ACE + ARB = Adverse Events

No Benefit, Possible Harm With Dual Blockade in Diabetic Nephropathy Jeffrey S. Berns, MDDisclosures December 17, 2013

I call to your attention a paper just published in the New England Journal of Medicine, with Linda Fried as the first author.[1]

This was an excellent randomized controlled trial among US veterans, almost all men, with type 2 diabetes, a urinary albumin/creatinine ratio greater than 300 mg/g creatinine, and an estimated glomerular filtration rate (GFR) between 30 and 89.9 mL/min/1.73 m2.
After participants with elevated serum potassium levels at baseline were excluded, the subjects were placed on losartan 100 mg/day, and once stable on that dose, were then randomly assigned to receive either placebo or lisinopril in a dose of 10-40 mg/day.

The study was stopped early.

The drug combination provided no benefit to major primary and secondary endpoints of the study, which included the rate of GFR decline, occurrence of cardiovascular events, occurrence of end-stage renal disease, or mortality. On average, the GFR declined between 2.7 and 2.9 mL/min/1.73 m2 per year.

In addition, patients receiving the active drug combination had an excess occurrence of hyperkalemia and acute kidney injury. The hazard ratio for hyperkalemia was 2.8, and for acute kidney injury, it was 1.7. No benefit, excess risk, and the study was stopped early.


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