Sildenafil is a potent selective inhibitor of cyclo-guanosine monophosphate (cGMP) -specific phosphodiesterase-5 (PDE5). Since PDE5, responsible for the disintegration of cGMP, is contained not only in the cavernous body of the penis, but also in the vessels of the lungs, sildenafil, being an inhibitor of this enzyme, increases cGMP content in smooth muscle cells of pulmonary vessels and causes their relaxation. In patients with pulmonary hypertension (LH), the use of sildenafil leads to an expansion of the lung vessels and, to a lesser extent, other vessels.
Sildenafil is selective for PDE5 in vitro. His activity in relation to PDE5 exceeds activity with respect to other known isoenzymes of phosphodiesterase: PDE6, which participates in transmission of a light signal in the retina of the eye - 10 times; FDE1 - 80 times; PDE2, PDE4, PDE7-PDE11 - more than 700 times. The activity of sildenafil with respect to PDE5 is more than 4000 times greater than its activity with respect to PDE3, cAMP-specific phosphodiesterase, involved in cardiac contraction.
Sildenafil causes a small and transient decrease in blood pressure (BP), which in most cases is not accompanied by clinical symptoms.After taking sildenafil inside at a dose of 100 mg, the maximum reduction in systolic and diastolic blood pressure in the prone position was an average of 8.3 mm Hg. and 5.3 mm Hg. respectively. After taking sildenafil in a dose of 80 mg 3 times a day in healthy male volunteers, the maximum decrease in systolic and diastolic blood pressure in the prone position was 9.0 mmHg on average. and 8.4 mm Hg. respectively.
After taking sildenafil in a dose of 80 mg 3 times a day in patients with systemic arterial hypertension, systolic and diastolic blood pressure decreased by an average of 9.4 mm Hg. and 9.1 mm Hg. respectively.
In patients with PH who received sildenafil in a dose of 80 mg 3 times a day, the decrease in blood pressure was less pronounced: systolic and diastolic blood pressure decreased by 2 mm Hg.
With a single oral intake in doses up to 100 mg by healthy volunteers sildenafil did not significantly affect the parameters of the electrocardiogram (ECG). When using the drug at a dose of 80 mg 3 times a day in patients with PH, clinically significant changes in the ECG were not detected.
In the study of hemodynamic effects of sildenafil with a single oral intake at a dose of 100 mg in 14 patients with severe coronary atherosclerosis (stenosis, at least,one coronary artery more than 70%), the average systolic and diastolic blood pressure at rest decreased by 7% and 6%, respectively, compared with the baseline level. Systolic pressure in the pulmonary artery was reduced by an average of 9%. Sildenafil did not affect cardiac output and did not worsen blood flow in the stenotic coronary arteries.
In some patients, 1 hour after taking 100 mg of sildenafil, the Funsworth-Munssel 100 test revealed a mild and transient impairment of the color perception (blue / green); 2 hours after taking the drug, these changes disappeared. It is believed that the violation of color vision is caused by the inhibition of PDE6, which participates in the process of light transmission in the retina of the eye. Sildenafil does not affect visual acuity, contrast perception, electroretinography data, intraocular pressure or pupil diameter.
In patients with confirmed initial macular degeneration sildenafil with a single admission in a dose of 100 mg did not cause significant changes in visual functions, in particular, visual acuity assessed by the Amsler lattice, the ability to distinguish the colors of a traffic light,estimated by the Humphrey perimetry method, and transient visual impairment, assessed using the photostress method.
Efficacy in adult patients with PH
The effectiveness of sildenafil was studied in 278 patients with primary LH (63%), LH associated with systemic connective tissue diseases (30%), and LH, which developed after the surgical treatment of congenital heart disease (7%). The majority of patients had II (107; 39%) or III (160, 58%) functional class of PH according to the WHO classification (World Health Organization), less frequently I (1; 0.4%) or IV (9.3%) functional classes. Patients with a left ventricular ejection fraction less than 45% or a left ventricular shortening fraction of less than 0.2 were excluded from the study, as well as patients for whom bosentan therapy was ineffective. Sildenafil in doses of 20 mg, 40 mg or 80 mg were used together with standard therapy (control group patients received a placebo). The primary endpoint was an increase in exercise tolerance for the 6-minute walk test at 12 weeks after initiation of treatment. In all three groups of patients who received sildenafil in different doses, it significantly increased in comparison with placebo. The increase in the distance covered (adjusted for placebo) was 45 m, 46 m and 50 m in patients who received sildenafil in doses of 20 mg, 40 mg and 80 mg respectively. Significant differences between the groups of patients who took sildenafil, not found.
Improvement in the test results of a 6-minute walk was noted after 4 weeks of therapy. This effect persisted at the 8th and 12th weeks of therapy. The average therapeutic effect was consistently observed in the results of a 6-minute walk test in all sildenafil groups compared with placebo in populations of patients specially selected for the following characteristics: demographic, geographical and features of the disease. The basic parameters (walking test and hemodynamics) and effects were basically similar in the groups of patients with PH of different WHO functional classes and various etiologies.
A statistically significant increase in the results of a 6-minute walk test was observed in the group of patients receiving 20 mg of sildenafil. For patients with PH functional classes II and III, improving the results of a 6-minute walk test, adjusted for placebo, is 49 meters and 45 meters, respectively.
In patients who received sildenafil in all doses, the mean pressure in the pulmonary artery was significantly lower compared with placebo. In patients who received sildenafil at doses of 20 mg, 40 mg and 80 mg, a reduction in pulmonary artery pressure adjusted for the placebo effect was: 2.7 mmHg, 3.0 mmHg. and 5.1 mm Hg. Art. respectively. In addition, the following indicators were found to improve: pulmonary vascular resistance, right atrial pressure and cardiac output. Changes in heart rate (HR) and systemic BP were insignificant. The degree of decrease in the resistance of pulmonary vessels was superior to the degree of decrease in peripheral vascular resistance. In patients who received sildenafil, revealed a tendency to improve the clinical course of the disease, in particular, a reduction in the frequency of hospitalizations for LH. The proportion of patients whose condition improved at least one functional class according to the WHO classification for 12 weeks in sildenafil groups was higher (28%, 36%, and 42% of patients who received sildenafil in doses of 20 mg, 40 mg and 80 mg, respectively) than in the placebo group (7%). In addition, sildenafil treatment compared with placebo led to an improvement in the quality of life, especially in terms of physical activity, and a trend toward improving the Borg's dyspnea index.The percentage of patients who had to add another class to standard therapy was higher in the placebo group (20%) than in the groups receiving sildenafil in doses of 20 mg (13%), 40 mg (16%) and 80 mg (10%).
Information on long-term survival
In an extended study, it was found that Revacio® increases the survival of patients with LH.
Efficacy in adults with LH in combination with epoprostenol
Efficacy of sildenafil was studied in 267 patients with stable course of LH on intravenous epoprostenol. The study included patients with primary LH and LH associated with systemic connective tissue diseases.
Patients were randomized to placebo and sildenafil (with fixed titration, starting at 20 mg to 40 mg and then 80 mg, 3 times daily) with combined therapy with intravenous epoprostenol. The primary endpoint was an increase in physical activity tolerance by a 6-minute walk test at 16 weeks after initiation of treatment. The increase in the distance traveled in the sildenafil group was 30.1 m compared to 4.1 m in the placebo group. In patients who took sildenafil, mean pulmonary artery pressure significantly decreased by 3.9 mm Hg. compared with the placebo group.
Clinical outcomes
Sildenafil therapy significantly increased the time to clinical deterioration of LH compared with placebo. According to the Kaplan-Mayer estimate, the risk of worsening was three times higher in patients receiving placebo (see Table 1). The time to clinical deterioration was defined as the time from randomization of patients to the first signs of impairment (death, lung transplantation, initiation of therapy with bosentan, or a change in the dose of epoprostenol due to clinical deterioration). In 23 patients from the placebo group, there were signs of clinical deterioration (17.6%), while in the sildenafil group, 8 patients (6.0%) showed impairment.
Table 1
| Placebo | Revacio® |
Number of patients with signs of clinical impairment, n (%) | 23 (17,6) | In (6.0) |
Proportion of patients with impairment (calculation by the Kaplan-Mayer method) Confidence interval 95% | 0,187 (0,12-0,26) | 0, 062 (0,02-0,10) |
In patients with primary LH, there was an average deviation in the 6-minute walk test: when used with sildenafil, 26.39 m, when applied with placebo, 11.84 m.In patients with PH associated with systemic connective tissue diseases? - 18.32 m and 17.50 m respectively.
Efficacy and safety of sildenafil in adult patients with LH (with simultaneous use with bosentan)
In general, the profile of side effects in the two groups (simultaneous use of sildenafil and bosentan and bosentan monotherapy) was the same and corresponded to the side effects profile with sildenafil.