Hypertension Research (2009) 32, 639–640 & 2009 The Japanese Society of Hypertension All rights reserved 0916-9636/09 $32.00 www.nature.com/hr COMMENTARY Combination therapy of angiotensin receptor blocker with statin or thiazolidinediones as promising therapeutic strategy for metabolic syndrome and atherosclerosis Shokei Kim-Mitsuyama Hypertension Research (2009) 32, 639–640; doi:10.1038/hr.2009.90; published online 19 June 2009 ypertension, insulin resistance/type 2 have multiple protective effects against remodeling in DS rats are at least partially H diabetes and hypercholesterolemia are vascular endothelial dysfunction and athero- attributed to a greater attenuation of tissue closely associated with each other, and they sclerosis, being mediated by anti-inflammatory oxidative stress and inflammation, indepen- all cause vascular endothelial dysfunction, and antioxidative effects.1,7 Interestingly, in dent of blood pressure and plasma cholesterol develop atherosclerosis and consequently both preclinical and clinical studies, the com- control. Furthermore, the additive improve- increase cardiovascular morbidity and mor- bination of an RAS blocker and a statin is ment of the vascular endothelial function by tality.1 Very importantly, there is a strong reported to provide additive beneficial effects the combination is mediated by both the synergy among hypertension, type 2 diabetes, on vascular endothelial dysfunction, athero- inhibition of endothelial nitric oxide synthase and hypercholesterolemia in terms of the risk sclerosis, inflammation or oxidative stress. uncoupling by olmesartan and the enhance- factors for the development of cardiovascular In this issue of Hypertension Research, ment of Akt phosphorylation by pravastatin. diseases. The frequent association of these Kanno et al.,8 have extended the benefits of Our previous study10 provides the mechan- diseases aggravates the process of vascular combination therapy of a statin and an ARB. isms underlying earlier clinical findings11 that endothelial dysfunction and atherosclerosis They have shown that the combination of the combination of a statin (simvastatin) with in patients with these comorbid conditions. pravastatin and olmesartan provided a syner- an ARB (losartan) improves endothelial func- Renin–angiotensin system (RAS) blockers, gistic improvement of glucose tolerance in tion and reduces inflammatory markers to a such as angiotensin-converting enzyme inhi- type 2 diabetic mice, and this synergistic greater extent than does either monotherapy bitors and AT1 receptor blockers (ARBs), are effect was associated with the enhancement in hypercholesterolemic, hypertensive patients. shown to be effective for the treatment of not of glucose uptake in skeletal muscle and Taken together with the report by Kanno only hypertension but also cardiovascular and adipose tissue. They have also demonstrated et al.,8 the combination of a statin and an renal diseases, by exerting multiple pleiotro- that the attenuation of tissue oxidative stress ARB is predicted to provide additive benefits pic effects, including the suppression of by combination therapy is involved in the in the prevention of cardiovascular diseases, cardiovascular hypertrophy and remodeling, synergistic improvement of insulin sensitivity through differential pleiotropic effects. the improvement of insulin sensitivity due to the combination. Furthermore, the More than half of hypertensive patients and vascular endothelial function, and anti- same group of investigators has previously are associated with insulin resistance and/or inflammatory and antioxidative effects.2–4 reported that a statin (fluvastatin) enhances type 2 diabetes, and the coexistence of hyper- Furthermore, RAS blockers are reported the inhibitory effects of an ARB (valsartan) tension and diabetes markedly increases to reduce the incidence of new-onset on atherosclerotic changes in apolipoprotein cardiovascular morbidity and mortality.12 diabetes in high-risk or hypertensive E-deficient mice.9 Taken together, Kanno Therefore, the development of an appropriate patients.5 3-hydroxy-3-methylglutaryl coen- et al.,8 propose that the combination of a therapeutic strategy for hypertensive patients zyme A (HMG CoA) reductase inhibitors statin and an ARB could confer a promising with diabetes is a key issue in achieving a (statins) are the most popular drugs for therapeutic strategy for metabolic syndrome successful reduction of cardiovascular dis- treatment of hypercholesterolemia and are and atherosclerosis. eases. Thiazolidinediones (TZDs),13 such as shown to reduce cardiovascular morbidity Previously, we have also reported that the pioglitazone, are synthetic peroxisome prolif- and mortality in high-risk patients.1,6 Similar combination of an ARB (olmesartan) and a erator-activated receptor-g agonists that act to RAS blockers, statins are well-known to statin (pravastatin) offers more beneficial as an insulin sensitizer and are widely used as effects on cardiovascular hypertrophy and one of the major therapeutic drugs for type 2 remodeling, and vascular endothelial dys- diabetes. Interestingly, clinical evidence14 Professor S Kim-Mitsuyama is at the Department of function in salt-loaded Dahl salt-sensitive indicates that pioglitazone not only Pharmacology and Molecular Therapeutics, Kumamoto hypertensive rats (DS rats) than does either ameliorates hyperglycemia by improving University Graduate School of Medical Sciences, 1-1-1 10 Honjyo, Kumamoto 860-8556, Japan. monotherapy. Greater protective effects of insulin sensitivity but also reduces the E-mail: kimmitsu@gpo.kumamoto-u.ac.jp their combination against cardiovascular incidence of cardiovascular events in high- Commentary 640 3 Prasad A, Quyyumi AA. Renin-angiotensin system Statins ARBs TZDs and angiotensin receptor blockers in the metabolic syndrome. Circulation 2004; 110: 1507–1512. 4 Yamamoto E, Dong YF, Kataoka K, Yamashita T, Tokutomi Y, Matsuba S, Ichijo H, Ogawa H, Kim-Mitsuyama S. Olmesartan prevents cardio- vascular injury and hepatic steatosis in obesity Beneficial pleiotropic effects and diabetes, accompanied by apoptosis signal regulat- ing kinase-1 inhibition. Hypertension 2008; 52: 573–580. Anti-oxidative stress 5 Abuissa H, Jones PG, Marso SP, O’Keefe Jr JH. Angio- Anti-inflammation tensin-converting enzyme inhibitors or angiotensin Improvement of endothelial function receptor blockers for prevention of type 2 diabetes: a Anti-atherosclerosis meta-analysis of randomized clinical trials. JAmColl Cardiol 2005; 46: 821–826. 6 Shepherd J, Cobbe SM, Ford I, Isles CG, Lorimer AR, MacFarlane PW, McKillop JH, Packard CJ. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group. NEnglJMed1995; 333: 1301–1307. 7 Koh KK, Han SH, Quon MJ. Inflammatory markers Additive or synergistic organ protection and the metabolic syndrome: insights from thera- peutic interventions. J Am Coll Cardiol 2005; 46: Figure 1 Beneficial pleiotropic effects of statins, angiotensin receptor blockers (ARBs) and 1978–1985. 8 Kanno H, Iwai M, Inaba S, Senba I, Nakaoka H, Sone thiazolidinediones (TZDs). These different classes of drugs, by different mechanisms, attenuate tissue H, Mogi M, Horiuchi M. Improvement of glucose intol- oxidative stress and inflammation, leading to the amelioration of vascular endothelial dysfunction, erance by combination of pravastatin and olmesartan in atherosclerosis and cardiovascular remodeling. type 2 diabetic KK-Ay mice. Hypertens Res 2009; 32: 706–711. 9 Horiuchi M, Cui TX, Li Z, Li JM, Nakagami H, Iwai M. risk type 2 diabetic patients, beyond blood From the preclinical studies described above, Fluvastatin enhances the inhibitory effects of a selec- tive angiotensin II type 1 receptor blocker, valsartan, on glucose control. Importantly, emerging there is a strong scientific rationale for com- vascular neointimal formation. Circulation 2003; 107: evidence shows that pioglitazone exerts mul- bining an ARB with a statin or a 106–112. tiple beneficial pleiotropic effects on not only TZD in terms of treatment of cardiovascular 10 Yamamoto E, Yamashita T, Tanaka T, Kataoka K, Tokutomi Y, Lai ZF, Dong YF, Matsuba S, Ogawa H, adipose tissue but also cardiovascular and diseases in high-risk comorbid patients Kim-Mitsuyama S. Pravastatin enhances beneficial 13,15 cerebral tissues. As the mechanisms (Figure 1). The combination of these different effects of olmesartan on vascular injury of salt-sensitive underlying pleiotropic effects differ between classes of drugs, besides normalization of hypertensive rats, via pleiotropic effects. Arterioscler Thromb Vasc Biol 2007; 27:556–563. pioglitazone and the RAS blocker, the com- blood pressure, lipid metabolism or blood 11 Koh KK, Quon MJ, Han SH, Chung WJ, Ahn JY, bination of these different classes of agents is glucose, exerts an additive or synergistic sup- Seo YH, Kang MH, Ahn TH, Choi IS, Shin EK. expected to exert an additive benefit in the pression of vascular endothelial dysfunction Additive beneficial effects of losartan combined with simvastatin in the treatment of hypercholesterolemic, reduction of cardiovascular morbidity and and atherosclerosis through a potent attenua- hypertensive patients. Circulation 2004; 110: mortality. We have previously examined the tion of oxidative stress and inflammation. 3687–3692. potential benefit of a combination of an Hence, a combination of an ARB with a statin 12 Verdecchia P, Reboldi G, Angeli F, Borgioni C, Gattobi- gio R, Filippucci L,