Winkelmayer WC et al. (2005) Underuse of ACE inhibitors and angiotensin II receptor blockers in elderly patients with diabetes. Am J Kidney Dis 46: 1080–1087

US guidelines recommend that diabetic patients with nephropathy, hypertension, or both, use angiotension-converting-enzyme (ACE) inhibitors or angiotension-II receptor blockers (ARBs) to help slow progression of chronic kidney disease. Winkelmayer et al. used Medicare data to explore application of these guidelines to treatment of elderly diabetic patients (≥65 years) who were eligible to receive comprehensive drug treatment from the state of Pennsylvania in 2002. Patients with end-stage renal disease were excluded from the analysis.

The primary outcome was the filling of a prescription for either an ARB or an ACE inhibitor during January–March 2003. Of the 30,750 eligible diabetic patients (mean age 78.4 ± 6.4 years, 81% female), 21,138 had received a diagnosis of hypertension, nephropathy, or both. Although these patients were eligible for comprehensive drug treatment with minimal copayments, only 50.7% of diabetic patients with hypertension and/or proteinuria filled a prescription for an ACE inhibitor or ARB during the 3-month period. Older patients (75–84 years and ≥85 years) were significantly less likely to fill a prescription for the drugs than patients aged 65–74 years (P = 0.01 and P <0.001, respectively). Patients with proteinuria but not hypertension were less likely to fill a prescription for the drugs than patients with hypertension only (P = 0.03).

The authors conclude that renoprotection guidelines were not being followed in the elderly diabetic patients they studied, but acknowledge that the study did not assess whether this was because drugs were not prescribed by physicians or because prescriptions were not filled by patients.