Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers: evidence for and against the combination in the treatment of hypertension and proteinuria.

Several treatment guidelines have made strong recommendations to physicians that treatment of nephropathy and hypertension should be based on the use of a long-acting angiotensin converting enzyme (ACE) inhibitor if tolerated. The recently published clinical trials, based on angiotensin II receptor blockers' effects on diabetic nephropathy and essential hypertension, have also shown significant endpoint reduction. Perhaps the time has come to broaden the recommendations to include the use of a renin-angiotensin-aldosterone system altering drug. But what if the treatment goal cannot be reached, and incessant proteinuria and high blood pressure levels persist despite high dosage treatment of either drug? How should this be handled? The dual blockade principle can possibly provide the solution by obtaining the broadest and most efficient blockade of circulating angiotensin II by using the combination of an ACE inhibitor and an angiotensin II receptor blocker. But large clinical trials are yet to come, and at present large endpoint trials have not been published. This article provides an overview of how far we have come with dual blockade treatment in hypertension and nephropathy.