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REPLY
Blood Pressure Control in Type 2 Diabetes Mellitus
Sandeep Vijan, MD, MS, and
Rodney A. Hayward, MD
16 March 2004 | Volume 140 Issue 6 | Pages 487-488
IN RESPONSE:
Dr. Krantz points out that ACE inhibitors may be preferred over ARBs for patients with systolic dysfunction or acute MI. We agree, although trials show no clear statistical differences in outcomes between the 2 drugs. However, we would note that our review was of the primary treatment of hypertension in diabetes, not the treatment of comorbid conditions. Many other situations may lead clinicians to alter the initial choice of agent; for example, in patients with angina pectoris, a ß-blocker or a calcium-channel blocker may sometimes be preferred, and for those with prostatic hypertrophy, some clinicians may prefer ß-blockers. A complete discussion of these conditions was beyond the scope of our review.
Although ACE inhibitors may be preferred over ARBs in some clinical situations, the evidence for preferential benefit of ARB treatment for hypertension in patients with diabetes is somewhat stronger. For example, the data on the effectiveness of treatment of renal disease in patients with type 2 diabetes mellitus are currently more robust for ARBs than for ACE inhibitors, particularly compared with other classes of antihypertensive agents (1-3). Similarly, the Losartan Intervention for Endpoint Reduction in Hypertension study suggested that ARBs are more effective than ß-blockers in patients with diabetes, hypertension, and left ventricular hypertrophy, while the United Kingdom Prospective Diabetes Study found no benefit of ACE inhibitors over ß-blockers (4, 5). As noted in our review, the studies comparing drug classes are somewhat inconsistent in their conclusions, and the current literature does not include much evidence to suggest that ARBs are necessarily better or worse than ACE inhibitors. Therefore, the American College of Physicians felt that the greater experience with and lower cost of ACE inhibitors were reasons to select them as preferred agents, and we concur with this conclusion. In our view, data from head-to-head comparisons of the 2 classes are needed to make further distinctions. In the interim, other factors—such as cost, side effect profile, and comorbid conditions—should be used to guide the choice of drug for an individual patient.
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Author and Article Information
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From Veterans Affairs Health Services Research and Development, Ann Arbor, MI 48113.
1. Nielsen FS, Rossing P, Gall MA, Skott P, Smidt UM, Parving HH. Long-term effect of lisinopril and atenolol on kidney function in hypertensive NIDDM subjects with diabetic nephropathy. Diabetes. 1997;46:1182-8. [PMID: 9200654].[Abstract]
2. Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345:851-60. [PMID: 11565517].[Abstract/Free Full Text]
3. Schnack C, Hoffmann W, Hopmeier P, Schernthaner G. Renal and metabolic effects of 1-year treatment with ramipril or atenolol in NIDDM patients with microalbuminuria. Diabetologia. 1996;39:1611-6. [PMID: 8960851].[Medline]
4. Lindholm LH, Ibsen H, Dahlof B, Devereux RB, Beevers G, de Faire U, et al. Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet. 2002;359:1004-10. [PMID: 11937179].[Medline]
5. Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. UK Prospective Diabetes Study Group. BMJ. 1998;317:713-20. [PMID: 9732338].[Abstract/Free Full Text]
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