In the Original Article, Olmesartan for the Delay or Prevention of Microalbuminuria in Type 2 Diabetes, Haller et al. investigated whether an angiotensin-receptor blocker (olmesartan) would delay microalbuminuria in patients with type 2 diabetes and normoalbuminuria. Olmesartan was associated with a delayed onset of microalbuminuria, even though blood pressure control in both groups was excellent.
Diabetic nephropathy is an increasingly common cause of end-stage renal disease, and the development and rate of renal deterioration are most closely related to the patient’s blood pressure. Guideline committees worldwide concur that the blood pressure in patients with diabetes and chronic kidney disease should be controlled to levels of 130/80 mm Hg or less.
• What is the role of angiotensin-converting-enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) for the management of patients with type 2 diabetes?
ACE inhibitors and ARBs slow the worsening of the glomerular filtration rate and lower the rate of albumin excretion. ACE inhibition delays the onset of microalbuminuria in patients with hypertension, type 2 diabetes, normoalbuminuria, and normal renal function.
• According to the results of this study, what were the benefits associated with the use of olmesartan as compared to placebo treatment?
Microalbuminuria developed in 8.2% of the patients in the olmesartan group (178 of 2160 patients who could be evaluated) and 9.8% in the placebo group (210 of 2139); the time to the onset of microalbuminuria was reduced by 23% with olmesartan (hazard ratio, 0.77; 95% confidence interval, 0.63 to 0.94; P=0.01).
Morning Report Questions
Q: What adverse events were associated with the use of olmesartan as compared to placebo treatment?
A: The number of deaths from cardiovascular causes was higher in the olmesartan group than in the placebo group (15 vs. 3, P=0.01), owing primarily to more cases in the olmesartan group of fatal myocardial infarctions (5 vs. 0) and sudden cardiac deaths (7 vs. 1).
Q: The increased death rate among patients treated with olmesartan was attributed to what patient group?
A: A greater number of fatal cardiovascular events in the olmesartan group was attributable in part to a higher rate of death from cardiovascular causes in the olmesartan group than in the placebo group among patients with preexisting coronary heart disease (11 of 564 patients [2.0%] vs. 1 of 540 [0.2%], P=0.02).