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Sheldon Hirsch, MD

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Ku et al¹ cite the findings of the Renal Outcomes With Telmisartan, Ramipril, or Both, in People at High Vascular Risk (ONTARGET) trial² in arguing against dual renin-angiotensin system (RAS) inhibition in chronic kidney disease. However, the ONTARGET trial evaluated patients with less than 1 g of proteinuria, many of whom were normotensive. This was not a study of patients for whom nephrologists typically consider dual RAS inhibition; ONTARGET does not address, much less rebut, the efficacy of dual RAS inhibition that has been demonstrated in the hypertensive, proteinuric cohort.³

As Ku et al¹ suggest, it is unwise to extrapolate safety from clinical studies carried out by specialists to community internal medicine practice, and routine use of dual RAS inhibition should be discouraged. However, dual RAS inhibition appears to be a reasonable option for hypertensive, proteinuric patients who do not respond optimally to a single RAS inhibitor, . . . [Full Text of this Article]

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