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January 26, 2004

Treatment of the Patient With Diabetes Mellitus and Risk of Nephropathy: What Do We Know, and What Do We Need to Learn?

Arch Intern Med. 2004;164(2):125-130. doi:10.1001/archinte.164.2.125

In patients with diabetes mellitus, advances in control of blood pressure and glycemia have led to reductions in neuropathy, retinopathy, and nephropathy. The results of large clinical trials indicate that angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers (ARBs) slow the development and progression of diabetic nephropathy in patients with type 2 diabetes mellitus, almost certainly because of their interruption of the renin-angiotensin-aldosterone system. The Irbesartan in Patients with Type 2 Diabetes and MicroAlbuminuria Study and Microalbuminuria Reduction With VAL-sartan study demonstrated an especially remarkable influence in patients with microalbuminuria treated with the ARBs irbesartan and valsartan. When ARB doses are progressively increased beyond those needed to control blood pressure, proteinuria declines in a manner not paralleled by blood pressure reductions. Monotherapy with ARBs has an advantage over angiotensin-converting enzyme inhibitors in that the influence of ARBs on the angiotensin receptor cannot be overcome by activation of the renin-angiotensin-aldosterone system, and the ARBs are substantially better tolerated.

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