Candesartan/Lisinopril for hypertensive type 2's

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Candesartan/Lisinopril Highly Effective For Diabetics

A DGReview of : " Randomised controlled trial of dual blockade of

renin-angiotensin system in patients with hypertension, microalbuminuria,

and non-insulin dependent diabetes: the candesartan and lisinopril

microalbuminuria (CALM) study "

BMJ -- 12/08/2000 -- By Harvey McConnell

Once daily candesartan is as effective as lisinopril for reducing blood

pressure and microalbuminuria in hypertensive patients with type 2 diabetes.

At the same time, combination treatment is well tolerated and more effective

in reducing blood pressure, report clinicians in the four-nation Candesartan

And Lisinopril Microalbuminuria (CALM) study.

Clinicians in 37 centres -- 12 in Australia, nine in Denmark, four in

Finland and 12 in Israel -- carried out the randomised, double-blind,

double-dummy study in 199 patients aged between 30 and 75, with type 2

diabetes and who had previously-diagnosed hypertension and microalbuminuria.

Patients underwent a four-week, placebo run-in period and 12 weeks'

monotherapy with candesartan 16 mg once daily or lisinopril 20 mg once

daily, followed by 12 weeks' monotherapy or combination treatment.

At 12 weeks, mean reductions in diastolic blood pressure were 9.5 mm Hg (7.7

mm Hg to 11.2 mm ) in the candesartan group and 9.7 mm Hg (7.9 mm Hg to 11.5

mm Hg,) in the lisinopril group. Urinary albumin:creatinine ratio were 30

percent in the candesartan group and 46 percent in the lisinopril group.

At 24 weeks, the mean reduction in diastolic blood pressure with combination

treatment (16.3 mm Hg, 13.6 mm Hg to 18.9 mm Hg ) was significantly greater

than that with candesartan (10.4 mm Hg, 7.7 mm Hg to 13.1 mm Hg) or

lisinopril (mean 10.7 mm Hg, 8.0 mm Hg to 13.5 mm Hg ).

Reduction in urinary albumin:creatinine ratio with combination treatment (50

percent; 36 percent to 61 percent ) was greater than with candesartan (24

percent, 0 percent to 43 percent) or lisinopril (39 percent, 20 percent to

54 percent). All treatments were generally well tolerated.

Clinicians said that with the study: " We can confirm that dual blockade of

the renin-angiotensin system, both at the level of ACE and at the level of

the AII receptor, is associated with more effective reduction in blood

pressure than observed with a single agent and that this observation extends

to patients with diabetes.

" We cannot, however, determine from the present study if these further

effects on urinary albumin excretion relate to more effective reduction in

blood pressure or to more complete blockade of the renin-angiotensin

system. "

Recent guidelines for blood pressure targets have emphasised the importance

of aggressive blood pressure reduction in diabetic patients with evidence of

renal disease, the clinicians point out.

" Our results show that dual blockade of the renin-angiotensin system is

particularly effective in decreasing blood pressure in these patients, and

support this new and potentially highly beneficial therapeutic approach for

the prevention of diabetic renal and vascular disease, " they conclude.