Treating high-risk diabetic hypertensive patients with comorbid conditions

Diabetes mellitus, a highly prevalent metabolic and vascular disease, affects 155 million people worldwide. Tight blood glucose control can significantly reduce the incidence of diabetic retinopathy, nephropathy, and neuropathy, but does not appear to significantly reduce its macrovascular complications. Several randomized clinical trials indicate that tight blood pressure control can reduce the risk of microvascular and macrovascular complications in patients with diabetes and hypertension. Blockade of the renin-angiotensin system (RAS) with angiotensin-converting enzyme (ACE) inhibitors has proven effective both in lowering blood pressure and in independently slowing the progression of nephropathy. If instituted early, ACE inhibitor therapy potentially may prevent progression to end-stage renal disease in normotensive patients with type 1 or 2 diabetes. Additionally, ACE inhibitors may reduce cardiovascular morbidity and mortality in this patient population. Angiotensin II (Ang II) receptor blockers (ARBs), which attenuate the deleterious effects of the RAS via blockade of the Ang II subtype 1 receptor, may also be beneficial. Clinical trials are under way to evaluate this possibility.