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Telmisartan versus benazepril in the treatment of proteinuria associated with feline CKD 

Clinical Scenario

Barney Clarke is a 14 year old male neutered domestic shorthaired cat with late stage 2 Chronic Kidney Disease. He was markedly hyperphosphatemic but this is now controlled on a renal specific diet. He has proteinuria and a urine protein:creatinine ratio (UPC) of 0.5. You want to treat his proteinuria and explain to his owner, Mr Clarke, that this may improve Barney's survival and that there are two types of medication available now; tablets or an oral solution.  Mr Clarke is a very dedicated owner and wants to do everything possible for Barney but worries about medicating him with oral treatment as he has never done it before and he asks you which is best. You wonder if there is a difference in efficacy between the two treatments...

3-Part Question (PICO)

In [cats with Chronic Kidney Disease] is [telmisartan more effective than benazepril] at [reducing proteinuria]?

Search Strategy and Summary of Evidence

Search Strategy

MEDLINE(R) In-Process & Other Non-Indexed Citations and MEDLINE(R) 1946 to Present using the OVID interface

(cat.mp. OR cats.mp. OR feline.mp. OR felines.mp. OR felis.mp. OR exp Cats/)

AND

(chronic renal failure.mp. OR chronic renal disease.mp. OR chronic renal insufficiency.mp. OR chronic kidney failure.mp. OR chronic kidney disease.mp. OR chronic kidney insufficiency.mp. OR exp Kidney Failure, Chronic/ OR exp Renal Insufficiency, Chronic/)

AND

(benazepril.mp. OR fortekor.mp. OR angiotensin converting enzyme inhibitor.mp. OR angiotensin converting enzyme inhibitors.mp. OR ACE inhibitor.mp. OR ACE inhibitors.mp. OR ACEi.mp. OR exp Angiotensin-Converting Enzyme Inhibitors/)

AND

(telmisartan.mp. OR angiotensin receptor blocker.mp. OR angiotensin receptor blockers.mp. OR AT1 receptor blocker.mp. OR AT1 receptor blockers.mp. OR ARB.mp. OR ARBs.mp. OR semintra.mp. OR exp angiotensin receptor antagonists/)

CAB Abstracts 1910 to Present using the OVID interface

(cat.mp. OR cats.mp. OR feline.mp. OR felines.mp. OR felis.mp. OR exp cats/)

AND

(chronic renal failure.mp. OR chronic renal disease.mp. OR chronic renal insufficiency.mp. OR chronic kidney insufficiency.mp. OR chronic kidney failure.mp. OR chronic kidney disease.mp. OR exp renal failure/ OR exp kidney disease/)

AND

(benazepril.mp. OR fortekor.mp. OR angiotensin converting enzyme inhibitor.mp. OR angiotensin converting enzyme inhibitors.mp. OR ACE inhibitor.mp. OR ACE inhibitors.mp. OR ACEi.mp.)

AND

(telmisartan.mp. OR angiotensin receptor blocker.mp. OR angiotensin receptor blockers.mp. OR AT1 receptor blocker.mp. OR AT1 receptor blockers.mp. OR ARB.mp. OR ARBs.mp. OR semintra.mp.)

Search Outcome

MEDLINE

  • 3 papers found in MEDLINE search
  • 0 papers excluded as they don't meet the PICO question
  • 0 papers excluded as they are in a foreign language
  • 2 papers excluded as they are review articles/in vitro research/conference proceedings
  • 1 total relevant papers from MEDLINE

CAB Abstracts

  • 4 papers found in CAB search
  • 2 papers excluded as they don't meet the PICO question
  • 0 papers excluded as they are in a foreign language
  • 1 papers excluded as they are review articles/in vitro research/conference proceedings
  • 1 total relevant papers from CAB

Total relevant papers

1 relevant papers from both MEDLINE and CAB Abstracts

Summary of Evidence

Sent et al (2015) Multicentre study across Europe

Title:

Comparison of efficacy of long-term oral treatment with telmisartan and benzepril in cats with chronic kidney disease

Patient group:

224 cats from 48 centres across Europe

Cats with IRIS stage 2-3 Chronic Kidney Disease (CKD), though 4 cats with stage 4 CKD were included in the final analysis.

Study Type:

Randomised controlled trial (noninferiority)

Outcomes:
  • Change in urine protein:creatinine ratio from baseline
  • Appetite
  • Demeanour 
Key Results:
  • Telmisartan was noninferior to benazepril in the reduction of UPC compared to baseline 

  • On Day 180, the mean  decrease  (-0.05 +/- 0.31) in UPC in the telmisartan group was significantly different from baseline (p = 0.016)

  • On Day 180, the mean decrease (-0.02 +/-0.48)  in UPC in the benazepril group was not significantly different from baseline (p=0.136)

  • 8/14 (57.2%) cats in the telmisartan group and 4/13 (30.8%) cats in the benazpril group changed from being proteinuric at the start of the study to nonproteinuric at day 180

  • 51/58 (87.9%) cats in the telmisartan group and 54/63 (85.7%) cats in the benazpril group changed from being borderline proteinuric at the start of the study to nonproteinuric or remained borderline proteinruric at day 180

  • Cats had the most significant change in behaviour in the first 60 days and were reported to be more active by their owners (no data given)

  • Approximately 80% cats had a normal appetite with little change in appetite seen (no data given)

  • 13/85 (15.3%) cats in the telmisartan group and 18/91 (19.8%) cats in the benazepril group were classed as treatment failures

  • 13/112 (11.6%) cats died in the telmisartan group and 22/112 (19.6%) cats in the benazepril group died during the study

  • One or more adverse events were reported in 61 cats in the telmisartan group and 65 cats in the benazepril group and were consistent with CKD or gastrointestinal disorders

Study Weaknesses:
  • No sample size given
  • Outcome assesments for quality of life not well described in methods or results, appear subjective and unvalidated
  • It is unlikely that the owners who administered the medications were blinded as there is a liquid and tablet preparation.
  • It is unclear whether the person who made the outcome assessments was blinded
  • The majority of cats had only borderline proteinuria (UPC <0.4)
Attachment:
Evidence appraisalEvidence appraisal

Comments

The majority of cats only have borderline proteinuria and it is undecided if cats with CKD and a UPC of less that 0.2 warrant treatment.

The cats came from 48 european centres and it is unknown if cats and CKD varies across Europe and between centres.

This is a well conducted and reported randomised controlled trial.

Bottom line

Telmisartan and benazepril are equally efficacious at reducing proteinuria in cats with chronic kidney disease.

Disclaimer

The BETs on this website are a summary of the evidence found on a topic and are not clinical guidelines. It is the responsibility of the individual veterinary surgeon to ensure appropriate decisions are made based on the specific circumstances of patients under their care, taking into account other factors such as local licensing regulations. Read small print

References

Sent U, Gossl R, Elliott J, Syme HM, Zimmering T, (2015). Comparison of efficacy of long-term oral treatment with telmisartan and benazepril in cats with chronic kidney disease. Journal of Veterinary Internal Medicine 29: 1479-1487.

About this BET

First author:
Rachel Dean
Second author:
Kathryn Wareham
Institution:

Centre for Evidence-based Veteirnary Medicine, University of Nottingham

Search last performed:
2016-05-17 08:45:16
Original publication date:
2016-06-29 08:45:16
Last updated:
2016-06-29 08:45:16
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