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Should All Pima Indians With Type 2 Diabetes Mellitus Be Prescribed Routine Angiotensin-Converting Enzyme Inhibition Therapy to Prevent Renal Failure?

      Objective

      To determine how effective angiotensinconverting enzyme (ACE) inhibitors must be in preventing diabetic nephropathy to warrant early and routine therapy in all Pima Indians with type 2 diabetes mellitus.

      Design

      A computerized medical decision analysis model was used to compare strategy 1, screening for microalbuminuria and treatment of incipient nephropathy as currently recommended with ACE inhibitor therapy, with strategy 2, a protocol wherein all patients were routinely administered an ACE inhibitor 1 year after diagnosis of type 2 diabetes mellitus. The model assumed that ACE inhibitors can block, at least in part, the pathogenic mechanisms responsible for early diabetic nephropathy (microalbuminuria).

      Results

      The model predicted that strategy 2 would produce more life-years at less cost than strategy 1, if routine drug therapy reduced the rate of development of microalbuminuria by 21% in all patients. Only a 9% reduction in the rate of development of microalbuminuria was cost-effective at $15,000 per additional life-year gained, and only a 2.4% reduction was cost-effective at $75,000 per additional life-year gained for strategy 2 over strategy 1.

      Conclusions

      Routine ACE inhibitor therapy in Pima Indians with type 2 diabetes mellitus could prove more effective and even cost saving than the currently recommended approach of microalbuminuria screening. A prospective trial examining this goal should be considered.
      ACE (angiotension-converting enzyme), ESRD (end-stage renal disease)
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      References

        • Ismail N
        • Becker B
        • Strzelczyk P
        • Ritz E
        Renal disease and hypertension in non-insulin-dependent diabetes mellitus.
        Kidney Int. 1999; 55: 1-28
        • Sievcrs ML
        • Nelson RG
        • Knowler WC
        • Bennett PH
        Impact of NIDDM on mortality and causes of death in Pima Indians.
        Diabetes Care. 1992; 15: 1541-1549
        • Gohdes D
        • National Diabetes Data Group
        Diabetes in North American Indians and Alaska Natives.
        in: Diabetes in America. 2nd ed. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bcthesda, Md1995: 683-701 (NIH publication 95-1468.)
        • Nelson RG
        • Newman JM
        • Knowler WC
        • et al.
        Incidence of end-stage renal disease in type 2 (non-insulin-dependent) diabetes mellitus in Pima Indians.
        Diabetologia. 1988; 31: 730-736
        • 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: 107-112
        • Morgenscn CE
        • Keanc WF
        • Bennett PH
        • et al.
        Prevention of diabetic renal disease with special reference to microalbuminuria.
        Lancet. 1995; 346: 1080-1084
        • Ravid R
        • Brosh D
        • Levi Z
        • Bar-Dayan Y
        • Ravid D
        • Rachmani R
        Use of cnalapril to attenuate decline in renal function in normo-tensive, normoalbuminuric patients with type 2 diabetes mellitus: a randomized controlled trial.
        Ann Intern Meet. 1998; 128: 982-988
        • World Health Organization Study Group
        Prevention of Diabetes Mellitus. World Health Organization, Geneva, Switzerland1994 (Technical Report Series, No. 844)
        • Siegel JE
        • Krolewski AS
        • Warram JH
        • Weinstein MC
        Cost-effectiveness of screening and early treatment of nephropathy in patients with insulin-dependent diabetes mellitus.
        J Am Soc Nephrol. 1992; 3: Slll-S119
        • Kiberd BA
        • Jindal KK
        Screening to prevent renal failure in insulin dependent diabetic patients: an economic evaluation.
        BMJ. 1995; 311: 1595-1599
        • Nelson RG
        • Knowler WC
        • Pettitt DJ
        • Hanson RL
        • Bennett PH
        Incidence and determinants of elevated urinary albumin excretion in Pima Indians with NIDDM.
        Diabetes Care. 1995; 18: 182-187
        • Kunzclman CL
        • Knowler WC
        • Pettitt DJ
        • Bennett PH
        Incidence of proteinuria in type 2 diabetes mellitus in the Pima Indians.
        Kidney Int. 1989; 35: 681-687
        • Nelson RG
        • Bennett PH
        • Beck GJ
        • et al.
        Diabetic Renal Disease Study Group. Development and progression of renal disease in Pima Indians with non-insulin dependent diabetes mellitus.
        NEngt JMed. 1996; 322: 1636-1642
      1. Drug Topics Red Book 1997. Medical Economics, Montvale, NJ1997
        • US Renal Data System
        USRDS 1997 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Md1997
        • Nelson RG
        • Hanson RL
        • Pettitt DJ
        • Knowler WC
        • Bennett PH
        Survival during renal replacement therapy for diabetic end-stage renal disease in Pima Indians.
        Diabetes Care. 1996; 19: 1333-1337
        • EUCLID Study Group
        Randomised placebo-controlled trial of lisinopril in normotensive patients with insulin-depcndunl diabetes and normoalbuminuria or microalbuminuria.
        Lancet. 1997; 349: 1787-1792
        • Siegel JE
        • Weinstein MC
        • Russell LB
        • Gold MR
        Recommendations for reporting cost-effectiveness analyses.
        JAMA. 1996; 276: 1339-1341
        • Laupacis A
        • Fceny D
        • Dctsky AS
        • Tugwell PX
        How attractive docs a new technology have to be to warrant adoption and utilization'7 tentative guidelines for using clinical and economic evaluations.
        CMAJ. 1992; 146: 473-481
        • Lwanga SK
        • Lemeshow S
        Sample Size Determination in Health Studies. World Health Organization, Geneva, Switzerland1991
        • Johnson JA
        • Nowat/ki TE
        • Coons SJ
        Health-related quality of life of diabetic Pima Indians.
        Med Care. 1996; 34: 97-102
        • UK Prospective Diabetes Study Group
        Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39.
        BMJ. 1998; 317: 713-720
        • Kiberd BA
        • Jindal KK
        Routine treatment of insulin-dependent diabetic patients with ACE inhibitors to prevent renal failure: an economic evaluation.
        Am J Kidney Dis. 1998; 31: 49-54