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ACE inhibitors vs angiotensin receptor blockers (ARB)

Clinical trials: 1) systematic review of 43 trials randomized controlled trials of at least 6 months duration - combined 43 trials involved 7545 patients with diabetic nephropathy - 36 trials of ACE inhibitor vs placebo - 4 trials of ARB vs placebo - 3 trials of ACE inhibitor vs ARB Results: - mortality reduced significantly with ACE inhibitors (RR = 0.79), but not with ARBs (RR = 0.99) - similar effects of ACE inhibitors & ARBs on end-stage renal disease & doubling of serum creatinine - small sample size confounded direct comparison of ACE inhibitors with ARB 2) randomized, double-blind placebo-controlled trial - 250 patients with diabetes mellitus type 2 with diabetic nephropathy - 82% with microalbuminuria - 18% with proteinuria - all patients with serum creatinine < 1.6 mg/dL & - GFR > 70 mL/min/1.73m2 enalapril (ACE inhibitor) up to 20 mg/day telmisartan* (ARB) up to 80 mg/day 5 years of follow-up Results: - mean decline in GFR was 18 mL/min/1.73m2 with telmisartan & 15 mL/min/1.73m2 (not a significant difference) - blood pressure control, changes in serum creatinine, microalbuminuria, end-stage renal disease & cardiovascular events were the same in the 2 groups * study supported by manufacturer of telmisartan

References

  1. Journal Watch 24(23):173, 2004 Strippoli GF, Craig M, Deeks JJ, Schena FP, Craig JC. Effects of angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists on mortality and renal outcomes in diabetic nephropathy: systematic review. BMJ. 2004 Oct 9;329(7470):828. Epub 2004 Sep 30. Review. PMID: 15459003 http://bmj.bmjjournals.com/cgi/content/full/329/7470/828
  2. Journal Watch 24(23):174, 2004 Barnett AH, Bain SC, Bouter P, Karlberg B, Madsbad S, Jervell J, Mustonen J; Diabetics Exposed to Telmisartan and Enalapril Study Group. Angiotensin-receptor blockade versus converting-enzyme inhibition in type 2 diabetes and nephropathy. N Engl J Med. 2004 Nov 4;351(19):1952-61. Epub 2004 Oct 31. PMID: 155166963)
  3. Prescriber's Letter 14(12): 2007 ACE Inhibitors Versus ARBs Detail-Document#: 231213 (subscription needed) http://www.prescribersletter.com
  4. Prescriber's Letter 15(6): 2008 ACE Inhibitors Versus ARBs Detail-Document#: 240610 (subscription needed) http://www.prescribersletter.com