Telmisartan

* CLINICAL QUESTION

Are angiotensin receptor blockers as good as angiotensin-converting enzyme inhibitors at preventing the progression of nephropathy?

* BOTTOM LINE

Despite a relatively low dose of 10 mg given once a day, enalapril (Vasotec) was at least as effective as telmisartan (Micardis) and showed a trend toward greater benefit in preventing decline in glomerular filtration rate. Although this study measured a disease-oriented endpoint, its results are consistent with the body of literature that supports the less expensive angiotensin-converting enzyme (ACE) inhibitors as the drug of choice over angiotensin receptor blockers (ARBs). (LOE=1b)

* STUDY DESIGN

Randomized controlled trial (double-blinded)

* ALLOCATION

Uncertain

* SETTING

Outpatient (any)

* SYNOPSIS

This study is what we call DOE (disease-oriented evidence), since it measured progression of nephropathy instead of the patient-oriented outcome of renal failure or need for dialysis. However, the results are worth knowing because we so often hear of the potential DOE-related advantages of ARBs over the older, less expensive, and less often promoted ACE inhibitors.

In this study, 250 subjects with diabetes and mild to moderate hypertension and evidence of early nephropathy (urinary albumin excretion rate between 11 and 999 [micro]g/minute and a serum creatinine less than 1.6 mg/dL) were randomized to receive either telmisartan 40 mg/d or enalapril 10 mg/d. Blood pressure medicines other than an ACE inhibitor or ARB could be added at the discretion of the treating physician to control blood pressure. The primary outcome was the glomerular filtration rate. There was a high dropout rate, and the last observation was appropriately carried forward for the analysis. The results for only those patients with complete data were also reported. In both cases, there was almost no difference in glomerular filtration rate for the first 2 years, with a trend toward greater benefit for enalapril that almost became significant at 4 years and declined slightly at 5 years.

Barnett AH, Bain SC, Bouter P, et al. Angiotensin-receptor blockade versus converting-enzyme inhibition in type 2 diabetes and nephropathy. N Engl J Med 2004; 351:1952-1961.

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