I am a 23 years old and have had diabetes for 17 years. I have always been under good control with the exception of a few highs here and there. (My last Hemoglobin A1c was 5.4%). I am very nervous about developing complications and tend to be extremely cautious when it comes to my health.

My boyfriend, a medical student, and I keep very well informed about research advancements and improved treatments for type�1 diabetes. After talking with several nephrologists and doing some research, we have become increasingly convinced that taking a low dose ACE inhibitor might help reduce my chances of developing kidney problems in the future. I am concerned that I may not be able to find a doctor willing to pursue this approach. How should I proceed, and would this be a reasonable course of action?

You raise a very important question. This is one we beat around a lot on rounds and in the clinic. There is clearly good data to support the use of ACE inhibitors in individuals with diabetes who have macro- or microalbuminuria.

Unfortunately, there is not data to demonstrate the benefit of ACE inhibitors prior to the development of microalbuminuria. In the absence of hypertension, I do not use ACE inhibitors when individuals are in the normal range for albumin excretion. We do not know if there is a linear relationship to kidney function and ACE inhibitor use which extends into the normal albumin excretion period. However, there will soon be information to make your decision as several clinical trials are underway worldwide to try and answer this question. The other side of the question is that there may not be a benefit, and there are side effects and monitoring associated with ACE inhibitors.

JTL