In reply: Peverill raises the question of how to integrate the new data on renal protection by angiotensin II receptor (AIIR) antagonists with existing data on cardiovascular protection by angiotensin-converting enzyme (ACE) inhibitors in patients with type 2 diabetes. An AIIR antagonist would be favoured for renal protection for a diabetic patient with hypertension and evidence of early or overt nephropathy. With regard to patients with microalbuminuria, the HOPE and MICRO-HOPE studies showed that therapy with the ACE inhibitor ramipril (10 mg/day) was associated with a 24% relative risk reduction for the development of overt nephropathy over 4.5 years.1 In contrast, treatment of similar patients with the AIIR antagonist irbesartan (300 mg/day) for 2.6 years resulted in a 70% risk reduction for the development of overt nephropathy.2 Use of an AIIR antagonist in patients with overt nephropathy has also been shown to slow progression to end-stage renal failure.3,4 As the HOPE and MICRO-HOPE studies specifically excluded such patients, evidence supporting use of an ACE inhibitor in this context is lacking.
The full article is accessible to AMA members and paid subscribers. Login to read more or purchase a subscription now.
Please note: institutional and Research4Life access to the MJA is now provided through Wiley Online Library.
- 1 Austin and Repatriation Medical Centre, Heidelberg, VIC.
- 2 Department of Medicine, Austin and Repatriation Medical Centre, Melbourne, VIC.
- 3 Department of Medicine, St Vincent's Hospital, Melbourne, VIC.
- 4 Department of Nephrology, Monash Medical Centre, Melbourne, VIC.
- 1. Heart Outcomes Prevention Evaluation (HOPE) Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 2000; 355: 253-259.
- 2. Parving H-H, Lenhert H, Brochner-Mortensen J, et al for the Irbesartan in Patients with Type 2 Diabetes and Microalbuminuria Study Group. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001; 345: 870-878.
- 3. Lewis EJ, Hunsicker LG, Clarke WR, 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: 851-860.
- 4. Brenner BM, Cooper ME, De Zeeuw D, et al for the RENAAL Study Investigators. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001; 345: 861-869.
- 5. He J, Whelton PK. Selection of initial antihypertensive drug therapy. Lancet 2000; 356: 1942-1943.
- 6. Staessen JA, J-G Wang, Lutgarde T. Cardiovascular protection and blood pressure reduction: a meta-analysis. Lancet 2001; 358: 1305-1314.