A major new international study published in the Journal of Hypertension has challenged traditional thinking by revealing that the thiazide-like diuretic indapamide SR (Natrilix SR) has equivalent efficacy to enalapril in reducing microalbuminuria (MA) in patients with type 2 diabetes.
The NESTOR (Natrilix SR versus Enalapril Study in Type 2 diabetic hypertensives with micrOalbuminuRia) study is the first randomised study over one year in duration to prove the efficacy of a diuretic on MA, and establishes indapamide SR as the first diuretic to show efficacy in MA reduction.
The implications of NESTOR for UK practice are potentially very significant. MA is an established risk factor in diabetic patients, but its importance, according to leading diabetologist Professor Anthony Barnett, Professor of Medicine at the University of Birmingham, may be underrated.
‘There is increasing evidence to show that microalbuminuria is a sensitive marker of organ damage, and its importance as a renal and cardiovascular risk factor is often under-recognised,’ he commented.
Current guidelines recommend first-line use of an ACE inhibitor or, if contraindicated, an angiotensin II receptor blocker (ARB) in patients with type 2 diabetes and MA. The NESTOR authors, however, believe that their findings are ‘consistent with the use of indapamide SR as first-line therapy in hypertensive type 2 diabetic patients.’
NESTOR is a multinational randomised trial involving 570 patients with essential hypertension, type 2 diabetes and MA, who were randomised to receive either enalapril 10mg or indapamide SR 1.5mg once daily. After one year, there was a significant and equivalent reduction in MA in both the indapamide SR (35%) and enalapril (39%) groups. However, SBP reduction in the indapamide group (-23.8 mmHg) was significantly greater than in the enalapril group (-21.0 mmHg). No significant difference occurred in DBP reduction (-13.0 vs -12.1 mmHg). 24-Hour ambulatory blood pressure measurement (24-h ABPM) in a subgroup of 99 patients showed a non-significant mean arterial pressure (MAP) difference of only -0.63 mmHg between treatments over the 24-hour period.
Both regimens were also very well tolerated throughout the 1-year follow-up, with 98% of study participants complying with treatment.