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October 24, 2002

Complications

Question from Placentia, California, USA:

I'm in my early 40s, have well-controlled type 1 diabetes (hemoglobin A1c: 5.9-6.1%) using a multiple injection regimen, and for six months, my endocrinologist and I debated about the preventative benefits that ACE inhibitors afforded before I finally, reluctantly, consented, and now she's also suggesting a cholesterol drug. Another endocrinologist I visited in an effort to garner a second opinion, says he wouldn't prescribe either medications since my numbers are all good, and there are no signs indicating problems. What's the current school of thought? Are these two drugs really beneficial for prevention?

Answer:

The use of ACE inhibitors in patients without microalbumin or elevated blood pressure is a controversial issue. Personally, I do not prescribe these drugs in individuals without the above mentioned conditions. Since approximately 25% people with type�2 and 33% of people with type�1 diabetes go on to develop progressive renal impairment, there is a large number that may not see the benefits of the drug. However, in those who do have microalbuminuria or hypertension, there is very good data to support the practice. Studies are underway that are actually looking at patients who have been put on ACE inhibitors without any problems that are evident. The investigators are looking to see if this medication, used in this way, will decrease the development of kidney or heart problems.

The story for cholesterol lowering is somewhat similar. Most recommendations for cholesterol management suggest that LDL-cholesterol (the bad cholesterol) should be maintained at levels less than 100 mg/dl. To treat individuals with LDL-cholesterol for numbers below this is questionable. Some people have justified it on the basis that href=”/dctionary/t.htm#triglycerides”>triglycerides may also be high and HDL-cholesterol (good cholesterol) is low. Here again, population studies are being performed that will allow us to test this type of strategy. The big problem is the answer is not available now.

In the absence of information, it should be kept in mind that these medications are not cheap and are associated with side effects. For people with type 2 diabetes, where heart, lipid, and vascular problems are more common than in type 1 diabetes, it should be expected that patients will have multiple medications to address the risks. Success in the management of type 2 diabetes is coupled to successful management of multiple risk factors. It is not possible to treat one problem and not the others and still get the best results.

JTL

[Editor’s comment: An inexpensive medication that most adults with diabetes should be taking to help decrease risk is aspirin.

WWQ]