There are several drugs available for the treatment of hypertension and the choice of antihypertensive drug
is sometimes determined by the presence of any additional condition in the patient For example, if the
patient also suffers from an increase in heart rate, a beta blocker like atenolol that reduces heart rate, as well as blood pressure, may be preferred.
‘Any antihypertensive drug can be used and it’s not mandatory to prescribe RAS blockers to treat high blood pressure in diabetes patients.’
Patients with diabetes often suffer from high blood pressure
and are at a high risk for heart and kidney disease. Over the years, people with diabetes and high blood pressure were preferably prescribed drugs that act on the renin-angiotensin-aldosterone system (RAS) for the treatment of their hypertension. This preference was based on large studies, which demonstrated that these drugs prevent heart
and kidney disease in diabetes patients, which they are prone to. Drugs that act through RAS include angiotensin converting enzyme (ACE) inhibitors like ramipril and lisinopril and angiotensin receptor blockers (ARBs) like losartan
In a recent study,
researchers investigated whether RAS blockers for the treatment of high blood pressure in diabetes patients are indeed better than other medications in preventing heart and kidney disease. They obtained information from 19 previously published trials that compared the use of ACE inhibitor (15 studies) or ARB (4 studies) to other
antihypertensive drugs which included calcium channel blocker, thiazide
diuretic or beta blocker.
The researchers did not find evidence that RAS inhibitors
were better than other antihypertensive drugs in reducing death, heart diseases like heart attack and angina, stroke, and kidney disease like an end-stage renal disease in patients with diabetes
. However, data on milder forms of kidney disease like doubling of Creatinine
levels in the blood could not be obtained.
The finding of the
study contrasts with the guidelines laid down by several committees which
indicate that these antihypertensive drugs should be used preferentially in
diabetes patients. However, it agrees with the 2013 Society of
Cardiology/European Society of Hypertension guidelines and the 2014 Eighth
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure which suggest that any antihypertensive can be used in
diabetes patients, especially in those patients without kidney disease. In
addition, the fact still remains that RAS blockers are superior to calcium
channel blockers in prevention of heart failure.
This study expands
the choice of antihypertensive drugs for the physician that can be used in
diabetes patients. Many diabetes patients require more than one
antihypertensive agent to control their blood pressure. The bottom-line is, whichever antihypertensive drug is used, it
is important to maintain the blood pressure normal in patients with diabetes to
Dr. Sanjeev Nair, Senior Consultant Nephrologist, Comments:
"The article being discussed has several limitations that should caution one from comprehensively changing current clinical practice. The findings of this study are the result of a meta-analysis of previously conducted studies with very different structures that does not lend itself to easy comparison. The ALLHAT trial, which had one of the largest study populations and was included in this analysis, did not study the effect of medication on urine protein leak, which is the earliest complication of diabetic renal involvement. Multiple trials have shown a benefit of RAAS blockade in decreasing urinary protein leak and delaying onset of End Stage Renal Disease in earlier stages. Therefore, while it maybe safe to conclude that in diabetics with hypertension and without any other comorbidities, all classes of anti-hypertensives are equally efficacious, in the specific scenario of a diabetic with renal involvement who requires an anti-hypertensive ACE inhibitors or ARBs should still be the first choice drug till a sufficiently powered prospective randomized controlled trial that does a direct comparison proves equally beneficial."
- Bangalore S, Fakheri R,
Toklu B, Messerli FH. Diabetes mellitus as a compelling indication for use of
renin angiotensin system blockers: systematic review and meta-analysis of
randomized trials. BMJ 2016;352:i438. http://dx.doi.org/10.1136/bmj.i438