Important Treatment Gaps in Vascular Protection for the Elderly After Type 2 Diabetes Therapy Initiation

Background: Canadian practice guidelines recommend the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) for vascular protection in individuals with diabetes who are at high risk of cardiovascular events, including those >= 65 years. We estimated the proportion of elderly persons who initiated an ACEI or an ARB in the year after beginning oral anti-diabetes (OAD) treatment, and we identified factors associated with this initiation. Methods: Using the Quebec Health Insurance Board (RAMQ) databases, we conducted a population-based cohort study of individuals >= 65 years recently prescribed an OAD. We excluded those who were already taking an ACEI or ARB. Factors associated with ACEI or ARB initiation were identified using multivariate logistic regression. Results: Among 43,700 individuals, 13,621 (31.2%) initiated an ACEI or ARB in the year after beginning OAD. Individuals were more likely to begin an ACEI or an ARB if they initially received both metformin and a sulfonylurea, lived in a rural region, began OAD treatment between 2001 and 2006, were hospitalized, or had >= 22 medical visits in the year before OAD initiation. Individuals >= 75 years, those who were prescribed an OAD by a general practitioner, initially received a sulfonylurea, or received >= 4 different medications in the year before OAD initiation were less likely to begin an ACEI or ARB. Conclusions: In the elderly not already taking ACEIs or ARBs, a low proportion of those undertaking OAD treatment are prescribed the recommended cardioprotection of an ACEI or ARB in the following year. Interventions are needed to close this treatment gap.