From the Guidelines
The American Diabetes Association (ADA) guideline recommends ACE inhibitors, such as lisinopril, as first-line therapy for hypertension in patients with diabetes. These guidelines specifically suggest ACE inhibitors like lisinopril for diabetic patients, especially those with albuminuria, due to their renoprotective effects beyond blood pressure control 1. The typical starting dose for lisinopril in diabetic patients is 5-10 mg once daily, which can be titrated up to 40 mg daily if needed for blood pressure control. When using lisinopril in diabetic patients, it's essential to monitor kidney function and potassium levels regularly, as ACE inhibitors can affect both. Patients should be aware that combining lisinopril with potassium-sparing diuretics or potassium supplements may increase the risk of hyperkalemia. The renoprotective benefit of lisinopril in diabetes occurs because it reduces intraglomerular pressure by dilating the efferent arteriole more than the afferent arteriole, thereby decreasing protein filtration and slowing progression of diabetic nephropathy.
Some key points to consider when using lisinopril in diabetic patients include:
- Monitoring kidney function and potassium levels regularly
- Avoiding combinations with potassium-sparing diuretics or potassium supplements
- Titration of the dose to achieve optimal blood pressure control
- Awareness of the potential for hyperkalemia
The ADA guideline is based on evidence from studies such as the Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT) and the Heart Outcomes and Prevention Evaluation (HOPE) study, which demonstrated the benefits of ACE inhibitors in reducing cardiovascular events and mortality in patients with diabetes 1. Overall, the use of lisinopril and other ACE inhibitors as first-line therapy for hypertension in patients with diabetes is supported by strong evidence and is a key component of the ADA guideline.
From the Research
Guideline for Lisinopril with Diabetes
- The guideline for lisinopril with diabetes is not explicitly stated in the provided studies, but the EUCLID (EUrodiab Controlled trial of Lisinopril in Insulin-Dependent Diabetes) trial 2 and the BRILLIANT study 3 suggest that lisinopril is renoprotective in patients with diabetes.
- The European Controlled trial of Lisinopril in Insulin-dependent Diabetes (EUCLID) study 2, 3 showed that lisinopril slowed the progression of renal disease, even in individuals with mild albuminuria.
- The National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group 4 recommends a blood pressure goal of less than 130/80 mmHg to preserve renal function and reduce CV events in people with hypertension and diabetes.
- A randomised crossover trial 5 found that lisinopril 40 mg once daily is generally safe and offers additional reductions in BP and UAER in comparison with the currently recommended dose of 20 mg.
- A review of lisinopril's pharmacology and clinical efficacy in elderly patients 6 suggests that it is effective in lowering blood pressure in elderly patients with hypertension, and may also improve neuropathy associated with diabetes.