Treating all patients with type 2 diabetes with ACE inhibitors reduces health costs.

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Renal disease is one of the most devastating and costly complications of diabetes.  A recent economic evaluation assessed whether routine use of ACE inhibitors in type 2 diabetes is cost-effective.

Clinical question:

In type 2 diabetes, are ACE inhibitors cost-effective for preventing renal disease?

The study compared three strategies:

  1. treat all patients at the time of their diagnosis of diabetes,
  2. screen for microalbuminuria once a year and treat patients with positive results,
  3. screen for macroalbuminuria (proteinuria) once a year and treat patients with positive results.

The evidence:

Evidence of efficacy was derived from existing meta-analyses, and costs were based on Dutch standards.  The main cost elements were drug, prescribing costs, screening costs and cost of care in end-stage renal disease.

The analysis showed that ACE inhibitors reduced overall health costs by preventing progression of renal disease.  This conclusion was tested by sensitivity analysis.

Appraisal hints

Users of this research should consider:

  • Whether all of the important costs have been considered.
  • The robustness of sensitivity analysis.
  • Potential adverse effects of ACE inhibitors.
  • Are the costs and QALYs realistic for your setting?


The full text of the original evaluation is available online:

Adarkwah CC, Gandjour A, Akkerman M, Evers SM. Cost-effectiveness of angiotensin-converting enzyme inhibitors for the prevention of diabetic nephropathy in the Netherlands: a Markov model. PLoS ONE 2011; 6(10):e26139.

The critical appraisal of this paper can be found on the DARE website.

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I am an information scientist with an interest in making knowledge from systematic research more accessible to people who need it. This means you. I've been attempting this in the area of Evidence-Based Health Care since 1995. So far the results have been mixed. For some reason we expected busy clinicians to search databases and appraise papers instead of seeing patients. We also expected publishers to make the research freely available to the people who paid for it.. Ha! Hence The National Elf service.

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