Can we further slow down the progression to end-stage renal disease in diabetic hypertensive patients?

Rational pharmacotherapy in the diabetic hypertension: analysis-prescribing patterns in a general hospital in Taiwan

OBJECTIVES

To examine prescribing at a 2800-bed hospital, also providing ambulatory services for 9000 visits per day, with a view to assessing the extent to which it followed international guidelines for treating diabetic hypertension.

METHOD

Patients receiving antidiabetic and antihypertensive drugs concomitantly during the 4-week study period were included.

RESULT

Of the 5015 eligible patients, most received combination antidiabetic therapy. Oral antidiabetic agents used alone or in combination included (in descending order) metformin, glibenclamide, gliclazide, glipizide, glimepiride and alpha-glucosidase inhibitors. Gliclazide accounted for most of the oral antidiabetic drug expenditure. Sulfonylurea plus metformin was the most popular regimen. Prescriptions for long-acting sulfonylureas did not differ between elderly and younger patients. For blood pressure control, calcium-channel blockers were most commonly used alone and overall, although current guidelines suggest that they should be second-line treatments. Inappropriate use of immediate-release nifedipine was noted. The combination, atenolol >100 mg/day and hydrochlorothiazide 50 mg/day (or an equivalent) were extensively used. Among 54.7% patients treated with combination antihypertensives, calcium-channel blockers and an angiotensin-converting enzyme inhibitor were most commonly used.

CONCLUSION

Most diabetic hypertensive patients were treated with combination therapy for glucose and blood pressure control. Prescriptions for antihypertensive drugs often differed from current guidelines, especially in the choice of agents and their combinations.

Prescribing patterns and therapeutic implications for diabetic hypertension in Bahrain

OBJECTIVE

To determine drug prescription patterns and the extent of conformity with World Health Organization/international Society of Hypertension (WHO/ISH) guidelines in diabetic hypertension.

DESIGN

Retrospective prescription-based survey.

SETTING

Seven primary-care health centers, comprising approximately one-third of primary-care health centers in Bahrain.

PATIENTS

Patients with type 2 diabetes and hypertension.

MAIN OUTCOME MEASURE

The prescribing pattern of antihypertensive and antidiabetic drugs.

RESULTS

Among a study sample of 1,463 patients with type 2 diabetes and hypertension, antidiabetic agents were prescribed as monotherapy in the following descending order: glyburide, gliclazide, insulin, and metformin. As combinations, sulfonylureas plus metformin was most popular, followed by metformin plus insulin, and sulfonylureas plus insulin. Sulfonylurea and metformin with insulin was rarely used. There was no significant difference in prescribing of glyburide and metformin between the elderly and young middle-aged diabetic patients; many patients older than 65 years were treated with a beta-blocker along with a long-acting sulfonylurea. Both as monotherapy and in overall use, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and calcium-channel blockers were most often prescribed. Among 35.5% patients treated with antihypertensive combinations, various two- and three-drug combinations of beta-blockers, ACE inhibitors, calcium-channel blockers, and diuretics were often used. The proportion of patients taking atenolol 100 mg/d was higher with combination regimens. Hydrochlorothiazide 25 mg or equivalent thiazide diuretics were extensively used.

CONCLUSIONS

The prescribing pattern of antihypertensives in diabetic hypertension differs in many instances from WHO/ISH guidelines, especially regarding the choice of antihypertensive drugs and their combinations. The appropriateness of antidiabetic drug choice is questionable in relation to the antihypertensive used.

Effect of nitrendipine and nisoldipine on renal structure and function in long-term experimental diabetes in rats

This study investigates the efficacy of late intervention with the calcium channel blockers (CCBs) nitrendipine and nisoldipine in preventing development of albuminuria and glomerular hypertrophy in experimental diabetes. Streptozotocin (STZ)-induced diabetic rats were treated with nitrendipine or nisoldipine for 6 weeks after 3 or 6 months of untreated diabetes. The CCBs were administered in the fodder in a concentration of 250 mg/kg. After 3 months of untreated diabetes, nitrendipine treatment for 6 weeks significantly reduced urinary albumin excretion (UAE; P < 0.05) and glomerular hypertrophy. Nitrendipine also prevented an increase in systemic blood pressure compared with untreated diabetes. Nisoldipine showed no significant effect on UAE or glomerular hypertrophy despite systemic blood pressures similar to those of the diabetic nitrendipine-treated group. After 6 months of untreated diabetes, treatment with nitrendipine or nisoldipine for 6 weeks did not show effects on UAE, glomerular hypertrophy, or systemic blood pressure. No effect was found on renal growth in the treatment groups, and neither nitrendipine nor nisoldipine had any effect on body weight, blood glucose level, or food intake.

Effect of the calcium channel blocker nitrendipine in normotensive and spontaneously hypertensive, diabetic rats on kidney morphology and urinary albumin excretion

OBJECTIVE

To investigate the effect of nitrendipine on the development of renal changes in experimental diabetes.

DESIGN

Streptozotocin (STZ)-induced diabetic normotensive Wistar rats (WIS) and spontaneously hypertensive rats (SHR) were randomly allocated to nitrendipine treatment (250 mg/kg fodder) or placebo treatment for 6 months.

METHODS

Blood pressure was assessed by the tail-cuff method, urinary albumin excretion (UAE) was determined, and glomerular basement membrane (GBM) thickness, mesangial volume, and mean glomerular volume (MGV) were estimated by morphometric measurements.

RESULTS

In diabetic WIS, nitrendipine significantly reduced UAE after 2 months of treatment (P< 0.05), while no effect was was seen after 4-6 months. In diabetic SHR, no effect on UAE was seen at any time. Nitrendipine was unable to inhibit the renal and glomerular enlargement in diabetic WIS and SHR. Diabetes plus hypertension was associated with significant increase in GBM thickness, while diabetes or hypertension alone showed no significant increase in GBM. Nitrendipine treatment was unable to prevent increased GBM in diabetic SHR.

CONCLUSION

Nitrendipine inhibits an early increase in UAE in normotensive, diabetic rats, but fails to sustain this effect in long-term diabetes. No effect of nitrendipine was observed in SHR.

Antihypertensive drugs and diabetic nephropathy

Diabetic nephropathy is the most common cause of end-stage renal disease in the United States. Hypertension is a major risk factor that predisposes individuals with diabetes to the development of renal disease and is very common in patients with diabetes. The benefit of blood pressure control on the rate of progression of diabetic nephropathy is being increasingly demonstrated in both type 1 and type 2 diabetic patients. Angiotensin converting enzyme inhibitors have proven renoprotective benefits in human studies, but the results of studies with calcium channel blockers are somewhat inconclusive. The other classes of antihypertensives also may have certain indications in the population of patients with diabetic nephropathy. In this paper we will critically review current strategies for the treatment of hypertension in patients with established diabetic nephropathy.