ORIGINAL ARTICLE

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DIABETIC HYPERTENSIVE CONTROL AND TREATMENT: A DESCRIPTIVE REPORT FROM THE AUDIT DIABETES CONTROL AND MANAGEMENT (ADCM) REGISTRY

13 601 cases (65.9%) of the total sample were on antihypertensive drugs. 64.1% of those on antihypertensive drugs were prescribed angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers; 35.3% were on β-blockers and 34.3% were on calcium channel blockers (Table 4). 14.2% of cases were on more than two anti-hypertensive drugs (Figure 1).

Table 4: Anti-hypertensives prescribed

Anti-hypertensive agent	n (%)
ACE inhibitor	8456 (62.2)
ARB	254 (1.9)
Centrally acting	59 (0.4)
Alpha-blockers	976 (7.2)
Calcium channel blocker	4669 (34.3)
Diuretic	2473 (18.2)
Beta-blocker	4797 (35.3)
Others	57 (0.4)
Total	21 741

Figure 1: Percentage of number of anti-hypertensive prescribed

DISCUSSION

Majority of cases were from the public health clinics; the greatest number of cases came from the state of Negeri Sembilan. Predominance of female patients (57.2%) and retired elderly individuals in the registry (77.6% were > 50 years) reflects the day to day patient profiles of Malaysian public health care centres.²⁷ However, the greater percentage of Indian as compared to Chinese patients recorded in the registry did not reflect the national ethnic representation. It was likely that this discrepancy was due to preference of Chinese patients seeking healthcare in the private sector³¹ or higher prevalence of DM among the Indians.

Similar to First Annual Report of National Eye database (2007) that stated 63.9% of diabetic patients were reported to have hypertension,³² the figure obtained in this study was 13 417 cases (65%). 19 484 cases (94.4%) had their BP readings recorded. It is a required routine for all diabetic patients to have their BP measured at the time of diagnosis and at each scheduled visit to the diabetic clinic.²³ There could be accidental omission of BP readings for some cases in the registry.

13 601 cases (65.9%) were taking antihypertensive drugs, a figure slightly higher than the 65% of cases that were reported to have hypertension. It could be that antihypertensive drugs were prescribed solely for renoprotection and cardioprotection rather than for hypertension, or cases with controlled hypertension were considered as normotensive and not included in the report. 8070 cases (41.4%) or 39.1% if calculation were to be based on total number of 20 646 cases, achieved target BP of ≤130/80 mmHg (Table 3). This figure was comparable to those of Thailand cohort³³ and slightly higher than the Swedish cohort (2003).³⁴

Out of all cases on antihypertensive treatment in the ADCM registry, 52.3% were receiving monotherapy. Only 14.2% were receiving three or more antihypertensive drugs, a figure less than the 21.6% of Thailand cohort that received combined drug therapy.³⁵ UKPDS 38 showed that diabetic patients with hypertension generally require three and more antihypertensive drugs after having the disease for more than nine years.¹⁵ ACEI that have been proven to confer significant renal and cardiac protection for high risk diabetic patients, were the most prescribed antihypertensive drugs.^36,37 Previous study conducted in Melaka Tengah district in year 2003 indicated that the most commonly used antihypertensive was a beta blocker, metoprolol.³⁸ This shows that there is greater awareness among healthcare providers of the usefulness of ACEI for diabetic patients. Angiotensin II receptor blocker is not widely prescribed because of its higher cost and prescribing is restricted only to medical specialists.

Phenomenon of therapeutic inertia (TI) was well-reported by Okonofua EC et al. in United States using the Hypertension Initiative database. It was found that TI could account for a 19% variance in BP control; patients who experienced higher TI score had systolic BP increased in their last visit when compared to first clinic visit and vice versa.³⁹ Poor achievement of target BP of ≤130/80 mmHg in ADCM could be partly due to this phenomenon of TI in view of decreasing percentage of achievement of target BP corresponding to increasing age groups and increasing duration of diabetes. Other factors for failure to achieve target BP include budget constraints, degree of patient adherence to medication and limited number of qualified Family Medicine Specialists.

Limitation of this audit was the retrospective retrieval of data from patient records by physicians not involved in the clinical care of these diabetic cases. Information recorded may be inaccurate or incomplete. Hopefully with improved training and good teamwork, these unfavourable factors may be overcomed.

To improve the outcome of this national audit of such a massive scale, we recommend that:

1. A steering committee to be established to look after timely reports and publications.
2. A team of bio-medical statisticians to analyse database and to provide expert advice.
3. Regular on-site training and support for SDP.

CONCLUSION

Hypertension is prevalent among patients with DM. Less than 50% of diabetic cases registered in the ADCM achieved good control of BP to the target level of ≤130/80 mmHg. Antihypertensive treatments were mainly monotherapy. Most commonly prescribed antihypertensive drug was ACEI. Prescribing skills of physicians for management of hypertension in patients with DM requires further improvements.

ACKNOWLEDGEMENT

We would like to acknowledge the Director General of Health for his support and approval in using these data from public health clinics for this study. We would like to express our thanks to Dr Jamaiyah Haniff of Clinical Research Centre (CRC), Hospital Kuala Lumpur, for facilitating access to the registry database and to CRC staff, Noor Akma Hassim and Tee Chin Kim. Special thanks to Ms Lena Yeap from ClinResearch Sdn Bhd for her support in the statistical analysis of data.

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