What is the preferred treatment for patients with diabetes, Angiotensin-Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARB)?

From the Guidelines

For patients with diabetes, ACE inhibitors are typically the preferred first-line medication choice, but ARBs are an excellent alternative, as both provide similar benefits in reducing cardiovascular risk and slowing diabetic nephropathy progression, as recommended by the most recent guidelines 1. The choice between ACE inhibitors and ARBs depends on various factors, including patient tolerance, cost, and potential side effects. ACE inhibitors, such as lisinopril, enalapril, and ramipril, are often tried first due to their slightly more robust evidence and potentially lower cost. However, ARBs, such as losartan, valsartan, and irbesartan, are a good alternative for patients who develop a dry cough, which affects 5-20% of people on ACE inhibitors. Both medication classes work by affecting the renin-angiotensin-aldosterone system, though through different mechanisms - ACE inhibitors prevent the formation of angiotensin II, while ARBs block its receptor. When initiating either medication, it is essential to monitor kidney function and potassium levels at baseline and within 1-2 weeks of starting therapy, as both can cause hyperkalemia or acute kidney injury in susceptible individuals, particularly those with pre-existing kidney disease 1. The most recent guidelines recommend using ACE inhibitors or ARBs as first-line therapy for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio ≥30 mg/g, as they have been shown to reduce the risk of progressive kidney disease and cardiovascular events 1. In patients with established coronary artery disease, ACE inhibitors or ARBs are also recommended as first-line therapy for hypertension 1. In terms of dosing, both ACE inhibitors and ARBs are typically started at lower doses and titrated up as needed for blood pressure control. For example, lisinopril can be started at 10mg daily, while losartan can be started at 50mg daily. The goal is to achieve the maximum tolerated dose that is indicated for blood pressure treatment, while minimizing the risk of side effects 1. Overall, the choice between ACE inhibitors and ARBs for patients with diabetes should be based on individual patient factors, as well as the most recent clinical guidelines and evidence-based recommendations.

Some key points to consider when choosing between ACE inhibitors and ARBs include:

• Patient tolerance and potential side effects
• Cost and availability of the medication
• Presence of pre-existing kidney disease or other comorbidities
• Level of albuminuria and risk of progressive kidney disease
• Presence of established coronary artery disease or other cardiovascular risk factors

By considering these factors and following the most recent clinical guidelines, healthcare providers can make informed decisions about the use of ACE inhibitors and ARBs in patients with diabetes, and help to reduce the risk of cardiovascular and kidney disease complications.

From the Research

Comparison of ACE Inhibitors and ARBs for Patients with Diabetes

• ACE inhibitors are still the preferred agents for most patients with diabetes, as they have been shown to provide end-organ protection and manage hypertension 2.
• However, ARBs have similar cardiovascular protective effects and may be considered as an alternative for patients who are intolerant to ACE inhibitors 3, 4.
• The choice between ACE inhibitors and ARBs should be based on individual patient characteristics, such as the presence of renal impairment or hyperkalemia 2.
• ACE inhibitors have been shown to delay the onset and slow the progression of diabetic nephropathy, independent of blood pressure effects 5.
• ARBs have also been shown to reduce diabetic nephropathy and complications related to nephropathy, and may be considered as an alternative to ACE inhibitors for patients with diabetes 3.

Side Effects and Considerations

• ACE inhibitors are associated with a higher risk of cough and angioedema compared to ARBs 2, 4.
• ARBs have a lower risk of adverse events and may be preferred for patients who are at risk of developing these side effects 4.
• The combination of ACE inhibitors and ARBs is not routinely indicated for either hypertension or end-organ protection, and may increase the risk of adverse events 2.
• Patients with diabetes should receive appropriate counseling and monitoring when taking ACE inhibitors or ARBs, including regular checks of electrolytes and renal function 2.

Clinical Evidence

• The ONTARGET trial demonstrated that the ARB telmisartan is as effective as the ACE inhibitor ramipril in providing cardiovascular protection in a high-risk population 3.
• A review of clinical trials found no difference in efficacy between ARBs and ACE inhibitors with regard to blood pressure and outcomes of all-cause mortality, cardiovascular mortality, myocardial infarction, heart failure, stroke, and end-stage renal disease 4.
• Experimental and epidemiological data suggest that ACE inhibitors have a specific "organ-protective" effect, and may improve kidney, heart, and eye function in patients with diabetes mellitus 6.