My mother has type 2 diabetes. Her diabetes doctor wants her to take Monopril [an ACE inhibitor] to control kidney protein levels, but her primary physician says the Monopril is causing her blood pressure to go too low and told her to stop taking it. She told each doctor what the other said, but neither wants to change his position. She has no idea who is right or what she should do. What would you suggest?

This is a fairly common clinical problem. Monopril is used not only to lower blood pressure but as an agent that protects the kidneys from continued injury and loss of function with most kidney diseases, including diabetes-induced kidney disease.

If your mother is having problems with low pressure, it should be backed off to lowest tolerated dose. If no dose is tolerated, the Monopril should be stopped. Fortunately, there are other agents that have similar benefits. They are known as angiotensin II receptor antagonists. They might be better tolerated because their blood pressure-lowering potential is not as great as the class that includes Monopril, a class known as ACE inhibitors.

It should be added that clear indications for the use of drugs that prevent kidney disease progression exist. They include high blood pressure greater than 130/80 and increased urine microalbumin. If no elevated blood pressure or increased albumin in the urine exist, it is controversial whether ACE inhibitors or angiotensin II receptor antagonists should be used prophylactically.

JTL

[Editor’s comment: Also, see How to Protect your Kidneys at the Diabetes Monitor.

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