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Blood Pressure Control in Type 2 Diabetes Mellitus
- Sandeep Vijan, MD, MS; and
- Rodney A. Hayward, MD
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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 β-blocker or a calcium-channel blocker may sometimes be preferred, and for those with prostatic hypertrophy, some clinicians may prefer β-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 β-blockers in patients with diabetes, hypertension, and left ventricular hypertrophy, while the United Kingdom Prospective Diabetes Study found no benefit of ACE inhibitors over β-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.
Sandeep Vijan, MD, MS
Rodney A. Hayward, MD
Veterans Affairs Health Services Research and Development; Ann Arbor, MI 48113
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
