Is diabetes still a compelling indication for renin-angiotensin-aldosterone system inhibitors?

TO THE EDITOR: The recent review by Momoniat et al, “ACE inhibitors and ARBs: Managing potassium and renal function,” provides a thorough overview of these important medication classes.¹ The authors state, “In general, a renin-angiotensin-aldosterone system inhibitor is recommended if the patient has diabetes; stage 1, 2, or 3 chronic kidney disease; or proteinuria.” The sentence suggests that patients with diabetes alone, even without nephropathy, are to receive renin-angiotensin-aldosterone system inhibitors.

We take issue with this statement. The current literature no longer supports the notion that diabetes mellitus is a compelling indication for use of renin-angiotensin-aldosterone system blockers in the absence of associated nephropathy. In a systematic review and meta-analysis of 19 randomized controlled trials that enrolled 25,414 participants with diabetes for a total of 95,910 patient-years of follow-up, we demonstrated that inhibitors of the renin-angiotensin-aldosterone system were not superior to other antihypertensive drug classes in patients with diabetes.² Specifically, renin-angiotensin-aldosterone system blockers were not superior to thiazides, calcium channel blockers, or beta-blockers at reducing the risk of hard cardiovascular and renal end points.² Current guidelines from the American Diabetes Association,³ European Society of Cardiology,⁴ and Joint National Committee⁵ also do not give preference to these drug classes in patients with diabetes without nephropathy.

Perhaps the word “diabetes” could be removed in the above-referenced sentence. Furthermore, heart failure with reduced ejection fraction could be added to the list of conditions that are indications for inhibition of the renin-angiotensin-aldosterone system irrespective of initial blood pressure level.

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