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Diabetes

Diabetes, age 21 prescribed altace

06/21/2005

Question:

I`ve been given Altace (ramipril, a drug in the class known as ACE inhibitors which are used to treat high blood pressure and diabetic kidney disease) and Lipitor (atorvastatin, a drug in the class known as "statins" which control cholesterol). My DR says my cholesterol is okay but I should take these drugs anyway. Am I too young? and should I get a 2nd opinion? I`ve had type 1 diabetes for 6 years. I`m male age 21. I smoke but am trying to quit.

Answer:

You have hit on a difficult question with broad application to many people.  Drugs in both of these classes have been recommended very broadly for people with certain types of diabetes within certain age ranges - but the essential question is whether these recommendations which are based on studies of population groups that differ from you are still applicable in your situation.

 Before we discuss this, let me say at the outset that nobody "knows" the right answer and that different doctors may well come to different judgements in a given situation and they may come to different judgements depending on the individual issues in the person they are helping to make a decision.

Regarding the ramipril, the clear cut reason to consider it is that there is good evidence that drugs in its class protect against worsening diabetic kidney disease (nephropathy).  There is also evidence that ramipril itself may protect against heart attacks.  While I haven't looked at the studies in a while, I am pretty sure that the conclusions about heart disease are based on older people than you and most likely people with type 2 diabetes.  It is a relatively safe drug but there is some risk of very uncommon severe reactions. My own approach has been to start the drug when a test called urine microalbumin starts to show an abnormal result, the earliest evidence of kidney disease.  I based this on the fact that one third of people with diabetes will never develop significant kidney disease.  However that approach doesn't take account of the heart risk benefits of the drug. 

Regarding the atorvastatin, it was originally prescribed only to people with high levels of LDL (so-called "bad") cholesterol.  However, there have been some studies recently, again, I believe done in older people than you who predominantly had type 2 diabetes, that show that this class of drugs reduces heart attack risk.

In both of these cases, there are arguments that the basic principles of how the heart and kidney disease processes are similar in both forms of diabetes.  The opposite argument is that these particular drugs have been around for less than 10 years and drugs in their classes have been on the market for 20-25 years and that you would be committed to a much longer duration of therapy starting at your young age.

So those are the general principles involved - I don't think I can give a more specific answer without knowing more about the individual involved.  This is an illustration of how the facts may appear different to a doctor when there is a specific patient sitting in front of him/her - this really calls for individual judgement.  Given that you don't precisely "fit the mold," I personally would want to make this particular judgement with a doctor who has a great deal of experience with different forms of diabetes and knows these issues well.  It is very controversial right now and the decision should not be made once and for all but considered subject to change as the evidence changes and your situation changes.

For more information:

Go to the Diabetes health topic, where you can:

Response by:

University of Cincinnati Robert M Cohen, MD
Professor of Clinical Medicine
Division of Endocrinology and Metabolism
Department of Internal Medicine
College of Medicine
University of Cincinnati
Robert M Cohen, MD