Recommendation for ACE/ARB Therapy in Diabetic Patients with Moderate Albuminuria

Introduction to ACE/ARB Therapy

The American Diabetes Association recommends ACE inhibitors or ARBs at the maximally tolerated dose indicated for blood pressure treatment in patients with urinary albumin-to-creatinine ratio 30-299 mg/g 3
Combinations of ACE inhibitors and ARBs should not be used, as they increase the risk of acute kidney injury and hyperkalemia without providing any additional benefit for renal outcomes 1, 2, 3

Telmisartan 80 mg daily is the maximum recommended dose and has been shown to reduce albuminuria more effectively than lower doses 1, 2, 3, 4
ACE inhibitors and ARBs should be titrated to achieve moderate to maximal doses approved for treatment of hypertension to optimize renal protection 5, 6
Check serum creatinine/eGFR and potassium at least annually, and within 1-2 weeks after any dose adjustment 3, 4

Thiazide-like diuretics (chlorthalidone or indapamide preferred) can be used as second-line agents for blood pressure control 3
Dihydropyridine calcium channel blockers (amlodipine, nifedipine) can be used as alternative or additional therapy for blood pressure control 3
Restrict dietary sodium to <2.3 g/day (ideally <2.0 g/day) to enhance the effectiveness of RAS blockade 5, 6
Optimize glycemic control (target HbA1c <7% for most patients) to reduce risk of nephropathy progression 4, 9

If hyperkalemia develops, use potassium-wasting diuretics or potassium binders rather than stopping the ARB 8
Multiple-drug therapy is generally required to achieve blood pressure targets in diabetic kidney disease, typically requiring 3 or more antihypertensive agents 5, 6