Research Supports Routine ACE Inhibitors in Patients with Type 2 Diabetes
Research Supports Routine ACE Inhibitors in Patients with Type 2 Diabetes
DOC News July 1, 2004
Volume 1 Number 1 p. 17
Cautiously optimistic results show reduction in mortality
Elizabeth Heubeck
Physicians have long prescribed the routine use of ACE inhibitor therapy for lower-risk patients with type 2 diabetes (i.e., those without cardiovascular disease)—despite a lack of evidence supporting the practice. New findings lend credence to this practice, and may serve to guide clinical practice.
Researchers from the University of Alberta, reporting their findings in the June issue of Diabetes Care, demonstrated a link between the routine use of ACE inhibitor therapy in patients with newly treated type 2 diabetes and a reduction in all-cause and cardiovascular-related mortality.
In what is believed to be the first study of its kind, investigators set out specifically to evaluate the cardiovascular-related effects of ACE inhibitors on patients with diabetes. They examined 5 years' worth of medical records on patients newly diagnosed with type 2 diabetes: 1,187 "new users" of ACE inhibitors and 4,989 who were not taking ACE inhibitors. In other studies used to support clinical decisions on prescribing ACE inhibitors for patients with type 2 diabetes, relevant data had to be extrapolated from sub-group analyses of larger trials.
That investigators observed a 23% reduction in cardiovascular-related mortality among subjects taking ACE inhibitors comes as little surprise; providers have long prescribed ACE inhibitors to prevent cardiovascular disease, a known major complication of diabetes. That the routine use of ACE inhibitors was found to result in a 51% reduction in all-cause mortality was perhaps the less anticipated, yet equally promising, finding.
What is the link between ACE inhibitors and lowered risk of noncardiovascular-related deaths in patients with type 2 diabetes? "The exact benefit on noncardiovascular-related deaths is not known," reported Jeffrey A. Johnson, PhD, principal investigator on the study. "It is well known, however, that ACE inhibitors do provide protective effects in patients with diabetes. Renal disease is a major complication resulting in significant morbidity and mortality in this population. As a result, through the cardiovascular and renal protective effects, a substantial reduction in mortality can be expected with the use of ACE inhibitors."
Just how powerful are ACE inhibitors at preventing deaths in this patient population? Investigators estimate that to prevent one death, 12 newly treated patients with type 2 diabetes would need to be treated with an ACE inhibitor for about 4 years.
Although ACE inhibitors pose no specific contraindications in patients with type 2 diabetes, Johnson warned that certain patients should not take them. These include patients with arterial stenosis, impaired renal function, impaired liver function, and aortic stenosis. Patients prone to hypotension or hyperkalemia, or with a hypersensitivity to other agents in the class, should also avoid ACE inhibitors.
"Cautiously optimistic" describes the investigators' attitude toward the study results. "I think it is too early to start recommending routine use of ACE inhibitors in all newly diagnosed patients," said Johnson. "However, I think it is an issue that every physician should be discussing with their patients."
Will the study results influence clinical guidelines? "While this article could reasonably influence practice, it will not likely in and of itself change the American Diabetes Association's clinical guidelines," said Chris Saudek, MD, of Johns Hopkins University School of Medicine. "It is, though, an interesting and useful piece of accumulating evidence." {blacksquare}
© 2004 American Diabetes Association
