Cardiovascular Drug Reviews

Vol. 8, No. 1, pp. 1-24

0 1990 Raven Press, Ltd., New York

Cilazapril

Ian L. Natoff, Michael R. Attwood, David A. Eichler, *Pnsca Kogler,

*Cornelis H. Kleinbloesem, and *Peter van Brummelen

Research Division, Roche Products Ltd., Hertfordshire,England, and *Departmentof

ClinicalResearch, F. Hofmann-LaRoche & Co. Ltd., Bade, Switzerland

Key Words. ACE inhibitors-Cilazapd-Cilazaprilat-Antihypertensive drugs-Hypertension.

Inhibitors of the angiotensin converting enzyme (ACE, kininase 11, EC 3.4.15.1)

are effectivein the treatment of both renal and essential hypertension in humans (40).
The first orally active inhibitor of ACE, captopril (73), has now been followed by
other proline-based inhibitors in which the sulhydryl zinc-ligand binding group has
been replaced by a homophenylalaninegroup as in enalapnlat (74,83) and ramiprilat
(10) (Fig. 1).
Conformationally restricted chemical structures that allow optimal binding to
ACE have been sought with the aid of molecular graphics. These studies (44,45) led
to the identification of cilazapril as the orally absorbed prodrug form of the potent
inhibitor of ACE, cilazaprilat (Fig. 1 ) (6,7,68,69).

CHEMISTRY
A two-dimensional model of the specific binding sites on ACE that recognize the
carboxylate, amide carbonyl, and thiol groups of captopril was proposed by Ondetti
et al. (73). The three-dimensionalrequirements for the inhibition of ACE were inves-
tigated by Hassall et al. (44,45), from which they postulated the design of a conforma-
tionally restricted molecule (7).
Initial studies from the nuclear magnetic resonance (NMR) spectra of captopril in
water revealed the preferred trans conformation about the amide bond (45). The
carboxylate group of captopril adopts an axial conformation to avoid sterichindrance
of the adjacent carbonyl group (38). Thus, having fixed the relative positions of the
amide carbonyl group and the carboxylate group in captopril, and confirmingthese
requirements as optimal in a series of novel bicyclic structures(45), it was possible to
overlay them in three dimensions by the use of molecular graphics (5). From this, it
was possible to study the positions available to the zinc-bindinggroup, the thiol. This

Address correspondenceand reprint requests to Dr. I. L. Natoff at Research Division, Roche Products
Ltd., P.O. Box 8, Welwyn Garden City, Herts AL7 3AY, England.

I
2 I. L. NATOFF ET AL.

captopril

enalaprilat

ramiprilat

eN H COZH
cilazaprilat

FIG. 1. Structural formulas of some angiotensin I converting cnzyme inhibitors.

group in captopril is capable of movement within a wide locus (45), and so its fixed
optimum position was unsure.
After determining for each thiol group in the novel bicyclic structures those re-
stricted positions accessible within the locus of the thiol of captopril, studies of the
relationshipof structure to activity revealed the optimum location (45). Replacement

CurdiuvuscularDrug Rrvieus, Lo[ 8. Nu. I , I990

 CILAZAPRIL 3

FIG. 2. Orientation of the cilazaprilat molecule at the angiotensin I converting enzyme.

of the thiol with the homophenylalanine unit not only bound the zinc ligand (Fig. 2),
but also was conceived to provide a better fit to the enzyme by mimicking the Phe[8]
side chain of angiotensin I (7). This line of reasoning, in two dimensions, had led
Merck scientists to synthesise enalapril(74).
The introduction of a seven-membered ring in the bicyclic unit corrected an unfa-
vorable torsion angle, which resulted in the synthesis of cilazaprilat (7). The orally
absorbed ethyl ester of this ACE inhibitor, cilazapril, is 9(S)-[1(S)-(ethoxycarbony1)-
3-phenylpropylamino]octahydro- 10-0x0- 6H-pyridazoE1,2-a]-[1,2]diazepine-1-(S)-
carboxylic acid. All chiral centres have an S configuration.
Cilazapril crystallizes from water as a monohydrate (molecular weight of 435.52)
with a melting point of 98C. It is soluble in water to the extent of about 0.5%.Cilaza-
prilat (molecular weight of 389.45) is a solid with a melting point of 242"C, and is
more than 2% soluble in water buffered to pH 7.5.

PRECLINICAL EXPERIMENTS
Biological PropertiesIn Vitro
Inhibitory Potency Against ACE I n Vitro
Inhibition of the activity of ACE is measured quantitatively from specific tissue
sources of enzyme, defined substrates, and under defined conditions of incubation.
Unless there is uniformity in these parameters, it is not possible to draw a quantitative
comparison of the potencies of the various inhibitors from different laboratories(65).
However, where the inhibitory activity of cilazaprilat has been compared simulta-
neously with that of other ACE inhibitors, the published data are summarized in
Table 1.
These results show that captopril is the weakest of the compounds tested, so dem-

Cardiovascular Drug Reviews, Vol. 8, No. I , 1990

4 I. L. NATOFF ET AL.

TABLE 1. Comparative biochemical evaluation of cilazaprilat, enalaprilat,

and captopril as ACE inhibitors
Substrate: HipHis-Leu Angiotensin 1

Rabbit Rabbit Human Hog Human Rabbit

Source of ACE lung" lung* plasma" kidney lung" lungb

Inhibitor
Cilazaprilat 1.93 0.97 0.61 2.83 I .39 0.78
(1.86-2.01) (0.90-1.04) (0.58-0.64) (2.54-3.13) (1.31-1.47) (0.72-0.85)
Enalaprilat 3.12 1.29 1.66 5.95 2.93 I .44
(2.98-3.26) (1.22-1.36) (1.54-1.80) (5.64-6.27) (2.79-3.07) (1.30-1.60)
Captopril 6.93 NDC 15.70 13.15 13.05 ND '
(5.68-8.28) (12.99-18.87) ( 1 1.48-15.09) (12.45-13.67)

Mean ICs0 values (nmol/L) from at least three independently prepared dose-effect curves.
Figures in parenthesesare 95% confidence limits.
Reaction initiated by addition of enzyme to a mixture of substrate and inhibitor (E + I + S ) .
Reaction initiated by addition of substrate to a preincubated (90 min, 37C) mixture of enzyme and
+
inhibitor (S + I E).
Not determined.

onstrating the increased potency endowed by the homophenylalanine zinc-ligand

binding group in cilazaprilat and enalaptilat. A salient feature of these data is that the
comparative potency of cilazaprilat, enalaprilat, and ramiprilat against rabbit lung
ACE when angiotensin I is used as the substrate is similar to that obtained using the
artificial substrateHip-His-Leu, verifying the suitability of this artificial substrate for
these studies. In each instance, cilazaprilat is one of the most potent of the com-
pounds studied.
Moreover, binding studies reveal cilazaprilat to be one of the most tightly bound
inhibitors of ACE, with a Ki of 0.05 nmol/L (68). The correspondingvalues for rami-
prilat and enalaprilat are Ki = 0.1 1 nmol/L (60) and Ki = 0.15 nmol/L (68), respec-
tively, while captopril is the least tightly bound, having a Ki of 1.7 nmol/L (24).

Biological Properties In Vivo

Bioavailability Studies
The bioavailabilities of cilazapril and cilazaprilat were studied in the rat and hu-
mans. The parent prodrug, cilazapril, was rapidly and almost completely absorbed
following oral administration, as assessed from recoveries of ACE inhibitory activity
in urine following oral and intravenous administration to rats (68). Oral administra-
tion of cilazaprilat to rats yielded urine with only a weak ACE inhibitory activity.
The oral absorption of cilazapril by the rat was calculated to be 98%, of cilazaprilat
was lo%, and of enalapril was 46%.Treatment of the urine of cilazapril-treated rats
with rat plasma to hydrolyse any unchanged parent drug did not reveal any further
ACE inhibitory activity, indicating that little or no unchanged parent prodrug was
excreted (68).
In humans, cilazaprilat has an oral bioavailability of 19%(range of 8-40%), but for
cilazapril the figure increases to 57% (range of 45-75%) (92).

Cardiovascular Drug Reviews, Vol. 8, No. 1, 1990

 CILAZAPRIL 5

Metabolism
Pharmacokinetic studies in humans indicate that cilazapril is converted almost
entirely to cilazaprilat (average urinary recovery = 91% of the dose of cilazapril).
No further breakdown occurs, and the clearance of cilazaprilat is almost exclusively
renal (92).

Inhibition ofACE in Diyerent Tissues

Despite the concerted efforts of many workers to establish a relationship between
the antihypertensive action of the ACE inhibitors and the degree of inhibition of
plasma ACE following their administration, it was not possible to show such a rela-
tionship in the case of captopril(87). Moreover, attempts to relate inhibition of ACE
by captopril and the homophenylalanine series of inhibitors in such tissues as heart,
liver, kidney, brain, and vascular smooth muscle from a variety of experimental ani-
mal species and humans (22,61,63,85) have all yielded equivocal results. Nakamura
et al. (64) made an exhaustive study of the effect of cilazaprilat on the ACE activity of
various paired vessels of complianceand resistance in the spontaneouslyhypertensive
(SH) rat, and were unable to establish a relationship between inhibition of ACE in
these vessels and blood pressure reduction. A temporal relationship was claimed for
inhibition of aortic and renal ACE with blood pressure reduction in SH rats after
withdrawal ofchronic dosing with ramipril(85,86). Thus, although plasma ACE inhi-
bition correlates with plasma concentrations of ACE inhibitors (90) and reductions
in circulatingplasma angiotensin I1 levels, these values have not been shown unequiv-
ocally to be quantitatively related to blood pressure reduction (1 3,70,86). Neverthe-
less, the chronic antihypertensiveactions of ACE inhibitors may be due to persistent
inhibition of tissue ACE, in particular in the walls of the resistance vessels, and of the
kidney (84-86).

Eflect on the Vasopressor/VusodepressorResponses

to Injected Angiotensin I and Bradykinin
All ACE inhibitors have qualitativelysimilar pharmacodynamic effects. Thus, c a p
topril and cilazapril reduce the pressor response to intravenouslyinjected angiotensin
I in rats (66,68) and cilazapril has been shown to attenuate this response following
intravenous injection in dogs (47) and oral administration to humans (12). Ramipril
has similar effects when administered orally to rats (84,85) and humans (17). The
relative potency and duration of their inhibitory effect on the angiotensin I pressor
response following administration of median effective doses (EDSO)to anaesthetised
rats is shown in Fig. 3.
The median inhibitory doses for the angiotensin I vasopressor response for the
variousACE inhibitorsin the anaesthetised rat are virtually equiactivein potentiating
the vasodepressor effects of bradykinin in the same species (cilazaprilat, 63 nmol/kg
i.v., dose ratio ( D R ) = 36.6; enalaprilat, 86 nmol/kg i.v., DR = 39.8; and captopril,
460 nmol/kg i.v., DR = 28.8) (68).
This observation demonstrates the relative potency of cilazaprilat compared to

Cardiovascular Drug Reviews, Vol. 8. No. I , 1990

6 r. L. NATOFF ET AL.

W
V
a
W
n I I I
I I
I
I I
0 15 25 35 45 55
MIN AFTER INJECTION OF ACE I N H I B I T O R
FIG. 3. Duration of inhibition of the angiotenin I/angiotensin I1 (AI/AII) pressor response ratio in the
urethane-anaesthetized rat after intravenous injection of the median effective doses of captopril (0.65
pmol/kg, n = 5 ) (small solid square), enalapril (0.31 pmol/kg, n = 4) (small solid circle), and cilazapril
(0.46 pmoI/k& n = 6) (small solid triangle). From ref. 68, with permission.

other ACE inhibitors, and the identity of kininase I1 with ACE using the indicator
responses for two separate substrates.

EFFECT ON BLOOD PRESSURE

Activity in Experimental Models of Hypertension
Cilazapril lowered blood pressure in the SH rat (68), was markedly active in the
high-renin, two-kidney renal hypertensive (Goldblatt)rat (68), and lowered the blood
pressure in the conscious and anaesthetised dog rendered hypertensive by left renal
artery constriction and encapsulation of the right kidney (47). It also has been shown
to prevent the development of hypertension in juvenile SH rats and newly clipped
two-kidney renal hypertensive rats (46). The antihypertensive activity of cilazapril
and other ACE inhibitors was enhanced by coadministration with diuretics in both
animals (68,76) and humans (70). Hydrochlorothiazide potentiated the action of cil-
azapril in SH rats (68), and the blood pressure lowering activity of cilazapril in dogs
was enhanced after fmsemide pretreatment (47).
There was no convincing evidence of an enhanced antihypertensive effect by com-
bining ACE inhibitors with @-blockersin adrenal demedullated SH rats (Natoff, un-
published observations),which normally respond to both agents individually (1 5,68).

CardiovascularDrug Reviews, Vol. 8, Nu. I , 1990

 CILAZAPRIL 7

This agreed with the clinical report of MacGregor et al. (58), who found no increase
in the control of blood pressure measured 2 h after the last dose of a combination of
captopril and propranolol. On the other hand, Staessen et al. (82) reported this same
combination to produce an additive antihypertensiveeffect in humans.

HaemodynamicActions
Cilazapril, 0.1- 1.O mg/kg i.v. caused dose-dependent falls in mean arterial and left
ventricular pressures of anaesthetised dogs. This was accompanied by a decrease in
the total peripheral resistance, left ventricular minute work, and stroke work (47).
The fall in cardiac output, which was seen only at the high dose (1 mg/kg i.v.) in the
absence of a change in heart rate, suggests a decreased stroke volume while a small
decrease in left ventricular end-diastolic pressure suggests a reduced cardiac filling
pressure. Cilazapril redistributed the unchanged cardiac output preferentially to the
kidney of conscious SH rats, in which it increased the regional blood flow to that
organ, unlike nitrendipine, which increased regional blood flow to all of the organs
examined, in parallel with an enhanced cardiac output (21). Thus, cilazapril may
reduce both afterload and preload (89).

Possible Pathways of Antihypertensive Action

Involvement of Prostaglandins
Inhibition of cyclo-oxygenase had no effect on the blood pressure lowering action
of subsequently administered cilazapril, enalapril, and captopril in two-kidney renal
hypertensive (Goldblatt) rats (67,72), while in the spontaneously hypertensive rats
with intact kidneys, and which have lower circulatingplasma renin levels, indometh-
acin reduced the antihypertensive activity of these three ACE inhibitors (67). Indo-
methacin and aspirin also interfered with the antihypertensive effect of captopril in
humans ( 1,62,81).
With due regard to the lack of specificity of indomethacin in attenuating the effect
of many antihypertensiveagents, its lack of effect on the action of ACE inhibitors on
the elevated blood pressure of the two-kidney renal hypertensive rat is significant.
Thus, it appears that the mechanism of the antihypertensiveeffect of cilazapril and
the other ACE inhibitorswill depend on the nature of the hypertension.Renovascular
hypertension, as in the two-kidney renal hypertensive rats, is dependent on elevated
levels of circulatingangiotensin 11; ACE inhibition will prevent angiotensin I1 biogen-
esis and is not affected by cyclo-oxygenase inhibition. Spontaneous hypertension in
rats is characterised by normal values for plasma renin. The attenuation ofthe antihy-
pertensive effect of cilazapril and the other ACE inhibitorsby cyclo-oxygenaseinhibi-
tion in these SH rats and in essential hypertensive patients (1,2) suggests that ACE
inhibitors lower normal-renin hypertension by a mechanism mediated by dilator
prostaglandins(65,67).

Interaction with Sympathetic Neurones

Angiotensin I1 is known to facilitate the release of noradrenaline from the postgan-
ghonic nerve endings in the sympathetic nervous system supplying the peripheral

CardiovascularDrug Reviews, Vol. 8, No. 1, 1990

8 I . L. NATOFF ET AL.

resistance vessels (94). Removal of this angiotensin I1 by ACE inhibition should there-
fore impair sympathetic transmission.
There is strong evidencethat this action of ACE inhibitors does not involve prosta-
glandins (PGs), because indomethacin pretreatment, which prevents the antihyper-
tensive action of cilazapril and the other ACE inhibitorsin the SH rat, does not impair
their inhibition of the vasopressor responses to stimulation of the sympathetic out-
flow in the pithed SH rat (67).
There is no evidence of a meaningful antihypertensive effect of ACE inhibitors
through the sympathetic systems in humans (88) since captopril still produces an
acute antihypertensive effect in patients previously treated with prazosin (48), and
neither captopril(20) nor enalapril(42) affects circulating plasma catecholamine lev-
els in humans.

Eflect on Baroreceptor Reflex

Intravenous injection of sodium nitroprusside into unanaesthetised rats produces
a fall in blood pressure that causes a reflex tachycardia. This tachycardia was the
same both in the absence and presence of the ACE inhibitorscilazapnl, enalapnl, and
lisinopril(23). There was also no evidence of any effect on the baroreflex response in
humans by ACE inhibitors (4). Tachycardia induced by exercise similarly was not
affected by administration of cilazapril, enalapril, and lisinopril to cats (16) and
dogs (9).

Experimental Myocardial Ischaemia

The area of myocardium at risk of necrosis was reduced in dogs treated with capto-
pril after coronary artery occlusion (34). Enalapril also lowered the increased oxygen
demand, the elevation of the ST segment of the electrocardiogram,and the increased
levels of creatine kinase in the cat following left coronary artery ligation (56).
In anaesthetised rats, cilazapril produced a significant reduction in the incidence
of reperfusion-induced premature ventricular contraction and ventricular fibrilla-
tion (54).

TOXICOLOGY
An extensive programme of toxicity studies to evaluate the preclinical safety of
cilazapril has been undertaken (Table 2).
Additional testing comprised 2-week intravenous studies with the active metabo-
lite, cilazaprilat, in rats and marmosets, antigenicity (immunostimulation)tests, and
the effects of salt loading in rats (31).

Acute Dose Studies

The acute oral, intrapentoneal, intravenous, or subcutaneoustoxicities of cilaza-
pril in mice, rats, and marmosets were low. The approximate median lethal doses by
the oral route were greater than 2,500 mg/kg in mice, and greater than 4,000 mg/kg
in rats and marmosets. By the intraperitoneal route, the approximate median lethal
doses were 1,300-1,600 mg/kg in mice and 830 mg/kg in rats. Intravenous and sub-

CardiovascularDrug Reviews, Vol.8. No. I , 1990

 CILAZAPRIL 9

TABLE 2. Standard and supplementary toxicity studies with cilazapril

Dose levels
Study type Species Route Duration/design (mg/kg/&y)
Acute Mouse p.0. Single dose 2,000,4,000,5,000
Acute Mouse i.v. Single dose 250
Acute Mouse i.p. Single dose 1,000, 1,400,2,000
Acute Mouse S.C. Single dose 1,000
Acute Mouse p.0. Single dose 1,000,2,000,4,000,5,000"
Acute Rat p.0. Single dose 4,000,5,000
Acute Rat i.p. Single dose 500,700, 1,000
Acute Rat p.0. Single dose 2,000,4,000,5,000"
Acute Marmoset p.0. Single dose 300,700, 1,500,3,000,
4,000,5,000
Subacute Rat p.0. 4 weeks 5 , 15,50"
Subacute' Rat p.0. 4 weeks 25, 125,625
Subacute Marmoset p.0. 4 weeks 5, 15,50"
Subacuted Marmoset p.0. 4 weeks 50
Subacute Rat p.0. I3 weeks 10,50,250
Subacute Cynomolgus p.0. 13 weeks 2.5.25.250
Subacute Baboon p.0. I3 weeks 2, 10,20,40
Chronic Rat p.0. 26 weeks 5-2,30-12,200-50
Chronic' Rat p.0. 26 weeks 0.1,0.5
Chronic' Rat p.0. 26 weeks I .o, 2.0
Chronic Marmoset p.0. 26 weeks 5-2,30-15,200-50
Chronic Baboon p.0. 52 weeks 0.5,4,40
Chronic Rat p.0. 78 weeks 0.5,4,40
Reproduction Rat p.0. Segment 1 I , 7,50
Reproduction Rat p.0. Segment 2 2,30,400
Reproduction' Rabbit P.o.,i.v., S.C. Segment 2 1.o-100
Reproduction Cynomolgus p.0. Segment 2 20
Reproduction Rat p.0. Segment 3 1,7,50
Mutagenicity In vitro" Ames test -
Mutagenicity In vitro S. cerevisiae
Mutagenicity In vitro Unscheduled DNA synthesis
Mutagenicity In vitro Chinese hamster V79 cells -
Mutagenicity In vitro Human lymphocytes -
Mutagenicity In vivo p.0. Micronucleus test 2,000
Carcinogenicity MOW p.0. 88 weeks 1,7,50
Carcinogenicity Rat D.0. 104 weeks 0.5.4.40

Ro 3 1-2848/002(monohydrobromide salt).
* Pyramiding-dose study.
Comparative study with captopril.
Supplementary study: effect on mature testes.
Supplementary studies: effects on body weight.
/Preliminary range-finding study.

cutaneousapproximate median lethal doses in mice were greater than 250 and 1,000
mg/kg, respectively.

Repeated Dose Studies

In repeated dose toxicity studies, the principal treatment-related effectswere gener-

ally those commonly observed with other angiotensinconverting enzyme inhibitors.

Cardiovascular Drug Reviews, Vol. 8, No. I , 1990

10 I. L. NATOFF ET AL.

Body Weight
Male rats showed a remarkable sex and species sensitivityto cilazapril with respect
to body weight gain, with a slight depression detectable at doses as low as 0.1 mg/kg/
day over 26 weeks, compared with no effect in females at 2 mg/kg/day. The tendency
of the male rat to thrive less well than the female has been demonstrated for other
ACE inhibitors including captopril(43) and enalapril(8). The marked sensitivity in
male rats contrasts with cilazapril studies in both sexes of other species, where no
effects on body weight were apparent at or below 2 mg/kg/day in mice, marmosets,
and large primates.
A 4-week salt loading study in male rats dosed with cilazapril, 100 mg/kg/day,
showed that the ACE inhibitor prevented the adverse increase in body weight, sug-
gesting its mode of action may be associated with natriuresis.

Uraemia
Uraemia was recorded in all repeated dose studies at dose levels greatly in excess
of those proposed for clinical use. It was observed in the high-dose groups of all studies
(40-250 mg/kg/day), and in the middle-dose groups (4-125 mg/kg/day) of 4-, 13-,
and 78-week rat studies. No effect was observed at the lower dose levels of any study
(0.5-10 mg/kg/day) that were still in excess of the anticipated clinical therapeutic
dose range (2-5 mg/kg/day). The uraemia presented as blood urea levels elevated
two- to fourfold over control values. The onset was characteristicallyearly, and con-
tinued throughout the dosing period without time-related increase in severity. The
effect was characteristicallyreversible.
Saline-loading blocked the occurrence of uraemia in rats. This finding, in the ab-
sence of a consistent association with renal damage, suggests that the uraemia is re-
lated to a reduction in the glomerular filtration rate in spite of increased regional
blood flow to the kidney (2 1).
Uraemia has been reported in toxicity studies with other ACE inhibitors including
captopril(43), enalapril (S), SCH 3 1846 ( 5 5 ) , pentopril(41), and ramipril(28). Saline
loading has prevented the occurrence of uraemia in experiments with captopril(43)
and enalapril(8).

Renal Histology
Thickening of the renal afferent glomerular arterioles (AGA) was observed in all
species, and was related both to the duration and dose levels employed. The most
pronounced changes were apparent in the 78- and 104-week rat studies where both
the AGA and interlobular arteries were thickened in the animals of the middle- (4
mg/kg/day) and high-dose (40 mg/kg/day) groups. In the cynomolgus monkey and
baboon studies, enlargement of the juxtaglomerular apparatus (JGA) was also re-
corded. This latter effect was less clearly distinguishablefrom mural thickening of the
AGAs in rats and mice. No vascular changes were observed in the low-dose group of
any study.
The mechanism responsible for vascular thickening in the kidneys is obscure, al-
though hypertrophy of the JGA resulting from ACE inhibition is an important factor

CardiovascularDrug Reviews. Vol. 8, No. 1. 1990

 CILAZAPRIL

where the AGA enters the glomerulus. A relationship with the mode of action of
cilazapril is clearly inferred by the renal specificity of these changes, and by their
association with other ACE inhibitors. Renal vascular thickening has been reported
for both captopril (43) and enalapril (8) in rats, and JGA enlargement and/or an
increase in renin content for captopril(43), ramipril(28), and SCH 31846 (55).
A proportion of studies of 13 weeks duration and beyond showed proximal convo-
luted tubule (PCT) changes, comprising tubular regeneration and dilatation in the
middle- and high-dose groups. PCT changeswere absent in the 52-week baboon study
(high dose, 40 mg/kg/day), but were observed, and reversible, in the 13-week cyno-
molgus monkey study at the extremely high dose of 250 mg/kg/day.
Adverse morphologicaleffects on the PCTs, from tubular dilatation to frank necro-
sis, have been reported for captopril (43), enalapril (8), pentopril(41), and ramipril
(28) in rodents and/or nonrodent species. The relationship between the mode of ac-
tion of enalapril and PCT damage in the dog has been explored (57), and it is postu-
lated that local ischaemia, due to reductions in arterial pressure, enhances initial di-
rect tubular cell damage. Saline loading reduced the seventy of this effect.

GastrointestinalEflects
Cilazapril caused major gastrointestinal mucosal damage and death at extremely
high doses (greaterthan 200 mg/kg/day) in multiple dose studies in rats and cynomol-
gus monkeys.
Gastric erosion and ulceration have been reported for captopril in rats, dogs, pri-
mates, and rabbits ( 18). Similar changes were evident with ramipril in rats (28).

Huemutology
Slight reversible decreases in red blood cell (RBC) count, packed cell volume, and
haemoglobin concentration were observed in the majority of the repeated dose stud-
ies. Associated changes with the peripheral RBC deficits were confined to extremely
high dose levels. These consisted of a slight decrease in the bone marrow nucleated
cell count in a 4-week rat study that examined cilazapril and captopril (as a positive
control), both at 625 mg/kg/day, and in the 13-week cynomolgus monkey study, at
250 mg/kg/day. A slight reduction was observed in the myeloid/erythroid ratio at
200 (reducing to 100 and then 50) mg/kg/day in the 26-week marmoset study. There
was no evidence of either a treatment-related reticulocyte response, extramedullary
haematopoiesis, or increased splenic and hepatic haemosiderosis in any study.
The effects on peripheral erythrocyte parameters are further placed in perspective
by their frequent occurrence in published toxicity studies with captopril (43) and
other ACE inhibitors including SCH 31846 (55), pentopril (41), and ramipril(28).
The mechanism of action is not understood, but it is possible that angiotensinogen,
as a precursor of erythropoietin, and ACE inhibitors may influence the formation of
renal erythropoietin (39).

Reproduction Studies
The reproduction toxicity studies undertaken in rats indicated no adverse effects
on fertility, embryonic and foetal growth, or postnatal development at dose levels

CardiovascularDrug Reviews, Vol. 8, No. I , 1990

12 I. L. NATOFF ET AL.

representing large multiples (70- to 300-fold) of the highest recommended human

dose of approximately 0.1 mg/kg/day. In the fertility and general reproduction (seg-
ment I) study, the incidence of renal cavitation (pelvic dilatation) in the caesarian-
derived F1 generation was increased in the middle- and high-dose group rats, which
received 7 and 50 mg/kg/day, respectively, and in the latter group, only among those
allowed natural delivery. A similar observation was made in the teratology (segment
11) rat study, where the incidence was raised at the high dose of 400 mg/kg/day. No
effect occurred in these studies at dose levels of 1 and 2 mg/kg/day. There was, how-
ever, no effect on the incidence of renal cavitation in the pen-/postnatal (segment
111) study, indicating a possible association with administration of gross overdoses
confined to the first and/or second trimester of pregnancy.
Because the rabbit is an unsuitable subject for teratology testing of cilazapril in
view of its gastric mucosal sensitivity, the cynomolgus monkey was selected as an
alternative nonrodent species. Gastric mucosal sensitivity has also been reported for
captopril ( 18). No evidence of teratogenicity or other effects was seen in this species.
However, other ACE inhibitors are contraindicatedin pregnancy (25-27) and capto-
pril and enalapril are foetotoxic in animals (18,33). This effect is considered, for cap-
topril, to be related to the compound's exaggeratedpharmacologicalaction ( 14,36).
There is evidence of adverse effects on the neonate that would contraindicate the
use of ACE inhibitors in treating hypertension of pregnancy. First, neonatal renal
failure and premature birth have been reported following treatment of hypertension
of pregnancy with verapamil, methyldopa, and enalapril(78,79).
Second, in the clinical control of hypertension of pregnancy with captopril, patent
ductus arteriosus was reported in the neonate (19). Patent ductus arteriosus in the
neonate is treated successfully with the cyclo-oxygenase inhibitor, indomethacin, in-
dicating its aetiology to be related to the action of prostaglandins. The inference that
ACE inhibitors control normal-renin hypertension by prostaglandin production (67)
suggests that these same prostaglandins may produce patent ductus arteriosus in neo-
nates. This circumstantialevidence therefore contraindicatesthe use of ACE inhibi-
tors in pregnancy.

Oncology and Mutagenicity

A comprehensive series of mutagenicity studies (Table 2) revealed no evidence of ge-
notoxic or clastogenic activity. Carcinogenicity studies in rats and mice demonstrated
no evidence of oncogenic potential at 400 to 500 times the highest clinical dose.

Antigenicity
Passive cutaneous anaphylaxis, active systemic anaphylaxis, and passive haemag-
glutination tests were negative for cilazapril,but gave strong reactions with appropri-
ate positive controls.

Summary of Toxicology
Cilazapnl has demonstrated reactions during toxicity studies that are common to
other ACE inhibitors. The majority of these reactions occur at considerable multiples

Cardiovascular Drug Reviews, Vol. 8,No. I , 1990

 CILAZAPRIL 13

of the clinical dose range and generally represent effects that are secondary to the
primary mode of action of the drug elicited at lower dose levels,

CLINICAL STUDIES
Pharmacokinetics
In humans, cilazapril was rapidly absorbed, with a maximum plasma concentra-
tion at about 1 h after oral administration. There was a rapid hydrolysis to cilazapri-
lat, which achieved a maximum plasma concentration at 1.5-2 h (37). In healthy
volunteers, the bioavailability of cilazaprilat from oral cilazapril was 45-75% (mean
= 57%) (92). The presence of food had a slight effect on absorption and hydrolysis of
cilazapril, reducing the peak plasma concentration of cilazaprilat by 29%,and delay-
ing its attainment by 1.1 h. Bioavailability was reduced by only 14%by the presence
of food (59).
The elimination of cilazapril from humans is primarily by biotransformation, but
renal excretion accounts for 10-35% of the administered dose. The elimination half-
life is about 1.5 h. Cilazaprilat is eliminated almost exclusively by renal excretion.
Since its distribution is characteristically biphasic, having a rapid decline in plasma
concentration over 8 h followed by a prolonged low-concentration terminal phase
from 24 h onwards, its elimination half-life was 1.5-2 h when plasma cilazaprilat
concentrationswere high, increasing to 30-50 h during the terminal phase when the
free fraction was low (37).
In patients with mild to moderate essential hypertension, the pharmacokinetics of
cilazaprilat were similar to those in healthy volunteers. In elderly volunteers (>65
years of age), 40% higher plasma concentrations of cilazaprilat resulted from a 1 mg
oral dose of cilazapril; the time taken to maximum plasma concentration was shorter
and clearance was reduced by 20-30% (93). In patients with impaired renal function,
the plasma levels of cilazaprilat were higher when the creatinine clearance was re-
duced (80). Hepatic disease was associated with longer-lasting effects of cilazapril,
resulting in a recommendation for a reduction in the dosage size and frequency
(Kleinbloesemand van Brummelen, personal communication).

Pharmacodynamic Effects and Mode of Action

Clinical Pharmacology
Cilazapril is converted in humans to the active ACE inhibitor, cilazaprilat, which
is a potent, reversible, and selective inhibitor of the enzyme. ACE inhibition was
indicated by a reduced activity of ACE in the plasma, and a lowering of the plasma
concentrationsof angiotensin I1 and aldosterone. Concomitantly,there was an eleva-
tion of the plasma concentration of angiotensin I and of the plasma renin activity
(PRA)(35). There was no effect on atrial natriuretic peptide (29).
After repeated doses of cilazapril, there was no evidence of a cumulative effect on
ACE, nor was there any evidence of a tolerance developingto the inhibitory activity
(7 1). In healthy volunteers, variable effects on blood pressure were observed, mainly
apparent as decreases in systolic and diastolic arterial pressure. Differences in sodium
and fluid intake may account for the differences in blood pressure response between

CardiovascularDrug Reviews, Vol. 8. No. 1. 1990

I4 I. L. NATOFF ET AL.

the various studies in normotensive volunteers. In hypertensive patients, however,

consistent blood pressure reductions were obtained in the majority of cases (3). In
these studies, there was no correlation between the baseline PRA and the fall in blood
pressure. Despite the vasodilatation causing the fall in blood pressure, only slight
increasesin heart rate were observed in humans, as has been reported in experimental
animals (47,68).
Cilazapril had no acute effect on cardiovascular reflexes, including the barorecep-
tor and diving reflex. Accordingly, the responses to the Valsalva manouevre, cold
pressor test, orthostasis, and to isometric and isotonic exercise were not changed.
Thus, sympathetic integrity was not affected by the drug. No effect on parasympa-
thetic function was found to explain the absence of .tachycardia despite vasodilata-
tion (32).
In healthy subjects, cilazapril increased effective renal plasma flow by 10-20%.
Since the glomerular filtration rate remained unaltered, the filtration fraction de-
creased slightly (70).
Sodium and chloride excretion rates in urine were slightly increased or remained
unaltered. Potassium excretion was not changed or was slightly decreased, resulting
in somewhat increased serum potassium concentrations. These effects on urinary
electrolytes can be explained by decreases in aldosterone concentrations.

Dose (Concentration)-Response Relationships

A close and steep correlation between cilazaprilat plasma concentration and ACE
inhibition was found. The curve had a sigmoidal shape. The potency of cilazaprilat,
defined as the concentration of cilazaprilat causing a 50% ACE inhibition, was ap-
proximately 1 ng/ml plasma ( 13,9 1). Thus, cilazaprilat is 10 times more potent than
captopril and 5 times more potent than enalaprilat as an inhibitor of plasma ACE in
humans.
There was a time lag between plasma cilazaprilatconcentration and the blood pres-
sure lowering effect, indicating that the plasma cilazaprilat concentration is not di-
rectly correlated to this effect ( 13,70).
In hypertensive patients, maximal blood pressure reduction was achieved with 5
mg of cilazapril, and clinical studies have shown that lower doses (2.5 and 1.25 mg)
are therapeutically effective (3).
In acute studies in healthy volunteers and in hypertensive patients, it appeared that
more than 90% of plasma ACE inhibition is needed before reductions in blood pres-
sure are evident ( 13,70). However, this relationship is likely to change during chronic
treatment.

Duration ofAction
In several studies, cilazapril had relatively long-lasting effects on ACE inhibition.
More than 50% of ACE was inhibited 24 h after the lowest dosage of cilazapril tested
( 1 .O mg) (9 1). ACE inhibition could be prolonged only slightlyby increasingthe dose,
which may be explained by the pharmacokinetics of the drug. Results from the angio-
tensin I challengetest showed a half-life of 4 h for cilazapril,which was similar to that
for enalapril, and twice as long as that for captopril(9 1).

Curdiovascular Drug Reviews, Vol. 8. No. 1. 1990

 CILAZAPRIL 15

Single-dose studies in hypertensive patients showed cilazapril at 5, 10, and 20 mg

to reduce similarly and significantly the plasma ACE activity and supine and erect
blood pressure without increasing the heart rate (3). In clinical studies, multiple dose
regimens of cilazapril greatly enhanced the duration of effect and lasted for 24 h in a
majority of the patients.

Interaction Studies
Coadministration of cilazapril with hydrochlorothiazideto healthy volunteers po-
tentiated the effects of the diuretic on sodium and chloride excretion (49,70) and a
greater duration of blood pressure reduction was observed.
Cilazapril had an additive blood pressure lowering effect when administered in
combination with propranolol in healthy volunteers and hypertensive patients
(1 132). These observationsagree with the additive antihypertensiveeffect occumng
with coadministrationof captopnl and propranolol to humans (82). In patients with
chronic renal failure, the combination of cilazapril and nitrendipine also showed an
additive effect on the blood pressure (53).
In a limited number of patients with essential hypertension, there is evidence that
the antihypertensiveeffect of cilazapril is attenuated by pretreatment with indometh-
acin (5 l), confirmingthe observation made in preclinical studies with SH rats (67).

CongestiveHeart Failure
Cilazapril has been effective in relieving congestive heart failure and improving
peripheral blood supply to exercised skeletal muscle in acute (75) and chronic (30)
studies.

CLINICAL EFFICACY IN HYPERTENSIVE PATIENTS

Cilazapril has been studied in several multiple dose trials involving more than
4,500 patients with mild to moderate hypertension. The demographic characteristics
of these patients are shown in Table 3. The majority of patients in the clinical trials
were treated at the recommended cilazapril dose range of 2.5 to 5 mg once daily.

Efficacy Results
Once-daily treatment with cilazapril was demonstrated to provide clinically and
statistically significantreductions in blood pressure in both placebo- and active agent-
controlled studies. All patients in these studies had mild to moderate hypertension,
i.e., sitting diastolic blood pressure between 95 and 1 15 mm Hg during the last two
visits of the 4-week placebo run-in period.

Placebo-ControlledStudies
The effect of various fixed doses of cilazapril ranging from 1 or 1.25 to 10 mg on
blood pressure was investigated in three double-blind, parallel-group studies. In each
of these studies, cilazapril or placebo was administered once daily for 4 weeks follow-
ing a placebo run-in period at the start of which all previous antihypertensivemedica-

Cardiovascular Drug Rwimus. Vol. 8, No. I , 1990

16 I. L. NATOFF ET A L .

TABLE 3. Demographic characteristicsofpatients

studied in multiple-dose therapeutic trials
with cilazapril (n = 4,527)
~ ~ ~~~

Parameter Percent ofpatients

Age (years)
565 89
>65 11
Sex
Male 59
Female 41
Race
White 86
Black 12
Other 2
Baseline SDBP (mm H g ) b
195 I
95-<100 35
100-<106 39
106-11 15 22
>I15 3
Baseline creatinine (mg/dl)
11.5 71
>IS 29

SD = standard deviation;SBDP = sitting diastolic blood

pressure.
Mean?SD,53+ 11.
*
Mean SD, 102 6. *

tion was discontinued. At the conclusion of the placebo run-in period, the baseline
sittingdiastolicblood pressures between all treatment groups were comparablewithin
each study. Except for the cilazapril 1 and 2.5 mg doses in the second study, all cilaza-
pril doses provided statistically significantly greater reductions in sitting diastolic
blood pressure compared to the corresponding placebo group (Fig. 4). The antihyper-
tensive efficacy of the various cilazapril doses did not differ significantly within each
of the three studies.
A clinically significant response to treatment was defined either as a normalisation
of sitting diastolic blood pressure (i.e., 590 mm Hg) or a decrease from baseline of
2 10 mm Hg without normalisation. The proportion of patients responding to mono-
therapy with cilazapril 1 or 1.25,2.5, 5, and 10 mg ranged from 43 to 62%. Similar
response rates have been reported for other ACE inhibitors (50,77).

Active Agent-Controlled Studies

The antihypertensive efficacy of cilazapril was compared to that of widely used
antihypertensive agents in five well-controlled, double-blind, parallel-group studies.
As in the placebo-controlled trials, the double-blind treatment periods in each of
these comparative trials was preceded by a 4-week placebo run-in period. Cilazapril
was given in a dose range of 2.5 to 5 mg once daily while the reference agents were
given at their recommended dosages, i.e., propranolol sustained release (SR),80 to
160 mg once daily; captopril, 25 to 50 mg twice daily; hydrochlorothiazide,25 to 50

CardiovascularDrugReviews. Vol. 8, No. 1, 1990

 CILAZAPRIL 17

CHANGE MEAN SITTING DIASTOLIC BLOOD PRESSURE (MM HG) 5 S.E.M.

FROM BASELINE
n = 51 24 118 26 123 56 24 1 2 0 56 26 114 50
0

-2

-4

-6

-8

-10

-12 j
-14 I
Placebo 1.0/1.2!3~ 2.5mg 5.Omg lOmg
CLZ CLZ CLZ CLZ
TREATMENT DOSAGE GROUPS
FIG. 4. Effect of various doses of cilazapril (CLZ) on blood pressure in fixeddose, placebo-controlled,
dose-finding studies after 4 weeks of treatment. Study 1 (solid bars), study 2 (dotted bars), study 3 (striped
bars). * = p < 0.05 for differencefrom placebo group.

mg once daily; atenolol, 50 to 100 mg once daily; and enalapril, 10 to 20 mg once

daily. The change in sitting diastolic blood pressure from baseline was assessed after
8 weeks of double-blind treatment. There were no statistically significant differences
in the change in diastolic blood pressure between cilazapril 2.5 to 5 mg once daily
and any of the active agent treatment groups (Fig. 5 ) .

Long- Term Eficacy

A total of 756 patients were treated with cilazapril or cilazapril plus hydrochlorothi-
a i d e (in case of incomplete response on cilazapril monotherapy) for 1 year or more.
Figure 6 shows the change in sitting diastolic blood pressure over time for the largest
of these trials. Patients had blood pressure measurements performed every 8 weeks
during a l-year period. Only 10% of the patients were prematurely withdrawn be-
cause of inadequate blood pressure control. In the remaining patients, a mean de-
crease. in sitting diastolic blood pressure of approximately 17 mm Hg was achieved,
largely by weeks 8 to 16 of treatment. Sitting diastolic blood pressure stabilised
around 85 to 87 mm Hg during treatment with cilazapril. The proportion of patients
responding (decreasein sitting diastolicblood pressure of 2 10 mm Hg and/or to 590
mm Hg) to cilazapril, 2.5 to 5 mg monotherapy, was 66%. Addition of hydrochloro-
thiazide, 12.5 to 25 mg/day to the 5 mg of cilazapril dose yielded a cumulative re-

CardiovascularDrugReviews, Vol. 8, No. 1, 1990

 18 I. L. NATOFF ET AL.

CLL/PROP CLZ/CAPT CLZ/HCTZ CLZ/ATEN CLZ/ENP

= 93/47 101/50 61/65 100/98 39/31

-6

-8

-10
1

-14

-16 I 1

FIG. 5. Cilazapril (CLZ) in comparison with other antihypertensiveagents in double-blind, parallel stud-
ies: ATEN, atenolol; C A R , captopril; ENP, enalapril; HCTZ, hydrochlorothiazide;PROP, propranolol
sustained release.

sponse rate of 90%. Tolerance was not seen nor was an abrupt increase in blood
pressure following treatment withdrawal observed.

Safety Results
The overall incidence of adverse events as well as the incidence of common adverse
eventsjudged by the investigator to be at least remotely related to study treatment was
similar among cilazapril- and placebo-treated subjects in the double-blind, placebo-

-
v)

weeks
-4 -3 -2 -1 Base- 8 16 24 32 40 48 52
line
FIG. 6. Effect of long-term therapy with cilazapril on sitting diastolic pressure. Cilazapnl alone, n = 200
(---); cilazapril and hydrochlorothiazide,n = 350 (. ..).

Curdiovuscular DrugReviews. Vol. 8. No.1. 1990

 CILAZAPRIL 19

TABLE 4. Overall incidence of adverse events in active agent-controlled studies

Percent incidence of adverse
Number of patients events

Reference agent Cilazapril Reference agent Cilazapril Reference agent

Propranolol SR 119 59 38 31
Captopril 132 62 28 31
Hydrochlorothiazide 84 85 16 22
Enalapril 87 99 17 I1
Atenolol 130 124 12" 22
_ _ _ ~

Statisticallysignificantlydifferent from reference agent,p < 0.05.

controlled studies. The overall incidence of adverse events was also comparable be-
tween cilazapril and propranolol SR, enalapril, hydrochlorothiazide, and captopril;
however, this was statistically significantly less with cilazapril than that with atenolol
(Table 4).With one exception, there were no major differences in the type or inci-
dence of adverse events between cilazapril or any of the five active agents in the dou-
ble-blind, comparative trials. The one exception was a higher incidence of drug-in-
duced, clinically relevant laboratory abnormalitiesin patients taking hydrochlorothi-
azide than in those receiving cilazapril.

Safety Projle of Cilazapril Monotherapy versus Cilazapril/Hydrochlorothiazide

Combination Therapy
More than 3,700 patients were treated with cilazapril alone in multiple dose stud-
ies. Of these, 1,068patients also received adjunctive hydrochlorothiazide therapy be-
cause their sitting diastolic blood pressure had not reached 90 mm Hg or less after a
defined period of treatment with cilazapril monotherapy. The extent of exposure of
these patients to cilazapril monotherapy or combination treatment was comparable;
it varied from 1 to 590 days (mean of 131 days) on cilazapril alone and from 2 to 524
days (mean of 165 days) on cilazapril plus hydrochlorothiazide.
Overall, the addition of low doses of hydrochlorothiazide (12.5 to 25 mg/day) to
cilazapriltherapy did not appreciablychange the adverse event profile. During cilaza-
pril monotherapy, 18% of patients reported one or more adverse events judged by
the investigator to be at least remotely related to study treatment. During cilazapril/
hydrochlorothiazide combination treatment, 20% of patients reported such adverse
events. Those that occurred with a frequency of 2 1% are presented in Table 5.
In patients receiving cilazapril as monotherapy or in combination with hydrochlo-
rothiazide, the incidence of rash and cough were 0.6 and 1.6%,respectively. At the
time the cough was observed, more than one-half of the patients had other concomi-
tant respiratory symptoms such as rhinitis, pharyngitis, or bronchitis. Mild, non-life-
threatening angioedema or facial oedema occurred in 0.16% of patients treated with
cilazapril either as monotherapy or in combination with hydrochlorothiazide.
The incidence of new or enhanced cases of proteinuria of 22+ (dipstick)or of L 1
g/24 h was 0.6%; in another 0.9% of the patients who started the trial at these levels,
the proteinuria decreased or remained stable during treatment with cilazapril. Four

Cardiovascular Drug Reviews, Vol. 8. No. 1.1990

20 I. L. NATOFF ET AL.

TABLE 5. Adverse event of 21% incidence during cilazapril therapy,

administered either as monotherapy or in Combination
with hydrochlorothiazide
Percent of patients reporting adverse events

Cilazapril Cilazapril
monotherapy + hydrochlorothiazide
Adverse event (n = 3.769) ( n = 1,068)

Headache 4.5 3.7

Dizziness 3.3 4.6
Fatigue 1.7 1.3
Coughing I .6 2.4
Chest pain 0.8 I .2
Somnolence 0.6 1.2

patients experienced reversible, clinically relevant increases in serum creatinine that

were judged to be possibly or probably related to their study treatment. Two of these
patients were receiving cilazapril monotherapy and two cilazapril plus hydrochloro-
thiazide at the time of the event. In two of these patients, renal arterial stenosis was
found. In one patient, a neutrophil count of <1,000mm3was recorded at the end of
the study; all neutrophil counts were within the normal range during the preceding 6
months of active treatment. No follow-up value was obtained and the patient did not
show any signs or symptoms of infection at any time.
Cilazapril,administered either as monotherapy or in combination with hydrochlo-
rothiazide, was well tolerated in patients 65 years of age or older. Coughing, dizziness,
palpitations, and somnolence have occurred at a higher rate of incidence in this el-
derly population than it did in younger patients.

Conclusion
In an extensive worldwide clinical development program, cilazapril, 2.5 to 5 mg
once daily was shown to have an antihypertensive efficacy comparable to that of
other frequently prescribed antihypertensive agents, including other marketed ACE
inhibitors. The tolerance to cilazapril was generally comparable to that of placebo.
No adverse effects developed that do not occur at the same or at a higher incidence
with other marketed ACE inhibitors such as enalapril or lisinopril as judged from the
literature.

SUMMARY
Cilazapril is one of the most potent of the new generation of antihypertensive
drugs. It is an inert prodrug with a high degree of oral bioavailability and is rapidly
hydrolysed in vivo to its active moiety, cilazaprilat. Cilazaprilat is highly specific for
the angiotensin converting enzyme, to which it is tightly bound, having a Ki value of
0.05 nmol/L. Cilazaprilatis approximately 3 and 30 times more potent than enalapri-
lat and captopril, respectively, in inhibiting the ACE activity of human plasma in
vitro, while it is about four times more potent than captopril and slightly more potent

Cardiovascular Drug Reviews, Val. 8, No. I , 1990

 CILAZAPRIL 21

than enalapril in reducing the pressor response to injected angiotensin I in the anaes-
thetised rat in vivo. Cilazapril effectivelylowers the high blood pressure of spontane-
ously hypertensive (SH) and two-kidney renal hypertensive (2KRH) rats, this effect
being potentiated in both models by coadministration of a diuretic, and attenuated
by coadministration of a cyclo-oxygenase inhibitor in the SH rat, but not in the
2KRH rat. There were no signs of the antihypertensiveeffect causing a tachyphylaxis
or becoming cumulative. In a comprehensive series of toxicity studies, cilazapril has
demonstrated effects in common with those produced by other ACE inhibitors when
administered to animals at excessivedose levels. The majority of the effects represent
an exaggeration of the drug's primary pharmacological activity. As with all new drugs,
its safety for use in pregnancy is not established. There is evidence that all ACE inhibi-
tors should be contraindicated in pregnancy, however. Clinical pharmacology and
efficacystudies with cilazapd and cilazaprilat closely parallel the findings from pre-
clinical animal studies, confirmingthat cilazapril is a potent, safe, and effective once-
daily monotherapy for the treatment of hypertension in humans.

REFERENCES
1 . Abe K, It0 T, Imai Y, et al. Indomethacin inhibits antihypertensiveeffect of captopril, SQ 14,225, in
low renin hypertension. Tohoku JExpMed 1980;32:1 1 7-8.
2. Abe K, It0 T, Sato M, et al. Role of prostaglandin in the antihypertensive mechanism of captopril in
low renin hypertension. Clin Sci 1980;59(suppl6):14 1 s-4.
3. Ajayi AA, Elliott HL, Reid JL. The influence of cilazapril on indices of autonomic function in normo-
tensives and hypertensives.Br J CIin Pharrnacol1986;22:167-75.
4. Ajayi AA, Reid JL. The effect of enalapril on baroreceptor mediated reflex function in normotensive
subjects. Br JClin Pharmacol1986;21:338-9.
5. Attwood MR. Chemical design of cilazapril. Br J Clin Pharrnacol1989;27:133s-7.
6 . Attwood MR, Francis RJ, Hassall CH, et al. New potent inhibitors of angiotensin converting enzyme.
FEBSLett 1984; 165:201-6.
7 . Attwood MR, Hassall CH, Krohn A, et al. The design and synthesis of the angiotensin converting
enzyme inhibitor cilazapril and other related bicyclic compounds. J Chem Soc Perkin Trans I
1986; 101 1-9.
8. Bagdon WJ, Bokelman DL, Stone CA. Toxicity study of MK 421 (enalapril maleate) (111) subacute
and one year chronic studies in beagle dogs. Jpn Pharmacol Ther 1985; 13:425-66.
9. Becker RHA, Fieber P, SchulzeK-J. Physical performance during sustained converting enzyme inhibi-
tion with Hoe 498 in consciousdogs.Arch In? Pharrnncodyn Ther 1985;278:303-13.
10. Becker RHA, Scholkens BA. Ramipril. In: Scriabine A, ed. New cardiovascu/ur drugs. New York
Raven Press, 198757-76.
1 1. Belz GG,Essig J, Kleinbloesem CH, Hoogkamer JFW,Wiegand UW, Wellstein A. Interactions be-
tween cilazapril and propranolol in man; plasma drug concentrations, hormones and enzyme re-
sponses, haemodynamics, agonist dose-effect curves and baroreceptor reflex. Br J Clin Pharmacol
1988;26:547-56.
12. Belz GG,Essig J, Wellstein A. Angiotensin converting enzyme inhibition by cilazapril in man assessed
by angiotensin I dose response. Nuunyn Schrniedebergs Arch Pharrnacoll985;330(suppl):R48.
13. Belz GG,Kirch W, Kleinbloesem CH. Angiotensin-converting enzyme inhibitors; relationship be-
tween pharmacodynamicsand pharmacokinetics. Clin Phurmacokinef 1988; I5:295-3 18.
14. Broughton Pipkin F, Symonds EM, Turner SR. The effect of captopril (SQ 14225) upon mother and
foetus in the chronically cannulated ewe and in the pregnant rabbit. J Physiol (Lond) 1982;323:415-
22.
15. Buckingham RE, Hamilton TC. Comparison of the antihypertensive response to beta-adrenoceptor
blocking drugs in intact and adrenal demedullated spontaneously hypertensive rats. Br J Pharmacol
1980;68:667-76.
16. Burden DT, Burke YM, Waterfall JF. Effects of the ACE inhibitor cilazapril and other antihyperten-
sive agents on exercise tachycardia and pressor responsesin cats. Br JPharmacol1988;93:254P.
17. Bussien JP, Nussberger J, Porchet M, et al. The effect of the converting enzyme inhibitor Hoe 498

Cardiovascular Drug Reviews, Vol. 8, No. I , 1990

22 I. L. NATOFF ET AL.

(ramipril) on the renin-angiotensin system of normal volunteers. Naunyn Schmiedebergs Arch Phar-
macol1985;329:63-9.
18. Captopril: summary basis of approval for NDA 18-343, pp. 3-5.
19. Caraman PL, Miton A, Huraultde Ligny B, et al. Grossessessous captopril. Therapie 1984; 3959-63.
20. Clementi WA. Durst NL. McNav JL. et al. CaDtoDril modifiesthe hemodvnamic and neuroendocrine
responsesto sodium nitroprusside in'hypertensivepatients. Hypertensioil986; 8:229-37.
21 Clozel J-P. Effects of nitrendipine and cilazapril alone or in combination on hemodynamics and re-
gional blood flows in conscious spontaneously hrpertensive rats. J Cardiovasc Pharmacol 1988; 12:
600-7.
22. Cohen ML, Kurz KD. Angiotensin convertingenzyme inhibition in tissues from spontaneouslyhyper-
tensive rats after treatment with captopril or MK-42 1. JPharmacol Exp Ther 1982;220:63-9.
23. Cowlrick IS. Acute effects of cilazapril and other antihypertensiveagents on the baroreflex of conscious
spontaneouslyhypertensive rats. Br J Pharmacol1987; 92:765P.
24. Cushman DW, Cheung HS, Sabo EF, Ondetti MA. Design of potent competitive inhibitors of angio-
tensin-converting enzyme. Carboxyalkanoyl and mercaptoalkanoyl amino acids. Biochemistry
1977; 16:5484-91.
25. Data sheet for Capoten (captopril) tablets (ER Squibb and Sons Ltd.). In: ABPI data sheet compen-
dium. London: Data Pharm Publications, 1988-89: 1454.
26. Data sheet for Carace/Zestril (lisinopril) (Morson/ICI). Month Index Med Specialities Lond
1988;July:l2.
27. Data sheet for Innovace (enalapril) (Merck Sharp & Dohme Ltd.). In: ABPI data sheet compendium.
London: Data Pharm Publications, 1988-89:947.
28. Donabauer HH, Mayer D. Acute, subchronic and chronic toxicity of the new angiotensin converting
inhibitor ramipril. Arzneimittelforschung 1988;38:14-20.
29. Doorenbos CJ, van Brummelen P . The effect of acute ACE inhibition on atrial natriuretic peptide. Br
JClin PharmacolI989;27:243~-7.
30. Drexler H, Banhardt U, Meinertz T, Wollschlager H, Lehmann M, Just H. Contrasting peripheral
short-term and long-term effects of converting enzyme inhibition in patients with congestive heart
failure. Circulation 1989;79:491-502.
31. Eichler DA, Clough DP. Toxicity testing of antihypertensive drugs. In: Ganten D, Mulro M, eds.
Handbook of experimental pharmacology: pharmacology of antihypertensive therapeutics, Vol. 93.
Heidelberg:Springer-Verlag, 1989.
32. Elliott HL, Ajayi AA, Reid JL. The influence ofcilazapnl on indices ofautonomic function in normo-
tensives and hypertensives.Br J Clin Pharrnacol1989;27:303~-7.
33. Enalapril: summary basis of approval for NDA 18-998, pp. 10-2.
34. Ertl G, Kloner RA, Alexander RW, et al. Limitation of experimental infarct size by an angiotensin-
converting enzyme inhibitor. Circulation 1982;65:40-8.
3 5 . Fasanella d'Amore T, Bussien JP, Nussberger J, et al. Effects of single doses of the converting enzyme
inhibitor cilazapril in normal volunteers. J Cardiovasc Pharmacoll987;9:26-3 1 .
36. Fems TF, Weir EK. Effect of captopril on uterine blood flow and prostaglandin E synthesis in the
pregnant rabbit. JClin Invest 1983;71:809-15.
37. FrancisRJ, Brown AN, Kler L, et al. Pharmacokineticsofthe convertingenzymeinhibitor cilazapril in
normal volunteersand the relationship to enzyme inhibition: development of a mathematical model. J
Cardiovasc Phurmacoll987;9:32-3.
38. Fujinaga M, James MNG. SQ 14225: I -(D3-mercapto-2-methyl propriony1)-L-proline. Acta Crystal-
logr [Sect B] 198036:3196-9.
39. Fyhrquist F, Rosenlof K., Gronhagen-Riska C, et al. Is renin substrate an erythropoietin precursor?
Nature (Lond) 1984;308:649-52.
40. Gavras H, Brunner HR, Turini GA, et al. Antihypertensive effect of the oral angiotensin converting-
enzyme inhibitor SQ 14225 in man. N EnglJMed 1978;298:991-5.
41. Goodman FR, Weiss GB, Hurley ME. Pentopril. In: Scriabine A, ed. New cardiovascular drugs. New
York: Raven Press, 198557.
42. Guidicelli JF, Berdeaux A, Edouard A, et al. The effect of enalapril on baroreceptor mediated reflex
function in normotensive subjects. Br J Clin Pharmucol1985;2021 1-8.
43. Hashimoto K, Imai K, Yoshimura S, Ohtaki T. Toxicological studies of captopril, an inhibitor of
angiotensin converting enzyme. 3. Twelve month studies on the chronic toxicity of captopril in rats. J
ToxicolSci 1981;6(supp12):215-46.
44. Hassall CH, Krohn A, Moody CJ, Thomas WA. The design of a new group of angiotensin-converting
enzyme inhibitors. FEBS Lett 1982; 147:175-9.
45. Hassall CH, Krohn A, Moody CT,Thomas WA. The design and synthesis of new triazolo, pyrazolo-,
and pyridazopyridazinederivativesas inhibitors of angiotensin convertingenzyme. JChem Soc Perkin
Trans I 1984; 155-64.

Cardiovascular Drug Rcviewr. Vol. 8,No. I . 1990

 CILAZAPRIL 23

46. Hefti F, Fischli W, Gerold M. Cilazapril prevents hypertension in spontaneously hypertensive rats. J
CardiovascPharmacol1986;8:641-8.
47. Holck M, Fischli W, Hefti F, et al. Cardiovascular effects of the new angiotensin-converting-enzyme
inhibitor, cilazapril, in anaesthetized and conscious dogs. J Cardiovasc Pharmacoll986;8:99-108.
48. Johns DW, Ayers CR, Williams SC. Dilation of forearm blood vessels after angiotensin-converting-
enzyme inhibition by captopril in hypertensive patients. Hypertension 1984;6:545-50.
49. Johnston GD, Passmore AP. The effects of cilazapril alone and in combination with frusemide in
healthy subjects. Br J Clin Pharmacol1989;27:235s-42.
50. Kaplan NM. Grand Rounds from Southwestern. Newer approaches to the treatment of hypertension:
part 11. CardiovascRevRep 1987;8:25.
5 I. Kirch W, Stroemer K, Hoogkamer JFW, Kleinbloesem CH. The influence of prostaglandin inhibition
by indomethacin on blood pressure and renal function in hypertensivepatients treated with cilazapril.
Br JClin PharmacolI989;27:297s-301.
52. Kleinbloesem CH,Erb J, Essig K, Breithaupt K, Belz GG. Haemodynamic and hormonal effects of
cilazapril in comparison with propranolol in healthy subjects and in hypertensive patients. Br J Clin
Pharmacol1989;27:309s-15.
53. Kloke HJ, Huysmans FThM, Wetzels JFM, Sluiter HE, Kleinbloesem CH, Koene RAP. Antihyper-
tensive effects of nitrendipine and cilazapril alone and in combination in hypertensive patients with
chronic renal failure. Br JClin Pharmacol1989;27:289~-96.
54. Lad N, Manning AS. Reperfusion arrhythmias in the anaesthetized rat: beneficial action of cilazapril.
Br JPharmacol1987;91:39OP.
55. LaRocca FT,Squibb RE, Powell ML, et al. Acute and subchronic toxicity ofa nonsulfhydrylangioten-
sin converting enzyme inhibitor. ToxicolAppl Pharmacoll986;8 2 104- 1 1.
56. Lefer AM, Peck RC. Cardioprotectiveeffects of enalapril in acute mycocardial ischaemia. Pharmacol-
ogy 1984;29:61-9.
57. MacDonald JS, Bagdon WJ, Peter CP, et al. Renal effects of enalapril in dogs. Kidney Znt
1987;3I(suppl20):S148-53.
58. MacGregor GA, Markandu ND, Banks RA, et al. Captopril in essential hypertension; contrasting
effects of adding hydrochlorothiazide or propanolol. Br M e d J 1982;284:693-6.
59. Massarella JW, DeFeo TM, Brown AN, Lin A, Wills RJ. The influence of food on the pharmacokinet-
ics and ACE inhibition of cilazapril. Br J Clin Pharmacol1989;27:205~-9.
60. Metzger H, Maier R, Sitter C, Stern H-O.2-[N-[(S)- I-ethoxycarbonyl-3-phenylpropyl]-L-analyl]-(1S,
3S, 5S)-2-azabicyclo[3.3.O]octane-3-carboxylicacid (Hoe 498)-a new and highly effective angioten-
sin I converting enzyme inhibitor. Arzneimittelforschung 1984;34:1402-6.
6 1. Miyauchi Y, Nishimura K, Ueda E, Kokobu T. Angiotensin converting enzyme activity in the vascular
tissue from rabbits. Biomed Res I98 I ;2:364-6.
62. Moore TJ, Crantz FR, Hollenberg NK, et al. Contribution of prostaglandins to the antihypertensive
action of captopril in essential hypertension. Hypertension 198 1;3:168-73.
63. Mujazaki M, Okunishi H, Nishimura K, Toda N. Vascular angiotensin-convertingenzyme activity in
man and other species. Clin Sci 1984;66:39-45.
64. Nakamura Y,Nakamura K, Matsukura T, et al. Vascular angiotensin converting enzyme activity in
spontaneously hypertensive rats and its inhibition by cilazapril. JHypertens 1988;6:105-10.
65. Natoff IL. Preclinical studies on angiotensin converting enzyme inhibitors. Curdiovasc Drugs Ther
1987;1: 15-27.
66. Natoff IL, Brewster M, Patel AT. Method for measuring the duration of inhibition of angiotensin I
converting enzyme in vivo.JPharmacol Methods 1981;5:305-12.
67. Natoff IL, Brewster M, Patel AT, et al.Effect ofindomethacin on the antihypertensiveand sympathetic
inhibitory activities of ACE inhibitors in the rat. Br J Pharmacol1985;85:337P.
68. Natoff IL, Nixon JS, Francis RJ, et al. Biological properties of the angiotensin-converting enzyme
inhibitor cilazapril.J Cardiovasc Pharmucoll985;7569-80.
69. Natoff IL, Redshaw S. Angotensin-convertingenzyme inhibitors-cilazapril and other bicyclic hexa-
hydropyridazines.Drugs Future 1987;12:475-83.
70. Nilsen OG,Sellevold OFM, Romfo OS, et al. Pharmacokineticsand effects on renal function following
cilazapril and hydrochlorothiazide alone and in combination in healthy subjects and hypertensive
patients. Br J Clin PhurmucolI989;27:323~-8.
7 1. Nussberger J, Fasanella d'Amore T, Porchet M, et al. Repeated administration of the converting en-
zyme inhibitor cilazapril to normal volunteers. J Cardiovasc Pharmacol1987;9:39-44.
72. Omata K, Otsuka Y, Chiba S, ct al. Indomethacin does not attenuate the hypotensive effect of capto-
pril, a converting enzyme inhibitor in Goldblatt hypertensive rats. Tohoku J Exp M e d 198 1; 1349-
19.
73. Ondetti MA, Rubin B, Cushman DW. Design of specific inhibitors of angiotensin converting enzyme:
new class of orally active antihypertensiveagents. Science 1977;196:441-4.

CardiovascularDrug Reviews. Vo/ 8, No. 1. 1990

24 I. L. NATOFF ET AL.

7 4 . Patchett AA, Hams E,Tristram EW, et al. A new class of angiotensin converting enzyme inhibitors.
Nature (Lond) 1980288:280-3.
75. Ribner HS, Zucker MJ, Stasior C, et al. Acute hemodynamic and hormonal effects ofcilazapril, a new,
long acting angiotensin converting enzyme inhibitor, in congestive heart failure. Clin Res 1987;35:
319A.
7 6 . Rubin B, Antonaccio MJ, Goldberg ME, et al. Chronic antihypertensive effects of captopril (SQ
14,225),an orally active angiotensinI-converting enzyme inhibitor, in conscious2-kidney renal hyper-
tensive rats. Eur JPharmacol1978;5 1:377-88.
7 7 . Sassano P, Chatellier G, Alhenc-Gelas F, Corvol P, Menard J. Antihypertensiveeffect of enalapril as
first-steptreatment of mild and moderate essential hypertension. Evaluation by two methods of blood
pressure measurement. Am J M e d 1984;77:18-22.
7 8 . SchubigerG, Flury G, NussbergerJ. Enalapril for pregnancy-induced hypertension: acute renal failure
in a neonate. Ann Intern Med 1988; 102:215-6.
7 9 . Scott AA, Purohit DM. Neonatal renal failure: a complication of maternal antihypertensivetherapy.
Am J Obstet Gynecoll989; 160 1223-4.
80. Sbioniri H, Gotoh E, Nobuyoshi T, Takeda K, Yabana M, Kaneko Y. Antihypertensiveeffects and
pharmacokinetics of single and consecutive doses of cilazapril in hypertensive patients with normal
and impaired renal function. JCardiovasc Pharmacol1988; 11:242-9.
8 1. Silberbauer K, Stanek B, Temp1 H. Acute hypotensive effect of captopril in man modified by prosta-
glandin synthesis inhibition. Br J Clin fharmacoll982; 142378-93.
82. Staessen J, Fagard R, Lijnen P, et al. The hypertensiveeffect of propranolol in captopril treated patients
does not involve the plasma renin angiotensin aldosteronesystem. Clin Sci 198 I ; 6 1:44 1s-4.
83. Sweet CS, Gross DM, Arbergast PT, et al. Antihypertensiveactivity of N-[(S)-I-(ethoxycarbonyl)-3-
phenylpropyl]-L-Ala-LPro (MK-42 I), an orally active converting enzyme inhibitor. J Pharmacol
Exp Ther 1981;216:558-66.
84. Unger Th, Fleck Th, Ganten D, Lang RE, Rettig F. 2-[N-[(S)- I -(ethoxycarbonyl)-3-phenylpropyl]-L-
alanyll-( IS,3S,5S)-2-azabicyclo [3.3.0]octane-3-carboxylicacid (Hoe 498):an antihypertensiveaction
and persistent inhibition of tissue converting enzyme activity in spontaneously hypertensive rats. Arz-
neimittelforschung 1984;34: 1426-30.
85. Unger Th, Ganten D, Lang RE, et al. Persistent tissue converting enzyme inhibition following chronic
treatment with Hoe498 and MK42 1 in spontaneously hypertensive rats. J Cardiuvasc Pharmacol
1985;7:36-41.
86. Unger Th, Ganten D, Lang RE, ScholkensB. Is tissue converting enzyme inhibition a determinant of
the antihypertensiveefficacy of converting enzyme inhibitors? Studies with two different compounds,
Hoe 498 and M K 42 I, in spontaneouslyhypertensive rats. J CardiovascPharmacol1984;6:872-80.
87. Unger Th, Schull B, Hubner D, et al. Plasma-converting enzyme activity does not reflect effectiveness
oforal treatment with captopril. Eur JPharmacol1981;72:255-9.
88. Vierhapper H, Witte PU, Waldhausl W. Unchanged pressor effect of norepinephrine in normal man
followingthe oral administration of two angiotensin converting enzyme inhibitors, captopril and Hoe
498. JHypertens 1986;4:9-11.
89. Waterfall JF. A review of the preclinical cardiovascularpharmacology ofcilazapril, a new angiotensin
converting enzyme inhibitor. Br JClin Pharmacol1989;27:139s-50.
90. Wellstein A, Essig J, Belz GG. Inhibition of angiotcnsin-1response by cilazapril and its time course in
normal volunteers. Clin Pharmacol Ther 1987;41:639-44.
9 1. Wellstein A, Essig J, Belz GG. A method for estimating the potency of converting enzyme inhibitors
in man. Br J Clin fharmacol I987;24397-9.
92. Williams PEO, Brown AN, Rajaguru S, et al. The pharmacokinetin and bioavailability of cilazapril
in normal man. BrJClinfharmacol1989;27:181~-8.
93. Williams PEO, Brown AN, Rajaguru S, Walters GE, McEwen J, Durnin C. A pharmacokinetic study
ofcilazapril in elderly and young volunteers. Br J CIin fharmacol1989;27:2 1 1s-5.
94. Zimmerman BG, Gisslen J. Pattern of renal vasoconstriction and transmitter release during sympa-
thetic stimulation in presence of angiotensin and cocaine. Jfharmacol Exp Ther 1968; 163:320-9.