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Monday, August 10, 2020

Simvastatin

From Wikipedia, the free encyclopedia
 
Simvastatin
Simvastatin.svg
Simvastatin3Dan.gif
Clinical data
Pronunciation/ˈsɪmvəstætɪn/
Trade namesZocor, other
AHFS/Drugs.comMonograph
MedlinePlusa692030
License data
Pregnancy
category
  • AU: D
  • US: X (Contraindicated)
Routes of
administration
by mouth
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability5%
Protein binding95%
MetabolismHepatic (CYP3A4)
Elimination half-life2 hours for simvastatin and 1.9 hours for simvastatin acid
ExcretionRenal 13%, faecal 60%
Identifiers
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard100.115.749 Edit this at Wikidata
Chemical and physical data
FormulaC25H38O5
Molar mass418.574 g·mol−1
3D model (JSmol)

Simvastatin, marketed under the trade name Zocor among others, is a lipid-lowering medication. It is used along with exercise, diet, and weight loss to decrease elevated lipid levels. It is also used to decrease the risk of heart problems in those at high risk. It is taken by mouth.

Common side effects include constipation, headaches, and nausea. Serious side effects may include muscle breakdown, liver problems, and increased blood sugar levels. A lower dose may be needed in people with kidney problems. There is evidence of harm to the developing baby when taken during pregnancy and it should not be used by those who are breastfeeding. It is in the statin class of medications and works by decreasing the manufacture of cholesterol by the liver.

Simvastatin was patented by Merck in 1980, and came into medical use in 1992. It is on the World Health Organization's List of Essential Medicines. It is available as a generic medication and at a relatively low cost. Simvastatin is made from the fungus Aspergillus terreus. In 2017, it was the eighth most commonly prescribed medication in the United States, with more than 56 million prescriptions.

Medical uses

The primary uses of simvastatin are to treat dyslipidemia and to prevent atherosclerosis-related complications such as stroke and heart attacks in those who are at high risk. It is recommended to be used as an addition to a low-cholesterol diet.

In the Scandinavian Simvastatin Survival Study (a placebo-controlled, randomized clinical trial of five years' duration), simvastatin reduced overall mortality in people with existing cardiovascular disease and high LDL cholesterol by 30% and reduced cardiovascular mortality by 42%. The risks of heart attack, stroke, or needing a coronary revascularization procedure were reduced by 37%, 28%, and 37%, respectively.

The Heart Protection Study evaluated the effects of simvastatin in people with risk factors including existing cardiovascular disease, diabetes, or stroke, but having relatively low LDL cholesterol. In this trial, which lasted 5.4 years, overall mortality was reduced by 13% and cardiovascular mortality was reduced by 18%. People receiving simvastatin experienced 38% fewer nonfatal heart attacks and 25% fewer strokes.

Simvastatin has been used to explore whether statins have an effect on delaying on the onset and progression of age-related macular degeneration (AMD). Results from one trial showed participants assigned to simvastatin had lower odds (0.51 OR) of having AMD progression at three years compared to those assigned to placebo, though the results were not significant. Overall, evidence is insufficient to conclude that simvastatin has an effect in delaying the onset and progression of AMD.

Contraindications

Simvastatin is contraindicated with pregnancy, breastfeeding, and liver disease. Pregnancy must be avoided while on simvastatin due to potentially severe birth defects. Patients cannot breastfeed while on simvastatin due to potentially disrupting the infant's lipid metabolism. High doses of simvastatin are also contraindicated with the widely used antihypertensive amlodipine. A lower dose is also recommended in people taking the calcium channel blockers, verapamil and diltiazem, as well as those taking amiodarone.

Adverse effects

Common side effects (>1% incidence) may include indigestion and eczema. Rare side effects include joint pain, memory loss, and muscle cramps. Cholestatic hepatitis, hepatic cirrhosis, rhabdomyolysis (destruction of muscles and blockade of renal system), and myositis have been reported in patients receiving the drug chronically. Serious allergic reactions to simvastatin are rare. If the following signs of a serious allergic reaction occur, seek medical attention immediately: rash, hoarseness itching/swelling, dizziness, or difficulty swallowing/breathing.

A type of DNA variant known as a single nucleotide polymorphism (SNP) may help predict individuals prone to developing myopathy when taking simvastatin; a study ultimately including 32,000 patients concluded the carriers of one or two risk alleles of a particular SNP, rs4149056, were at a five-fold or 16-fold increased risk, respectively. In 2012, the Clinical Pharmacogenetics Implementation Consortium has released guidelines regarding the use of rs4149056 genotype in guiding dosing of simvastatin and updated the guideline in 2014.

In March 2012, the U.S. Food and Drug Administration (FDA) updated its guidance for statin users to address reports of memory loss, liver damage, increased blood sugar, development of type 2 diabetes, and muscle injury. The new guidance indicates:
  • FDA has found that liver injury associated with statin use is rare but can occur.
  • The reports about memory loss, forgetfulness, and confusion span all statin products and all age groups. The FDA says these experiences are rare, but that those affected often report feeling "fuzzy" or unfocused in their thinking.
  • A small increased risk of raised blood sugar levels and the development of type 2 diabetes have been reported with the use of statins.
  • Some drugs interact with statins in a way that increases the risk of muscle injury called myopathy, characterized by unexplained muscle weakness or pain.
On 19 March 2010, the FDA issued another statement regarding simvastatin, saying it increases the risk of muscle injury (myopathy) when taken at high doses or at lower doses in combination with other drugs. The highest dose rate causes muscle damage in 610 of every 10,000 people in contrast to a lower dose, which causes muscle damage in eight of 10,000 people. The FDA warning, released again on 8 June 2011, suggested that high-dose "simvastatin should be used only in patients who have been taking this dose for 12 months or more without evidence of muscle injury" and that it "should not be started in new patients, including patients already taking lower doses of the drug."

Interactions

Simvastatin has important interactions with grapefruit juice and other drugs, including some that are commonly used for the treatment of cardiovascular disease. These interactions are clinically important because increasing simvastatin serum levels above those normally provided by the maximum recommended dose increases the risk of muscle damage, including the otherwise rare and potentially fatal side effect of rhabdomyolysis.

Consuming large amounts of grapefruit juice increases serum levels of simvastatin by up to three-fold, increasing the risk of side effects. The FDA recommends that people taking statins should avoid consuming more than a quart (946 ml) of grapefruit juice per day.

Simvastatin also interacts with other drugs, including some used to treat cardiovascular problems. It should not be taken by people who are also taking the antifungal drugs fluconazole, itraconazole, or posaconazole; the antibiotics erythromycin, clarithromycin, or telithromycin; HIV protease inhibitors; the antidepressant nefazodone; the cardiovascular drug gemfibrozil; the immunosuppressant ciclosporin, or the endometriosis drug danazol. Reduced maximum doses of simvastatin apply for patients taking certain other drugs, including the cardiovascular drugs verapamil, diltiazem, amiodarone, amlodipine, and ranolazine.

Pharmacology

All statins act by inhibiting 3-hydroxy-3-methylglutaryl (HMG) coenzyme A reductase. HMG-CoA reductase, the rate-limiting enzyme of the HMG-CoA reductase pathway, the metabolic pathway responsible for the endogenous production of cholesterol. Statins are more effective than other lipid-regulating drugs at lowering LDL-cholesterol concentration, but they are less effective than the fibrates in reducing triglyceride concentration. However, statins reduce cardiovascular disease events and total mortality irrespective of the initial cholesterol concentration. This is a major piece of evidence that statins work in another way than the lowering of cholesterol (called pleiotropic effects).

The drug is in the form of an inactive lactone that is hydrolyzed after ingestion to produce the active agent. It is a white, nonhygroscopic, crystalline powder that is practically insoluble in water, and freely soluble in chloroform, methanol, and ethanol.

Simvastatin is an effective serum lipid-lowering drug that can decrease low density lipoprotein (LDL) levels by up to 50%. Simvastatin had been shown to interact with lipid-lowering transcription factor PPAR-alpha  and that interaction might control the neurotrophic action of the drug.

History

The development of simvastatin was closely linked with lovastatin. Biochemist Jesse Huff and his colleagues at Merck began researching the biosynthesis of cholesterol in the early 1950s.[35] In 1956, mevalonic acid was isolated from a yeast extract by Karl Folkers, Carl Hoffman, and others at Merck, while Huff and his associates confirmed that mevalonic acid was an intermediate in cholesterol biosynthesis. In 1959, the HMG-CoA reductase enzyme (a major contributor of internal cholesterol production) was discovered by researchers at the Max Planck Institute. This discovery encouraged scientists worldwide to find an effective inhibitor of this enzyme.

By 1976, Akira Endo had isolated the first inhibitor, mevastatin, from the fungus Penicillium citrinium while working at Daiichi Sankyo in Japan. In 1979, Hoffman and colleagues isolated lovastatin from a strain of the fungus Aspergillus terreus. While developing and researching lovastatin, Merck scientists synthetically derived a more potent HMG-CoA reductase inhibitor from a fermentation product of A. terreus, which was designated MK-733 (later to be named simvastatin).

In 1994, publication of the results of the Scandinavian Simvastatin Survival Study (4S) provided the first unequivocal evidence that lowering LDL cholesterol via statin treatment reduces cardiovascular events and overall mortality. A total of 4,444 people with coronary heart disease 5.5 to 8.0 mmol/L were randomized to simvastatin treatment or placebo and followed for an average of 5 years. Compared to the placebo group, those treated with simvastatin experienced a 30% decrease in overall mortality, a 42% reduction in coronary death, a 34% reduction in major coronary events, and a 37% reduction in revascularization procedures.

Society and culture

Cost

Simvastatin is relatively inexpensive. The wholesale cost in some LMIC is around US$0.01 to 0.15 per 20 mg dose as of 2014. The defined daily dose is 30 mg per the World Health Organization. The price decreased from roughly US$1,200 to $40 per year of medication in LMIC following the patent expiring in 2006. In the United States, it costs about US$10 to 20 per month since patent protection ended. In the UK in 2008, the typical per-patient cost to the NHS of simvastatin was about £1.50 per month. (40 mg/day costs UK NHS £1.37/month in 2012) The price in Canada is about $CAD 130 to 160 per year as of 2016. Under provisions of the Patient Protection and Affordable Care Act (PPACA) in the United States, there is no cost for simvastatin 10 mg, 20 mg, and 40 mg for adults aged 40–75 years based on United States Preventive Services Task Force (USPSTF) recommendations.

Economics

Simvastatin was introduced in the late 1980s, and since 2006 in many countries, it is available as a generic preparation. This has led to a decrease of the price of most statin drugs, and a reappraisal of the health economics of preventive statin treatment.

Prior to losing U.S. patent protection, simvastatin was Merck & Co.'s largest-selling drug and second-largest selling cholesterol-lowering drug in the world. In 2005, recorded US$3.1 billion of sales in the United States and US$4.4 billion worldwide.

Zocor had an original patent expiry date of 24 December 2005 but was extended by the United States Patent and Trademark Office (USPTO) to expire on 23 June 2006. The USPTO granted the patent extension after Merck submitted data from studies of the drug's positive effect on children. In the UK, the patent for simvastatin had expired by 2004.

In the UK, simvastatin was the most prescribed medication in the community in 2013, with 39.9 million items dispensed. This compares to 30.9 million items for aspirin, and 27.7 million for levothyroxine sodium, the second- and third-most prescribed drugs in the UK in 2013.

Marketing

Simvastatin was initially marketed by Merck & Co under the trade name Zocor but is available generically in most countries following the patent expiry. A combination of simvastatin along with ezetimibe is sold under the brand name Vytorin and is jointly marketed by Merck and Schering-Plough.

Brand names include Zocor, Zocor Heart Pro, marketed by the pharmaceutical company Merck & Co., Simlup, Simvotin, Simcard [India], Denan (Germany), Liponorm, Sinvacor, Sivastin (Italy), Lipovas (Japan), Lodales (France), Zocord (Austria and Sweden), Zimstat, Simvahexal (Australia), Lipex (Australia and New Zealand), Simvastatin-Teva, Simvacor, Simvaxon, Simovil (Israel), available in Thailand under the brand Bestatin manufactured by Berlin Pharmaceutical Industry Co Ltd and others.

The U.S. patent for Zocor expired on 23 June 2006. Ranbaxy Laboratories (at the 80-mg strength) and Teva Pharmaceutical Industries through its Ivax Pharmaceuticals unit (at all other strengths) were given approval by the FDA to manufacture and sell simvastatin as a generic drug with 180-day exclusivity. Dr. Reddy's Laboratories also has a license from Merck & Co. to sell simvastatin as an authorized generic drug.

Fenofibrate

From Wikipedia, the free encyclopedia
 
Fenofibrate
Fenofibrate structure.svg
Clinical data
Trade namesFenoglide, Lipofen, others
AHFS/Drugs.comMonograph
MedlinePlusa601052
License data
Pregnancy
category
  • AU: B3
  • US: N (Not classified yet)
Routes of
administration
By mouth
ATC code
Legal status
Legal status
  • UK: POM (Prescription only) 
  • US: ℞-only
  • In general: ℞ (Prescription only)
Pharmacokinetic data
Protein binding99%
Metabolismglucuronidation
Elimination half-life20 h
Excretionurine (60%), feces (25%)
Identifiers
CAS Number
PubChem CID
IUPHAR/BPS
DrugBank
ChemSpider
UNII
KEGG
ChEBI
ChEMBL
CompTox Dashboard (EPA)
ECHA InfoCard100.051.234 Edit this at Wikidata
Chemical and physical data
FormulaC20H21ClO4
Molar mass360.83 g·mol−1
3D model (JSmol)
Melting point80 to 81 °C (176 to 178 °F)

Fenofibrate, sold under the brand name Tricor among others, is a medication of the fibrate class used to treat abnormal blood lipid levels. It is less preferred to statin medications as it does not appear to reduce the risk of heart disease or death. Its use is recommended together with dietary changes. It is taken by mouth.

Common side effects include liver problems, breathing problems, abdominal pain, muscle problems, and nausea. Serious side effects may include toxic epidermal necrolysis, rhabdomyolysis, gallstones, blood clots, and pancreatitis. Use in pregnancy and breastfeeding is not recommended. It works by a number of mechanisms.

It was patented in 1969, and came into medical use in 1975. It is available as a generic medication. In 2017, it was the 70th most commonly prescribed medication in the United States with more than eleven million prescriptions.

Medical uses

Fenofibrate is mainly used for primary hypercholesterolemia or mixed dyslipidemia. Fenofibrate appears to decrease the risk of cardiovascular disease and possibly diabetic retinopathy in those with diabetes mellitus, and firstly indicated for the reduction in the progression of diabetic retinopathy in patients with type 2 diabetes and existing diabetic retinopathy in Australia. It also appears to be helpful in decreasing amputations of the lower legs in this same group of people. Fenofibrate also has an off-label use as an added therapy of high blood uric acid levels in people who have gout.

It is used in addition to diet to reduce elevated low-density lipoprotein cholesterol (LDL), total cholesterol, triglycerides (TG), and apolipoprotein B (apo B), and to increase high-density lipoprotein cholesterol (HDL) in adults with primary hypercholesterolemia or mixed dyslipidemia.
It is used in addition to diet for treatment of adults with severe hypertriglyceridemia. Improving glycemic control in diabetics showing fasting chylomicronemia will usually decrease the need for pharmacologic intervention.

Statins remain the first line for treatment of blood cholesterol. AHA guidelines from 2013 did not find evidence for routine use of additional medications.

Additionally, in 2016, the FDA filed "Withdrawal of Approval of Indications Related to the Coadministration With Statins in Applications for Niacin Extended-Release Tablets and Fenofibric Acid Delayed Release Capsules" noting "the Agency has concluded that the totality of the scientific evidence no longer supports the conclusion that a drug-induced reduction in triglyceride levels and/or increase in HDL cholesterol levels in statin-treated patients results in a reduction in the risk of cardiovascular events. Consistent with this conclusion, FDA has determined that the benefits of niacin ER tablets and fenofibric acid DR capsules for coadministration with statins no longer outweigh the risks, and the approvals for this indication should be withdrawn."

Contraindications

Fenofibrate is contraindicated in:

Adverse effects

The most common adverse events (>3% of patients with coadministered statins) are

Precautions

When fenofibrate and a statin are given as combination therapy, it is recommended that fenofibrate be given in the morning and the statin at night, so that the peak dosages do not overlap.
Musculoskeletal
Hepatotoxicity
  • Can increase serum transaminases; liver tests should be monitored periodically
Nephrotoxicity
Biliary
  • Can increase cholesterol excretion into the bile, leading to risk of cholelithiasis; if suspected, gallbladder studies are indicated. See "Interaction" section under Bile acid sequestrant
Coagulation/Bleeding
  • Exercise caution in concomitant treatment with oral Coumadin anticoagulants (e.g. warfarin). Adjust the dosage of Coumadin to maintain the prothrombin time/INR at desired level to prevent bleeding complications.

Overdose

"There is no specific treatment for overdose with fenofibric acid delayed-release capsules. General supportive care is indicated, including monitoring of vital signs and observation of clinical status". Additionally, hemodialysis should not be considered as an overdose treatment option because fenofibrate heavily binds to plasma proteins and does not dialyze well.

Interactions

These drug interactions with fenofibrate are considered major and may need therapy modifications:
  • Bile acid sequestrants (e.g. cholestyramine, colestipol, etc.): If taken together, bile acid resins may bind to fenofibrate, resulting in a decrease in fenofibrate absorption. To maximize absorption, patients need to separate administration by at least 1 h before or 4 h to 6 h after taking the bile acid sequestrant.
  • Immunosuppressants (e.g. ciclosporin or tacrolimus): An increased risk of renal dysfunction exists with concomitant use of immunosuppressants and fenofibrate. Approach with caution when coadministering additional medications that decrease renal function
  • Vitamin K antagonists (e.g. warfarin): As previously mentioned, fenofibrate interacts with coumadin anticoagulants to increase the risk of bleeding. Dosage adjustment of vitamin K antagonist may be necessary.
  • Statins: Combination of statins and fenofibrate may increase the risk of rhabdomyolysis or myopathy.

Mechanism of action

"In summary, enhanced catabolism of triglyceride-rich particles and reduced secretion of VLDL underlie the hypotriglyceridemic effect of fibrates, whereas their effect on HDL metabolism is associated with changes in HDL apolipoprotein expression."

Fenofibrate is a fibric acid derivative, a prodrug comprising fenofibric acid linked to an isopropyl ester. It lowers lipid levels by activating peroxisome proliferator-activated receptor alpha (PPARα). PPARα activates lipoprotein lipase and reduces apoprotein CIII, which increases lipolysis and elimination of triglyceride-rich particles from plasma.

PPARα also increases apoproteins AI and AII, reduces VLDL- and LDL-containing apoprotein B, and increases HDL-containing apoprotein AI and AII.

Formulations

Fenofibrate is available in several formulations and is sold under several brand names, including Tricor by AbbVie, Lipofen by Kowa Pharmaceuticals America Inc, Lofibra by Teva, Lipanthyl, Lipidil, Lipantil micro and Supralip by Abbott Laboratories, Fenocor-67 by Ordain Health Care, Fibractiv 105/35 by Cogentrix Pharma( India), Fenogal by SMB Laboratories, Antara by Oscient Pharmaceuticals, Tricheck by Zydus (CND), Atorva TG by Zydus Medica, Golip by GolgiUSA and Stanlip by Ranbaxy (India). Different formulations may differ in terms of pharmacokinetic properties, particularly bioavailability; some must be taken with meals, whereas others may be taken without regard to food.

The active form of fenofibrate, fenofibric acid, is also available in the United States, sold as Trilipix. Fenofibric acid may be taken without regard to the timing of meals.

Controversy

In the United States, Tricor was reformulated in 2005. This reformulation is controversial, as it is seen as an attempt to stifle competition from generic equivalents of the drug, and is the subject of antitrust litigation by generic drug manufacturer Teva. Also available in the United States, Lofibra is available in 54 and 160 mg tablets, as well as 67, 134, and 200;mg micronized capsules. Generic equivalents of Lofibra capsules are currently available in all three strengths in the United States. In Europe, it is available in either coated tablet or capsule; the strength range includes 67, 145, 160 and 200 mg. The differences among strengths are a result of altered bioavailability (the fraction absorbed by the body) due to particle size. For example, 200 mg can be replaced by 160 mg micronized fenofibrate. The 145 mg strength is a new strength that appeared in 2005-2006 which also replaces 200 or 160 mg as the fenofibrate is nanonised (i.e. the particle size is below 400 nm).

History

Fenofibrate was first synthesized in 1974, as a derivative of clofibrate, and was launched on the French market shortly thereafter. It was initially known as procetofen, and was later renamed fenofibrate' to comply with World Health Organization International Nonproprietary Name guidelines.

Fenofibrate was developed by Groupe Fournier SA of France, which was acquired in 2005 by Solvay Pharmaceuticals, a business unit of the Belgian corporation Solvay S.A.. In 2009, Solvay was, in turn, acquired by Abbott Laboratories (now AbbVie in the US and Mylan in Europe, Canada, Australia, New Zealand and Japan).

Research

COVID-19

In July 2020, researchers from Israel and the U.S. suggested that fenofibrate might significantly slow down the replication of the SARS-CoV-2 virus in lung cells. This hypothesis awaits testing in clinical trials.

American civil religion

From Wikipedia, the free encyclopedia
 
American civil religion is a sociological theory that a nonsectarian quasi-religious faith exists within the United States with sacred symbols drawn from national history. Scholars have portrayed it as a cohesive force, a common set of values that foster social and cultural integration. The ritualistic elements of ceremonial deism found in American ceremonies and presidential invocations of God can be seen as expressions of the American civil religion. The very heavy emphasis on pan-Christian religious themes is quite distinctively American and the theory is designed to explain this.

The concept goes back to the 19th century, but in current form, the theory was developed by sociologist Robert Bellah in 1967 in his article, "Civil Religion in America". The topic soon became the major focus at religious sociology conferences and numerous articles and books were written on the subject. The debate reached its peak with the American Bicentennial celebration in 1976. There is a viewpoint that some Americans have come to see the document of the United States Constitution, along with the Declaration of Independence and the Bill of Rights as cornerstones of a type of civic or civil religion or political religion. Political sociologist Anthony Squiers argues that these texts act as the sacred writ of the American civil religion because they are used as authoritative symbols in what he calls the politics of the sacred. The politics of the sacred, according to Squiers are "the attempt to define and dictate what is in accord with the civil religious sacred and what is not. It is a battle to define what can and cannot be and what should and should not be tolerated and accepted in the community, based on its relation to that which is sacred for that community."

According to Bellah, Americans embrace a common "civil religion" with certain fundamental beliefs, values, holidays, and rituals, parallel to, or independent of, their chosen religion. Presidents have often served in central roles in civil religion, and the nation provides quasi-religious honors to its martyrs—such as Abraham Lincoln and the soldiers killed in the American Civil War. Historians have noted presidential level use of civil religion rhetoric in profoundly moving episodes such as World War II, the Civil Rights Movement, and the September 11th attacks.

In a survey of more than fifty years of American civil religion scholarship, Squiers identifies fourteen principal tenets of the American civil religion:
  1. Filial piety
  2. Reverence to certain sacred texts and symbols of the American civil religion (The Constitution, The Declaration of Independence, the flag, etc.)
  3. The sanctity of American institutions
  4. The belief in God or a deity
  5. The idea that rights are divinely given
  6. The notion that freedom comes from God through government
  7. Governmental authority comes from God or a higher transcendent authority
  8. The conviction that God can be known through the American experience
  9. God is the supreme judge
  10. God is sovereign
  11. America's prosperity results from God's providence
  12. America is a "city on a hill" or a beacon of hope and righteousness
  13. The principle of sacrificial death and rebirth
  14. America serves a higher purpose than self-interests
In an examination of over fifty years of political discourse, Squiers finds that filial piety, reference to certain sacred texts and symbols of the American civil religion, the belief in God or a deity, America is a "city on a hill" or a beacon of hope and righteousness, and America serves a higher purpose than self-interests are the most frequently referenced. He further found that there are no statistically significant differences in the amount of American civil religious language between Democrats and Republicans, incumbents and non-incumbents nor Presidential and Vice-Presidential candidates.

This belief system has historically been used to reject nonconformist ideas and groups. Theorists such as Bellah hold that American civil religion can perform the religious functions of integration, legitimation, and prophecy, while other theorists, such as Richard Fenn, disagree.

Development of concept

Alexis de Tocqueville believed that Christianity was the source of the basic principles of liberal democracy, and the only religion capable of maintaining liberty in a democratic era. He was keenly aware of the mutual hatred between Christians and liberals in 19th-century France, rooted in the Enlightenment and the French Revolution. In France, Christianity was allied with the Old Regime before 1789 and the reactionary Bourbon Restoration of 1815-30. However he said Christianity was not antagonistic to democracy in the United States, where it was a bulwark against dangerous tendencies toward individualism and materialism, which would lead to atheism and tyranny.

Also important were the contributions of French philosopher Jean-Jacques Rousseau (1712–1778) and French sociologist Émile Durkheim (1858–1917).

The American case

Most students of American civil religion follow the basic Bellah/Durkheimian interpretation. Other sources of this idea include philosopher John Dewey who spoke of "common faith" (1934); sociologist Robin Murphy Williams' American Society: A Sociological Interpretation (1951) which stated there was a "common religion" in America; sociologist Lloyd Warner's analysis of the Memorial Day celebrations in "Yankee City" (1953 [1974]); historian Martin Marty's "religion in general" (1959); theologian Will Herberg who spoke of "the American Way of Life" (1960, 1974); historian Sidney Mead's "religion of the Republic" (1963); and British writer G. K. Chesterton, who said that the United States was "the only nation ... founded on a creed" and also coined the phrase "a nation with a soul of a church".

In the same period, several distinguished historians such as Yehoshua Arieli, Daniel Boorstin, and Ralph Gabriel "assessed the religious dimension of 'nationalism', the 'American creed', 'cultural religion' and the 'democratic faith'".

Premier sociologist Seymour Lipset (1963) referred to "Americanism" and the "American Creed" to characterize a distinct set of values that Americans hold with a quasi-religious fervor.

Today, according to social scientist Ronald Wimberley and William Swatos, there seems to be a firm consensus among social scientists that there is a part of Americanism that is especially religious in nature, which may be termed civil religion. But this religious nature is less significant than the "transcendent universal religion of the nation" which late eighteenth century French intellectuals such as Jean-Jacques Rousseau and Alexis de Tocqueville wrote about.

Evidence supporting Bellah

Ronald Wimberley (1976) and other researchers collected large surveys and factor analytic studies which gave support to Bellah's argument that civil religion is a distinct cultural phenomenon within American society which is not embodied in American politics or denominational religion.

Examples of civil religious beliefs are reflected in statements used in the research such as the following:
  • "America is God's chosen nation today."
  • "A president's authority ... is from God."
  • "Social justice cannot only be based on laws; it must also come from religion."
  • "God can be known through the experiences of the American people."
  • "Holidays like the Fourth of July are religious as well as patriotic."
  • "God Bless America"
Later research sought to determine who is civil religious. In a 1978 study by James Christenson and Ronald Wimberley, the researchers found that a wide cross section of American citizens have civil religious beliefs. In general though, college graduates and political or religious liberals appear to be somewhat less civil religious. Protestants and Catholics have the same level of civil religiosity. Religions that were created in the United States, the Latter Day Saints movement, Adventists, and Pentecostals, have the highest civil religiosity. Jews, Unitarians and those with no religious preference have the lowest civil religion. Even though there is variation in the scores, the "great majority" of Americans are found to share the types of civil religious beliefs which Bellah wrote about.

Further research found that civil religion plays a role in people's preferences for political candidates and policy positions. In 1980 Ronald Wimberley found that civil religious beliefs were more important than loyalties to a political party in predicting support for Nixon over McGovern with a sample of Sunday morning church goers who were surveyed near the election date and a general group of residents in the same community. In 1982 James Christenson and Ronald Wimberley found that civil religion was second only to occupation in predicting a person's political policy views.

Coleman has argued that civil religion is a widespread theme in history. He says it typically evolves in three phases: undifferentiation, state sponsorship in the period of modernization, differentiation. He supports his argument with comparative historical data from Japan, Imperial Rome, the Soviet Union, Turkey, France and The United States.

Civil religion in practice

American Revolution

The American Revolution was the main source of civil religion. It produced a Moses-like leader (George Washington), prophets (Thomas Jefferson, Thomas Paine), apostles (John Adams, Benjamin Franklin) and martyrs (Boston Massacre, Nathan Hale), as well as devils (Benedict Arnold), sacred places (Valley Forge), rituals (raising the Liberty Tree), flags (the Betsy Ross flag), sacred holidays (July 4th) and a holy scripture (The Declaration of Independence and the Constitution).

Ceremonies in the early Republic

The Apotheosis of Washington, as seen looking up from the capitol rotunda

The elitists who ran the Federalists were conscious of the need to boost voter identification with their party. Elections remained of central importance but for the rest of the political year celebrations, parades, festivals, and visual sensationalism were used. They employed multiple festivities, exciting parades, and even quasi-religious pilgrimages and "sacred" days that became incorporated into the American civil religion. George Washington was always its hero, and after his death he became a sort of demigod looking down from heaven to instill his blessings on the party.

At first the Federalists focused on commemoration of the ratification of the Constitution; they organized parades to demonstrate widespread popular support for the new Federalist Party. The parade organizers, incorporated secular versions of traditional religious themes and rituals, thereby fostering a highly visible celebration of the nation's new civil religion.

The Fourth of July became a semi-sacred day—a status it maintains in the 21st century. Its celebration in Boston proclaimed national over local patriotism, and included orations, dinners, militia musters, parades, marching bands, floats and fireworks. By 1800, the Fourth was closely identified with the Federalist party. Republicans were annoyed, and stage their own celebrations on the fourth—with rival parades sometimes clashing with each other. That generated even more excitement and larger crowds. After the collapse of the Federalists starting in 1815, the Fourth became a nonpartisan holiday.

President as leader of civil religion

Since the days of George Washington presidents have assumed one of several roles in American civil religion, and that role has helped shape the presidency. Linder argues that:
Throughout American history, the president has provided the leadership in the public faith. Sometimes he has functioned primarily as a national prophet, as did Abraham Lincoln. Occasionally he has served primarily as the nation's pastor, as did Dwight Eisenhower. At other times he has performed primarily as the high priest of the civil religion, as did Ronald Reagan. In prophetic civil religion, the president assesses the nation's actions in relation to transcendent values and calls upon the people to make sacrifices in times of crisis and to repent of their corporate sins when their behavior falls short of the national ideals. As the national pastor, he provides spiritual inspiration to the people by affirming American core values and urging them to appropriate those values, and by comforting them in their afflictions. In the priestly role, the president makes America itself the ultimate reference point. He leads the citizenry in affirming and celebrating the nation, and reminds them of the national mission, while at the same time glorifying and praising his political flock.
Charles W. Calhoun argues that in the 1880s the speeches of Benjamin Harrison display a rhetorical style that embraced American civic religion; indeed, Harrison was one of the credo's most adept presidential practitioners. Harrison was a leader whose application of Christian ethics to social and economic matters paved the way for the Social Gospel, the Progressive Movement and a national climate of acceptance regarding government action to resolve social problems.

Linder argues that President Bill Clinton's sense of civil religion was based on his Baptist background in Arkansas. Commentator William Safire noted of the 1992 presidential campaign that, "Never has the name of God been so frequently invoked, and never has this or any nation been so thoroughly and systematically blessed." Clinton speeches incorporated religious terminology that suggests the role of pastor rather than prophet or priest. With a universalistic outlook, he made no sharp distinction between the domestic and the foreign in presenting his vision of a world community of civil faith.

Brocker argues that Europeans have often mischaracterized the politics of President George W. Bush (2001–2009) as directly inspired by Protestant fundamentalism. However, in his speeches Bush mostly actually used civil religious metaphors and images and rarely used language specific to any Christian denomination. His foreign policy, says Bocker, was based on American security interests and not on any fundamentalist teachings.

Hammer says that in his 2008 campaign speeches candidate Barack Obama portrays the American nation as a people unified by a shared belief in the American Creed and sanctified by the symbolism of an American civil religion.

Would-be presidents likewise contributed to the rhetorical history of civil religion. The speeches of Daniel Webster were often memorized by student debaters, and his 1830 endorsement of "Liberty and Union, now and forever, one and inseparable" was iconic.

Symbolism of the American flag

According to Adam Goodheart, the modern meaning of the American flag, and the reverence of many Americans towards it, was forged by Major Robert Anderson's fight in defense of the flag at the Battle of Fort Sumter, which opened the American Civil War in April 1861. During the war the flag was used throughout the Union to symbolize American nationalism and rejection of secessionism. Goodheart explains the flag was transformed into a sacred symbol of patriotism:
Before that day, the flag had served mostly as a military ensign or a convenient marking of American territory ... and displayed on special occasions like the Fourth of July. But in the weeks after Major Anderson's surprising stand, it became something different. Suddenly the Stars and Stripes flew ... from houses, from storefronts, from churches; above the village greens and college quads. ... [T]hat old flag meant something new. The abstraction of the Union cause was transfigured into a physical thing: strips of cloth that millions of people would fight for, and many thousands die for.

Soldiers and veterans

An important dimension is the role of the soldiers, ready to sacrifice their lives to preserve the nation. They are memorialized in many monuments and semi-sacred days, such as Veterans Day and Memorial Day. Historian Jonathan Ebel argues that the "soldier-savior" is a sort of Messiah, who embodies the synthesis of civil religion, and the Christian ideals of sacrifice and redemption. In Europe, there are numerous cemeteries exclusively for American soldiers who fought in world wars. They have become American sacred spaces.

Pacifists have made some sharp criticisms. For example, Kelly Denton-Borhaug, writing from the Moravian peace tradition, argues that the theme of "sacrifice" has fueled the rise of what she calls "U.S. war culture." The result is a diversion of attention from what she considers the militarism and the immoral, oppressive, sometimes barbaric conduct in the global American war on terror. However, some Protestant denominations such as the Churches of Christ, have largely turned away from pacifism to give greater support to patriotism and civil religion.

Pledge of Allegiance

Kao and Copulsky argue the concept of civil religion illuminates the popular constitutional debate over the Pledge of Allegiance. The function of the pledge has four aspects: preservationist, pluralist, priestly, and prophetic. The debate is not between those who believe in God and those who do not, but it is a dispute on the meaning and place of civil religion in America.

Cloud explores political oaths since 1787 and traces the tension between a need for national unity and a desire to affirm religious faith. He reviews major Supreme Court decisions involving the Pledge of Allegiance, including the contradictory Minersville School District v. Gobitis (1940) and West Virginia v. Barnette (1943) decisions. He argues that the Pledge was changed in 1954 during the Cold War to encourage school children to reject communism's atheistic philosophy by affirming belief in God.

School rituals

Adam Gamoran (1990) argues that civil religion in public schools can be seen in such daily rituals as the pledge of allegiance; in holiday observances, with activities such as music and art; and in the social studies, history and English curricula. Civil religion in schools plays a dual role: it socializes youth to a common set of understandings, but it also sets off subgroups of Americans whose backgrounds or beliefs prevent them from participating fully in civil religious ceremonies.

Ethnic minorities

The Bellah argument deals with mainstream beliefs, but other scholars have looked at minorities outside the mainstream, and typically distrusted or disparaged by the mainstream, which have developed their own version of U.S. civil religion.

White Southerners

Wilson, noting the historic centrality of religion in Southern identity, argues that when the White South was outside the national mainstream in the late 19th century, it created its own pervasive common civil religion heavy with mythology, ritual, and organization. Wilson says the "Lost Cause"—that is, defeat in a holy war—has left some southerners to face guilt, doubt, and the triumph of what they perceive as evil: in other words, to form a tragic sense of life.

Black and African Americans

Woodrum and Bell argue that black people demonstrate less civil religiosity than white people and that different predictors of civil religion operate among black and white people. For example, conventional religion positively influences white people's civil religion but negatively influences black peoples' civil religion. Woodrum and Bell interpret these results as a product of black American religious ethnogenesis and separatism.

Japanese Americans

Iwamura argues that the pilgrimages made by Japanese Americans to the sites of World War II-era internment camps have formed a Japanese American version of civil religion. Starting in 1969 the Reverend Sentoku Maeda and Reverend Soichi Wakahiro began pilgrimages to Manzanar National Historic Site in California. These pilgrimages included poetry readings, music, cultural events, a roll call of former internees, and a nondenominational ceremony with Protestant and Buddhist ministers and Catholic and Shinto priests. The event is designed to reinforce Japanese American cultural ties and to ensure that such injustices will never occur again.

Hispanic and Latino Americans

Mexican-American labor leader César Chávez, by virtue of having holidays, stamps, and other commemorations of his actions, has practically become a "saint" in American civil religion, according to León. He was raised in the Catholic tradition and using Catholic rhetoric. His "sacred acts," his political practices couched in Christian teachings, became influential to the burgeoning Chicano movement and strengthened his appeal. By acting on his moral convictions through nonviolent means, Chávez became sanctified in the national consciousness, says León.

Enshrined texts


Christian language, rhetoric, and values helped colonists to perceive their political system as superior to the corrupt British monarchy. Ministers' sermons were instrumental in promoting patriotism and in motivating the colonists to take action against the evils and corruption of the British government. Together with the semi-religious tone sometimes adopted by preachers and such leaders as George Washington, and the notion that God favored the patriot cause, this made the documents of the Founding Fathers suitable as almost-sacred texts.

The National Archives Building in Washington preserves and displays the Declaration of Independence, the Constitution and the Bill of Rights. Pauline Maier describes these texts as enshrined in massive, bronze-framed display cases. While political scientists, sociologists, and legal scholars study the Constitution and how it is used in American society, on the other hand, historians are concerned with putting themselves back into a time and place, in context. It would be anachronistic for them to look at the documents of the "Charters of Freedom" and see America's modern "civic religion" because of "how much Americans have transformed very secular and temporal documents into sacred scriptures". The whole business of erecting a shrine for the worship of the Declaration of Independence strikes some academic critics looking from point of view of the 1776 or 1789 America as "idolatrous, and also curiously at odds with the values of the Revolution." It was suspicious of religious iconographic practices. At the beginning, in 1776, it was not meant to be that at all.

On the 1782 Great Seal of the United States, the date of the Declaration of Independence and the words under it signify the beginning of the "new American Era" on earth. Though the inscription, Novus ordo seclorum, does not translate from the Latin as "secular", it also does not refer to a new order of heaven. It is a reference to generations of society in the western hemisphere, the millions of generations to come.

Even from the vantage point of a new nation only ten to twenty years after the drafting of the Constitution, the Framers themselves differed in their assessments of its significance. Washington in his Farewell Address pleaded that "the Constitution be sacredly maintained."' He echoed Madison in "Federalist No. 49" that citizen "veneration" of the Constitution might generate the intellectual stability needed to maintain even the "wisest and freest governments" amidst conflicting loyalties. But there is also a rich tradition of dissent from "Constitution worship". By 1816, Jefferson could write that "some men look at constitutions with sanctimonious reverence and deem them like the ark of the covenant, too sacred to be touched." But he saw imperfections and imagined that potentially, there could be others, believing as he did that "institutions must advance also".

Regarding the United States Constitution, the position of The Church of Jesus Christ of Latter-day Saints (LDS Church) is that it is a divinely inspired document.

Seventh-Day Adventists

While the civil religion has been widely accepted by practically all denominations, one group has always stood against it. Seventh-Day Adventists deliberately pose as "heretics", so to speak, and refuse to treat Sundays as special, due to their adherence to the Ten Commandments dictating that Saturday is the holy day. Indeed, says Bull, the denomination has defined its identity in contradistinction to precisely those elements of the host culture that have constituted civil religion.

Making a nation

The American identity has an ideological connection to these "Charters of Freedom". Samuel P. Huntington discusses common connections for most peoples in nation-states, a national identity as product of common ethnicity, ancestry and experience, common language, culture and religion. Levinson argues:
It is the fate of the United States, however, to be different from "most peoples," for here national identity is based not on shared Proustian remembrances, but rather on the willed affirmation of what Huntington refers to as the "American creed," a set of overt political commitments that includes an emphasis on individual rights, majority rule, and a constitutional order limiting governmental power.
The creed, according to Huntington, is made up of (a) individual rights, (b) majority rule, and (c) a constitutional order of limited government power. American independence from Britain was not based on cultural difference, but on the adoption of principles found in the Declaration. Whittle Johnson in The Yale Review sees a sort of "covenanting community" of freedom under law, which, "transcending the 'natural' bonds of race, religion and class, itself takes on transcendent importance".

Becoming a naturalized citizen of the United States requires passing a test covering a basic understanding of the Declaration, the U.S. Constitution, and the Bill of Rights, and taking an oath to support the U.S. Constitution. Hans Kohn described the United States Constitution as "unlike any other: it represents the lifeblood of the American nation, its supreme symbol and manifestation. It is so intimately welded with the national existence itself that the two have become inseparable." Indeed, abolishing the Constitution in Huntington's view would abolish the United States, it would "destroy the basis of community, eliminating the nation, [effecting] ... a return to nature."

As if to emphasize the lack of any alternative "faith" to the American nation, Thomas Grey in his article "The Constitution as scripture", contrasted those traditional societies with divinely appointed rulers enjoying heavenly mandates for social cohesion with that of the United States. He pointed out that Article VI, third clause, requires all political figures, both federal and state, "be bound by oath or affirmation to support this Constitution, but no religious test shall ever be required ..." This was a major break not only with past British practice commingling authority of state and religion, but also with that of most American states when the Constitution was written.

Escape clause. Whatever the oversights and evils the modern reader may see in the original Constitution, the Declaration that "all men are created equal"—in their rights—informed the Constitution in such a way that Frederick Douglass in 1860 could label the Constitution, if properly understood, as an antislavery document. He held that "the constitutionality of slavery can be made out only by disregarding the plain and common-sense reading to the Constitution itself. [T]he Constitution will afford slavery no protection when it shall cease to be administered by slaveholders," a reference to the Supreme Court majority at the time. With a change of that majority, there was American precedent for judicial activism in Constitutional interpretation, including the Massachusetts Supreme Court, which had ended slavery there in 1783.
 
Accumulations of Amendments under Article V of the Constitution and judicial review of Congressional and state law have fundamentally altered the relationship between U.S. citizens and their governments. Some scholars refer to the coming of a "second Constitution" with the Thirteenth Amendment, we are all free, the Fourteenth, we are all citizens, the Fifteenth, men vote, and the Nineteenth, women vote. The Fourteenth Amendment has been interpreted so as to require States to respect citizen rights in the same way that the Constitution has required the Federal government to respect them. So much so, that in 1972, the U.S. Representative from Texas, Barbara Jordan, could affirm, "My faith in the Constitution is whole, it is complete, it is total ...".

After discussion of the Article V provision for change in the Constitution as a political stimulus to serious national consensus building, Sanford Levinson performed a thought experiment which was suggested at the bicentennial celebration of the Constitution in Philadelphia. If one were to sign the Constitution today, whatever our reservations might be, knowing what we do now, and transported back in time to its original shortcomings, great and small, "signing the Constitution commits one not to closure but only to a process of becoming, and to taking responsibility for the political vision toward which I, joined I hope, with others, strive."

Cryogenics

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