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Diuretics Effective for Seniors with Diabetes, High
Blood Pressure
Works as well as ACE-inhibitors and calcium channel
blockers
June 29, 2005 For senior citizens with diabetes,
which is almost 19 percent of those over 65, there was welcome news this
week from research saying diuretics work as well as ACE-inhibitors and
calcium channel blockers in protecting against heart attack and
improving survival, and offer more protection against congestive heart
failure.
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What American Diabetes Association says
about senior citizens and diabetes |
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June 2005 - Diabetes is the fifth-deadliest disease in
the United States. This year, more than 213,000 will die from
the disease and its related complications. The total annual
economic cost of diabetes in 2002 was estimated to be $132
billion, or one out of every 10 health care dollars spent in the
United States.
There are 18.2 million people in the United
States, or 6.3% of the population, who have diabetes. While an
estimated 13 million have been diagnosed, unfortunately, 5.2
million people (or nearly one-third) are unaware that they have
the disease.
Studies indicate that diabetes is generally
under-reported on death certificates, particularly in the cases
of older persons with multiple chronic conditions such as heart
disease and hypertension. Because of this, the toll of diabetes
is believed to be much higher than officially reported.
Prevalence
> Diabetes prevalence increases with
age.
> Approximately half of all diabetes cases occur in people
older than 55 years of age.
> The risk for type 2 diabetes increases with age.
Approximately 18.3% (8.6 million) of the United States
population age 60 and older have diabetes.
Seniors and diabetes-related complications
The complications of diabetes include heart
disease, stroke, vision loss/blindness, amputations and kidney
disease.
> Heart disease and stroke. More than
65% of people with diabetes will die of heart disease or stroke,
and they are likely to die younger that people who do not have
diabetes. People with diabetes have the same cardiovascular risk
as if they have already had a heart attack. People with diabetes
are 2 to 4 times more likely to have heart disease (more than
77,000 deaths due to heart disease annually). Heart disease
death rates are also 2 to 4 times as high as adults without
diabetes. And, people with diabetes are 2 to 4 times more likely
to suffer a stroke.
> Blindness due to diabetic retinopathy. Each year 12,000 to
24,000 people lose their sight because of diabetes. Diabetes is
the leading cause of new blindness in people 20-74 years of age.
> Kidney disease due to diabetic nephropathy. Ten to 21% of
all people with diabetes develop kidney disease. Diabetic
nephropathy is the leading cause of end-stage renal disease
(kidney failure), accounting for 43% of new cases. In 2000,
41,046 people with diabetes initiated treatment for end-stage
renal disease, and 129,183 people with diabetes underwent
dialysis or kidney transplantation. People with diabetes who are
over 65 years of age are twice as likely to be hospitalized for
kidney infections compared with those without diabetes.
> Nerve disease and amputations. About 60-70% of people with
diabetes have mild to severe forms of diabetic nerve damage,
which, in severe forms, can lead to lower limb amputations. In
fact, diabetes is the most frequent cause of non-traumatic lower
limb amputations. The risk of a leg amputation is 15-40 times
greater for a person with diabetes. Each year, 82,000 people
lose their foot or leg to diabetes. |
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The latest findings from the Antihypertensive and
Lipid-Lowering Treatment to Prevent Heart Attack Trial or ALLHAT,
sponsored by the National Heart, Lung, and Blood Institute, are
published in the June 27 issue of Archives of Internal Medicine.
ALLHAT is the largest study to compare these three
major classes of medications to treat high blood pressure. The study
originally reported in 2002 that diuretics were more beneficial as
initial treatment for high blood pressure for protecting against adverse
cardiovascular outcomes. This latest analysis shows that even among
diabetics and those with mildly elevated fasting glucose - a sign of
pre-diabetes - the less costly diuretics are at least as effective, may
be more beneficial for some people.
About 73 percent of adults with diabetes have high
blood pressure - which in diabetic patients is defined as greater than
or equal to 130/80 mm Hg - or use prescription medications for their
hypertension. Both diabetes and high blood pressure are major risk
factors for coronary heart disease, and when both are present,
significantly increase the risk for developing heart and kidney
diseases. High blood pressure can lead to congestive heart failure, a
condition in which the heart is weakened and cannot pump enough blood
throughout the body.
Controlling high blood pressure is an urgent
concern especially for people with diabetes. Our findings demonstrate
the advantages of diuretics in diabetics as well as in those with
impaired and normal fasting glucose levels, said NHLBI director Dr.
Elizabeth G. Nabel. As a physician, I have seen the consequences of
poorly controlled hypertension and diabetes. These results show many
people and their families can be spared that devastation.
The ALLHAT blood pressure study was a randomized,
double-blind trial involving 42,418 participants with high blood
pressure, ages 55 and older. Of those, 31,512 participants were randomly
assigned to a diuretic (chlorthalidone); a calcium channel blocker (amlodipine);
an angiotensin converting enzyme (ACE) inhibitor (lisinopril). 13,101
had diabetes, 1,399 had elevated fasting glucose and 17,012 had normal
glucose levels.
Compared with the ACE inhibitor and the calcium
channel blocker, the diuretic was:
> More protective against congestive heart
failure in patients both with and without diabetes (by about 1/6
compared with the ACE-inhibitor, and by about 1/3 compared with the
calcium channel blocker).
> More effective in lowering systolic blood pressure the measure
of blood pressure when the heart beats among those with and without
diabetes.
> At least equally protective against fatal coronary heart disease
or non-fatal heart attacks in people with diabetes, those with elevated
fasting glucose, and non-diabetics.
> Equally protective against death from all causes, end-stage kidney
disease, or cancer in people with diabetes, those with elevated fasting
glucose, and non-diabetics.
> In Black study participants, more protective against stroke in
people with and without diabetes (compared with the ACE-inhibitor).
This study shows the advantage of diuretics for
preventing congestive heart failure in most people with high blood
pressure regardless of diabetes status. Because some patients may
respond differently to medications, they should discuss these results
and their treatment with their doctors before making any changes,
advises Dr. Jeffrey Cutler, NHLBI Senior Adviser.
There were more heart attacks among participants
with impaired fasting glucose taking the calcium channel blocker
compared with those taking the diuretic. This finding was unexpected and
inconsistent with other results and may have occurred just by chance,
according to Cutler.
Previous studies have found that ACE inhibitors
slow progression of kidney damage in diabetic patients with kidney
disease, who generally have protein in their urine. ALLHAT did not
collect urine samples to measure protein (albumin) levels so analyses as
to whether the ACE inhibitor was superior to the diuretic in this
respect is not possible. However, an ALLHAT report in the April 25
Archives of Internal Medicine found no difference among the treatments
in progression of kidney disease among diabetic patients with reduced
kidney function.
NHLBI is part of the National Institutes of Health
(NIH), the Federal Governments primary agency for biomedical and
behavioral research. NIH is a component of the U.S. Department of Health
and Human Services. NHLBI press releases and other materials including
information about high blood pressure and heart disease are available
online at
www.nhlbi.nih.gov. Current guidelines on high blood pressure
treatment can be found at
http://www.nhlbi.nih.gov/guidelines/hypertension/index.htm.
The National Institutes of Health (NIH) The
Nation's Medical Research Agency is comprised of 27 Institutes and
Centers and is a component of the U. S. Department of Health and Human
Services. It is the primary Federal agency for conducting and supporting
basic, clinical, and translational medical research, and investigates
the causes, treatments, and cures for both common and rare diseases. For
more information about NIH and its programs, visit
www.nih.gov.
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