Skip to main content

Advertisement

SpringerLink
Log in

Indications for and utilization of ACE inhibitors in older individuals with diabetes

Findings from the national health and nutrition examination survey 1999 to 2002

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

Abstract

BACKGROUND: Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) improve cardiovascular outcomes in high-risk individuals with diabetes. Despite the marked benefit, it is unknown what percentage of patients with diabetes would benefit from and what percentage actually receive this preventive therapy.

OBJECTIVES: To examine the proportion of older diabetic patients with indications for ACE or ARB (ACE/ARB). To generate national estimates of ACE/ARB use.

DESIGN AND PARTICIPANTS: Survey of 742 individuals ≥ 55 years (representing 8.02 million U.S. adults) self-reporting diabetes in the 1999 to 2002 National Health and Nutrition Examination Survey.

MEASUREMENTS: Prevalence of guideline indications (albuminuria, cardiovascular disease, hypertension) and other cardiac risk factors (hyperlipidemia, smoking) with potential benefit from ACE/ARB. Prevalence of ACE/ARB use overall and by clinical indication.

RESULTS: Ninety-two percent had guideline indications for ACE/ARB. Including additional cardiac risk factors, the entire (100%) U.S. non-institutionalized older population with diabetes had indications for ACE/ARB. Overall, 43% of the population received ACE/ARB. Hypertension was associated with higher rates of ACE/ARB use, while albuminuria and cardiovascular disease were not. As the number of indications increased, rates of use increased, however, the maximum prevalence of use was only 53% in individuals with 4 or more indications for ACE/ARB.

CONCLUSIONS: ACE/ARB is indicated in virtually all older individuals with diabetes; yet, national rates of use are disturbingly low and key risk factors (albuminuria and cardiovascular disease) are being missed. To improve quality of diabetes care nationally, use of ACE/ARB therapy by ALL older diabetics may be a desirable addition to diabetes performance measurement sets.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Mokdad AH, Ford ES, Bowman BA, et al. Diabetes trends in the US: 1990–1998. Diab Care. 2000;23:1278–83.

    Article  CAS  Google Scholar 

  2. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001;286:1195–200.

    Article  CAS  PubMed  Google Scholar 

  3. Medicare Current Beneficiary Survey. Self-reported health conditions and risk factors of Medicare beneficiaries, by age and gender, 2000. Available at: http://www.cms.hhs.gov/MCBS/CMSsrc/2000/sec2.pdf. Accessed April 12, 2004.

  4. Bertoni AG, Krop JS, Anderson GF, Brancati FL. Diabetes-related morbidity and mortality in a national sample of U.S. elders. Diab Care. 2002;25:471–5.

    Article  Google Scholar 

  5. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. N Engl J Med. 1993;329:1456–62.

    Article  CAS  PubMed  Google Scholar 

  6. Ravid M, Lang R, Rachmani R, Lishner M. Long-term renoprotective effect of angiotensin-converting-enzyme inhibition in non-insulin-dependent diabetes mellitus. A 7-year follow-up study. Arch Intern Med. 1996;156:286–9.

    Article  CAS  PubMed  Google Scholar 

  7. Ravid M, Brosh D, Levi Z, Bar-Dayan Y, Ravid D, Rachmani R. Use of enalaprill to attenuate decline in renal function in normotensive, normoalbuminuric patients with type 2 diabetes mellitus. Ann Intern Med. 1998;128:982–8.

    CAS  PubMed  Google Scholar 

  8. Viberti G, Mogensen CE, Groop LC, Pauls JF. Effect of Captopril on progression to clinical proteinuria in patients with insulin-dependent diabetes mellitus and microalbuminuria. JAMA. 1994;271:275–9.

    Article  CAS  PubMed  Google Scholar 

  9. Kvetny J, Gregersen G, Pedersen RS. Randomized placebo-controlled trial of perindopril in normotensive, normoalbuminuric patients with type 1 diabetes mellitus. Q J Med. 2001;94:89–94.

    CAS  Google Scholar 

  10. Ahmad J, Siddiqui MA, Ahamd H. Effective postponement of diabetic nephropathy with enalapril in normotensive type 2 diabetic patients with microalbuminuria. Diab Care. 1997;20:1576–81.

    Article  CAS  Google Scholar 

  11. ACE Inhibitors in Diabetic Nephropathy Trialist Group. Should all patients with type 1 diabetes mellitus and microalbuminuria receive angiotensin-converting enzyme inhibitors? A meta-analysis of individual patient data. Ann Intern Med. 2001;134:370–9.

    Google Scholar 

  12. Haider A, Oh P, Peloso PM. An evidence-based review of ACE inhibitors in incipient diabetic nephropathy. Can J Clin Pharmacol. 2000;7:115–9.

    CAS  PubMed  Google Scholar 

  13. Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med. 2000;342:145–53.

    Article  Google Scholar 

  14. Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet. 2000;355:253–9.

    Article  Google Scholar 

  15. Niskanen L, Hedner T, Hansson L, Lanke J, Niklason A for the CAPPP Study Group. Reduced cardiovascular morbidity and mortality in hypertiensive diabetic patients on first-line therapy with an ACE inhibitor compared with a diuretic/[beta]-blocker-based treatment regimen: a subanalysis of the Captopril prevention project. Diab Care. 2001;24:2091–6.

    Article  CAS  Google Scholar 

  16. Brenner BM, Cooper ME, de Zeeuw D, et al. Effect of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345:861–9.

    Article  CAS  PubMed  Google Scholar 

  17. Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with neuropathy due to type 2 diabetes. N Engl J Med. 2001;345:851–60.

    Article  CAS  PubMed  Google Scholar 

  18. Parving HH, Lehnert H, Brochner-Mortensen J, Gomis R, Andersen S, Amer P. Irbesartan in patients with type 2 diabetes and microalbuminuria study group. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med. 2001;345:870–8.

    Article  CAS  PubMed  Google Scholar 

  19. Lindholm LH, Ibsen H, Dahlof B, et al. Cardiovascular morbidity and mortality in patients with diabetes in the Losartan intervention for endpoint reduction in hypertension study (LIFE): a randomized trial against atenolol. Lancet. 2002;359:1004–10.

    Article  CAS  PubMed  Google Scholar 

  20. The EUCLID Study Group. Randomised placebo-controlled trial of lisinopril in normotensive patients with insulin-dependent diabetes and normoalbuminuria or microalbuminuria. Lancet. 1997;349:1787–92.

    Article  Google Scholar 

  21. Shlipak M. Diabetic nephropathy. Clin Evid. 2005;13:149–54.

    Google Scholar 

  22. Bennett PH, Haffner S, Kasiske BL, et al. Screening and management of microalbuminuria in patients with diabetes mellitus: recommendations to the scientific advisory board of the national kidney foundation from an ad hoc committee of the council on diabetes mellitus of the national kidney foundation. Am J Kidney Dis. 1995;25:107–12.

    Article  CAS  PubMed  Google Scholar 

  23. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diab Care. 1997;20(suppl 1):S5-S13.

    Google Scholar 

  24. Konstam M, Dracup K, Baker D, et al. Heart failure: evaluation and care of patents with left-ventricular systolic dysfunction. In: MA Konstam, ed. Clinical Practice Guideline No. 11. Rockville, MD: Agency for Health Care Policy & Research; 1994.

    Google Scholar 

  25. American Diabetes Association. Standards of medical care in diabetes. Diab Care. 2005;28(suppl 1):S4-S36.

    Article  Google Scholar 

  26. Sixth report of the joint national committee on prevention, detection, evaluation and treatment of high blood pressure. Arch Intern Med. 1997;157:2413–42.

    Google Scholar 

  27. NHANES 1999–2000 Data Release. Prescription medication subsection of dietary supplements and prescription medication section. Available at: http://www.cdc.gov/nchs/data/nhanes/frequency/rxq_rxdoc.pdf Accessed October 4, 2005.

  28. NHANES 2001–2002 Data Documentation: April 2005. Prescription medication subsection of dietary supplements and prescription medication section. Available at: http://www.cdc.gov/nchs/data/nhanes/nhanes_01_02/rxq_rx_b_doc.pdf Accessed October 4, 2005.

  29. Paster RZ, Snavely DB, Sweet AR, et al. Use of losartan in the treatment of hypertensive patients with a history of cough induced by angiotensin-converting enzyme inhibitors. Clin Therap. 1998;20:978–89.

    Article  CAS  Google Scholar 

  30. Tanser PH, Campbell LM, Carranza JK, Toutouzas P, Watts Rfor the Multicentre Cough Study Group. Candesartan cilexetil is not associated with cough in hypertensive patients with enalapril-induced cough. Am J Hypertens. 2000;13:214–8.

    Article  CAS  PubMed  Google Scholar 

  31. NHANES. NHANES analytic guidelines: June 2004 version. Available at: http://www.cdc.gov/nchs/data/nhanes/nhanes_general_june_04.pdf. Accessed March 3, 2005.

  32. Goldberg RB. Cardiovascular disease in patients who have diabetes. Cardiol Clin. 2003;21:399–413.

    Article  PubMed  Google Scholar 

  33. Kramer HJ, Nguyen QD, Curhan G, Hsu C. Renal insufficiency in the absence of albuminuria and retinopathy among adults with type 2 diabetes mellitus. JAMA. 2003;289:3273–7.

    Article  PubMed  Google Scholar 

  34. Dunn EJ, Burton CJ, Feest TG. The care of patients with diabetic nephropathy: audit, feedback, and improvement. Q J Med. 1999;92:443–9.

    CAS  Google Scholar 

  35. Gold JA. A word from WIPRO: improving use of ACE inhibitors in diabetic nephropathy. Wisc Med J 1996:588–9.

  36. Scarsi KK, Bjornson DC. The use of ACE inhibitors as renoprotective agents in Medicaid patients with diabetes. Ann Pharmacother. 2000;34:1002–6.

    Article  CAS  PubMed  Google Scholar 

  37. Gordian ME, Kelly J. Why patients with diabetes, hypertension and/or proteinuria are NOT on angiotensin converting enzyme inhibitors. Alaska Med. 1998;40:51–4.

    CAS  PubMed  Google Scholar 

  38. Rosen AB, Karter AJ, Liu JY, Selby JV, Schneider EC. Use of ACE-inhibitors and angiotensin receptor blockers in high-risk clinical and ethnic groups with diabetes. J Gen Intern Med. 2004;19:671–7.

    Google Scholar 

  39. Gerstein HC, Mann JFE, Yi Q, et al. Albuminuria and risk of cardiovascular events, death, and heart failure in diabetic and nondiabetic individuals. JAMA. 2001;286:421–6.

    Article  CAS  PubMed  Google Scholar 

  40. Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in non-diabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998;339:229–34.

    Article  CAS  PubMed  Google Scholar 

  41. Hillen T, Coshall C, Tilling K, Rudd AG, McGovern R, Wolfe CDA. Cause of stroke recurrence is multifactorial: patterns, risk factors, and outcomes of stroke recurrence in the South London Stroke Register. Stroke. 2003;34:1457–63.

    Article  PubMed  Google Scholar 

  42. Valmadrid CT, Klein R, Moss SE, Klein BEK. The risk of cardiovascular disease mortality associated with microalbuminuria and gross proteinuria in persons with older-onset diabetes mellitus. Arch Intern Med. 2000;160:1093–100.

    Article  CAS  PubMed  Google Scholar 

  43. National Committee for Quality Assurance (NCQA). The state of managed care quality, 2001. Available at: http://www.ncqa.org/somc2001/diabetes/cdc6_datx.html. Accessed September 12, 2002.

  44. Bicket DP. Using ACE inhibitors appropriately. Am Fam Physician. 2002;66:461–8.

    PubMed  Google Scholar 

  45. Reardon LC, Macpherson DS. Hyperkalemia in outpatients using angiotensin-converting enzyme inhibitors. How much should we worry? Arch Intern Med. 1998;158:26–32.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA

    Allison B. Rosen MD, MPH, ScD

  2. Center for Practice Management and Outcomes Research, Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI, USA

    Allison B. Rosen MD, MPH, ScD

  3. Division of General Medicine, University of Michigan Health Systems, 300 North Ingalls, Suite 7E10, 48109, Ann Arbor, MI

    Allison B. Rosen MD, MPH, ScD

Authors
  1. Allison B. Rosen MD, MPH, ScD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Allison B. Rosen MD, MPH, ScD.

Additional information

The authors have no conflicts of interest to report.

The author would like to thank Roger Davis, PhD, for statistical advice, as well as Norman Hollenberg, MD, and Rodney Hayward, MD, for their thoughtful comments on an earlier version of this manuscript.

Funding and Financial Support: At the initiation of this work, Dr. Rosen was supported by an AHRQ Health Services Research Fellowship at the Harvard School of Public Health, grant number 5 T32 HS00020-16.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Rosen, A.B. Indications for and utilization of ACE inhibitors in older individuals with diabetes. J Gen Intern Med 21, 315–319 (2006). https://doi.org/10.1111/j.1525-1497.2006.00351.x

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1111/j.1525-1497.2006.00351.x

Key words

Search

Navigation