A 48-year-old woman presents to your clinic complaining of excessive urination and constant hunger and thirst. She has no other complaints and no past medical history. Her family history is significant for hypertension, type 2 diabetes mellitus, and hyperlipidemia. She does not smoke but lives a sedentary lifestyle. On examination, she is afebrile with a blood pressure of 134/88 mmHg, heart rate of 84 beats per minute, and respiratory rate of 14 breaths per minute. The rest of her examination is normal. The patient is scheduled for a return visit to have fasting laboratory tests drawn. At her return visit, her blood pressure is 138/86 mmHg. Her fasting glucose is 156 mg/dL, and urine albumin-to-creatinine ratio is 200 mg/g.
What is the next step in management for this patient?
A. Encourage diet and lifestyle modificationsStart an ACE inhibitor now. This patient is presenting with a new diagnosis of diabetes mellitus and is normotensive; however, she has moderate albuminuria. Although there is debate over whether ACE inhibitors (or ARBs) should be used as primary prevention for diabetic nephropathy, there is good data to support starting an ACE inhibitor with at least moderate albuminuria (early diabetic nephropathy). It can be started whether or not the patient is hypertensive. The reason ACE inhibitors are thought to be renoprotective comes from their role in reducing intraglomerular pressure. Early in the course of diabetes, there is hyperfiltration and intraglomerular hypertension that damages the nephrons. ACE inhibitors and ARBs prevent angiotensin II from causing vasoconstriction of the efferent arterioles. The effect is relaxation of the efferent arteriole and a reduction in the intraglomerular pressure, which decreases proteinuria (which is itself toxic to the tubules) and delays the onset of diabetic nephropathy. The bottom line for the shelf examination is that ACE inhibitors and ARBs are renoprotective in diabetes, and should be taken in nearly all diabetic patients with hypertension, nephropathy, and/or cardiovascular disease, whether or not they are hypertensive.
(A) Encouraging diet and lifestyle modifications is always a right answer, but is not always the best answer. In this case, it would be inappropriate to counsel the patient without starting an ACE inhibitor. (B) The patient is stable and can be managed as an outpatient. If the patient had diabetic ketoacidosis or hyperosmolar hyperglycemic state, then she should be managed as an inpatient. (D) The Eighth Joint National Committee (JNC 8) recommended a blood pressure target of <140/90 mmHg in all diabetic patients, and so an antihypertensive agent without renoprotective effects (e.g., hydrochlorothiazide) should not be started. (Note: remember that the shelf examination is not always up to date and might recommend a blood pressure goal of <130 to 135/80 to 85 mmHg.)