CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 2, March/April 2011
98
AFRICA
Opinions in Hypertension Management
Affordable hypertension therapy for diabetic patients
Type 2 diabetes is one of the most expen-
sive chronic diseases to treat, and in South
Africa, with prescribed minimum bene-
fits (PMB) applying to this disease, both
private and public-sector funders are on
the alert for cost-benefit issues. Perhaps
one of the cost-benefit issues funders
have missed is the current and future
savings that can be made with effective
anti-hypertension therapy from the outset
at diabetes diagnosis.
Initial choice of anti-hypertensive
defines preventative strategies
Achievement of blood pressure goals
early in a patient’s blood pressure-control
strategy influences compliance. In a study
of blood pressure treatment in a health
maintenance organisation (HMO) in the
United States, changes in anti-hyperten-
sive therapy were investigated in patients
whose initial therapy was angiotensin
converting enzyme inhibitors (ACEIs),
angiotensin receptor blockers (ARBs) or
calcium channel blockers (CCBs).
1
Achievement of blood pressure goals
was highest for initiators with ARBs
as the therapeutic regimen (81.4%),
compared with ACEIs (75.5%) and CCBs
(68.9%). Adherence to therapy and need
for therapeutic change was significantly
least likely among ARB recipients (60%)
compared with ACEI (72%) and CCB
recipients (75%).
Although patients do require modi-
fication of hypertensive therapy over
time, it is clear that the initial choice
of anti-hypertensive therapy should be
carefully considered, particularly for
diabetic patients who need to reach lower
blood pressure targets than non-diabetic
patients.
ARBs in diabetic patient care:
cost trends
There are compelling indications for the
use of ARBs as the anti-hypertensive
agent of choice for patients with the
metabolic syndrome, in type 2 diabetes
patients with microalbuminuria or albu-
minuria (or even before these conditions
develop), and in patients who have expe-
rienced a myocardial infarction or those
with left ventricular hypertrophy.
2
Probably the largest factor affecting
the appropriate use of ARBs is cost.
However, experience with the generi-
fication of ACE inhibitors shows that
prescribing an ARB now will be defla-
tionary in the future.
A study in the USA of Medicaid costs
3
has shown that on generification, expend-
iture per ACE inhibitor claim dropped by
59% from 1991 to 2008, after adjusting
for inflation for the period. This scenario
of deflation in ACE inhibitor costs is like-
ly to be repeated in the ARB environment.
Avoiding new-onset diabetes
Atrial hypertension presents a risk factor
for the development of type 2 diabetes,
while some anti-hypertensive therapies
can promote the development of type 2
diabetes. It is well known for example that
β
-blockers and diuretics impair glucose
metabolism, while studies indicate that
the use of ACE inhibitors and ARBs lead
to fewer cases of new-onset diabetes.
4
In ONTARGET (ONgoing Telmisartan
Alone and in combination with Ramipril
Global Endpoint Trial), the incidence of
diabetes was diagnosed in 366 (6.7%)
of the patients in the ramipril group and
399 (7.5%) patients treated with telmisar-
tan, showing no significant differences
among the groups, and demonstrating that
telmisartan is effective in preventing new-
onset diabetes.
In the TRANSCEND trial where
telmisartan was compared with placebo,
telmisartan treatment resulted in a further
15% relative risk reduction in new-onset
diabetes despite high statin usage.
Preventing renal disease in
diabetic patients
ACE inhibitors and ARBs that inhibit the
renin–angiotensin system are recognised
as first-line therapy in the prevention of
diabetic kidney disease.
5
Telmisartan provides renal benefit at all
stages of the renal disease continuum in
patients with type 2 diabetes. It improves
endothelial function in patients with
normoalbuminuria, delays the progres-
sion to overt nephropathy in patients with
microalbuminuria, and reduces proteinu-
ria in patients with macroalbuminuria.
Effectiveness of telmisartan is compa-
rable to that of ACE inhibitors, but with
greater tolerability. The effect of telmisar-
tan on protein excretion in diabetic
nephropathy appears to be better than
that of losartan and equivalent to that of
valsartan.
In conclusion, telmisartan offers effec-
tive hypertension therapy for diabetic
patients and costs are likely to be defla-
tionary as generification extends in the
ARB market.
6
J Aalbers, Special Assignments Editor
1. Engel-Nitz NM,
et al
. Antihypertensive
medication changes and blood pressure goal
achievement in a managed care population.
J
Hum Hypertens
2010;
24
(10): 659–668.
2. Rayner B. How do recent developments
affect the angiotensin receptor blockers as
a class.
Cardiovasc J Afr
2009;
20
(2): 145.
3. Brian B,
et al
. ACE inhibitor and ARB
utilization and expenditures in the Medicaid
fee – for service program from 1991 to 2008.
J Manag Car Pharm
2010;
16
(9): 671–679.
4. Grimm C,
et al
. New onset diabetes and
antihypertensive treatment. GMS Health
Technology Assessment. 16 March
2010;doi:10.3205/hta000081.
5. The Ontarget investigators: telmisartan,
ramipril, or both in patients at high risk
for vascular events.
N Engl J Med
2008;
358
(15): 1547–1559.
6. Schmieder RE, Bakris G, Weir MR.
Telmisartan in incipient and overt diabetic
renal disease. DOI:10.5301/JN.2011.6416.
