NEW HIGH BLOOD PRESSURE STUDY

One of the ramifications of diabetes is nephropathy, diabetic kidney disease. It has been known for some time that ACE (angiotensin-converting enzyme) Inhibitors, a class of blood pressure medications, have been effective in reducing kidney disease in patients with type 1 diabetes. It was assumed these medications would be equally effective in cases of type 2 diabetes. A Los Angeles, California study of the efficacy of different blood pressure reduction therapies has suggested otherwise.

Harry J. Ward, MD, Professor of Medicine at UCLA, and his colleagues recently presented a paper to the American Society of Hypertension, which showed that, for his study subjects (1100 inner-city African-Americans, Hispanics, and poor Whites, 241 with type 2 diabetes, 40% of them showing microalbuminuria or proteinuria) the fact of blood pressure reduction is more important than the means. If you get the blood pressure down, the study suggests, the rate of kidney disease will drop.

One hundred fifty five of the study's diabetic patients had their hypertension treated with ACE inhibitors. Eighty-six were treated with other medications, such as calcium channel blockers, alpha-blockers, or diuretics.

Reasoning that patient compliance may be as important as class of medication, Dr. Ward's study also compared the efficacy of four different behavioral approaches:

* Traditional care, where patients merely visited the doctor and received their prescription;

* Exit interviews, where patients received individualized counseling sessions to reinforce their understanding of treatment instructions;

* Computerized tracking, by which patients received timely reminders to visit the clinic; and

* Home visits/focus groups, involving visits by community workers to patients' homes to assess problems with patient compliance, and to work with patients' families, spouses etc., to improve compliance.

What did they find? After four years of follow-up, the investigators observed no significant difference in the rate of diabetic kidney disease progression (how fast it got worse) between those study participants treated with ACE inhibitors and those treated with other therapies. They also found that the "biobehavioral" interventions offered by the study significantly improved patient compliance, and were a major component in the success of any one of the therapies.

Dr. Ward noted that although in type 1 diabetes ACE inhibitors have been demonstrated to be the best choice for kidney protection, in type 2 the ACE inhibitors were not necessarily better than the other anti-hypertensives tested. It appears that for type 2 diabetics who suffer from hypertension and nephropathy, the need to get the blood pressure down is more important than the class of medications used to do so.

Dr. Ward also noted there are still unanswered questions, and that several more studies of type 2 diabetes and hypertension are currently underway to answer them. Two studies he mentioned involve the new angiotensin receptor antagonists (Losartan and Irbesartan). When they are reported (in two or three years), we should have a much better idea which are the best therapies for high blood pressure and type 2 diabetes.