Another nail in the coffin for combination ACE/ARB in diabetic nephropathy!
http://www.nejm.org/doi/full/10.1056/NEJMoa1303154?query=TOC
Also see Kiran/Pradeep's posts on this article on Nov 10th.
Regarding Pradeep's question: might there still be a role for combined ACE/ARB in non-diabetics with CKD and proteinuria? Obviously this study was in diabetics and will not directly inform ACE+ARB use in non-diabetics. But its impressive that their findings generally confirm those in ONTARGET, suggesting adverse outcomes (renal failure, hyperkalemia) with combination therapy. ONTARGET included both diabetics and non-diabetics, and subgroup analysis suggested the adverse outcomes were not affected by the presence/absence of diabetes.
So I will continue to consider combined ACE/ARB only in very exceptional circumstances (perhaps multi-drug resistant hypertension and/or severe refractory proteinuria), and only with diligent laboratory monitoring.
This comment has been removed by the author.
ReplyDeleteUnderstanding the risks of combined ACEI/ARB and dual RAAS blockade, I would rather consider using low dose aldosterone blockers in patients with proteinuria with acceptable renal function. Although no solid data , this seems to be the logical approach. There are couple of interesting investigational drugs that may benefit for patients with diabetic nephropathy with proteinuria, eGFR of 25-75 ml/min and stable or max RAAS blockers and consider them referring to research center.
ReplyDeleteKiran: are you aware of any data (or any physiologic rationale) supporting ACE+aldactone as safer than ACE+ARB? My sense is the studies with ACE+aldactone just haven't been done on the same scale as the ACE+ARB studies. If they were, I suspect we would see the same type of outcomes re: hyperkalemia, AKI.
DeleteThe info you provided in the blog that was really unique I love it!!!
ReplyDeleteNephrologist Specialization