Management of hypertension in patients with diabetes mellitus - Defining the role of lisinopril

Hypertension and diabetes mellitus are significant and independent risk fac tors for cardiovascular disease. Antihypertensive therapy reduces cerebrovascular and cardiovascular morbidi ty and mortality in patients with hypertension. Tight blood pressure (BP) c ontrol [target diastolic BP (DBP) less than or equal to 80mm Hg] reduced th e incidence of major cardiovascular events by 51% compared with less tight control (DBP less than or equal to 90mm Hg) in patients with diabetes melli tus in the Hypertension Optimal Treatment (HOT) study, Similarly, in the UK Prospective Diabetes Study (UKPDS), tight BP control [mean systolic BP (SB P)/DBP = 144/82mm Hg] with captopril or atenolol reduced diabetes mellitus- related morbidity and mortality by 24% compared with less tight control (me an SBP/DBP = 154/87mm Hg), Importantly, the frequency of microvascular dise ase (including retinopathy) was reduced by 37% among those randomised to ti ght BP control in the UKPDS. In the diabetic subgroup in the Heart Outcomes Prevention Evaluation (HOPE) study, there was a 25% reduction in the composite end-point of death due t o cardiovascular causes, or myocardial infarction or stroke during 5 years of treatment with ramipril 10 mg/day relative to placebo. Lisinopril is an ACE inhibitor indicated for use in hypertension, heart fai lure and post-myocardial infarction. As an antihypertensive agent the drug is effective and generally well tolerated in patients with type 1 or 2 diab etes mellitus and in those with early or overt nephropathy. In the Swedish Treatment of Old People (STOP) Hypertension 2 trial, there w as no difference in the relative risk of cardiovascular death between those assigned to ACE inhibitors (lisinopril or enalapril), calcium channel bloc kers (felodipine or isradipine) or 'conventional' antihypertensive therapy (thiazide diuretics or beta blockers); treatment effects did not differ sig nificantly between diabetic and nondiabetic patients (10.9% of the 6614 pat ients had diabetes mel litus). Importantly, lower frequencies of nonfatal o r fatal myocardial infarction [relative risk (RR) 0.77; 95% confidence inte rval (CI) 0.61 to 0.96] and congestive heart failure (RR 0.78; CI 0.83 to 0 .97) were detected during 4 years' treatment with lisinopril or enalapril t han felodipine or isradipine in this study. Lisinopril reduced albumin excretion rates in patients with type 1 or 2 dia betes mellitus. In the 2-year EURODIAB Controlled Trial of Lisinopril in ID DM (EUCLID) study, albumin excretion rates decreased by 49.7% relative to p lacebo in normotensive patients with type 1 diabetes mellitus and microalbu minuria during treatment with lisinopril 10 to 20 mg/day, Progression of re tinopathy was attenuated in normotensive patients with type 1 diabetes mell itus during treatment with lisinopril in this study. In conclusion, lisinop ril, like other ACE inhibitors should be considered a first-line agent fur reducing BP and attenuating nephropathy in patients with type 1 or 2 diabet es mellitus.