Efficacy of renin-angiotensin system inhibitors, calcium channel blockers, and diuretics in hypertensive patients with diabetes: subgroup analysis based on albuminuria in a systematic review and meta-analysis
Abstract
In hypertensive patients with diabetes, the effectiveness of renin-angiotensin system (RAS) inhibitors in improving mortality, cardiovascular events, and renal outcomes, compared to other antihypertensive drugs such as calcium channel blockers (CCBs) and diuretics, remains uncertain, particularly in the context of albuminuria. A comprehensive literature search was conducted using PubMed, the Cochrane Library, and the Japan Medical Abstracts Society databases up to October 2024. A meta-analysis of 12 randomized controlled trials, including 14,163 patients, was performed. RAS inhibitors showed no significant advantage over CCBs or diuretics for all-cause mortality (relative risk [RR]: 1.00, 95% confidence interval [CI]: 0.92-1.08, p = 0.98), myocardial infarction (RR: 0.64, 95% CI: 0.32-1.31, p = 0.22), stroke (RR: 1.14, 95% CI: 1.00-1.31, p = 0.05), composite cardiovascular events (RR: 0.93, 95% CI: 0.81-1.07, p = 0.45), or end-stage renal disease (RR: 0.88, 95% CI: 0.72-1.08, p = 0.21). Subgroup analyses stratified by albuminuria status revealed no significant benefits of RAS inhibitors, regardless of albuminuria presence. The findings emphasize the need for cautious interpretation due to limited sample sizes, wide confidence intervals, and low precision. These results highlight the importance of considering not only RAS inhibitors but also other antihypertensive drugs as the first-line choice for blood pressure control in diabetic patients, with careful attention to side eff…
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In the absence of kidney disease, ACE inhibitors or ARBs are useful to manage blood pressure but have not proven superior to alternative classes of antihypertensive therapy, including thiazide-like diuretics and dihydropyridine calcium channel blockers.
“In the absence of kidney disease, ACE inhibitors or ARBs are useful to manage blood pressure but have not proven superior to alternative classes of antihypertensive therapy, including thiazide-like diuretics and dihydropyridine calcium channel blockers (93).”
From 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes—2026 (2026) · cites this paper as [93]
ACE inhibitors, ARBs, thiazide-like diuretics, and dihydropyridine calcium channel blockers have been demonstrated to reduce cardiovascular events in people with diabetes.
“Initial treatment for hypertension should include any of the drug classes demonstrated to reduce cardiovascular events in people with diabetes (27): ACE inhibitors (62), angiotensin receptor blockers (ARBs) (62), thiazide-like diuretics (63), or dihydropyridine calcium channel blockers (64).”
From 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes—2026 (2026) · cites this paper as [62]
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References 43 · Cited by 10
- Authors
- Ichikawa, D., Kawarazaki, W., Saka, S., Kanaoka, T., Ohnishi, H., Arima, H., & Shibata, S.
- Affiliations
- St. Marianna University School of Medicine (JP)
- International University of Health and Welfare (JP)
- Saiseikai Yokohama-shi Nanbu Hospital (JP)
- Yokohama City University (JP)
- Sapporo Medical University (JP)
- Fukuoka University (JP)
- Teikyo University (JP)
- Corresponding author
- Ichikawa, Daisuke
- ORCID
- Venue
- Hypertension Research
- Published
- 2025-02-14
- Volume
- 48
- Issue
- 6
- Pages
- 1880-1890
- ISSN
- 0916-9636 (ISSN-L)
- 1348-4214
- OpenAlex
- W4407572577
- Cited by
- 10
- References
- 43
- Citations by year
- 2026: 3 · 2025: 7
- FWCI
- 1.82
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- Locations
- Hypertension Research (publishedVersion)
- PubMed (publishedVersion)
- Institutional Repositories DataBase (IRDB) (submittedVersion)
- Funders
- Japan Society for the Promotion of Science (23K07680)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Blood Pressure and Hypertension Studies
- Health Sciences › Medicine › Nephrology › Chronic Kidney Disease and Diabetes
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Renin-Angiotensin System Studies
- Keywords
- renin-angiotensin system inhibitors, calcium channel blockers, diuretics, hypertension, diabetes mellitus, albuminuria, antihypertensive drugs, all-cause mortality, cardiovascular events, end-stage renal disease, blood pressure control
- MeSH terms
- Albuminuria, Angiotensin-Converting Enzyme Inhibitors, Antihypertensive Agents, Calcium Channel Blockers, Diabetes Mellitus, Diuretics, Humans, Hypertension, Renin-Angiotensin System, Angiotensin Receptor Antagonists
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