Clinical Research Important Treatment Gaps in Vascular Protection for the Elderly After Type 2 Diabetes Therapy Initiation Line Gu  enette, BPharm, MSc, PhD, a,b,c Marie-Claude Breton, PhD, a,b,c Haithem Hamdi, DPharm, MSc, a,b,c Jean-Pierre Gr  egoire, PhD, FISPE, FCAHS, a,b,c and Jocelyne Moisan, PhD a,b,c a Faculty of Pharmacy, Universit  e Laval, Qu  ebec City, Qu  ebec, Canada b Chair on Adherence to Treatments, Universit  e Laval, Qu  ebec City, Qu ebec, Canada c Centre de recherche du CHU de Qu ebec, Hôpital du Saint-Sacrement, Qu ebec City, Qu ebec, Canada ABSTRACT Background: Canadian practice guidelines recommend the use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) for vascular protection in individuals with diabetes who are at high risk of cardiovascular events, including those  65 years. We estimated the proportion of elderly persons who initiated an ACEI or an ARB in the year after beginning oral anti- diabetes (OAD) treatment, and we identified factors associated with this initiation. Methods: Using the Quebec Health Insurance Board (RAMQ) data- bases, we conducted a population-based cohort study of individuals  65 years recently prescribed an OAD. We excluded those who were already taking an ACEI or ARB. Factors associated with ACEI or ARB initiation were identified using multivariate logistic regression. Results: Among 43,700 individuals, 13,621 (31.2%) initiated an ACEI or ARB in the year after beginning OAD. Individuals were more likely to begin an ACEI or an ARB if they initially received both metformin and a sulfonylurea, lived in a rural region, began OAD treatment between 2001 and 2006, were hospitalized, or had  22 medical visits in the year before OAD initiation. Individuals  75 years, those who were prescribed an OAD by a general practitioner, initially received a sulfo- nylurea, or received  4 different medications in the year before OAD initiation were less likely to begin an ACEI or ARB. R  ESUM  E Introduction : Les lignes directrices canadiennes sur la pratique recommandent l’utilisation des inhibiteurs de l’enzyme de conversion de l’angiotensine (IECA) ou des antagonistes des r ecepteurs de l’an- giotensine II (ARA) dans la protection vasculaire des individus dia- b etiques, incluant ceux  65 ans, qui sont expos es à un risque  elev e d’ ev enements cardiovasculaires. Nous avons estim e la proportion de personnes âg ees qui entreprenaient un traitement par un IECA ou un ARA dans l’ann ee après le d ebut du traitement antidiab etique oral (TAO), et nous avons identifi e les facteurs associ es à cette nouvelle m edication. M ethodes : À partir des bases de donn ees de la R egie de l’assurance maladie du Qu ebec (RAMQ), nous avons men e une  etude de cohorte sur une population d’individus  65 ans chez qui un TAO a r ecemment  et e prescrit. Nous avons exclu ceux qui prenaient d ejà un IECA ou un ARA. Les facteurs associ es à l’amorce du traitement par un IECA ou un ARA ont  et e identifi es par la r egression logistique multivari ee. R esultats : Parmi les 43 700 individus, 13 621 (31,2 %) ont entrepris un traitement par un IECA ou un ARA dans l’ann ee après le d ebut du TAO. Les individus  etaient plus susceptibles de commencer le traite- ment par un IECA ou un ARA s’ils avaient initialement reçu la met- formine et une sulfonylur ee, vivaient dans une r egion rurale, avaient commenc e le TAO entre 2001 et 2006, avaient  et e hospitalis es ou Type 2 diabetes is an increasingly common disease worldwide and is very prevalent among the elderly. 1,2 In Canada in 2010, approximately 18.0% of the population aged  65 years had diabetes. 2 Diabetes is associated with several comorbidities, including cardiovascular disease, which is the leading cause of mortality in elderly individuals with type 2 diabetes. 3 Since 2003, the Canadian Diabetes Association guidelines have recommended the use of an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin II receptor blocker (ARB) in individuals with diabetes who are at high risk for cardio- vascular events. 4-6 All men aged  45 years and women aged  55 years who have diabetes are considered at high risk of a cardiovascular event. 4,5 Consequently, all elderly individ- uals with diabetes should receive pharmacologic vascular protection from an ACEI or an ARB. Several studies have Received for publication April 12, 2013. Accepted September 3, 2013. Corresponding author: Dr Line Gu enette, Centre de recherche du CHU de Qu ebec, Axe sant  e des populations et pratiques optimales en sant  e, Hôpital du Saint-Sacrement, 1050 chemin Sainte-Foy, Qu ebec City, Qu ebec G1S 4L8, Canada. Tel.: þ1-418-682-7511 (4694); fax: þ1-418-682-7962. E-mail: line.guenette@pha.ulaval.ca See page 1598 for disclosure information. 0828-282X/$ - see front matter Ó 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2013.09.001 Canadian Journal of Cardiology 29 (2013) 1593e1598