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 angiotensin-converting enzyme (ACE) inhibitors must be in preventing diabetic nephropathy to warrant early and routine therapy in all Pima Indians with type 2 diabetes mellitus.


METHODS
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.
Kiberd
B A
BA
Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
Jindal
K K
KK
D000293:Adolescent; D000328:Adult; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000191:economics* / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D020000:Decision Support Systems, Clinical; D003924:Diabetes Mellitus, Type 2 / Q000150:complications* / Q000191:economics*; D003928:Diabetic Nephropathies / Q000150:complications / Q000191:economics* / Q000209:etiology / Q000517:prevention & control*; D005260:Female; D006801:Humans; D015994:Incidence; D007198:Indians, North American; D007676:Kidney Failure, Chronic / Q000191:economics* / Q000209:etiology / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D011507:Proteinuria / Q000191:economics / Q000209:etiology / Q000517:prevention & control; D014481:United States
D000806:Angiotensin-Converting Enzyme Inhibitors