Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors for the Treatment of Hypertensive Patients With Type 2 Diabetes Mellitus.

Abstract

Mavrakanas et al reviewed treatment strategies in people with type 2 diabetes and hypertension (1Mavrakanas T.A. Lipman M.L. Angiotensin-converting enzyme inhibitors vs. angiotensin receptor blockers for the treatment of hypertension in adults with type 2 diabetes: Why we favour angiotensin receptor blockers.Can J Diabetes. 2018; 42: 118-123Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar). In that manuscript, they noted that although angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) have similar cardioprotective and renal-protective properties, ARBs present fewer side effects, such as cough and angioedema. In addition, ARBs or ACEIs in combination with selective sodium-glucose cotransporter type 2 inhibitors increase the advantage of protection for cardiovascular and renal complications, which have not been confirmed in mineralocorticoid receptor blockers. I have 2 comments about their study. First, Kaplan reported the comparison between ACEIs and ARBs in patients with diabetes and hypertension and pointed out that ACEIs remain the best choice if the patients tolerated the side effects (2Kaplan N.M. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for hypertension: Are they equivalent?.J Am Soc Hypertens. 2015; 9: 582-583Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar). In this report, Mavrakanas et al cautioned about the lack of statistical power for the treatment/benefit of ARBs. Recent increases in ARB prescriptions could provide larger statistical power, and a meta-analysis, including recent prospective studies, would improve the validity of the study's outcome. Second, Hicks et al recently reported a population-based cohort study that presented the increased risk for lung cancer with the use of ACEIs in comparison with ARBs (3Hicks B.M. Filion K.B. Yin H. et al.Angiotensin converting enzyme inhibitors and risk of lung cancer: Population based cohort study.BMJ. 2018; 363: k4209Crossref PubMed Scopus (127) Google Scholar), with an adjusted hazard ratio of ACEI against ARB of 1.14 (1.01 to 1.29). The risk gradually increased with longer durations of ACEI use, especially when it exceeds 5 years. Unfortunately, there was no description of comorbidity with type 2 diabetes, although the results were adjusted for statin use and number of medications. This risk assessment of neoplasm incidence would also become important for favouring ARBs over ACEIs. ACEIs accelerate the activity of bradykinin in tissues, and angiogenesis might be stimulated (4Hudey S.N. Westermann-Clark E. Lockey R.F. Cardiovascular and diabetic medications that cause bradykinin-mediated angioedema.J Allergy Clin Immunol Pract. 2017; 5: 610-615Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar). In addition, increase in substance P by ACEIs could partially explain the higher incidence of cancer (5Devin J.K. Pretorius M. Nian H. et al.Substance P increases sympathetic activity during combined angiotensin-converting enzyme and dipeptidyl peptidase-4 inhibition.Hypertension. 2014; 63: 951-957Crossref PubMed Scopus (53) Google Scholar). In summary, currently, the advantages of ARBs in people with type 2 diabetes and hypertension currently outweigh the use of ACEIs. Conflict of interest: none. Angiotensin-Converting Enzyme Inhibitors vs. Angiotensin Receptor Blockers for the Treatment of Hypertension in Adults With Type 2 Diabetes: Why We Favour Angiotensin Receptor BlockersCanadian Journal of DiabetesVol. 42Issue 2PreviewCardiovascular disease is the principal cause of morbidity and mortality in patients with diabetes mellitus. The incidence or progression of kidney disease is also common in these patients. Several clinical trials have established the efficacy of angiotensin receptor blockers for the prevention of adverse cardiovascular and renal outcomes in this population and are summarized in this review article. Head-to-head comparison of angiotensin receptor blockers with angiotensin-converting enzyme inhibitors has shown similar cardioprotective and renoprotective properties of both medication classes. Full-Text PDF Response to the Letter to the Editor From Dr Kawada, “Angiotensin Receptor Blockers and Angiotensin-Converting Enzyme Inhibitors for the Treatment of Hypertensive Patients With Type 2 Diabetes Mellitus”Canadian Journal of DiabetesVol. 44Issue 1PreviewWe thank Dr Kawada for the interest in our article (1) and thoughtful comments on angiotensin receptor blocker (ARB) use in patients with hypertension and type 2 diabetes (2). We agree that the recent increase in ARB prescriptions could provide greater statistical power to detect efficacy of ARBs against cardiovascular and renal events. Indeed, a recent network meta-analysis in patients with diabetes and kidney disease showed that ARBs reduce the incidence of end-stage kidney disease, doubling serum creatinine and myocardial infarction, and are associated with higher rates of albuminuria regression, compared with placebo (3). Full-Text PDF