My 26-year-old son has had type 1 diabetes since the age of 14. His A1c is usually in the 7% range, but has recently risen to 8%. He is thin, does not smoke and has normal blood pressure readings at his doctor’s visits. He sees a family practice doctor, not an endocrinologist. His doctor recently put him on a blood pressure medication (lisinopril 5mg) as a preventative. Is this standard practice or is it better to keep a close eye on his blood pressure and put him on something at the first sign of a rise in his blood pressure? Every medication has a side effect. I take 10 mg of lisinopril and have a constant annoying dry cough due to the medication.

Thank you for asking this question. At a medical school, I am asked this question regularly. I would say that half of our faculty (in general practice) prescribes ACE inhibitors without knowledge or concern of blood pressure or albumin excretion. However, it should be pointed out that there is no literature to support “preventative therapy.” There is good supportive data to promote ACE inhibitor therapy for elevated levels of albumin excretion, even at low levels of elevated albumin excretion called microalbuminuria. In addition, ACE inhibitor therapy is also recommended for treatment for hypertension with 130/80 being the target blood pressure for people with diabetes. In your case, there is an acceptable alternative in the use of drugs called angiotensin receptor blockers (ARBs). They are often used instead of ACE inhibitors (of which lisinopril is a type) when the cough becomes bothersome.

I would make the point that the physician who prescribed the lisinopril is not necessarily practicing bad medication, but there is not support in the literature for such a practice. Blood pressure should be checked at every visit. Albumin excretion should be checked yearly, usually as a random urine for albumin:creatine ratio. It is more convenient and less bothersome to do the random urines than to do the twenty-four hour urine collections.

JTL