In patients with diabetes, renin angiotensin system (RAS) blockers perform similarly to other antihypertensive medications, according to a study published in BMJ.

Current recommendations offer conflicting advice regarding prescribing RAS blockers over other antihypertensive agents to patients with diabetes. This new research supports recommendations that suggest using any class of antihypertensive agent as first-line treatment rather than favoring RAS blockers.

The researchers analyzed 19 randomized, controlled trials that included 25,414 patients with diabetes for a combined 95,910 patient years of follow-up (mean 3.8 years per participant). Fifteen studies compared RAS blockers with calcium channel blockers, 3 studies compared them with a thiazide diuretic, and 2 studies compared them with a β blocker.

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A meta-analysis showed that compared with other antihypertensive agents, RAS blockers performed similarly. They had a comparable risk of death (relative risk, 0.99), cardiovascular death (1.02), myocardial infarction (0.87), angina pectoris (0.80), stroke (1.04), heart failure (0.90), and revascularization (0.97). The relative risk of major adverse cardiovascular events was 0.97 for both RAS blockers and other antihypertensive agents, and the risk for end stage renal disease was the same.

Compared with only calcium channel blockers, RAS blockers had a similar risk of death (1.01), cardiovascular death (1.17), myocardial infarction (0.84), angina pectoris (0.69), stroke (1.08), and revascularization (1.01). RAS blockers, however, had a significantly reduced risk of heart failure (0.78).

RAS blockers had similar risks compared with thiazide diuretics alone, though the small number of studies comparing them led to wider confidence intervals. The same was true for RAS blockers versus β blockers.

“The results support the recommendation of both the 2013 European Society of Cardiology/European Society of Hypertension guidelines and the 2014 eighth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure that any class of antihypertensive agents can be used in people with diabetes especially in those without renal impairment,” wrote the authors.


  1. Bangalore S, Fakheri R, Toklu B, et al. Diabetes mellitus as a compelling indication for use of renin angiotensin system blockers: systematic review and meta-analysis of randomized trials. BMJ. 2016;352.