Tags

Type your tag names separated by a space and hit enter

Beyond ONTARGET: angiotensin-converting enzyme inhibition and angiotensin II receptor blockade in combination, a lesser evil in some?
Diabetes Obes Metab 2010; 12(12):1072-8DO

Abstract

AIM

Following the recent Ongoing Telmistartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET) finding of adverse renal outcomes, dual renin-angiotensin blockade has fallen out of favour, despite antihypertensive and antiproteinuric efficacy. However, in high-risk severe hypertension, not studied in ONTARGET, whether combination treatment should be withheld or withdrawn is not clear. We examine the renal effects of angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin II receptor blocker (ARB) monotherapy versus combination therapy in patients with type 2 diabetes and varying degrees of hypertension.

METHODS

Subjects attending a hospital diabetes centre were selected as case (combination therapy, n = 120) and control (monotherapy, n = 480). Subjects were matched for age, gender, ethnicity, estimated glomerular filtration rate (eGFR), blood pressure (BP) and study duration. Patients were stratified by BP, hypertension stage 1 (BP < 160/100, n = 506) and stage 2 (≥160/100, n = 94), and by treatment group. Data were analysed for the primary renal outcome of eGFR decline ≥20 ml/min, over a median of 3.7 years.

RESULTS

In keeping with the ONTARGET study, for stage 1 hypertension, combination treatment is significantly worse than monotherapy for the primary outcome of eGFR decline ≥20 ml/min (20 vs. 10.7%, p = 0.01). In contrast, for stage 2 hypertension, this endpoint was reached less often for combination versus monotherapy (12.0 vs. 23.2%, p = 0.2). Combination treatment was also not detrimental in patients with proteinuria or eGFR < 60 ml/min and was associated with fewer macrovascular events.

CONCLUSION

Given that hypertension control is paramount and in the spirit of primum non nocere, these data are reassuring should clinicians choose to use ACE-I and ARB combination therapy in the very hypertensive diabetic patient.

Authors+Show Affiliations

Diabetes Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia. jencia.wong@email.cs.nsw.gov.auNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

20977578

Citation

Wong, J, et al. "Beyond ONTARGET: Angiotensin-converting Enzyme Inhibition and Angiotensin II Receptor Blockade in Combination, a Lesser Evil in Some?" Diabetes, Obesity & Metabolism, vol. 12, no. 12, 2010, pp. 1072-8.
Wong J, Molyneaux L, Constantino M, et al. Beyond ONTARGET: angiotensin-converting enzyme inhibition and angiotensin II receptor blockade in combination, a lesser evil in some? Diabetes Obes Metab. 2010;12(12):1072-8.
Wong, J., Molyneaux, L., Constantino, M., Twigg, S. M., & Yue, D. K. (2010). Beyond ONTARGET: angiotensin-converting enzyme inhibition and angiotensin II receptor blockade in combination, a lesser evil in some? Diabetes, Obesity & Metabolism, 12(12), pp. 1072-8. doi:10.1111/j.1463-1326.2010.01298.x.
Wong J, et al. Beyond ONTARGET: Angiotensin-converting Enzyme Inhibition and Angiotensin II Receptor Blockade in Combination, a Lesser Evil in Some. Diabetes Obes Metab. 2010;12(12):1072-8. PubMed PMID: 20977578.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Beyond ONTARGET: angiotensin-converting enzyme inhibition and angiotensin II receptor blockade in combination, a lesser evil in some? AU - Wong,J, AU - Molyneaux,L, AU - Constantino,M, AU - Twigg,S M, AU - Yue,D K, PY - 2010/10/28/entrez PY - 2010/10/28/pubmed PY - 2011/6/4/medline SP - 1072 EP - 8 JF - Diabetes, obesity & metabolism JO - Diabetes Obes Metab VL - 12 IS - 12 N2 - AIM: Following the recent Ongoing Telmistartan Alone and in Combination With Ramipril Global Endpoint Trial (ONTARGET) finding of adverse renal outcomes, dual renin-angiotensin blockade has fallen out of favour, despite antihypertensive and antiproteinuric efficacy. However, in high-risk severe hypertension, not studied in ONTARGET, whether combination treatment should be withheld or withdrawn is not clear. We examine the renal effects of angiotensin-converting enzyme inhibitor (ACE-I) and angiotensin II receptor blocker (ARB) monotherapy versus combination therapy in patients with type 2 diabetes and varying degrees of hypertension. METHODS: Subjects attending a hospital diabetes centre were selected as case (combination therapy, n = 120) and control (monotherapy, n = 480). Subjects were matched for age, gender, ethnicity, estimated glomerular filtration rate (eGFR), blood pressure (BP) and study duration. Patients were stratified by BP, hypertension stage 1 (BP < 160/100, n = 506) and stage 2 (≥160/100, n = 94), and by treatment group. Data were analysed for the primary renal outcome of eGFR decline ≥20 ml/min, over a median of 3.7 years. RESULTS: In keeping with the ONTARGET study, for stage 1 hypertension, combination treatment is significantly worse than monotherapy for the primary outcome of eGFR decline ≥20 ml/min (20 vs. 10.7%, p = 0.01). In contrast, for stage 2 hypertension, this endpoint was reached less often for combination versus monotherapy (12.0 vs. 23.2%, p = 0.2). Combination treatment was also not detrimental in patients with proteinuria or eGFR < 60 ml/min and was associated with fewer macrovascular events. CONCLUSION: Given that hypertension control is paramount and in the spirit of primum non nocere, these data are reassuring should clinicians choose to use ACE-I and ARB combination therapy in the very hypertensive diabetic patient. SN - 1463-1326 UR - https://www.unboundmedicine.com/medline/citation/20977578/Beyond_ONTARGET:_angiotensin_converting_enzyme_inhibition_and_angiotensin_II_receptor_blockade_in_combination_a_lesser_evil_in_some L2 - https://doi.org/10.1111/j.1463-1326.2010.01298.x DB - PRIME DP - Unbound Medicine ER -