Treatment of Hypertension in Adults With Diabetes DR AMAL HARFOUSH

Hypertension (defined as a blood pressure ≥140/90 mmHg) is an extremely common comorbid condition in diabetes, affecting ∼ 20–60% of patients with diabetes, depending on obesity, ethnicity, and age.

In type 2 diabetes, hypertension is often present as part of the metabolic syndrome of insulin resistance also including central obesity and dyslipidemia. In type 1 diabetes, hypertension may reflect the onset of diabetic nephropathy. Hypertension substantially increases the risk of both macrovascular and microvascular complications, including stroke, coronary artery disease, and peripheral vascular disease, retinopathy, nephropathy, and possibly neuropathy. In recent years, adequate data from well-designed randomized clinical trials have demonstrated the effectiveness of aggressive treatment of hypertension in reducing both types of diabetes complications.

hypertension as a risk factor for complications of diabetes Diabetes increases the risk of coronary events twofold in men and fourfold in women Part of this increase is due to the frequency of associated cardiovascular risk factors such as hypertension, dyslipidemia and clotting abnormalities

In observational studies, people with both diabetes and hypertension have approximately twice the risk of cardiovascular disease as nondiabetic people with hypertension. Hypertensive diabetic patients are also at increased risk for diabetes- specific complications including retinopathy and nephropathy. In the U.K. Prospective Diabetes Study (UKPDS) epidemiological study, each 10-mmHg decrease in mean systolic blood pressure was associated with reductions in risk of 12% for any complication related to diabetes, 15% for deaths related to diabetes, 11% for myocardial infarction, and 13% for microvascular complications. No threshold of risk was observed for any end point.

The European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) published new guidelines today for the management of hypertension, simplifying treatment decisions for physicians with the recommendation that all patients be treated to <140 mm Hg systolic blood pressure [1].

The new guidelines do make exceptions for special populations, such as those with diabetes and the elderly. For those with diabetes, the ESH/ESC writing committee recommend that physicians treat patients to <85 mm Hg diastolic blood pressure.

In patients younger than 80 years old, the systolic blood-pressure target should be 140 to 150 mm Hg, but physicians can go lower than 140 mm Hg if the patient is fit and healthy. The same advice applies to octogenarians, although physicians should also factor in the patient's mental capacity in addition to physical heath if targeting to less than 140 mm Hg.

patients can be stratified into four categories high-normal blood pressure ( systolicor85-89mmHg diastolic) grade1 hypertension ( systolic or diastolic mm Hg), grade2 hypertension ( systolic or mm Hg diastolic) grade 3 hypertension ( >180 systolic or >110 mm Hg diastolic). The presence or absence of other cardiovascular risk factors or organ damage/disease should be then factored into treatment

the new guidelines also make a host of lifestyle recommendations for lowering blood pressure. they are recommending salt intake of approximately 5 to 6 g per day, in contrast with a typical intake of 9 to 12 g per day. A reduction to 5 g per day can decrease systolic blood pressure about 1 to 2 mm Hg in normotensive individuals and 4 to 5 mm Hg in hypertensive patients

While the optimal body-mass index (BMI) is not known, the guidelines recommend getting BMIs down to 25 kg/m2 and reducing waist circumferences to <102 cm in men and <88 cm in women. Losing about 5 kg can reduce systolic blood pressure by as much as 4 mm Hg, while aerobic endurance training in hypertensive patients can reduce systolic blood pressure 7 mm Hg

physicians can typically give low/moderate-risk individuals a few months with lifestyle changes to determine whether they're having an impact on blood pressure. They should be more aggressive with higher-risk patients, however, noting that drug therapy is started typically within a few weeks if diet and exercise are ineffective.

the guidelines reconfirm the importance of combination therapy, mainly because "there is no question that many patients need more than one drug for their blood pressure to be controlled.“ In patients at high risk for cardiovascular events or those with a markedly high baseline blood pressure, physicians can consider starting patients with combination therapy rather than a single drug In those at low or moderate risk for cardiovascular events or with mildly elevated blood pressure, a single starting agent is preferred.

many studies demonstrate the benefits of ACE inhibitors on multiple adverse outcomes in patients with diabetes, including both macrovascular and microvascular complications, in patients with either mild or more severe hypertension and in both type 1 and type 2 diabetes, the established practice of choosing an ACE inhibitor as the first-line agent in most patients with diabetes is reasonable.

In patients with microalbuminemia or clinical nephropathy, both ACE inhibitors (type 1 and type 2 patients) and ARBs (type 2 patients) are considered first-line therapy for the prevention of and progression of nephropathy

other strategies including diuretic and β-blocker–based therapy are also supported by evidence. Because of lingering concerns about the lower effectiveness of DCCBs (compared with ACE inhibitors, ARBs, β- blockers, or diuretics) in decreasing coronary events and heart failure and in reducing progression of renal disease in diabetes these agents should be used as second-line drugs for patients who cannot tolerate the other preferred classes or who require additional agents to achieve the target blood pressure.

Other classes, including α-blockers, may be used under specific indications (such as symptoms of BPH for α-blockers) or other agents have failed to control the blood pressure or have unacceptable side effects. Blood pressure, orthostatic changes, renal function, and serum potassium should be monitored at appropriate intervals. Treatment decisions should be individualized based on the clinical characteristics of the patient, including comorbidities as well as tolerability, personal preferences, and cost.

In patients with type 1 diabetes, with or without hypertension, with any degree of albuminuria, ACE inhibitors have been shown to delay the progression of nephropathy. In patients with type 2 diabetes, hypertension and microalbuminuria, ACE inhibitors and ARBs have been shown to delay the progression to macroalbuminuria. In those with type 2 diabetes, hypertension, macroalbuminuria (>300 mg/day), nephropathy, or renal insufficiency, an ARB should be strongly considered. If one class is not tolerated, the other should be substituted.

 In patients over age 55 years, with hypertension or without hypertension but with another cardiovascular risk factor (history of cardiovascular disease, dyslipidemia, microalbuminuria, smoking), an ACE inhibitor (if not contraindicated) should be considered to reduce the risk of cardiovascular events.  In patients with a recent myocardial infarction, β- blockers, in addition, should be considered to reduce mortality.

In patients with microalbuminuria or overt nephropathy, in whom ACE inhibitors or ARBs are not well tolerated, a non-DCCB or β-blocker should be considered

 In patients 60 years or over, start treatment in blood pressures >150 mm Hg systolic or >90 mm Hg diastolic and treat to under those thresholds.  In patients 18 years with either chronic kidney disease (CKD) or diabetes.  In nonblack patients with hypertension, initial treatment can be a thiazide- type diuretic, CCB, ACE inhibitor, or ARB, while in the general black population, initial therapy should be a thiazide-type diuretic or CCB.  In patients >18 years with CKD, initial or add-on therapy should be an ACE inhibitor or ARB, regardless of race or diabetes status.

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