Which is more effective for controlling hypertension in diabetic patients: Angiotensin-Converting Enzyme Inhibitors (ACEI) or Angiotensin Receptor Blockers (ARB)?

From the Guidelines

Both ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are equally effective for controlling hypertension in diabetic patients, with the choice between them depending on patient tolerance and specific clinical considerations. When considering the management of hypertension in diabetic patients, the primary goal is to reduce morbidity, mortality, and improve quality of life by achieving optimal blood pressure control. According to the American Diabetes Association standards of medical care in diabetes 2018 1, an ACE inhibitor or an angiotensin receptor blocker, at the maximally tolerated dose indicated for blood pressure treatment, is recommended as the first-line treatment for hypertension in patients with diabetes. Key considerations in choosing between ACEIs and ARBs include:

• The presence of specific side effects, such as cough, which is more common with ACEIs and may necessitate switching to an ARB.
• The patient's renal function and urinary albumin-to-creatinine ratio, as both ACEIs and ARBs have renoprotective effects but require monitoring of serum creatinine and potassium levels.
• The severity of hypertension, which may require the use of multiple antihypertensive medications, including a diuretic, to achieve blood pressure targets. Given the equivalence in efficacy between ACEIs and ARBs for hypertension control in diabetic patients, as supported by the American Diabetes Association guidelines 1, the initial choice between these two classes of medications should be based on individual patient factors, such as tolerance and comorbid conditions, rather than a presumed superiority of one class over the other.

From the FDA Drug Label

The Veterans Affairs Nephropathy in Diabetes (VA NEPHRON-D) trial enrolled 1448 patients with type 2 diabetes, elevated urinary-albumin-to-creatinine ratio, and decreased estimated glomerular filtration rate (GFR 30 to 89.9 mL/min), randomized them to lisinopril or placebo on a background of losartan therapy and followed them for a median of 2. 2 years. Patients receiving the combination of losartan and lisinopril did not obtain any additional benefit compared to monotherapy for the combined endpoint of decline in GFR, end stage renal disease, or death, but experienced an increased incidence of hyperkalemia and acute kidney injury compared with the monotherapy group

The FDA drug label does not directly compare the effectiveness of Angiotensin-Converting Enzyme Inhibitors (ACEI) and Angiotensin Receptor Blockers (ARB) for controlling hypertension in diabetic patients. However, it does mention a study where patients receiving the combination of losartan (ARB) and lisinopril (ACEI) did not obtain any additional benefit compared to monotherapy, suggesting that both classes may have similar effectiveness when used alone.

• Key points:
  • No direct comparison of effectiveness between ACEI and ARB for hypertension control in diabetic patients.
  • A study found no additional benefit of combining losartan (ARB) and lisinopril (ACEI) compared to monotherapy.
  • Both ACEI and ARB may be effective for controlling hypertension in diabetic patients, but the label does not provide a direct comparison of their effectiveness 2.

From the Research

Comparison of ACEI and ARB for Controlling Hypertension in Diabetic Patients

• Both Angiotensin-Converting Enzyme Inhibitors (ACEI) and Angiotensin Receptor Blockers (ARB) are considered effective for controlling hypertension in diabetic patients 3, 4, 5, 6, 7.
• ACE inhibitors are still the preferred agents for most patients, as they have been shown to slow the progression of diabetic nephropathy by reducing glomerular hypertension 3, 5.
• ARBs have also been shown to decrease proteinuria and slow the progression of renal disease in type 2 diabetic patients 4.
• The choice between ACEI and ARB may depend on individual patient characteristics, such as renal function and the presence of other comorbidities 5, 6.
• Both ACEI and ARB are recommended as first-line pharmacotherapy for the treatment of hypertension in non-black patients with diabetes, while calcium channel blockers or thiazide diuretics may be preferred in black patients 6, 7.

Efficacy and Safety of ACEI and ARB

• ACE inhibitors have been shown to be effective in reducing myocardial infarctions and episodes of heart failure in diabetic patients 4.
• ARBs have been shown to be effective in reducing proteinuria and slowing the progression of renal disease in type 2 diabetic patients 4.
• Both ACEI and ARB are generally well-tolerated, but may cause adverse effects such as cough, angioedema, and hyperkalemia 5.
• The combination of ACEI and ARB is not routinely indicated for either hypertension or end-organ protection, and may increase the risk of adverse effects 5.

Blood Pressure Targets and Management

• Most guidelines recommend a target blood pressure of <140/90 mmHg for patients with diabetes 6, 7.
• Achieving this target may require combination therapy with multiple agents, including ACEI, ARB, calcium channel blockers, and diuretics 6, 7.
• Newer antidiabetic medications, such as GLP-1 receptor agonists and SGLT2 inhibitors, may also have a role in lowering blood pressure and reducing cardiovascular risk in patients with diabetes 6.