ACE Inhibitors for All With Diabetes?

In his article "High-Risk Hypertensive Patients: How to Optimize Therapy UsingACE Inhibitors and ARBs" (CONSULTANT, October 2003, page 1390), Dr JanBasile recommends angiotensin-converting enzyme (ACE) inhibitors for patientswith type 1 diabetes with or without hypertension, whether or not nephropathyis present. The point is emphasized both in the text and in the accompanying algorithm.Dr Basile cites the 2003 clinical practice recommendations of the AmericanDiabetic Association (ADA) to support his views. However, the ADA publicationstates, "In patients with type 1 diabetes, with or without hypertension, withany degree of albuminuria, ACE inhibitors have been shown to delay the progressionof nephropathy."¹To the best of my knowledge, at no time did the ADA recommend ACE inhibitorsfor all patients with type 1 diabetes regardless of whether microalbuminuriais present. The implication of Dr Basile's recommendation is that about1 million Americans with type 1 diabetes should be taking ACE inhibitors.---- Sola Osundeko, MD
DuBois, Pa
Some controversy does remain about the need for renin-angiotensinsystem blockade with an ACE inhibitor in all persons with diabetes,especially those who are not hypertensive or have no evidence ofnephropathy. No evidence-based trial has studied the use of ACE inhibitorsin these patients. I therefore understand why Dr Osundekohas concerns about the use of ACE inhibitors in all 1 million Americans whohave type 1 diabetes. However, many diabetes experts, despite the lack ofevidence, currently recommend ACE inhibitors for all patients with diabetesbecause they believe that the long-term effect of these agents will be both cardioprotectiveand nephroprotective. The most recent ADA consensus guidelinesstate: "Because many studies demonstrate the benefit of ACE inhibitorson multiple adverse outcomes in patients with diabetes, including both macrovascularand microvascular complications, in patients with either mild or moresevere hypertension and in both type 1 and type 2 diabetes, the establishedpractice of choosing an ACE inhibitor as the first-line agent in most patientswith diabetes is reasonable."1 I hope my recommendation--despite the lack oftrial-based evidence--is reasonable as well.---- Jan Basile, MD
Associate Professor of Medicine
Medical University of South Carolina
Charleston

References:

REFERENCE:
1.

American Diabetes Association. Treatment of hypertension in adults with diabetes.

Diabetes Care.

2003;26(suppl 1):S80-S82.