Introduction ACE inhibitors and cough. Diabetes mellitus and diabetic nephropathy.
One of the more common ACE inhibitor side-effects is dry-
cough. Various reports put the incidence of cough at
Recent research is now being published, that supports our
between 5 and 39%. Not always does this side-effect lead to
previous suspicions. It is nearly ten years since data was first
discontinuation of the ACE inhibitor, fortunately. On
published revealing the benefits of ACE inhibitors and
enough occasions, however, therapy is ceased and the
improved diabetic control on renal tissue in type I diabetes
There is probably some differences in the nephropathy
Therapies to either treat the cough, or angiotensin II receptor
physiology of both type I and type II diabetes. The
histopathology is similar. The clinical picture is similar, except
– perhaps – the severity of macrovascular changes in type II
The cough seems to be related to a genetic predisposition,
diabetes mellitus seen, especially in groups such as in the
and a particular genotype is associated with the ACE-
Polynesian population. The survival of the type II diabetes
induced cough. Short of gene analysis, how to identify these
mellitus patients with established diabetic nephropathy is also
high-risk people is not yet available. Meanwhile anti-cough
remedies such as cromoglycate, baclofen, theophylline, or
NSAIDs – even oral iron! - will continue to be used.
Type I diabetes mellitus patients with established diabetic
nephropathy (more than micro-albuminuria) progress to end-
A second option is the application for and approval of an A-
stage renal failure in 7 to 10 years, and longer with better
control of HbA1c, and BP and use of ACE inhibitors.
Angiotensin II receptor blockers.
The question remained over the benefits of ACE inhibitor
therapy and diabetes control in type II diabetes mellitus
These agents have quickly replaced ACE inhibitors where a
patients. It is pleasing to see that evidence supporting the
cough side effect has occurred, rather than the additional of
management of diabetes mellitus types I and II similarly, for
cough-therapies. The pharmaceutical companies have been
both diabetes control and ACE inhibitors is now available.
quick to show the renal benefits of ACE inhibition are
similarly seen with the A-II receptor blockers – leaving very
With the recent evidence of therapies delaying the progression
few patients suffering with the ACE inhibitor cough.
of established nephropathy in type II diabetes mellitus patients
we can hope the two to four year period from diagnosis to
But which is better “renally” - ACE or A-II blockade?
ESRF will be also prolonged. We do not know if good diabetic control in ESRF patients will benefit their survival and/or reduce the macrovascular
W H A T ’ S I N H E R E T H I S T I M E ?
complications. Similarly we do not know which group will gain greater benefit attaining good glucose and blood pressure
What is new? – Diabetes nephropathy prevention
control aggressively - type I or type II diabetes mellitus. Such studies may never be undertaken.
We must go with what we have now. Clearly good glucose
A-II-receptor blockers replace cough therapies.
control by keeping the HbA1c in the optimal range (monitoring HbA1c every three months should be adequate) and blood
Added benefit of ACEIs and A-II blockers together
pressure control are even more important goals to strive for.
ACE and A-II in combination. Dr David Voss ED Specialist Physician
Some South Auckland diabetes mellitus type II patients took part Renal and Internal Medicine
in a multi-centre, multi-national study recently published. The
trial studied the A-II receptor blocker irbesartan. Blood pressure
control, mortality and diabetic nephropathy (the time taken for
the serum creatinine to double) were some of the end-points.
Contact on cellular phone
Mortality reduced in the treated arm. Blood pressure control was
similar in the irbesartan and placebo arms of the study.
From the renal failure progression aspect, irbesartan was
effective in prolonging the time taken for the serum creatinine to
double, and hence delaying the time to end-stage renal failure.
So what? This is further support to the theories, and further
evidence that A-II receptor blockers, along with ACE inhibitors
are renal friendly. They provide protection to the renal tissue
over and above that seen with just improved blood pressure
control. Irbestartan lowered the number of patients whose diabetic nephropathy progressed.
Qualifications BSc (Biochemistry, Otago) 1981
Clearly, in impaired renal function, stimulation of the reno-
MBChB (Otago) 1984
angiotensin system is not a good thing; and blockade of either the
receptor or enzymatic pathway is a good thing.
MRCP(UK) 1993 Interests
Investigation of renovascular disease and
In a subsequent analysis of this irbesartan in hypertensive and
diabetic patients study, the results equated to:
Investigation of proteinuria and haematuria
with hypertension and type II diabetes mellitus
Investigation and management of impaired renal
for three years
one patient from worsening renal function/end-stage kidney failure or death. East Auckland Rooms So where from here for diabetes mellitus patients?
Type I and type II diabetes patients should optimise
Patients with microalbuminuria, or established
nephropathy (with macroalbuminuria, with or without impaired
renal function) should definitely be considered for an ACE or an A-II blocker (nothing new here).
South Auckland Rooms
Of interest, some early evidence suggests that we are not
using enough ACE inhibition. We should be using much higher
doses of ACE inhibition (eg. quinapril 40mg/day) even in the
presence of renal dysfunction, and gain further renal protection
And of more interest, the combination of a high dose of
an ACE inhibitor with an A-II receptor blocker is more reno-protective than either agent alone.
O r i g i n a l A r t i c l e Singapore Med J 2009; 50 (2) : 208 Antibiotic susceptibility pattern of Staphylococcus species isolated from telephone receivers Smith S I, Opere B, Goodluck H T, Akindolire O T, Folaranmi A, Odekeye O M, Omonigbehin E A ABSTRACT prevent the spread of infectious diseases through Introduction: Microorganisms are transferred the use of publ
Summary No Country of one’s own An advisory report on treaty protection for stateless persons in the Netherlands Worldwide, an estimated 12 million people have no nationality. In other words, they are stateless. Statelessness is a problem because possessing a nationality means that there is at least one country where one has the right to reside. Nationality confers a number of othe