The DREAM trial: Using ramipril and rosiglitazone to prevent diabetes

Abstract

The DREAM (Diabetes REduction Approaches with ramipril and rosiglitazone Medications) Trial Investigators: Effect of rosiglitazone on the frequency of diabetes in patients with impaired glucose tolerance or impaired fasting glucose: a randomized control trial. Lancet 2006, 368:1096-1105. The DREAM Trial Investigators: Effect of ramipril on the incidence of diabetes. N Engl J Med 2006, 355:1551-1562. Rating: •Of importance. Introduction: Diabetes is a common chronic disease that affects people of all ages, ethnicities, and socioeconomic status. The micro-and macrovascular complications of diabetes are associated with considerable morbidity and mortality, adversely affecting quality of life and dramatically increasing health care expenditures [1]. Globally, the prevalence of diabetes is projected to double in the next 25 years. Thus, this epidemic constitutes a major public health challenge and mandates aggressive efforts to find effective prevention strategies. A number of studies have indicated that diet alone or in combination with exercise can markedly reduce risk for diabetes in people at high risk [2]. Both the Finnish Diabetes Prevention Study [3] and the US Diabetes Prevention Program (DPP) [4] demonstrated that incident diabetes could be reduced by 58% with intensive lifestyle modification. Pharmacologic approaches have also been tested in several trials. In the DPP [4], metformin reduced incident diabetes by 31%; in the STOP-NIDDM (Study to Prevent Non-Insulin-Dependent Diabetes Mellitus) trial [5] acarbose decreased incident diabetes by 25%; and in the XENDOS (XENical in the Prevention of Diabetes in Obese Subjects) study [6] orlistat decreased incident diabetes by 37%.Two studies of troglitazone, an insulin-sensitizing thiazolidinedione (TZD) that was removed from the market in 2000 due to hepatic toxicity, suggested that this class of drugs had potentially greater efficacy in diabetes prevention. In the DPP, subjects randomized to troglitazone had a 75% reduction in new diabetes over an average of 9 months of treatment, before the drug was removed from the trial [7]. A second study conducted in women with prior gestational diabetes indicated that troglitazone decreased the risk for diabetes by 55% [8].