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Comparative effectiveness of renin-angiotensin system blockers and other antihypertensive drugs in patients with diabetes: systematic review and bayesian network meta-analysis.
BMJ. 2013 Oct 24; 347:f6008.BMJ

Abstract

OBJECTIVE

To assess the effects of different classes of antihypertensive treatments, including monotherapy and combination therapy, on survival and major renal outcomes in patients with diabetes.

DESIGN

Systematic review and bayesian network meta-analysis of randomised clinical trials.

DATA SOURCES

Electronic literature search of PubMed, Medline, Scopus, and the Cochrane Library for studies published up to December 2011.

STUDY SELECTION

Randomised clinical trials of antihypertensive therapy (angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), α blockers, β blockers, calcium channel blockers, diuretics, and their combinations) in patients with diabetes with a follow-up of at least 12 months, reporting all cause mortality, requirement for dialysis, or doubling of serum creatinine levels.

DATA EXTRACTION

Bayesian network meta-analysis combined direct and indirect evidence to estimate the relative effects between treatments as well as the probabilities of ranking for treatments based on their protective effects.

RESULTS

63 trials with 36,917 participants were identified, including 2400 deaths, 766 patients who required dialysis, and 1099 patients whose serum creatinine level had doubled. Compared with placebo, only ACE inhibitors significantly reduced the doubling of serum creatinine levels (odds ratio 0.58, 95% credible interval 0.32 to 0.90), and only β blockers showed a significant difference in mortality (odds ratio 7.13, 95% credible interval 1.37 to 41.39). Comparisons among all treatments showed no statistical significance in the outcome of dialysis. Although the beneficial effects of ACE inhibitors compared with ARBs did not reach statistical significance, ACE inhibitors consistently showed higher probabilities of being in the superior ranking positions among all three outcomes. Although the protective effect of an ACE inhibitor plus calcium channel blocker compared with placebo was not statistically significant, the treatment ranking identified this combination therapy to have the greatest probability (73.9%) for being the best treatment on reducing mortality, followed by ACE inhibitor plus diuretic (12.5%), ACE inhibitors (2.0%), calcium channel blockers (1.2%), and ARBs (0.4%).

CONCLUSIONS

Our analyses show the renoprotective effects and superiority of using ACE inhibitors in patients with diabetes, and available evidence is not able to show a better effect for ARBs compared with ACE inhibitors. Considering the cost of drugs, our findings support the use of ACE inhibitors as the first line antihypertensive agent in patients with diabetes. Calcium channel blockers might be the preferred treatment in combination with ACE inhibitors if adequate blood pressure control cannot be achieved by ACE inhibitors alone.

Authors+Show Affiliations

Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Meta-Analysis
Review
Systematic Review

Language

eng

PubMed ID

24157497

Citation

Wu, Hon-Yen, et al. "Comparative Effectiveness of Renin-angiotensin System Blockers and Other Antihypertensive Drugs in Patients With Diabetes: Systematic Review and Bayesian Network Meta-analysis." BMJ (Clinical Research Ed.), vol. 347, 2013, pp. f6008.
Wu HY, Huang JW, Lin HJ, et al. Comparative effectiveness of renin-angiotensin system blockers and other antihypertensive drugs in patients with diabetes: systematic review and bayesian network meta-analysis. BMJ. 2013;347:f6008.
Wu, H. Y., Huang, J. W., Lin, H. J., Liao, W. C., Peng, Y. S., Hung, K. Y., Wu, K. D., Tu, Y. K., & Chien, K. L. (2013). Comparative effectiveness of renin-angiotensin system blockers and other antihypertensive drugs in patients with diabetes: systematic review and bayesian network meta-analysis. BMJ (Clinical Research Ed.), 347, f6008. https://doi.org/10.1136/bmj.f6008
Wu HY, et al. Comparative Effectiveness of Renin-angiotensin System Blockers and Other Antihypertensive Drugs in Patients With Diabetes: Systematic Review and Bayesian Network Meta-analysis. BMJ. 2013 Oct 24;347:f6008. PubMed PMID: 24157497.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Comparative effectiveness of renin-angiotensin system blockers and other antihypertensive drugs in patients with diabetes: systematic review and bayesian network meta-analysis. AU - Wu,Hon-Yen, AU - Huang,Jenq-Wen, AU - Lin,Hung-Ju, AU - Liao,Wei-Chih, AU - Peng,Yu-Sen, AU - Hung,Kuan-Yu, AU - Wu,Kwan-Dun, AU - Tu,Yu-Kang, AU - Chien,Kuo-Liong, Y1 - 2013/10/24/ PY - 2013/10/26/entrez PY - 2013/10/26/pubmed PY - 2013/12/16/medline SP - f6008 EP - f6008 JF - BMJ (Clinical research ed.) JO - BMJ VL - 347 N2 - OBJECTIVE: To assess the effects of different classes of antihypertensive treatments, including monotherapy and combination therapy, on survival and major renal outcomes in patients with diabetes. DESIGN: Systematic review and bayesian network meta-analysis of randomised clinical trials. DATA SOURCES: Electronic literature search of PubMed, Medline, Scopus, and the Cochrane Library for studies published up to December 2011. STUDY SELECTION: Randomised clinical trials of antihypertensive therapy (angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), α blockers, β blockers, calcium channel blockers, diuretics, and their combinations) in patients with diabetes with a follow-up of at least 12 months, reporting all cause mortality, requirement for dialysis, or doubling of serum creatinine levels. DATA EXTRACTION: Bayesian network meta-analysis combined direct and indirect evidence to estimate the relative effects between treatments as well as the probabilities of ranking for treatments based on their protective effects. RESULTS: 63 trials with 36,917 participants were identified, including 2400 deaths, 766 patients who required dialysis, and 1099 patients whose serum creatinine level had doubled. Compared with placebo, only ACE inhibitors significantly reduced the doubling of serum creatinine levels (odds ratio 0.58, 95% credible interval 0.32 to 0.90), and only β blockers showed a significant difference in mortality (odds ratio 7.13, 95% credible interval 1.37 to 41.39). Comparisons among all treatments showed no statistical significance in the outcome of dialysis. Although the beneficial effects of ACE inhibitors compared with ARBs did not reach statistical significance, ACE inhibitors consistently showed higher probabilities of being in the superior ranking positions among all three outcomes. Although the protective effect of an ACE inhibitor plus calcium channel blocker compared with placebo was not statistically significant, the treatment ranking identified this combination therapy to have the greatest probability (73.9%) for being the best treatment on reducing mortality, followed by ACE inhibitor plus diuretic (12.5%), ACE inhibitors (2.0%), calcium channel blockers (1.2%), and ARBs (0.4%). CONCLUSIONS: Our analyses show the renoprotective effects and superiority of using ACE inhibitors in patients with diabetes, and available evidence is not able to show a better effect for ARBs compared with ACE inhibitors. Considering the cost of drugs, our findings support the use of ACE inhibitors as the first line antihypertensive agent in patients with diabetes. Calcium channel blockers might be the preferred treatment in combination with ACE inhibitors if adequate blood pressure control cannot be achieved by ACE inhibitors alone. SN - 1756-1833 UR - https://www.unboundmedicine.com/medline/citation/24157497/Comparative_effectiveness_of_renin_angiotensin_system_blockers_and_other_antihypertensive_drugs_in_patients_with_diabetes:_systematic_review_and_bayesian_network_meta_analysis_ L2 - http://www.bmj.com/lookup/pmidlookup?view=long&pmid=24157497 DB - PRIME DP - Unbound Medicine ER -