ACE inhibitors vs angiotensin receptor blockers (ARB)

Clinical trials

• 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
• 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