Most, if not all, elderly people with diabetes have at least one indication for ACE inhibitors or angiotensin receptor blockers, but only about 40% are receiving the drugs, according to a national survey.
“Given that indications for ACE/ARB therapy are so prevalent in this population, it may be time to simplify our treatment algorithms by expanding indications … to include all older individuals with diabetes regardless of their measured risk factors,” said Dr. Allison B. Rosen of the University of Michigan Health Systems, Ann Arbor.
Dr. Rosen analyzed data from 4 years of the National Health and Nutrition Examination Survey to calculate the proportion of older diabetic patients with clinical indications for ACE inhibitors or ARBs. Her study sample included 742 respondents who represented over 8 million Americans aged 55 years or older who have diabetes.
A total of 92% of the respondents had at least one indication besides diabetes for the medications, according to several sets of guidelines. These indications included albuminuria, cardiovascular disease, congestive heart failure, and hypertension.
Two other risk factors—hyperlipidemia and smoking—are listed as indications on some guidelines, and patients with these risk factors are believed to benefit from ACE inhibitor or ARB therapy. When these indications were added to the list, 100% of the respondents had at least one indication for the medications, Dr. Rosen said.
Yet despite this “nearly universal” indication for treatment, only 43% of the respondents were taking an ACE inhibitor or an ARB, she said (J. Gen. Intern. Med. 2006;DOI:10.1111/j.1525–1497.2006.00351.x).
Of particular note, 53% of those with diabetes and four or more additional indications were taking the drugs, a “disturbingly low” rate for such high-risk patients. The likelihood that these clearly needy patients would actually be receiving appropriate medication “was not much higher than the toss of a coin,” she commented.
Moreover, patients with albuminuria and preexisting cardiovascular disease, two key indications that should invariably prompt a physician to prescribe ACE inhibitors or ARBs, had the same low rate of use as patients who didn't have these crucial risk factors.
Dr. Rosen described her study as “the first nationally representative study to ask what proportion of older patients with diabetes would benefit from renin-angiotensin system blockade.”