Skip to main content Accessibility help

Cost-effectiveness of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in newly diagnosed type 2 diabetes in Germany

  • Charles Christian Adarkwah (a1) and Afschin Gandjour (a2)


Objectives: Type 2 diabetes is the main cause of end-stage renal disease in Europe and the United States. Angiotensin-converting enzyme (ACE) inhibitors slow down the progression of renal disease and, therefore, provide a renal-protective effect. The aim of this study was to assess the most cost-effective time to start an ACE inhibitor (or an angiotensin II receptor blocker in the event of cough) in patients with type 2 diabetes in Germany.

Methods: Three strategies were compared: treating all patients at the time of diagnosing type 2 diabetes, screening for microalbuminuria, and screening for macroalbuminuria. A lifetime Markov decision model with simulated 50-year-old patients with newly diagnosed diabetes mellitus was developed using published data on costs and health outcomes and simulating the progression of renal disease. A statutory health insurance perspective was adopted.

Results: In the base-case analysis, the treat-all strategy is associated with the lowest costs and highest benefit and, therefore, dominates screening both for macroalbuminuria and microalbuminuria. A multivariate sensitivity analysis shows that the probability of savings is 89 percent.

Conclusions: Patients with type 2 diabetes should receive an ACE inhibitor immediately after diagnosis if they do not have contraindications. The potential for cost savings would be even larger if the prevention of cardiovascular events were considered.



Hide All
1. Ahmad, J, Siddiqui, MA, Ahmad, H. Effective postponement of diabetic nephropathy with enalapril in normotensive type 2 diabetic patients with microalbuminuria. Diabetes Care. 1997;20:15761581.
2. Arnesen, T, Trommald, M. Roughly right or precisely wrong? Systematic review of quality-of-life weights elicited with the time trade-off method. J Health Serv Res Policy. 2004;9:4350.
3. Barnett, AH, Bain, SC, Bouter, P, et al; for the Diabetics Exposed to Telmisartan and Enalapril Study Group. Angiotensin-receptor blockade versus converting-enzyme inhibition in type 2 diabetes and nephropathy. N Engl J Med. 2004;351:19521961.
4. Bertoni, AG, Krop, JS, Anderson, GF, et al. Diabetes-related morbidity and mortality in a national sample of U.S. elders. Diabetes Care. 2002;25:471475.
5. Bleichrodt, H, Johannesson, M. Standard gamble, time trade-off and rating scale: Experimental results on the ranking properties of QALYs. J Health Econ. 1997;16:155175.
6. Braun, S, Prenzler, A, Mittendorf, T, et al. Appraisal of resource use in the German health-care system from the perspective of the statutory health insurance [in German]. Gesundheitswesen. 2009;71:1923.
7. Briggs, AH, Ades, AE, Price, MJ. Probabilistic sensitivity analysis for decision trees with multiple branches: Use of the Dirichlet distribution in a Bayesian framework. Med Decis Making. 2003;23:341350.
8. Brown, GC, Brown, MM, Sharma, S, et al. Quality of life associated with diabetes mellitus in an adult population. J Diabetes Complications. 2000;14:1824.
9. Bundesministerium für Gesundheit und Soziale Sicherung, Krankheitskosten nach Alter und Geschlecht, 2002. (accessed May 23, 2006).
10. Casas, JP, Chua, W, Loukogeorgakis, S, et al. Effect of inhibitors of the renin-angiotensin system and other antihypertensive drugs on renal outcomes: Systematic review and meta-analysis. Lancet. 2005;366:20262033.
11. Churchill, DN, Torrance, GW, Taylor, DW, et al. Measurement of quality of life in end-stage renal disease: The time trade-off approach. Clin Invest Med. 1987;10:1420.
12. Comper, WD, Osicka, TM, Jerums, G. High prevalence of immuno-unreactive intact albumin in urine of diabetic patients. Am J Kidney Dis. 2003;41:336342.
13. Cook, DJ, Guyatt, GH. Interpreting, integrating, and individualizing evidence about the prevention of diabetic nephropathy. Ann Intern Med. 1999;131:707708.
14. Dolan, P, Gudex, C, Kind, P, et al. Valuing health states: A comparison of methods. J Health Econ. 1996;15:209231.
15. Frei, U, Schober-Halstenberg, HJ. Nierenersatztherapie in Deutschland. Bericht über Dialysebehandlung und Nierentransplantation in Deutschland 2005/2006 Berlin: Quasi-Niere; 2006.
16. Gandjour, A, Kleinschmit, F, Lauterbach, KW; INTERCARE International Investigators. European comparison of costs and quality in the prevention of secondary complications in Type 2 diabetes mellitus (2000–2001). Diabet Med. 2002;19:594601.
17. Giani, G, Janka, HU, Hauner, H, et al. Epidemiologie and Verlauf des Diabetes mellitus in Deutschland. In: Scherbaum, WA, Kiess, W, eds. Evidenzbasierte Diabetes-Leitlinien DDG. Deutsche Diabetes-Gesellschaft; 2004.
18. Glaeske, G, Jahnsen, K. GEK-Arzneimittel-Report 2007. (accessed October 1, 2008).
19. Golan, L, Birkmeyer, JD, Welch, HG. The cost-effectiveness of treating all patients with type 2 diabetes with angiotensin-converting enzyme inhibitors. Ann Intern Med. 1999;131:660667.
20. Gold, MR, Siegel, JE, Russell, LB, et al. Cost-effectiveness in health and medicine. New York: Oxford University Press; 1996.
21. Guideline of the American Diabetes Association (ADA). Nephropathy in Diabetes. Diabetes Care. 2004;27 (Suppl):79S83S.
22. Hasslacher, C, Gandjour, A, et al. Diagnostik, Therapie und Verlaufskontrolle der Diabetischen Nephropathie. In: Scherbaum, WA, Lauterbach, KW, Renner, R, eds. Evidenzbasierte Diabetes-Leitlinien DDG. Deutsche Diabetes Gesellschaft; 2000.
23. Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: Results of the HOPE study and MICRO-HOPE substudy. Lancet. 2000;355:253259.
24. John, JA, Whitaker, D, Johnson, DG. Statistical thinking in business. 2nd ed. Boca Raton, FL: Chapman & Hall/CRC; 2006.
25. K/DOQI Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease. Guideline 11: Use of angiotensin-converting-enzyme inhibitors and angiotensin receptor blockers in CKD. Am J Kidney Dis. 2004;43 (Suppl 1):S1S290.
26. Kasiske, BL, Kalil, RS, Ma, JZ, et al. Effect of antihypertensive therapy on the kidney in patients with diabetes: A meta-regression analysis. Ann Intern Med. 1993;118:129138.
27. Kassenärztliche Bundesvereinigung Berlin. Einheitlicher Bewertungsmaßstab für ärztliche Leistungen. Berlin; 13.07.2006.
28. Koester, I, von Ferber, L, Ihle, P, et al. The cost burden of diabetes mellitus: The evidence from Germany—the CoDiM Study. Diabetologia. 2006;49:14981504.
29. Koopman, RJ, Mainous, AG III, Diaz, VA, et al. Changes in age at diagnosis of type 2 diabetes mellitus in the United States, 1988 to 2000. Ann Fam Med. 2005;3:6063.
30. Kuntz, KM, Weinstein, MC. Modelling in economic evaluation. In: Drummond, M, McGuire, A, eds. Economic evaluation in health care. Merging practice with theory. Chapter 7. Oxford: Oxford University Press; 2005:141171.
31. Lewis, EJ, Hunsicker, LG, Bain, RP, et al. The effect of angiotensin-converting enzyme inhibition on diabetic nephropathy. N Engl J Med. 1993;329:14561462.
32. Lewis, EJ, Hunsicker, LG, Clarke, WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345:851860.
33. Matchar, DB, McCrory, DC, Orlando, LA, et al. Systematic review: Comparative effectiveness of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers for treating essential hypertension. Ann Intern Med. 2008;148:1629.
34. McIntosh, A, Hutchinson, A, Marshall, S, et al. Clinical guidelines and evidence review for type 2 diabetes. Renal disease: Prevention and early management. Sheffield: ScHARR, University of Sheffield; 2002.
35. Nebel, M. Costs of renal replacement therapies in Germany in 1999. Nieren- und Hochdruckkrankheiten. 2002;3:8592.
36. Neubauer, G, Breu, M, Pommer, W. Prospective cost-comparison study on centre haemodialysis and peritoneal dialysis in Germany. München: ifG Institut für Gesundheitsökonomik; 2000.
37. Niskanen, LK, Penttila, I, Parviainen, M, et al. Evolution, risk factors, and prognostic implications of albuminuria in NIDDM. Diabetes Care. 1996;19:486493.
38. Parving, HH, Lehnert, H, Brochner-Mortensen, J, et al. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med. 2001;345:870878.
39. Rosen, AB, Hamel, BH, Weinstein, MC, et al. Cost-effectiveness of full Medicare coverage of angiotensin-converting enzyme inhibitors for beneficiaries with diabetes. Ann Intern Med. 2005;143:8999.
40. Rote Liste: Arzneimittelverzeichnis für Deutschland. BPI Service GmbH, ed. Aulendorf: Editio Cantor; 2005.
41. Rote Liste Service GmbH. Rote Liste: Arzneimittelverzeichnis für Deutschland [online]. (accessed October 1, 2008).
42. Scheid, DC, McCarthy, LH, Lawler, FH, et al. Screening for microalbuminuria to prevent nephropathy in patients with diabetes: A systematic review of the evidence. J Fam Pract. 2001;50:661668.
43. Schroeder, A, Heiderhoff, M, Koebberling, J. Determination of albuminuria in the urine of diabetics for prevention and control of diabetic nephropathy. Köln: DIMDI; 2005.
44. Selbstverwaltung für German Refined-Diagnosis Related Groups. G-DRG V2006 Browser 2006 [online]. (accessed November 24, 2006).
45. Statistisches Bundesamt. Sterbetafel 2005/2007. (accessed October 1, 2008).
46. Statistisches Bundesamt. Verbraucherpreisindex für Deutschland. (accessed August 23, 2007).
47. Steines, W, Piehlmeier, W, Schenkirsch, G, et al. Effectiveness of a disease management programme for patients with type 2 diabetes mellitus and albuminuria in primary care—the PROSIT project (Proteinuria Screening and Intervention). Exp Clin Endocrinol Diabetes. 2004;112:8894.
48. Strippoli, GFM, Bonifati, C, Craig, M, et al. Angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists for preventing the progression of diabetic kidney disease. Cochrane Database Syst Rev. 2006; CD006257.
49. Strippoli, GFM, Craig, M, Craig, JC. Antihypertensive agents for preventing diabetic kidney disease. Cochrane Database Syst Rev. 2005; CD004136.
50. The EUCLID Study Group. Randomised placebo-controlled trial of lisinopril in normotensive patients with insulin-dependent diabetes and normoalbuminuria or microalbuminuria. Lancet. 1997;349:17871792.
51. U.S. Department of Health and Human Services. Third national health and nutrition examination survey, 1988–1994, NHANES III Household Adult and Laboratory Data Files (CD-ROM). Public use data file documentation number 76200. Hyattsville, MD: U.S. Department of Health and Human Services. National Center for Health Statistics, Centers for Disease Control and Prevention; 1996.
52. U.S. Rena Data System. USRDS 2001 annual data report: Atlas of ESRD in the United States. Bethesda, MD: National Institutes of Diabetes and Digestive and Kidney Diseases; 2001.
53. VA/DoD clinical practice guideline for the management of diabetes mellitus (2003). (accessed August 21, 2007).


Type Description Title
Supplementary materials

Adarkwah et al. supplementary materials
Table 1 and Figure 1

 Word (100 KB)
100 KB

Cost-effectiveness of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in newly diagnosed type 2 diabetes in Germany

  • Charles Christian Adarkwah (a1) and Afschin Gandjour (a2)


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed