Health Services Research & Development

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2006 HSR&D National Meeting Abstract


1045 — Prescription of Diuretics with Angiotensin System Inhibitors in Diabetes and Chronic Kidney Disease

Author List:
Kern EO (Case Western Reserve University and Louis Stokes Cleveland Dept of Veterans Affairs Medical Center)
Tiwari A (Dept of Veterans Affairs- New Jersey Health Science Center)
Tseng CL (Dept of Veterans Affairs- New Jersey Health Science Center)
Miller DR (Center for Health Quality, Outcomes and Economic Reserach/ Boston University School of Public Health)
Aron DS (Case Western Reserve University and Louis Stokes Cleveland Dept of Veterans Affairs Medical Center)
Pogach L (Dept of Veterans Affairs- New Jersey Health Science Center)

Objectives:
Angiotensin converting-enzyme inhibitors or angiotensin receptor blockers (ACE-I/ARB) can slow progression of renal disease in patients with diabetic nephropathy, but treatment may be hindered by the side effect of hyperkalemia. The study objective was to determine whether concurrent treatment with potassium-wasting diuretics increased the likelihood of treatment with ACE-I/ARB in Veterans Administration (VA) patients with diabetes and chronic kidney disease (CKD).

Methods:
VA patients with diabetes in 1999-2000 identified from the Diabetes Epidemiology Cohorts were classified as having Stage 3 or 4 CKD using a validated equation to estimate glomerular filtration rate. We identified 82,163 such patients of whom 87% were dually enrolled in Medicare. After excluding 8,821 patients receiving prescriptions for potassium-sparing diuretic agents, we evaluated the association of ACE-I/ARB prescription by VA practitioners with concurrent prescription of potassium-wasting diuretics, controlling for nephrology care received either from the VA system or Medicare.

Results:
VA practitioners prescribed ACE-I/ARB for 66.1% of 82,163 veterans with diabetes and Stage 3 or 4 CKD. Those receiving specialty Nephrology care were more likely to receive a prescription for ACE-I/ARB (69.9% vs. 65.6%, p<.0001) and to have a prescription for potassium-wasting diuretics (71.5% vs. 51.8%, p <.0001). Controlling for Nephrology care, practitioners were 5.3 times more likely (p<.0001) to prescribe ACE-I/ARB if potassium-wasting diuretics were also prescribed.

Implications:
More than one third of VA patients with diabetes and CKD fail to be prescribed ACE-I/ARB by VA practitioners, and treatment in specialty Nephrology care only slightly increases the frequency of ACE-I/ARB prescription. The strong association of a prescription for potassium-wasting diuretics with a prescription for ACE-I/ARB suggests that concurrent treatment with these medications may ameliorate the hyperkalemia induced by ACE-I/ARB and reduce an important barrier to use of ACE-I/ARB in clinical practice.

Impacts:
Approximately 30% of VA patients with diabetes have Stage 3 or 4 CKD and diabetes is the largest cause of end-stage renal disease (ESRD). Increasing the number of patients treated with ACE-I/ARB may reduce cases of ESRD. Educating practitioners to prevent ACE-I/ARB-induced hyperkalemia by concurrent prescription of potassium-wasting diuretics may allow greater use of ACE-I/ARB among veterans with diabetes and CKD.