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ACE Inhibitors vs. ARBs in Patients with Diabetic Nephropathy: A Meta-Analysis

Two classes of drugs, angiotensin-converting-enzyme (ACE) inhibitors and angiotensin II-receptor blockers (ARBs), delay the progression of diabetic nephropathy. What is their effect on mortality? In a systematic review of randomized controlled trials of at least 6 months' duration, investigators identified 43 trials that involved 7545 patients with diabetic nephropathy: 36 trials of ACE inhibitors versus placebo, 4 of ARBs versus placebo, and 3 of ACE inhibitors versus ARBs.

In the placebo-controlled trials, mortality risk was reduced significantly with ACE inhibitors (relative risk, 0.79) but not with ARBs (RR, 0.99), despite similar effects of the two drug classes on renal outcomes (e.g., end-stage renal disease, doubling of serum creatinine concentration). However, small sample sizes prevented an adequate head-to-head comparison of ACE inhibitors and ARBs.

Comment: In patients with diabetic nephropathy, ACE inhibitors and angiotensin II-receptor blockers each clearly delay development of renal complications. However, a mortality benefit has been demonstrated only with the ACE inhibitors. Until we have adequate head-to-head comparisons of the two drug classes, ACE inhibitors should be viewed as first-line therapy in diabetic nephropathy. At the time of publication, the full text of the original article was available free of charge.

— Keith I. Marton, MD

Published in Journal Watch General Medicine November 9, 2004

Citation(s):

Strippoli GFM et al. 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; 329:828-31.

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