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Item
#7
Renin-Angiotensin-Aldosterone
Blockade Remains Underused in Type 2 Diabetes
Given
the additional evidence provided by these three studies,
clinicians must be encouraged to make use of these agents
Drugs
that block the renin-angiotensin-aldosterone system remain
underused as a means of preventing renal deterioration in patients
with type 2 diabetes, according to an editorial by T.H. Hostetter
in the New England Journal of Medicine.
The accumulating evidence on the
efficacy of these agents in type 2 diabetes has been bolstered by
three new studies. Parving et al showed that the
angiotensin-II–receptor blocker irbesartan had a renoprotective
effect that was independent of its effect on blood pressure in
patients with type 2 diabetes, hypertension, and microalbuminuria.
Glomerular filtration rates were normal at the beginning of the
study, and 2 years later diabetic nephropathy (urinary albumin
excretion rate >200 μg/min or at least 30% higher than
baseline) had developed in 5.2% of patients receiving 300 mg a day
of irbesartan and in 14.9% of controls.
Lewis et al compared irbesartan (300
mg a day) with the calcium channel blocker amlopidine (10 mg a
day) and placebo in patients with type 2 diabetes and established
nephropathy. In a similar group of patients, Brenner et al
compared the angiotensin-II–receptor blocker losartan (50 to 100
mg a day) with placebo in a similar group of patients who were
also taking conventional antihypertensive therapy.
In both studies, patients taking the
angiotensin-II–receptor blocker had lower levels of proteinuria,
lower rates of decline in the glomerular filtration rate, and
later onset (about 2 years) of end-stage renal disease.
Unfortunately, these studies did not
address the effects of angiotensin-II–receptor blockers in
Hispanic, black, and Native American patients, in whom the risk of
end-stage renal disease is particularly high. For example, a
recent study indicated that the ameliorating effect of
angiotensin-converting enzyme (ACE) inhibitors on left ventricular
dysfunction is less in black patients than in white patients.
However, the African American Study
of Kidney Disease and Hypertension did show that an ACE inhibitor
was more effective in mitigating the progression of renal disease
than a calcium channel blocker. Thus, blockade of the
renin-angiotensin-aldosterone system appears to be prudent for
these patients as well, said Hostetter.
Given the additional evidence
provided by these three studies, clinicians must be encouraged to
make use of these agents, he said.
Hostetter TH.
Prevention of end-stage renal disease due to type 2 diabetes
[editorial]. N Engl J Med. 2001;345:910-912.
================================
Did
You Know:
Ginger
Kanzer-Lewis’ column thisweek features her latest article
“Tale
of 2 Women”
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