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Review: In diabetes, ACE-Is, but not ARBs, reduce mortality and major CV events compared with placebo or active treatment

Ann Intern Med. 2014;161(4):JC2. doi:10.7326/0003-4819-161-4-201408190-02002
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ACEIs are good but ARBs should not be ignored
Posted on September 2, 2014
Gauranga Dhar
Bangladesh Institute of Family Medicine and Research
Conflict of Interest: None Declared
This is a very good article where ACEIs found superior to ARBs in reducing cardiovascular and all cause mortality in diabetic population. This study must have a good practical implication. On the other hand beneficial effects of ARBs also cannot be ignored.
Insulin resistance probably one of the main causes of comorbidities/adverse events in type 2 diabetes patients. Some studies suggest that both ACEIs and ARBs increase skeletal muscle blood flow, hence increase insulin sensitivity. A meta-analysis performed by Mid America Heart Institute (Kansas) showed that due to beneficial effects on insulin resistance, both ARBs and ACEIs, lead to decreased number of new onset of type 2 diabetes. 24% reduction found by ACEIs and 23% by ARBs. Exactly same result was found in VALUE trial where valsartan was associated with 23% reduction of new onset of type 2 diabetes.
ADA guideline on “Hypertension management in adults with diabetes” suggests that patients with clinical nephropathy, ACEIs are first line drug in both type 1 and type 2 diabetes. On the other hand, ARBs should be considered as first line antihypertensive agents in patients with clinical nephropathy associated with type 2 diabetes.

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