New concepts in blood pressure-lowering management in diabetic patients: the case for early ACE inhibitor combination therapy with diuretics.

Type II diabetes and the dysmetabolic syndrome are becoming more and more prevalent, not only in the Western world, but also in many developing countries. The key issue is early prevention and treatment, not only antihyperglycaemic and antihyperlipidaemic treatment, but also, and maybe in particular, antihypertensive treatment. The first issue is first of all screening patients for elevated blood pressure and for microalbuminuria, especially if blood pressure elevation or diabetes is present. Especially, diabetic patients are at risk. The key feature in the therapeutic approach is blocking the renin-angiotensin system, which has proven effective in many original studies. Also the combination with diuretics is a key issue, since these patients have sodium retention. It has been discussed whether ACEi, ARBs or diuretics should be initial treatment, but usually a combination treatment is recommended to reduce blood pressure early and efficiently. The PREMIER study emphasized combination therapy, since the study had very efficient outcomes with combination therapy compared to an ACEi alone as far as blood pressure lowering is concerned, but also with reduction in microalbuminuria and, indeed, end point-reduction. Cardiovascular events showed a decreased incidence with the combination therapy with Preterax (perindopril/indapamide) compared with the enalapril group.