For those intolerant to ACE inhibitors and ARBs, what is the best therapy for reducing the risk of diabetic nephropathy?

Angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs) are the first-line agents for reducing the risk of diabetic nephropathy. For patients intolerant to these agents, non-dihydropyridine calcium antagonists (NDCAs), such as verapamil and diltiazem, are preferred agents to treat hypertension in those with diabetes who have proteinuria (strength of recommendation [SOR]: A, based on a systematic review). Diuretics are effective in treating hypertension in patients with diabetes who are at high risk for cardiovascular disease. One study suggests sustained-release indapamide (a diuretic) is effective as first-line treatment in hypertensive patients with diabetes and proteinuria (SOR: B, based on a randomized controlled trial [RCT]). Atenolol was as effective as the ACE inhibitor captopril in lowering the risk of diabetic microvascular and macrovascular complications, according to a substudy of the United Kingdom Prospective Diabetic Study (UKPDS) (SOR: B, based on RCT)