ACEIs, ARBs still preferred in older hypertensive patients with diabetes

The American Diabetes Association and Seventh Report of the Joint National Committee prefer angiotensin converting enzyme inhibitors, or ACEIs, and angiotensin II receptor blockers, or ARBs, in patients with diabetes and hypertension who require drug therapy when there is no other compelling indication for another agent. If one agent is not tolerated, the other may be substituted.1,2 While several other antihypertensive agents demonstrate comparable effectiveness in cardiovascular morbidity and mortality, ACEIs and ARBs also provide the added renal benefits, which may help patients with diabetes in preserving renal function.1,2,3 Studies have demonstrated that these benefits continue in the older population.4,5,6 In fact, one trial of patients older than age 80 with hypertension who were treated with indapamide with or without perindopril still had significant reduction in cardiovascular disease-related mortality.5

These studies have clarified:

  • Even in the setting of CKD, ACEIs and ARBs are preferred due to their favorable effects on the progression of diabetic and non-diabetic renal disease.1,2
  • One trial demonstrates that the use of an ARB reduced the risk of end-stage renal disease by 50 percent in patients age 65 and older, with a similar risk of adverse reactions as in younger patients (e.g., side effects including hyperkalemia).6

When blood pressure remains inadequately controlled with an ACEI or ARB, add-on drug therapy is recommended, but not substituting for the ACEI or ARB to retain the favorable outcomes associated with these medications.1,2


  1. American Diabetes Association. Standards of Medical Care in Diabetes – 2012. Diabetes Care 2012; 35:S11-63.
  2. National Institutes of Health, National Heart, Lung, and Blood Institute. The Seventh report of the Joint National Committee: Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. JAMA 2003; 289(19):2560-2571.
  3. United Kingdom Prospective Diabetes Study (UKPDS) Group. Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. BMJ 1998; 317:713–720.
  4. Guidelines for Improving the Care of the Older Person with Diabetes Mellitus. Journal of American Geriatric Society 2003; 51(5):S265-280.
  5. Beckett N, et al. Treatment of Hypertension in Patients 80 Years of Age or Older (HYVET). N Engl J Med 2008; 358:1887-1898.
  6. Winkelmayer WC, Cooper ME, Zhang A, et al. Efficacy and safety of angiotenin II receptor blockade in elderly patients with diabetes. Diabetes Care 2006; 29(10):2210-2217.