Letters to the Editor

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

Robert Fakheri, MD, Sripal Bangalore, MD and Franz Messerli, MD
Cleveland Clinic Journal of Medicine January 2020, 87 (1) 9; DOI: https://doi.org/10.3949/ccjm.87c.01001

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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