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ACE Inhibitors

Discussion in 'Parents of Children with Type 1' started by GChick, Dec 25, 2015.

  1. GChick

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    Went to the doctor the other day after having labs etc and while I've never had "protein" (microalbumin) in my urine and didn't this time either, he mentioned that the new standard of care is to prescribe ACE inhibitors to all diabetics as a preventative measure.

    What is the general consensus here on that? I mean if I were still a teenager and only had a decade of this disease under my belt so far I probably woulda said "gimme all the preventative stuff you can!"... But at this stage in the game, more than three decades in... I'm not sure it feels "worth" it to me? One more pill, one more medication, when it seems as though what I've been doing is working pretty well. I know that there is low incidence of side effects, but there still is one more set of side effects to look out for.

    Has any of you (or your children) who has never had an incident with protien in the urine been broached with the idea of ACE Inhibitors and decided to do it?

    Any with no incidence of protien been broached with the idea and said naaaaaah... I'll pass?
     
  2. Theo's dad Joe

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    I don't have D, but I will mention for what it is worth that I had moderately high blood pressure and took an ACE inhibitor. My BP was around 140/95ish and it brought it down, but after losing 20 pounds and also dropping ibuprophin and reducing sugar intake (I have been told by several cardiologists who I know very well that they believe NSAIDS to raise blood pressure considerably and have had many patients move into the normal range simply by eliminating NSAIDS) I was 115-75 without it and have not gone back. Did gain back 10 pounds, used ibuprophin again and it went back up, dropped the ibuprophen and it was back down in a week. Keep in mind too that I used NSAIDS once or twice a day for headaches, but when I got off of them the headaches went away.

    Also lisinopril which I tried first gave me a reflexive cough that is known to be associated with lisinopril. It came on over several months and it kept me awake coughing reflexively all night long. It was not bearable and the lack of sleep I felt was far worse than the lower blood pressure. I had it changed from Altace (ramipril) to Diovan and the cough went away right away, but again dropping Ibuprophen and staying at a good weight for me keeps me under or around 120/80 without medication now.

    I had no side effects at all on Diovan that I could tell.

    I did not know that ACE inhibitors were standard practice to diabetics with normal blood pressure. I had been told that at age 30, statin drugs are recommended as standard. Keep in mind that all of these standards came about without a lot of tight blood sugar control.

    Now isn't the ACE inhibitor helping the kidneys by keeping blood pressure in the normal range? If blood pressure is normal is there another advantage? I don't see a reason to push pressure below normal as that may lead to problems of low perfusion which may be bad on its own.
     
    Last edited: Dec 25, 2015
  3. forHisglory

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    Wouldn't a patient with type 1 diabetes be more at risk for kidney disease? And, isn't 60% of kidney function lost before the first clinical signs appear or on bloodwork? In other words, if you are at higher risk for kidney disease or failure then the protective effects of an ACE inhibitor may prolong the progression of even sub clinical kidney disease. Since complications increase over time maybe that is why the endo is recommending it now or in light of new information. What did he/she say was the reason?
     
    Last edited: Dec 25, 2015
  4. forHisglory

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    Some trials have shown ACE inhibitors to be renoprotective independent of their hypotensive actions.
     
  5. Theo's dad Joe

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    My wife says they DO protect the kidneys. She is not sure when they are usually recommended (what age) for diabetics, but they are generally recommended as standard practice.

    Again, when I used them the key was to find one (Diovan in my case) that did not cause a "Lisinopril cough" and aside from that I did not experience any side effects, BUT if you already have normal blood pressure they can make you hypotensive, and poor perfusion from low blood pressure can create problems. It might compound with hypoglycemia and it also can mean that some organs don't get the perfusion that is optimal.
     
  6. forHisglory

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    Yes, the "when" is a good question. Our endo hasn't recommended them in our case but I'm sure that would change if lab work showed microalbuminemia or other signs of kidney compromise. In that case, I don't know if the hypotensive effects would be patient dependent or dose/formulation dependent but I've heard they are generally well tolerated in most people (you do have a point about those without hypertension to start). In a completely healthy person with diabetes like the OP, the prevention of microalbuminemia is the main goal but she is rightfully concerned about side effects....but if those concerns were laid to rest (does your wife know if most get hypotensive?) I can't see much downside. After all, complications can arise in even those with a stellar A1C and detection of subclinical damage isn't possible ....another reason this disease is the pits. I personally wouldn't want to add another medication to my regime, but if her endo thought it would cause damage/harm to her by making her hypotensive one would hope he/she would be aware of that and not recommend it in the first place. Gotta be your own advocate for sure!

    Edit: I would want to know the ultimate benefit of renoprotection (50% reduction in progression I read somewhere?) and if side effects of the patient is minimal, I would most likely add the med to my maintenance. Facing dialysis is a major slap to quality of life. In fact as I read the OPs post I got upset our children and those with type 1 have to face such decisions based on this s$&@; disease.
     
    Last edited: Dec 26, 2015
  7. Theo's dad Joe

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    Kidney protection is a top priority IMO. I have also wondered if C-peptide might have an independent protective effect on the kidneys considering that kidney damage happens with very good A1Cs. I have read that C-peptide has an independent heart protective effect (based on the fact that some MODYs) who have C-peptide but higher A1Cs (8.0-10.0) have very little rate of heart attack-almost the same as non-Ds.

    On another note, this study found increased insulin sensitivity with ACE inhibitors http://www.ncbi.nlm.nih.gov/pubmed/15915547

    Though some added risk of hypos needs to be kept in mind-ratios etc might change.
     
  8. Brenda

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    This provides some information on how to protect one's kidneys: http://www.niddk.nih.gov/health-inf...problems/Pages/keep-your-kidneys-healthy.aspx

    More importantly, look at the Standards of Care (chapter 9): http://www.diabetes.teithe.gr/UsersFiles/entypa/STANDARDS OF MEDICAL CARE IN DIABETES 2015.pdf Specifically, see pages 558-560 I may be misreading it, but I think there is no clear cut recommendation about ACE inhibitors. I think it is more clear cut if you have protein in your urine or higher blood pressure.

    If you take an ACE inhibitor and are really bothered by the cough, you can consider an ARB instead, although the Standards of Care indicate that ARBs are not as protective as ACEs at least with respect to cardiovascular disease. Not sure about the kidneys.
     
    Last edited: Dec 27, 2015
  9. quiltinmom

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    It's a personal decision. We saw a nephrologist a few months ago and she recommended he stay on the lisinopril for the protection. It's one little pill, not very expensive ($2.50 for a month supply) and if it can prevent kidney problems later, I'm all in.

    That said, it may not be right for everyone. My best suggestion is to talk to a nephrologist for their expert medical advice.

    Just use caution while taking an NSAID while on ace inhibitor. The nephrologist explained it well, better than I can here. I didn't get this advice when he was first put on lisinopril, and I wish I had. So I'm passing it on to anyone else who may not know.

    Just my 2 cents.
     
    Last edited: Dec 26, 2015
  10. Megnyc

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    I have never had protein in my urine. I take lisinopril for kidney protection. My BP is on the lower end (100/60) and I have had no side effects. It is a personal decision but to me one additional pill with minimal if any side effects is worth it. You can always stop taking it and it is pretty affordable. I think I just paid about $13 for a 90 day supply. I was under the impression it was pretty standard for adults with diabetes to take an ACE inhibitor for kidney protection.
     
  11. rgcainmd

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    I'm confused; maybe I don't understand what you are saying. Advil is not an MAOI.
     
  12. quiltinmom

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    Sorry, I meant NSAID. Duh.

    All these acronyms get mixed up. I will change it in my original post.
     
  13. Brenda

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    If you are still unsure what to do, get a second opinion. Of course, I realize that finding another endo is not always that easy. Maybe there is a GP in your area who has some diabetes expertise.
     
  14. rgcainmd

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    After thinking through risks versus benefits of prophylactic treatment with an ACE inhibitor, I'm going to ask my daughter's endo about starting her on low-dose Lisinopril.
     
  15. GChick

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    Sorry I posted the initial message then disappeared for the Christmas/New years.

    Actually what I've got goin' on is the reverse. Went to my local GP with (a lot of) experience with diabetes who recommended it, and asked that I discuss it with my Endo (who is not local for various reasons) if I wasn't sure. Endo has never raised the issue.

    No issues with microalbumin (have even had a hand notation from one of my endos on my lab results noting "Great Kidneys!" before :p)

    Blood pressure has also generally been slightly below the "normal" gold-standard number, so I wasn't concerned with blood pressure either.

    Meh... it is just one more pill or whatever, but I'm irritated enough with having to take the tiny thyroid medication every morning, which would probably have perceptible effects if missed for a long time... whereas itd be easy to convince myself to not take something that I couldn't "perceive" as doing anything.

    Also, I had no idea how cheap the pill was, so that could help sway me if I'm leaning that way anyway. Ah well, at least its something I don't have to rush to decide.
     
  16. GChick

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    Now, that I did not know. I had a one time test where cholesterol was in a higher range than "slightly above normal" in which the doc recommended them... but I said "no thanks (for the time being)" and lowered it naturally and he didn't suggest them this year because I successfully brought it down quite a bit.

    Don't get me wrong, I have no problem popping a pill if I feel I need it and was guilty for a time of popping an NSAIDS for the slightest ache from time to time (did nothing to my blood pressure though). I guess I just don't like feeling "dependent" on one more thing... particularly something that doesn't "appear" needed (I know.... doesn't mean its not), and that reflexive cough thing doesn't sound appealing.
     
  17. GChick

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  18. GChick

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    That was an interesting point brought up by one of the "more mature" posters before that I had never considered, think it was Richard. Even to the extent mentioning that that might be something that todays patients might be "missing" due to todays synthetic insulins (which I believe are still better due to the quality of life improvements and flexibility)... the C-peptides.

    I have generally found myself "lucky" in my diabetes care. Sure I have always "tried" to have good control too, but I cant help but feel just plain lucky sometimes. And so sometimes I wonder if that is from possibly taking "Cow Insulin" for the first 13 years with the disease which probably contained some of the cows natural C-peptides which many of todays patients don't get the benefit of. Don't know if there is any validity to it... but maybe <shrug>?


    Interesting. Probably neither good or bad, but interesting and maybe just requires retweaking dosages.
    Heh... if I were in a colder climate, maybe I could get two weeks out of a pump cartridge/300 units :eek:
     
  19. Theo's dad Joe

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    As for statins, their reduction in heart disease may be independent of their effect on cholesterol.
     
  20. Lakeman

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    Generally I am skeptical about taking drugs except when clearly indicated. It seems to me that the current standards of care or somewhat arbitrary and tomorrow they may be found to be far less effective than the standard du jour. That being said our kids are in a group that has a higher risk for kidney disease which becomes more likely the longer they live and the longer they have had T1D.

    Yes I would consider an ACE inhibitor. But I would also consider Telmisartan. For me as a person who prefers natural without rejecting modern medicine I would also consider the following too:

    Dont drink too little water
    Don't eat too much or too little salt
    Eat lots of vegetables and fruits
    Avoid nsaids and other drugs that are hard on the kidneys and that includes alcohol and tobacco
    Do get vitamins D and B12
    Do eat curcumin
    Don't be obese or have metabolic syndrome to the extent you can control it
    Do work hard to avoid high blood glucose
    Do avoid a diet high in carbs and sugars
    Do try to avoid AGEs

    Just my opinion but I bet that list would outweigh the benefits of an ACE inhibitor.
     

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