Breaking Health News, April 19, 2006

Key Heart Meds Not Given to Many Diabetics

Just 43 percent of persons with diabetes over the age of 55 receive medications that could help protect their heart and kidneys, even though nearly all of these patients could benefit from such medications, a new US study finds.

Even among diabetic patients with existing heart and kidney problems - patients with the most to gain from medications like angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) - the rate of use was just 53 percent, the researchers said.

ACEIs and ARBs

The classes of prescription medications, called ACE inhibitors (ACEIs) and ARBs for short, have been recommended by national diabetes treatment guidelines for years, because of the strong evidence that they can prevent heart attacks, strokes, kidney failure, and other problems that disproportionately threaten older people who have diabetes.

The relatively inexpensive medications are especially recommended for diabetics who already show signs of heart or kidney damage, or who have high blood pressure.

Angiotensin converting enzyme inhibitors (ACEI) relax blood vessels and make it easier for the heart muscle to pump blood to vital organs. ARBs are a similar group of medications.

These medications are also recommended to improve survival in heart attack survivors who have left ventricular systolic dysfunction.

Saving More Lives, Money Possible

The first national study of the actual use of ACEIs and ARBs in diabetics over age 55 reveals a large gap between what should be and what is. The study was funded by the US Agency for Healthcare Research and Quality (AHRQ).

The study, published in the Journal of General Internal Medicine, was conducted by Dr. Allison Rosen, an assistant professor of internal medicine at the University of Michigan Medical School, using data from the National Health and Nutrition Examination Survey (NHANES).

"These are drugs that we know save lives and save money, and still we're only using them in less than half of the people who could benefit," says Dr. Rosen, who also holds positions at the U-M School of Public Health and the VA Ann Arbor Healthcare System.

"It's especially striking that their rate of use isn't much higher in people most likely to gain - that is, those with multiple clinical indications and risk factors," Dr. Rosen continues.

The study did not identify the reasons why the use of these medications is so low, but Dr. Rosen said the reasons may include: lack of physician awareness; cost to patients; and ineffective measures to track and encourage medication use.

Study Findings

The study was based on data from a nationally representative sample of adults over age 55 with diabetes. All study participants had a thorough health exam, medication review, and interview as part of the NHANES program.

Dr. Rosen assessed the percentage that were using any medication in the ACEI or ARB class, and tallied up each person's total number of indications and risk factors that would increase the benefit that they would receive from the medications.

Three clinical indications were examined: Cardiovascular disease of any sort including heart failure, history of heart attack or stroke, or clogged coronary arteries; high blood pressure, whether controlled by medication or not; and the presence of protein in the patient's urine, a condition that indicates impaired kidney function.

National guidelines recommend that any diabetic who has even one clinical indications should be taking an ACE inhibitor or ARB, except for a very small number who may not be able to tolerate them due to side effects.

Studies also suggest that the medications are beneficial to diabetics who smoke or have high cholesterol, but who have not yet experienced cardiovascular problems, high blood pressure, or kidney problems.

In all, 92 percent of the participants in the study met at least one of the three clinical guideline indications, and 100 percent either had one of the clinical indications or an additional risk factor for cardiovascular disease.

Just over 34 percent had cardiovascular disease, almost 47 percent had kidney damage, and nearly 83 percent had high blood pressure. Nearly 73 percent had high cholesterol and 24 percent smoked.

"In other words, every one of the people in this nationally-representative survey probably should have been taking an ACE inhibitor or an ARB, and most weren't," says Dr. Rosen.

"The more risk factors and indications someone had, the more likely they were to be on one of these drugs, but still, even in people with four or more indications to be treated with these life saving drugs, only 53 percent were on them," she adds.

ACEI, ARB Use Encouraged

Dr. Rosen says she hopes the study results will encourage physicians, insurers, hospitals, and others to find new ways to encourage ACEI and ARB use among people with diabetes.

She notes that the current "quality benchmarks" that are used to rate health care providers and health plans do not typically include measurements of ACEI and ARB use for persons with diabetes.

They do, however, often include a measure of how often diabetics receive urine tests for early signs of kidney disease - but they do not measure what happens after the results of those tests come back, especially if a problem is found.

"The way we're measuring quality in this area is not working," Dr. Rosen says. "We need to create incentives and benchmarks that will encourage responsible prescribing of ACE inhibitors and ARBs, while also creating conditions that will lower patients' barriers to using these medications."

Dr. Rosen suggests that diabetes patients talk to their physician about whether they should be taking ACE inhibitors or ARBs.

Always consult your physician for more information.

Online Resources

(These links are provided for the education and convenience of our Neighbors. AAMC is not responsible for the content of Internet sites.)

Agency for Healthcare Research and Quality (AHRQ)

American Association of Clinical Endocrinologists

American Diabetes Association

Centers for Disease Control and Prevention (CDC)

Everyday Choices, ADA, AHA, and ACS

Journal of General Internal Medicine

National Diabetes Education Program

National Diabetes Information Clearinghouse

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

National Institutes of Health (NIH)

National Library of Medicine

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Diabetes and Heart Disease

Heart and vascular disease often go hand-in-hand with diabetes. Persons with diabetes are at a much greater risk for heart attacks, strokes, and high blood pressure.

Other vascular problems due to diabetes include poor circulation to the legs and feet.

Unfortunately, many of the cardiovascular problems associated with diabetes can go undetected and can start early in life.

Persons with diabetes often experience changes in the blood vessels that can lead to cardiovascular disease.

In persons with diabetes, the linings of the blood vessels may become thicker, making it more difficult for blood to flow through the vessels. When blood flow is impaired, heart problems or stroke can occur.

Blood vessels can also suffer damage elsewhere in the body due to diabetes, leading to eye problems, kidney problems, and poor circulation to the legs and feet.

Serious cardiovascular disease can begin before the age of 30 in persons with diabetes.

The two most common types of diabetes are type 1 and type 2.

Type 1 diabetes (also called insulin-dependent diabetes mellitus) is an autoimmune disease in which the body's immune system attacks the cells in the pancreas that produce insulin, resulting in no or a low amount of insulin.

Type 2 diabetes (also called non-insulin dependent diabetes mellitus) is the result of the body's inability to make enough, or to properly use, insulin.

According to the American Diabetes Association, damage to the coronary arteries is two to four times more likely in asymptomatic (without symptoms) persons with type 1 diabetes than in the general population.

Because symptoms may be absent at first, the American Diabetes Association recommends early diagnosis and treatment, and management of risk factors.

Many studies demonstrate that persons with type 2 diabetes are at increased risk for heart disease.

In fact, one study found that persons with type 2 diabetes without apparent heart problems ran the same risk for heart disease as persons without diabetes who had already suffered one heart attack.

Always consult your physician for more information.