Inadequate use of evidence‐based doses of ramipril in type 2 diabetic patients with hypertension: HOPE for better results

Ramipril at a maximum dose of 10 mg/day in patients with diabetes mellitus was shown in the MICRO‐HOPE study to reduce both micro‐ and macrovascular disease but, within the confines of a busy clinical service serving a largely socially deprived population, patients are often maintained on submaximal doses of the drug. We performed a cross sectional study of 600 hypertensive patients (mean age 65.3±8.7 years, 300 males, diabetes duration 13±8.8 years) selected randomly from our computerised diabetes clinic database to audit our application of the evidence‐based dose of ACE‐inhibitor (ACE‐I) by case notes review. Sixty percent of patients were taking ACE‐I monotherapy, 4% were taking beta blocker alone, 12% were taking two agents and 24% were taking three or more antihypertensive agents. A total of 13.5% achieved a target blood pressure (BP) of 130/80mmHg. In all, 120 patients (mean age 64.7±7.3 years, 62 males) with type 2 diabetes (diabetes duration 12.3±6.7 years) were treated with ACE‐I either alone or in combination therapy, of whom only 20% (24) of patients achieved target BP levels. Seventy‐two percent of patients were taking suboptimal doses of ACE‐I. Of those who were taking maximal doses of ACE‐I, 67% (16) achieved target BP levels compared with 8.3% (eight) patients who did not achieved target BP levels (p<0.05).

We conclude that the conventional practice of dose titration via liaison between primary and secondary care has failed to deliver optimal doses of ACE‐I. The implementation of a policy such as that in our service where patients requiring ACE‐I treatment were routinely prescribed a ‘titration pack’ would hopefully facilitate BP reduction using evidence‐based doses of ACE‐I. Copyright © 2005 John Wiley & Sons, Ltd.