Presentation is loading. Please wait.

Presentation is loading. Please wait.

TAIWAN TANABE 陳榮明 Jimmy Chen 藥師 - 地區經理 嘉南 – 藥學 FOR CARDIOVASCULAR DISEASES CONCOR TM 5mg/1.25mg Bisoprolol hemifumarate Indications: Hypertension,Angina,CHF.

Similar presentations


Presentation on theme: "TAIWAN TANABE 陳榮明 Jimmy Chen 藥師 - 地區經理 嘉南 – 藥學 FOR CARDIOVASCULAR DISEASES CONCOR TM 5mg/1.25mg Bisoprolol hemifumarate Indications: Hypertension,Angina,CHF."— Presentation transcript:

1

2 TAIWAN TANABE 陳榮明 Jimmy Chen 藥師 - 地區經理 嘉南 – 藥學

3 FOR CARDIOVASCULAR DISEASES CONCOR TM 5mg/1.25mg Bisoprolol hemifumarate Indications: Hypertension,Angina,CHF Dosage:5 ~ 10mg QD,1.25-QD TANABE/MERCK KGaA The Highest ß1-selectivity. The Best Quality of Life TAIWAN TANABE

4 First Choice of Antihypertensive Agent    /0    ?? ? ++ ? ++ + ? + +†++??+ +†++?? ++++??++++?? Diuretics  -Blockers Calcium antagonists ACE inhibitors ARBs  - Blockers ‡ Central agents Peak Exercise * Plasma K + Blood Lipids Insulin Resistance RenalElderlyCADStroke WHO/ISH First Choice JNC First Choice (Uncomplicated) MetabolicOutcome Studies * capacity for maximum exercise. † Secondary protection well documented but primary protection less so. ‡ Small  in stroke, angina, in ALLHAT, heart failure increased. JNC=Joint National Committee VI, 1997 WHO/ISH=World Health Organization-International Society of Hypertension, Taiwan Tanabe

5 Are the β-blockers all the same?

6 TAIWAN TANABE Classification of  -Blockers  -Blockers  1 -SelectiveNon-  1 -Selective Without ISA Bisoprolol Atenolol Betaxolol Metoprolol With ISA Acebutolol Without ISA Nadolol Propranolol Sotaolol Timolol Carvedilol With ISA Carteolol Pindolol Labetalol ISA:Intrinsic Sympathomimetic Activity Adapted from: European Heart Journal (2004) 25,

7 The most obvious pharmacological aspect of Beta-blockers with ISA is that they produce less of a decrease in resting heart rate than agents without ISA Intrinsic Sympathomimetic Activity (ISA) or Partial Agonist Effect Intrinsic Sympathomimetic Activity (ISA) or Partial Agonist Effect TAIWAN TANABE

8 ISA Is Controversially Discussed TAIWAN TANABE

9 Secondary prevention of myocardial infarction with different types of β -blockers % Reduction of mortality β 1 -selective without ISA Non-selective without ISA β1-selective with ISA Non-selective with ISA Adapted form:Progress in Cardiovascular Diseases. 27(5):335-71, 1985 Mar-Apr β-blockers without ISAβ-blockers with ISA TAIWAN TANABE

10 β1 selectivity:

11 Adapted from:European Heart Journal. 21(5):354-64, 2000 Mar Physiological effect of adrenergic receptor

12 300:1 1:35 1:75 increasing ß 1 -selectivity increasing ß 2 -selectivity ICI :1 Propranolol Atenolol Betaxolol Bisoprolol no selectivity Ratio of constants of inhibition 1:20 Metoprolol Bisoprolol: ß 1 -selectivity of various ß-blockers Wellstein A et al. J Cardiovasc Pharmacol 1986; 8 (Suppl. 11): Wellstein A et al. Eur Heart J 1987; 8 (Suppl. M): 3–8

13 b24824 PlaceboBisoprolol(20mg)Atenolol(100mg) AWR (cm H 2 O/I/s) HR (beats/min) b = before n = 12 ± SEM Bisoprolol: ß 1 -selectivity and lung function in coronary patients with chronic obstructive bronchitis Dorow P. Eur J Clin Pharmacol 1986; 31:143–147 x

14 – 0.4 – 0.8 AWR (cm H 2 O s/l) PlaceboBisoprolol 10 mg20 mg100 mg Atenolol n = 12 ± SEM Bisoprolol: ß 1 -selectivity and lung function in asthmatic hypertensives (2 h after administration) Chatterjee SS. J Cardiovasc Pharmacol 1986; 8 (Suppl. 11): 74–77 x

15 n= *4041 (* n=36 for triglycerides) ± SEM total cholesterol LDL-cholesterol HDL-cholesterol triglycerides lipids (mmol/l)cholesterol (mmol/l) months n= months Bisoprolol: ß 1 -selectivity and lipid metabolism in long-term therapy Bisoprolol: ß 1 -selectivity and lipid metabolism in long-term therapy Frithz G et al. J Cardiovasc Pharmacol 1986; 8 (Suppl. 11): 134–138 x

16 0 –10 –20 –30 – months Mepindolol 10 mg/day (n = 16) Bisoprolol 10 mg/day (n = 17) Propranolol 160 mg/day (n = 15) Atenolol 100 mg/day (n = 22) vs. baseline *p<0.05 **p<0.01 Δ % HDL-cholesterol Bisoprolol: ß 1 -selectivity and lipid metabolism in long-term therapy Bisoprolol: ß 1 -selectivity and lipid metabolism in long-term therapy Fogari R et al. J Cardiovasc Pharmacol 1990; 16 (Suppl 5): S 76–80

17 Bisoprolol 10 mg Metoprolol 50 mg Propranolol 40 mg Control lactate (mmol/l) Bisoprolol: ß 1 -selectivity and glucose metabolism Leopold G et al. Br J Clin Pharmacol 1986; 22:293–300

18 Propranolol Metoprolol Labetalol Carvedilol Atenolol Nadolol Sotalol PindololTimolol Lipophilic Hydrophilic TAIWAN TANABE

19 Balance Clearance Bisoprolol TAIWAN TANABE

20 *dose-dependent Bisoprolol: Comparison to ß 1 -selective ß-blockers Borchard U. ß-Rezeptorenblocker, Klinik und Praxis, Aesopus Verlag 1996

21 Bisoprolol: Comparison to non-selective ß-blockers Borchard U. ß-Rezeptorenblocker, Klinik und Praxis, Aesopus Verlag 1996

22 Three indications of Bisoprolol Essential Hypertension Angina Stable Chronic Heart Failure (Moderate~Severe)

23 Three Indications of Bisoprolol Essential Hypertension Angina Stable Chronic Heart Failure (Moderate~Severe)

24 days Bisoprolol Bisoprolol 5 mg n = 15/group Bisoprolol 10 mg Bisoprolol 20 mg PlaceboBisoprolol Placebo Δ SBP 0 – 10 – 20 – 30 – 40 (mm Hg) days 0 Δ DBP – 10 – 20 – 30 (mm Hg) Bisoprolol: Dose-dependent blood pressure reduction in hypertensives Kirsten R et al. J Cardiovasc Pharmacol 1986; 8 (Suppl. 11): 113–121 ± SEMx

25 Bisoprolol: Dose-dependent blood pressure reduction 3 and 24 hours after administration Davidov ME et al. Clin Cardiol 1994; 17: 263–268 0 – 2 – 4 – 6 – 8 – 10 – 12 – 14 – 16 DBP sitting (mm Hg) Bisoprolol dose Placebo 5 mg10 mg20 mg –3.6 –3.0 –10.5 –7.4 –12.7 –12.8 –14.7 – h p.a. 24 h p.a. 3 h p.a. 24 h p.a. n = 240 S ± SEM

26 SBP DBP h (mm Hg) last day of placebo after 4 weeks of bisoprolol(10mg) n = 8 Bisoprolol: Circadian rhythm Keim HJ. Therapiewoche 1988; 47:3507–3513

27 Bisoprolol: Treatment of hypertension in comparison to atenolol Neutel JM et al. Am J Med 1993; 94:181–187 0 –5 –10 –15 –20 10 a.m.4 p.m.10 p.m.4 a.m.10 a.m. time of day mean change in diastolic blood pressure (mm Hg ) DBP Bisoprolol (n = 107) night Atenolol(n = 96) dose intake

28 BisoDIASEndgültig months SBP (m(mm Hg) DBP (m(mm Hg) HR ( beats/min) n = Bisoprolol: Long-term treatment of hypertension Giesecke HG et al. J Cardiovasc Pharmacol 1990; 16 (Suppl 5): 175

29 Bisoprolol clinical study in Japan n=80n=73n=71 Total patients=81 Period:12 weeks Dosage: Bisoprolol 5mg QD Adapted from: 日本老年醫學會雜誌 35 卷 1 號 (1998:1) P33~38 TAIWAN TANABE

30 Diabetic Hypertension Beta-Blockers: Continue to surprise us

31 JNC Ⅶ Clinical Trial and Guideline Basis for Compelling Indications for Individual Drug Classes JNC Ⅶ Clinical Trial and Guideline Basis for Compelling Indications for Individual Drug Classes High-Risk Conditions With Compelling Indication* Heart Failure Post-myocardial infarction High coronary disease risk Diabetes Chronic kidney disease Recurrent stroke prevention Recommended Drugs Diuretic Beta-Blocker ACE Inhibitor ARB CCB Aldosterone Antagonist Clinical Trial Basis ACC/AHA Heart Failure Guideline, MERIT-HF, COPERNICUS, CIBIS, SOLVD, AIRE, TRACE, ValHERT, RALES ACC/AHA Post-MI Guideline, BHAT, SAVE, Capricorn, EPHESUS ALLHAT, HOPE, ANBP2, LIFE, CONVINCE NKF-ADA Guidelin, UKPKS, ALLHAT NKF Guideline, Captopril Trial, RENAAL, IDNT, REIN, AASK PROGRESS Adapted from: JAMA ; 289 :

32 Beta-blockers: another choice for HT with DM therapy

33 UK Prospective Diabetes Study largest multi-centre randomised controlled trial of different therapies of Type 2 diabetes largest study ever conducted in the prevention of diabetic complications in type II diabetics: study duration: clinical centres patient population: 5102 type 2 diabetic patients 53,000 patient years follow-up

34 UKPDS Blood Pressure Control Study tight vs. less tight: results Tight blood pressure control significantly reduces risks for any diabetes-related endpoint 24% (p=0.0046) diabetes-related deaths32% (p=0.019) stroke44% (p=0.013) microvascular disease37% (p=0.0092) heart failure56% (p=0.0043) retinopathy progression34% (p=0.0038) deterioration of vision47% (p=0.0036)

35 Table 1— Indications for initial treatment and goals for adult hypertensive diabetic patients SystolicDiastolic Goal (mmHg)13080 Behavioral therapy alone (maximum 3 months) then add pharmacologic treatment 130–13980–89 Behavioral therapy pharmacologic treatment Adapted from:DIABETES CARE, VOLUME 25, NUMBER 1, JANUARY 2002

36 UKPDS Study Adapted from:BMJ, Volume 317(7160).September 12,

37 UKPDS Blood Pressure Control Study results favour ß-blocker: Adapted from:BMJ, Volume 317(7160).September 12,

38 UKPDS Study Adapted from:BMJ, Volume 317(7160).September 12, Intermittent claudication or cold feet 0 15 (4) < Bronchospasm 0 22(6) <0.0001

39 After UKPDS management of blood pressure was not a high priority for type 2 diabetics first choice treatment ACE inhibitors management of blood pressure was not a high priority for type 2 diabetics first choice treatment ACE inhibitors management of blood pressure should have high priority in the treatment of type 2 diabetes first choice treatment or Beta- blocker ACE inhibitor or Beta- blocker management of blood pressure should have high priority in the treatment of type 2 diabetes first choice treatment or Beta- blocker ACE inhibitor or Beta- blocker Before UKPDS UKPDS Blood Pressure Control Study implications

40 Treatment of Hypertension in Adults With Diabetes A-level evidence: Initial drug therapy may be with ACE inhibitors, ARBs, β-blockers, or diuretics. Additional drugs may be chosen from these classes or another drug class. In patients with a recent myocardial infarction, β-blockers, in addition,should be considered to reduce mortality. Adapted from:DIABETES CARE, VOLUME 25, NUMBER 1, JANUARY 2002

41 Three Indications of Bisoprolol Essential Hypertension Angina Stable Chronic Heart Failure (Moderate~Severe)

42 Objectives: To evaluate the effects of Bisoprolol o.d. and Nifedipine slow release b.i.d. on the occurrence and circadian distribution of ischaemic episodes in patients with stable angina pectoris Randomised double-blind controlled study with two parallel groups T I B B S Total Ischaemic Burden Bisoprolol Study von Arnim Th et al. JACC 1995; 1: 231–230

43 10 days4 weeks 48 h Holter History ETT Inclusion for prephase If > 2 ischaemic episodes, inclusion for active treatment 20 mg o.d. Bisoprolol 10 mg o.d. Bisoprolol 40 mg b.i.d. Nifedipine s.r. 20 mg b.i.d. Nifedipine s.r. Placebo 48 h Holter TIBBS: Flow chart von Arnim Th et al. JACC 1995; 1: 231–238

44 BisoDIASEndgültig43 No./48 h Baseline40 mg20 mgBaseline20 mg10 mg Nifedipine s.r. b.i.d. (n = 112)Bisoprolol o.d. (n = 111) TIBBS: Number of ischaemic episodes at baseline, on low dose and on high dose von Arnim Th et al. JACC 1995; 1: 231–238 ± SEMx

45 BisoDIASEndgültig44 minutes Baseline40 mg20 mgBaseline20 mg10 mg Nifedipine s.r. b.i.d. (n = 112)Bisoprolol o.d. (n = 111) TIBBS: Duration of ischaemic episodes at baseline, on low dose and on high dose von Arnim Th et al. JACC 1995; 1: 231–238 ± SEMx

46 BisoDIASEndgültig45 min. x mm Baseline40 mg20 mgBaseline20 mg10 mg Nifedipine s.r. b.i.d. (n = 112)Bisoprolol o.d. (n = 111) TIBBS: Total ischaemic burden at baseline, on low dose and on high dose von Arnim Th et al. JACC 1995; 1: 231–238 ± SEMx

47 Three Indications of Bisoprolol Essential Hypertension Angina Stable Chronic Heart Failure (Moderate~Severe)

48 Heart Failure From Contraindication to Indication Beta-Blockers: Continue to surprise us

49 The organism responds to the reduced cardiac output situation in CHF by a number of compensatory mechanisms to maintain cardiac output Frank-Starling mechanism (  CO) Raised sympathetic-nervous activity Renin-angiotensin-aldosterone system Enhanced exploitation of blood oxygen in the peripheral TAIWAN TANABE Compensatory mechanisms in CHF

50 u Rise in oxygen consumption u Arrhythmogenicity u Diminished diastolic filling u Systolic function impairment u Cardiotoxic effect of endogenous catecholamines u Down-regulation of the  -receptors u Metabolic disorders TAIWAN TANABE Chronically raised sympathetic tonus is accompanied by a number of unfavourable cadiovascular effects

51  -blockers 應用於治療 CHF 的理論基礎

52

53 -beneficial concomitant therapy in CHF Publication:The Lancet 1999; 353:9-13 TAIWAN TANABE

54 Double-blind, placebo-controlled, randomised trial 2,647 patients included (NYHA III + IV) Bisoprolol administered on top of standard therapy (diuretic + ACE inhibitor) CIBIS II Cardiac Insufficiency Bisoprolol Study CIBIS II Investigators and Committees. Lancet 1999; 353: 9–13

55 Primary objective –All-cause mortality Secondary objectives –Cardiovascular mortality –Hospital admissions –Cardiovascular mortality or cardiovascular hospital admissions –Permanent treatment withdrawal CIBIS II Objectives CIBIS II Objectives CIBIS II Investigators and Committees. Lancet 1999; 353: 9–13

56 Ambulatory patients with stable CHF of all aetiologies NYHA functional class III or IV Stable on ACE inhibitor and diuretic Aged 18 – 80 years Left ventricular ejection fraction - 35% CIBIS II Main inclusion criteria CIBIS II Main inclusion criteria CIBIS II Investigators and Committees. Lancet 1999; 353: 9–13

57 W1 W2W3W4 W5W6W7 W8 W9W10W11 W12 W13W14W15W16Week Bisoprolol dose (mg)  No run-in period  Dose increased according to tolerability CIBIS II Dose titration CIBIS II Investigators and Committees. Lancet 1999; 353: 9–13

58 PlaceboBisoprolol (n=1320) (n=1327) Demographic data Mean (range) age (years)61 (22–80)61 (26–80) Sex (M/F)1062 (80%)1070 (81%) 258 (20%)257 (19%) NYHA class III1096 (83%)1106 (83%) IV 224 (17%) 221 (17%) Heart failure Documented ischaemic heart disease654 (50%)662 (50%) Primary dilated cardiomyopathy157 (12%)160 (12%) Others*509 (40%)505 (38%) Mean (SD) LV ejection fraction 27.6 (5.5%)27.5 (6.0%) *Coronary angiography unavailable or no history of myocardial infarction CIBIS II Characteristics (I) CIBIS II Investigators and Committees. Lancet 1999; 353: 9–13

59 PlaceboBisoprolol (n=1320)(n=1327) Concomitant medication Diuretic1310(99%)1305(98%) ACE inhibitor1274(96%)1273(96%) Dihydropyridine-type calcium antagonist23(2%)23(2%) Nitrate762(58%)773(58%) Digoxin670(51%)697(53%) Amiodarone206(16%)185(14%) Anticoagulant413(31%)399(30%) Antiplatelet agent558(42%)537(40%) CIBIS II Characteristics (II) CIBIS II Characteristics (II) CIBIS II Investigators and Committees. Lancet 1999; 353: 9–13

60  34% reduction in all-cause mortality with bisoprolol Time after inclusion (days) Survival Bisoprolol: 156 deaths(11.8%) (n = 1327) Placebo: 228 deaths(17.3%) (n = 1320) log rank test, p < CIBIS II Survival CIBIS II Survival CIBIS II Investigators and Committees. Lancet 1999; 353: 9–13

61 Patients Unknown cause of death Non-cardio- vascular deaths Other cardio- vascular deaths Myocardial infarction Pump failure Sudden death 0.45 (0.27 – 0.74) 0.75 (0.37 – 1.50) 1.17 (0.67 – 2.03) 0.85 (0.31 – 2.34) 83 6% p= % 36 3% 0.56 (0.39 – 0.80) 0.74 (0.48 – 1.14) Hazard ratio: (95% CI) p=0.17 p=0.75 p=0.58 p=0.41 p= Bisoprolol (n = 1327) Placebo (n = 1320) % 7 1% 8 1% 28 2% 23 2% 14 1% 18 1% 23 2% 49 4% CIBIS II Causes of deaths CIBIS II Investigators and Committees. Lancet 1999; 353: 9–13

62 In the bisoprolol-treated group of patients there was a reduction in All-cause mortality (independent of aetiology) by34% (p<0.0001) Sudden death by44% (p<0.0011) All-cause hospital admissions by20% (p<0.0006) CIBIS II Main results at a glance CIBIS II Investigators and Committees. Lancet 1999; 353: 9–13

63 CIBIS II successfully demonstrated that ß 1 - selective bisoprolol – given in addition to standard therapy – reduces significantly all-cause mortality and all-cause hospitalisation in CHF patients. Bisoprolol is the first ß-blocker which has proven its efficacy in a single large-scale CHF study with all-cause mortality as primary objective. Bisoprolol was as well tolerated as placebo with a premature permanent treatment withdrawal rate of 15% in both groups. CIBIS II Conclusions CIBIS II Conclusions CIBIS II Investigators and Committees. Lancet 1999; 353: 9–13

64

65 ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult β-receptor blockers Bisoprolol 1.25 mg once daily 10 mg once daily Carvedilol mg twice daily 25 mg twice daily; 50mg twice daily for patients more than 85 kg Metoprolol tartrate 6.25 mg twice daily 75 mg twice daily Metoprolol succinate Extended release 12.5 to 25 mg daily Drug Initial Dose Maximum Dose

66 Major Trials of  -Blockade in Heart Failure LVEF Target /Mean dose Mortality Sudden Death NYHA (mg/day) US Carvedilol < /45 mg  65% †  52% † mo II-IV carvedilol (P=.0001) (P<.05) CIBIS-II < /7.5 mg  34%  44% y III-IV bisoprolol (P<.0001) (P<.0011) MERIT-HF < /159 mg  34%  41% y II-IV metoprolol XL (P=.0062) (P=.002) BEST < /152 mg  10%  12% y III-IV bucindolol NS NS COPERNICUS < 25 50/ 37 mg  35% NA mo IV carvedilol (P=.0014) † Not a planned endpoint.

67 Effect of  -Blockade on All-Cause Mortality Relative risk and 95% confidence intervals CIBIS-II: 1.3 years placebo 228/1320 (17%); bisoprolol 156/1327 (12%) P=.0001 MERIT-HF: 12 months placebo 217/2001 (11%); metoprolol 145/1990 (7%) P=.006 CIBIS-I: 1.9 years placebo 67/321 (20%); bisoprolol 53/320 (16%) P=.22 US Carvedilol Trials: 7.6 months* placebo 31/398 (8%); carvedilol 22/696 (3%) P=.001 * Not a planned endpoint.

68 CIBIS III Cardiac Insufficiency Bisoprolol Study CIBIS III Comparison of the efficacy and safety of initiation of treatment with bisoprolol or enalapril as monotherapy followed by their combination in patients with chronic heart failure (CHF)

69 CIBIS III Background Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001; 22: Chronic heart failure:  still a major clinical and public health problem  current pharmacological therapy:  ACE-inhibitors  Beta-blockers  Diuretics  Digitalis glycosides  Aldosterone antagonists

70 Initiation of treatment in patients with CHF with the β 1 -selective β-blocker bisoprolol (to which enalapril is subsequently added) is as effective and safe as a regimen beginning with the ACEi enalapril (to which bisoprolol is subsequently added). DOI: /CIRCULATIONAHA Hypothesis

71 6 months6 to 18 months week months bisoprolol(mg/d) enalapril(mg/d) bisoprolol(mg/d) Monotherapy Combination therapy Randomisation 24months enalapril(mg/d) 2468 CIBIS III Dose titration

72 To show that initial mono-therapy with bisoprolol followed by combination therapy with enalapril is comparable (non-inferior) to the reverse order in preventing death and hospitalization for all causes (combined endpoint). DOI: /CIRCULATIONAHA Primary objective

73 CIBIS III Primary objectives First primary objective: -Initiation of monotherapy with bisoprololol followed by the addition of enalapril (combination therapy) is comparable (non-inferior) to initiation with enalapril in CHF patients in preventing all-cause death and hospitalisation (combined endpoint) at end of study Second primary objective (if first primary objective is met): -Initiation of monotherapy with bisoprolol is superior to initiation with enalapril in CHF patients (combined endpoint) at end of study

74 Intention-to-treat (ITT) population Bisoprolol-first Enalapril-first Per-protocol (PP) population Combined primary endpoint % without endpoint % without endpoint B/E vs E/B 163 vs 165 pts HR 0.97 (95% CI ) non-inferiority P=0.046 B/E vs E/B 178 vs 186 pts HR 0.94 (95% CI ) non-inferiority P= months Bisoprolol-first significantly non- inferior to enalapril-first if upper limit of 95% CI below hazard ratio (HR) 1.17, P< (=RR 1.125, AR +5%) In the PP population, bisoprolol- first was not significantly non- inferior to enalapril-first In the ITT population, bisoprolol- first was significantly non-inferior to enalapril-first Numbers at risk 3% risk reduction 6% risk reduction DOI: /CIRCULATIONAHA

75 All-cause hospitalization throughout study (ITT) % without hospitalization 505 months Numbers at risk Bisoprolol-first Enalapril-first DOI: /CIRCULATIONAHA B/E vs E/B 151 vs 157 pts hospitalized HR 0.95 (95% CI ) P=0.66 (difference) 5% risk reduction

76 All cause mortality throughout study (ITT) B/E vs E/B 65 vs 73 deaths HR 0.88 (95% CI ) P=0.44 (difference) % survival months 505 Bisoprolol-first Enalapril-first Numbers at risk DOI: /CIRCULATIONAHA % risk reduction

77 Primary endpoint at end of monotherapy (ITT) (all cause mortality and all cause hospitalization) B/E vs E/B 109 vs 108 pts HR 1.02 (95% CI ) P=0.90 (difference) % without endpoint months 505 Numbers at risk Bisoprolol-first Enalapril-first DOI: /CIRCULATIONAHA % risk increase

78 Conclusions (1) In terms of combined mortality / hospitalization Bisoprolol-first was non-inferior to enalapril-first in the ITT sample Bisoprolol-first was close to non-inferior to enalapril-first in the PP sample DOI: /CIRCULATIONAHA

79 There was no difference in safety between the two strategies, showing that a bisoprolol-first strategy does not cause concerns Conclusions (2) DOI: /CIRCULATIONAHA

80 Bisoprolol-first might increase survival in the early phase of treatment, allowing a greater number of patients to subsequently benefit from combined β-blocker + ACEi. The bisoprolol-first strategy could be further improved with greater experience of up-titration of the β-blocker-first, leading to less worsening of CHF. This should be further examined. Thoughts for the future DOI: /CIRCULATIONAHA

81 Clinical implication The CIBIS III result supports a free choice of initial treatment for CHF - enalapril or bisoprolol - based on the physician’s individual judgment in each patient DOI: /CIRCULATIONAHA

82 Put into clinical practice CHF specific logo dosage easy to identify from all sides dose specific color code CHF specific color code

83 β 1 :β 2 = 75:1 Bisoprolol Non-ISA CIBIS Ⅱ CIBISIII TIBBS DECREASE CIBIS Ⅱ CIBISIII TIBBS DECREASE Balance Clearance NHI price: Concor 5 = NT 7.6 NHI price: Concor 5 = NT 7.6 TAIWAN TANABE Hypertension Angina CHF Hypertension Angina CHF

84 Thanks for your coming! TAIWAN TANABE Concor wins your heart!!


Download ppt "TAIWAN TANABE 陳榮明 Jimmy Chen 藥師 - 地區經理 嘉南 – 藥學 FOR CARDIOVASCULAR DISEASES CONCOR TM 5mg/1.25mg Bisoprolol hemifumarate Indications: Hypertension,Angina,CHF."

Similar presentations


Ads by Google