Novel Pharmacological Approaches in the Treatment of Hypertension: A Focus on RNA-Based Therapeutics.

Hypertension remains the leading cause of cardiovascular disease and premature death globally, affecting half of the US adults. A high proportion of hypertensive patients exhibit uncontrolled blood pressure, associated with poor adherence, linked to pill burden and adverse effects. Novel pharmacological strategies are urgently needed to improve blood pressure control. Dysregulation of the renin-angiotensin system increases blood pressure through its primary effector, angiotensin II, which results in tissue remodeling and end-organ damage. Silencing liver angiotensinogen (the sole source of angiotensin II) has been achieved using novel RNA therapeutics, including the antisense oligonucleotide, IONIS-AGT (angiotensinogen)-LR X, and the small-interfering RNA, zilebesiran. Conjugation to N-acetylgalactosamine enables targeted delivery to hepatocytes, where endosomal storage, slow leakage, and small-interfering ribonucleic acid recycling (for zilebesiran) result in knockdown over several months. Indeed, zilebesiran has an impressive and durable effect on systolic blood pressure, reduced by up to 20 mm Hg and sustained for 6 months after a single administration, likely due to its very effective knockdown of angiotensinogen, without causing acute kidney injury or hyperkalemia. By contrast, IONIS-AGT-LR X caused less knockdown and marginal effects on blood pressure. Future studies should evaluate any loss of efficacy relating to antidrug antibodies, safety issues associated with long-term angiotensinogen suppression, and broader benefits, especially in the context of common comorbidities such as type 2 diabetes and chronic kidney disease.