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Diabetes

Altace and prevention of kidney disease

01/23/2008

Question:

My endo put me on 5mg of Altace several years ago as a preventative measure even though my blood pressure was excellent and had no signs of kidney disease. I have recently noticed that sometimes my blood pressure is slightly elevated in the a.m.(first # may be as high as 135-160) before taking Altace. My Dr. increased my dosage to 10mg. I believe that taking the Altace has resulted in a dependency on the drug and is at least in part, the reason my blood pressure is rising. He says it does not. I am a 57 year old female have been a type I for 40 years. I am 5 ft 6" tall and weigh 134 lbs. I am in very good health, on an insulin pump, exercise, practice yoga and have been on a vegan diet for about 9 months and lost about 35 lbs. since going on the diet. I`d like to get off the Altace. Given that I eat no meat or dairy shouldn`t my risk be lower than the average diabetic? Should I go off the drug gradually? Would I be putting myself at risk?

Answer:

There are many aspects to your question.  I do suspect that your vegan diet has likely reduced your risk of cardiovascular complications of diabetes.  I don't know that it would necessarily have as much effect on your risk of diabetic renal disease although perhaps some.  If you have gone 40 years with type 1 diabetes and are not showing significant evidence of renal disease, my suspicion would be that you are less likely than the average person at an earlier stage of type 1 diabetes to have renal disease in your future. 

On the one hand I don't think that taking an angiotensin converting enzyme (ACE) inhibitor, would create dependence on the drug.  On the other hand, if the drug is effective but does not have the duration of action in you that is expected in the average person, I could envision that treatment with the drug could result in increased activity of the renin-angiotensin system which results in higher blood pressure during the hours of the day when the drug wears off. 

Even though I differ from many other diabetes specialists in not putting absolutely everybody with diabetes on an ACE inhibitor or a related drug, I would be hesitant to have you go off the ACE inhibitor now.  Blood pressure tends to rise with time in the vast proportion of people with diabetes and that is one of the most advantageous classes of drugs available. If your blood pressure is not adequately controlled, you might try testing it different times of day.  If it is controlled early after the dose and not later, perhaps you need to go to twice daily dosing even though this drug is said to be a once a day drug.

I think this is one of those situations where the advantages of the food lifestyle you have chosen and the medications you are on can work together to further reduce your risk of kidney and/or cardiovascular events.  You don't mention what your underlying lipid situation is.  In either case, your food choices will further reduce your risk.  If you made your choices because of unfavorable lipid results, then your underlying risk is greater than if that was not the case, so that should be a factor in medication choices.

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Response by:

Robert M Cohen, MD Robert M Cohen, MD
Professor of Clinical Medicine
College of Medicine
University of Cincinnati