Pleiotropic effects of telmisartan beyond blood pressure control

Telmisartan is an effective antihypertensive agent. In ONTARGET study, it was non-inferior to ramipril in preventing vascular events in high risk patients, and was better tolerated. In ROADMAP study, though olmesartan delayed the onset of microalbuminuria in patients with type 2 diabetes and normoalbuminuria, a greater number had fatal cardiovascular (CV) events. NAVIGATOR study demonstrated the low propensity of valsartan to result in new onset diabetes without reduction in the incidence of CV outcomes. These studies, viewed together, indicate that there are differentials in CV outcomes with different sartans. Selective CV risk reduction with telmisartan may be partially attributed to its unique molecular architecture, strong binding affinity to angiotensin I receptor, highest molecular lipophilicity, greatest volume of distribution, longest plasma half life, and better improvement in vascular compliance and endothelial function. The improvement in insulin sensitivity, though not unique to telmisartan, is contributed by both angiotension receptor blockage as well as partial PPAR g activation. None other sartan activates PPAR receptors. Therefore it is possible that metabolic effects of PPAR activation at least partially account for the differentials in CV outcomes with telmisartan. g