Elliott William J, Meyer Peter M
Department of Preventive Medicine, Rush Medical College of Rush University at Rush University Medical Center, Chicago, IL 60612, USA.
Lancet. 2007 Jan 20;369(9557):201-7. doi: 10.1016/S0140-6736(07)60108-1.
The effect of different classes of antihypertensive drugs on incident diabetes mellitus is controversial because traditional meta-analyses are hindered by heterogeneity across trials and the absence of trials comparing angiotensin-converting-enzyme (ACE) inhibitors with angiotensin-receptor blockers (ARB). We therefore undertook a network meta-analysis, which accounts for both direct and indirect comparisons to assess the effects of antihypertensive agents on incident diabetes.
We undertook a systematic review up to Sept 15, 2006, and identified 48 randomised groups of 22 clinical trials with 143,153 participants who did not have diabetes at randomisation and so were eligible for inclusion in our analysis. 17 trials enrolled patients with hypertension, three enrolled high-risk patients, and one enrolled those with heart failure. The main outcome was the proportion of patients who developed diabetes.
Initial drug therapy used in the trials (and the number of patients with diabetes of the total number at risk) included: an ARB (1189 of 14,185, or 8.38%), ACE inhibitor (1618 of 22,941, or 7.05%), calcium-channel blocker (CCB, 2791 of 38,607, or 7.23%), placebo (1686 of 24,767, or 6.81%), beta blocker (2705 of 35,745, or 7.57%), or diuretic (998 of 18,699, or 5.34%). With an initial diuretic as the standard of comparison (eight groups), the degree of incoherence (a measure of how closely the entire network fits together) was small (omega=0.000017, eight degrees of freedom). The odds ratios were: ARB (five groups) 0.57 (95% CI 0.46-0.72, p<0.0001); ACE inhibitor (eight groups) 0.67 (0.56-0.80, p<0.0001); CCB (nine groups): 0.75 (0.62-0.90, p=0.002); placebo (nine groups) 0.77 (0.63-0.94, p = 0.009); beta blocker (nine groups) 0.90 (0.75-1.09, p=0.30). These estimates changed little in many sensitivity analyses.
The association of antihypertensive drugs with incident diabetes is therefore lowest for ARB and ACE inhibitors followed by CCB and placebo, beta blockers and diuretics in rank order.
不同种类的降压药物对新发糖尿病的影响存在争议，因为传统的荟萃分析受到各试验间异质性的阻碍，且缺乏比较血管紧张素转换酶（ACE）抑制剂与血管紧张素受体阻滞剂（ARB）的试验。因此，我们进行了一项网状荟萃分析，该分析考虑了直接和间接比较，以评估降压药物对新发糖尿病的影响。
我们进行了一项截至2006年9月15日的系统评价，确定了22项临床试验中的48个随机分组，共有143153名参与者，这些参与者在随机分组时没有糖尿病，因此有资格纳入我们的分析。17项试验纳入高血压患者，3项纳入高危患者，1项纳入心力衰竭患者。主要结局是发生糖尿病的患者比例。
试验中使用的初始药物治疗（以及糖尿病患者在总风险人群中的数量）包括：ARB（14185人中的1189人，即8.38%）、ACE抑制剂（22941人中的1618人，即7.05%）、钙通道阻滞剂（CCB，38607人中的2791人，即7.23%）、安慰剂（24767人中的1686人，即6.81%）、β受体阻滞剂（35745人中的2705人，即7.57%）或利尿剂（18699人中的998人，即5.34%）。以初始利尿剂作为比较标准（八组），不一致程度（衡量整个网络拟合程度的指标）较小（ω=0.000017，自由度为8）。比值比为：ARB（五组）0.57（95%可信区间0.46 - 0.72，p<0.0001）；ACE抑制剂（八组）0.67（0.56 - 0.80，p<0.0001）；CCB（九组）0.75（0.62 - 0.90，p = 0.002）；安慰剂（九组）0.77（0.63 - 0.94，p = 0.009）；β受体阻滞剂（九组）0.90（0.75 - 1.09，p = 0.30）。在许多敏感性分析中，这些估计值变化不大。
因此，降压药物与新发糖尿病的关联中，ARB和ACE抑制剂最低，其次依次是CCB、安慰剂、β受体阻滞剂和利尿剂。
