Is the newest angiotensin-receptor blocker azilsartan medoxomil more efficacious in lowering blood pressure than the older ones? A systematic review and network meta-analysis

Abstract

Angiotensin-receptor blockers are often considered insufficiently efficacious in reducing blood pressure. However, newer angiotensin-receptor blockers may be more effective than the older ones. A network meta-analysis was performed to compare the efficacy of various angiotensin-receptor blockers in reducing office and ambulatory blood pressure in hypertensive patients. Relevant literature was searched from English and Chinese databases for randomized controlled trials involving angiotensin-receptor blockers in hypertension. Efficacy variables included systolic and diastolic blood pressure either in the office or on ambulatory blood pressure monitoring. Absolute blood pressure reductions at 6-12 weeks of treatment and their credible intervals were reported. A total of 34 publications provided adequate data for analysis (n = 14 859). In 28 studies on office systolic blood pressure (n = 12 731), against the common comparator valsartan 80 mg, the differences in systolic blood pressure were in favor of azilsartan medoxomil (20-80 mg), irbesartan (300 mg), olmesartan (20-40 mg), telmisartan (80 mg), and valsartan (160-320 mg), but not candesartan (8-16 mg), losartan (50-100 mg), irbesartan (150 mg), olmesartan (10 mg), and telmisartan (40 mg). The ranking plot shows that azilsartan medoxomil 80 mg had a possibility of 99% being the best in the class. Similar results were observed for office diastolic blood pressure and from 13 studies for 24-hour ambulatory systolic and diastolic blood pressure. In conclusion, angiotensin-receptor blockers had different blood pressure lowering efficacy. The newest angiotensin-receptor blocker azilsartan medoxomil at the dose of 80 mg seemed to be most efficacious in reducing both systolic and diastolic blood pressure in the office and on ambulatory measurement.

Keywords: ambulatory; angiotensin-receptor blocker; blood pressure; efficacy; network meta-analysis; systematic review.

FIGURE 1

Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) diagram of the systematic review search strategy

FIGURE 2

Network of direct comparisons between various angiotensin‐receptor blockers for office (upper panels) and ambulatory (lower panels) systolic (left panels) and diastolic (right panels) blood pressure. Abbreviations: AZL‐M 20, AZL‐M 40, and AZL‐M 80 indicate azilsartan medoxomil 20, 40, and 80 mg daily, respectively; CAN 8, CAN 16, and CAN 32, candesartan 8, 16, and 32 mg daily, respectively; IRB 150 and IRB 300, irbesartan150 and 300 mg daily, respectively; LOS 50 and LOS 100, losartan 50 and 100 mg daily, respectively; OLM 10, OLM 20, and OLM 40, olmesartan 10, 20, and 40 mg daily, respectively; TEL 40 and TEL 80, telmisartan 40 and 80 mg daily, respectively; VAL 40, VAL 160, and VAL 320, valsartan 40, 160, and 320 mg daily, respectively

FIGURE 3

Absolute mean (95% credible interval, CRI) difference in office systolic (left panel) and diastolic (right panel) blood pressure for various angiotensin‐receptor blockers in comparison with valsartan 80 mg daily. For explanations on the abbreviations of drugs, see the legend to Figure 2

FIGURE 4

Absolute mean (95% credible interval, CRI) difference in ambulatory systolic (left panel) and diastolic (right panel) blood pressure for various angiotensin‐receptor blockers in comparison with valsartan 80 mg daily. For explanations on the abbreviations of drugs, see the legend to Figure 2