Why Imidazoline Receptor Modulator in the Treatment of Hypertension?

The influence of the sympathetic nervous system on blood pressure control was impressively demonstrated in 1940 by bilateral excision of sympathetic nerve fibers. Thereafter, the first generation of drugs lowering blood pressure by central modulation of the sympathetic outflow through alpha 2-adrenoceptor for stimulation, such as alpha-methyldopa, guanabenz, clonidine, and guanfacine, were marketed. However, these compounds were often tolerated poorly, because they caused orthostatic hypotension, sedation, tachycardia or bradycardia, dry mouth, and reduced cardiac output. The mode of action of the second generation centrally acting antihypertensive drugs moxonidine and rilmenidine is different from that of the first generation compounds (e.g., clonidine). Contrary to clonidine, the newer drugs bind more selectively to I1-imidazoline receptors rather than to alpha 2-adrenoceptors where first-generation drugs act. The high affinity and selectivity of these two drugs for this recently discovered new receptor class make it possible to discriminate between I1-imidazoline receptor-mediated blood pressure lowering, on the one hand, and alpha 2-adrenoceptor-mediated side effects, on the other. Discrimination of the two effects was substantiated either by studies using moxonidine alone or in interaction experiments with I1-imidazoline receptor or alpha 2-adrenoceptor antagonists. The high selectivity of moxonidine at the I1-imidazoline receptor allows discrimination between alpha 2-adrenoceptors and I1-imidazoline receptors and is reflected in man by the relatively low incidence of adverse drug events during moxonidine treatment. Concentration of endazoline, a specific mediator of I1-imidazoline receptors, is elevated in some patients with essential hypertension. Modulation of I1-imidazoline receptors by moxonidine could be interpreted as antagonism with regard to the endogenous agonistic effect of the endogenous "transmitter" endazoline. On the other hand, moxonidine acted directly as an agonist at the putative I1-imidazoline receptor. Therefore, to clear the ground, characterization as well as physiological function of the mediator for imidazoline receptors seems essential. The therapeutic relevance of using drugs selective for I1-imidazoline receptors for blood pressure reduction in hypertensive patients is substantiated by the finding that in human rostral ventrolateral medulla (RVLM), which is essential in central blood pressure regulation, the relation between alpha 2-adrenoceptors and I1-imidazoline receptors is about one to ten (1:10). Reduction of a long-lasting sympathetic overdrive may avoid the deteriorating effects on the heart and peripheral circulation. These recent findings give a rational explanation for the very low incidence of sedation and the absence of respiratory depression, orthostatic hypotension, and rebound hypertension that banned the former central acting antihypertensive drugs from first-line treatment despite the advantages of central mediated blood pressure control.