Letters
Cardiovascular diseases Endocrinology
Volume 176 - Issue 6

Renal protection by angiotensin II receptor antagonists in patients with type 2 diabetes

Authors:  George Jerums, Mark E Cooper, Richard E Gilbert and Robert C Atkins

Med J Aust 2002; 176 (6): 296-297. || doi: 10.5694/j.1326-5377.2002.tb04417.x
Published online: 18 March 2002
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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.

An ACE inhibitor could be used if a diabetic patient has microalbuminuria and a history of coronary heart disease or additional risk factors for cardiovascular disease, especially if normotensive. However, almost all patients with microalbuminuria require antihypertensive therapy as well as therapy to protect target organs. The relative importance of blood-pressure-lowering versus non-lowering effects of antihypertensive therapy on reducing risk of cardiovascular disease remains uncertain.5 Furthermore, a recent meta-analysis of cardiovascular protection in 62 605 patients with hypertension (including the HOPE and United Kingdom Prospective Diabetes studies) did not find that ACE inhibitors affected cardiovascular prognosis beyond their antihypertensive effects.6

Finally, it is important to note that neither ACE inhibitors nor AIIR antagonists provide total protection from cardiovascular and renal events, and that further improvements are needed for both microvascular and macrovascular protection in patients with type 2 diabetes.

Authors

  • George Jerums1
  • Mark E Cooper1
  • Richard E Gilbert1
  • Robert C Atkins1
  • 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.

Correspondence: roger.peverill@med.monash.edu.au

References

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