Lenox Internal Medicine

Well, here’s an interesting approach to preventing vascular complications in type II diabetes.

In this Lancet article, the researchers tried putting all patients on a fixed dose combination of ACE inhibitor and diuretic.

Traditional strategies set arbitrary blood pressure levels at which treatment is initiated and arbitrary goals against which treatment should be titrated. This strategy neglects those diabetic patients without what is typically defined as hypertension, and yet for whom blood pressure remains an important determinant of their risk of vascular disease. Additionally, this strategy is usually resource-intensive, needing multiple patient visits, careful monitoring of both blood pressure and side-effects, and the coordination of complex drug regimens. Perhaps partly as a consequence of such complexity, surveys of blood pressure control indicate that few patients receiving antihypertensive drugs achieve recommended goals for blood pressure.

The findings:

The relative risk of death from cardiovascular disease was reduced by 18%… and death from any cause was reduced by 14% … Although the confidence limits were wide, the results suggest that over 5 years, one death due to any cause would be averted among every 79 patients assigned active therapy.

We know that ACE inhibitors slow the progression of diabetic nephropathy. So they’re indicated for that, they’re indicated for hypertension - why not just put all diabetics on them?

I’m all for keeping things simple. All my type II diabetics can go on lisinopril, hydrochlorothiazide, metformin and simvastatin right off the bat - a sort of diabetic cocktail. This would save me an awful lot of monitoring and decision-making on each visit.

Of course, patients don’t like taking a lot of pills. Maybe we could just put them all in one big combination pill?

In all seriousness, I do think the next movement in diabetes care management may be toward simplification - i.e. rather than basing treatment decisions on separate pieces of patient data that need to be collected at various intervals (blood pressure, glycohemoglobin, microalbumin, LDL, etc.), base them on overall goals of reducing macrovascular and microvascular disease .