Intervention Review

Blood pressure lowering efficacy of renin inhibitors for primary hypertension

  1. Vijaya M Musini*,
  2. Patricia M Fortin,
  3. Ken Bassett,
  4. James M Wright

Editorial Group: Cochrane Hypertension Group

Published Online: 8 OCT 2008

Assessed as up-to-date: 9 AUG 2011

DOI: 10.1002/14651858.CD007066.pub2

How to Cite

Musini VM, Fortin PM, Bassett K, Wright JM. Blood pressure lowering efficacy of renin inhibitors for primary hypertension. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD007066. DOI: 10.1002/14651858.CD007066.pub2.

Author Information

  1. University of British Columbia, Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver, BC, Canada

*Vijaya M Musini, Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, 2176 Health Science Mall, Vancouver, BC, V6T 1Z3, Canada.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 8 OCT 2008




  1. Top of page
  2. Abstract
  3. Plain language summary


Hypertension is a chronic condition associated with an increased risk of mortality and morbidity. The renin-angiotensin-aldosterone system is an important target site for five antihypertensive drug classes: beta blockers, renin inhibitors, ACE inhibitors, angiotensin receptor blockers (ARBs) and aldosterone inhibitors. Renin is the enzyme responsible for converting angiotensinogen to angiotensin I, which is then converted to angiotensin II. Renin inhibitors prevent the formation of both angiotensin I and angiotensin II . Renin inhibitors do not affect kinin metabolism and may produce fewer adverse effects than ACE inhibitors such as dry cough or angioedema.


To quantify the dose-related blood pressure lowering efficacy of renin inhibitors versus placebo in the treatment of primary hypertension.

Search methods

We searched the following databases for randomised, double blind, placebo-controlled trials of renin inhibitors: Medline (1966-June 2011), EMBASE (1988-June 2011), Cochrane CENTRAL, the Hypertension Group Specialised Register and bibliographic citations from retrieved references. No language restrictions were applied.

Selection criteria

Study design had to meet the following criteria: double-blinded, placebo-controlled; random allocation to a specific dose of renin inhibitor group and parallel placebo group; duration of follow-up of at least three weeks.

Data collection and analysis

Two reviewers independently extracted data and assessed trial quality using risk of bias tables. Disagreements were resolved by discussion or a third reviewer. Data synthesis and analyses were done using the Cochrane Review Manager software, RevMan 5.1. Data for continuous variables were combined using a weighted mean difference method and dichotomous variables were analysed using relative risk with 95% CI.

Main results

Eight trials met the inclusion criteria. Six trials (N=3694) in the original review and two additional trials comparing the renin inhibitor, aliskiren (N=3393), to placebo (N=1623 ) met the inclusion criteria for this updated review. Aliskiren was the only renin inhibitor studied in these studies. The meta-analysis shows that aliskiren has a dose-related systolic/diastolic blood pressure lowering effect as compared to placebo: aliskiren 75 mg -2.6/-2.1 mm Hg, aliskiren 150 mg -5.6/-2.9 mm Hg, aliskiren 300 mg -7.9/-4.8, aliskiren 600 mg -11.4/-6.6 mm Hg. Aliskiren 300 mg significantly lowered both SBP and DBP as compared to aliskiren150 mg (SBP:-2.97 (95% CI -3.50, -1.90) and DBP: -1.86 (95% CI -2.39, -1.33). Aliskiren has no effect on blood pressure variability. No data was available to assess the effect of aliskiren on heart rate and pulse pressure. This review found weak evidence that with short-term use, aliskiren does not increase withdrawals due to adverse effects as compared to placebo.

Authors' conclusions

Aliskiren has a dose-related blood pressure lowering effect better than placebo. This effect is similar to that determined for ACE inhibitors and ARBs.


Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary

Blood pressure lowering efficacy of aliskiren

Elevated blood pressure or hypertension can lead to heart attacks and stroke. A new class of drugs called renin inhibitors is indicated for the treatment of hypertension. Aliskiren is a member of this new class and is the only one studied (or approved) for this indication at this time. We asked whether aliskiren was better than placebo for reducing blood pressure in patients with hypertension, and whether this drug had increased side effects leading to withdrawals. We searched the scientific literature and found 8 randomised controlled trials comparing aliskiren to placebo. We concluded that aliskiren is better than placebo at lowering blood pressure and that the magnitude of this effect could be similar to other classes of drugs when the maximum recommended dose is used. The trials were too short to assess side effects.