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Antihypertensive therapy and new onset diabetes

Introduction The prevalence of obesity, the metabolic syndrome and frank diabetes has doubled in the USA over the past decade. With more than 60% of adults and 30% of children classified as overweight or obese, the USA has become the fattest nation on earth [1]. Approximately one-half of all overweight subjects have insulin resistance and a full 25% of the USA population has multiple risk factors for cardiovascular disease [2,3]. Cardiovascular risk factors tend to cluster and insulin resistance, or diabetes, obesity and hypertension are common in the same patient. Ever since the pioneering observation of Colin Dollery’s team [4,5] more than 20 years ago, a variety of studies have documented that long-term diuretic therapy, particularly when combined with a -blocker, diminishes glucose tolerance and increases the risk of new onset diabetes. Conversely, as has been demonstrated in recent trials, treatment with antihypertensive drugs such as blockers of the renin– angiotensin system or calcium antagonists appears to decrease this risk (Table 1) [6–17]. In a recent issue of the journal, Opie et al. [18] presented a meta-analysis of seven studies in almost 60 000 patients showing that compared to ‘old therapies’ ( -blockers and diuretics), blockers of the renin–angiotensin system decreased the occurrence of new onset diabetes by 20% (P , 0.001) and calcium antagonists by 16% (P , 0.001), respectively. It must be emphasized that new onset diabetes was not a pre-specified endpoint in any of the above prospective randomized trials. Opie et al. [18] calculated that the number-needed-to-treat by new, rather than old, therapies to avoid one case of new onset diabetes was 60–70 for a duration of 4 years.