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ACE Inhibitors in Diabetes

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Diabetes, especially type II diabetes mellitus in adults is commonly associated with arterial hypertension. There are numerous antihypertensive drugs that can be generally prescribed in arterial hypertension: adrenergic receptor antagonists (β-blockers, α-blockers, mixed α, β-blockers), adrenergic receptor agonists (α-2 agonists), angiotensin-converting-enzyme (ACE) inhibitors, angiotensin II receptor antagonists, calcium channel blockers, diuretics, renin inhibitors, vasodilators. However, in diabetes pharmacokinetics as well as pharmacodynamics of any drug may follow an altered pathway that precludes or transforms their wide application in treating concomitant arterial hypertension and cardiovascular disorders. For example, the 2007 Guidelines for the Management of Arterial Hypertension (Mancia et al, 2007) states:

β-blockers and thiazide diuretics should not be preferred as the first step drugs because they may worsen insulin resistance and lead to increased doses or numbers of antidiabetic agents.

In diabetes, management of concomitant diseases is of paramount importance. As soon as cardiovascular abnormalities (like arterial hypertension or congestive heart failure) are adequately medicated, the quality of life and the expectant life duration improve substantially. In combination with tight glycemic control, this approach benefits most. The Institute for Clinical Systems Improvement emphasizes (Riethof et al, 2012): “A randomized controlled trial has shown a 50% reduction in major cardiovascular events through a multifactorial intervention targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, aspirin and ACE inhibitor use in individuals with microalbuminuria”.

ACE blockers have shown clear benefits in arterial hypertension management in diabetes mellitus. These agents not only control blood pressure safely enough to be recommended (Mancia et al, 2007), but also show advantages in randomized controlled trials. In the Table 1, the evidence-based conclusions on ACE inhibitors in diabetes and arterial hypertension are shown.

Table 1. Evidence for ACE inhibitors in diabetes mellitus type II.

Author

Study description

Results

Yususf et al, 2000

More than 3,000 patients aged > 55 y with diabetes and cardiovascular events were assigned placebo or ACE inhibitor

4.5 y follow up

Ramipril showed benefits for cardiovascular events that were greater than that attributable to the decrease in blood pressure

Wing et al, 2003

More than 6,000  mean age 72 y

4.1 y follow up

ACE inhibitors when compared to diuretics showed better outcomes and less death rate

ACE inhibitors are among the first line remedies in treating arterial hypertension in diabetes type II. They are especially indicated when microalbuminuria develops since these agents show clear renoprotective features, they increase the body’s sensitivity to insulin, they also have protective qualities for the heart, eye and peripheral nerve function. All these attribute to the modern evidence based clinical implications of the ACE inhibitors in diabetes type II in adults.

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