % change
60
62.7
50
40
30
20
10
0 -1.6
-10 -14.1
-20
TC TG t-PA
Ahaneku JE. Pharmacol Res 2000;41(1):81-84
Cilnidipine in these patients offers:
• Antiplatelet effect
This is a result of the elevated endothelial Ca++ ions & increased eNOS expression
or activity
*2,2-diphenyl-1-picrylhydrazyl
50
100 100
DPPH Scavenging
DPPH Scavenging
Activity (%)
Activity (%)
50 50
0 0
Cold pressor test was performed at the end of 1st & 2nd month of treatment
• Suppresses sympathetic activity in veins & therefore less potential for Pedal
edema
Antiplatelet effect
Metabolically Neutral
• Minimal or negligible effect on glycemic or lipid metabolism for co-
administration in Diabetics and Dyslipidemic patients
Pleiotrophic Effects
• Anti-inflammatory, antiproliferative or antioxidant properties
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