Angiotensin receptor blockade

Three recent studies in type 2 diabetic subjects have evaluated the effects of angiotensin receptor blockade (ARB) on the risk for progression of diabetic nephropathy. In 2 of these studies the secondary endpoints included vascular events in which part of the composite endpoint was stroke. Although beneficial effects on progression of diabetic nephropathy was demonstrated for the ARB medication use in each of the studies, no statistically significant benefit was reported on overall with irbesartan by Lewis et al. (49). A 10 % reduction in fatal/non fatal cardiovascular events (p = 0.26) was reported for losartan. (50). Each of these studies did not have sufficient power to detect differences in cardiovascular events, but even the absence of a trend toward reductions seen with the ACE inhibitor ramipril in the HOPE study is notable. Whether this reflects some differences in patient populations, effects of ACE-inhibition (with alterations in both angiotensin and bradykinin, compared to only reduction in angiotensin effect) or insufficient power to show an effect is not clear.