Issue 91 Item 13 Why ACE inhibitors Remain Central to Management of Type 2 Diabe
In addition to hypoglycemia and antihypertensive agents—particularly ACE inhibitors—-play a central role in the management of type 2 diabetes.
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As a recent review of the subject points out, ACE inhibitors have earned this
status not only because of their demonstrated potent antihypertensive properties
but also because of reported protective effects on the kidney and heart, and to
a lesser extent, on the eye and peripheral nerves. Moreover, cost-effectiveness
studies indicate that these drugs provide such benefits at considerable indirect
costs.
The reviewers noted that the best clinical evidence of ACE Inhibitor nephro-protection
is exemplified by a 1993 report from the Cooperative Study Group showing that
captopril reduced the risk of death, dialysis, or renal transplantation by 80%,
compared with placebo, and more recently by the MICRO-HOPE Investigators, who
reported a 24% reduction in the risk of overt nephropathy with ramipril, also
compared with placebo, in addition, the 1999 DIAB1OPSIES study showed that
proteinuna increased in patients given a placebo but decreased In those treated
with perindopril; morphometric analysis revealed that cortical interstitial
fractional volume Increased significantly in the placebo group but remain
unchanged in the perlndopril group.
ACE inhibitors, the reviewers pointed out, have not only markedly reduced the
cardiovascular mortality in patients with diabetes but also reduced the
incidence of heart failure and other cardiac events—with the same or better
efficacy. Compared with beta-blockers or diuretics, and sometimes with better
compliance. In the HOPE data, ramipril treatment was shown to reduce the risks
of myocardial infarction, stroke, cardiovascular death, and coronary
revascularization by 22%, 33%. 37%, and 17%, respectively. These risk reductions
were not accounted for by the 2 to 3 mm Hg fall in blood pressure produced by
ramipril.
As for the eye, progression of diabetic retinopathy in the EUCLID study (1997)
was slowed by 50% in lisinopril-treated patients compared with placebo-treated
patients, and MICRO-HOPE data showed a 16% reduction in the likelihood of laser
therapy in ramipril-treated patients, even though the study was not designed to
examine retinopathy.
Finally, improved nerve conduction velocity was noted in one 1996 study after
12 weeks of lisinopril therapy and after 12 months of trandolapril therapy In a
1995 study.
The reviewers noted that continued improvements in the use or ACE inhibitors
will require studies involving various unexamined issues, includiung comparison
of results in patients with the same risk factors, particularly hereditary
cardiovascular risk factors, and head-to-head comparisons of different ACE
inhibitors and of ACE inhibitors and other agents, such as angiotensin II
receptor blockers.
Cordonniar DJ et el. Role of ACE inhibitors in patients with diabetes. Drugs.
2001;C1:1883-1892,
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