1. Blood Pressure and Diabetes Colin M. Dayan University of Bristol/UBHT

2. Percent of deaths Geiss LS, et al. In: Diabetes in America. National Institutes of Health;1995. Causes of Death in People With Diabetes Ischemic heart disease Other heart disease Diabetes Malignant neoplasms Cerebrovascular disease Pneumonia/ influenza All other www.hypertensiononline.org

3. Any diabetes-related endpoints risk reduction 24% p=0.0046

4. Benefits of Tight BP and Tight Glucose Control UKPDS -50 -40 -30 -20 -10 0 Tight glucose control Tight BP control Microvascular endpoints * Stroke Any diabetes- related endpoint Diabetes-related deaths * * * *P<0.02, tight BP control (achieved BP 144/82 mm Hg) vs.. less tight control (achieved BP 154/87 mm Hg). † P<0.03, intensive glucose control (achieved HbA 1c 7.0%) vs. less intensive control (achieved HbA 1c 7.9%). UKPDS Group. BMJ. 1998;317:703-713. UKPDS Group. Lancet. 1998;352:837-853. Risk reduction (%) † †

5. Case 1 61 yr old man Type 2 diabetes diagnosed last year Albumin/creatinine ratio = 13.5 Creatinine = 103 BP = 155/90 Cholesterol = 5.5 HbA1c = 7.2% on Metformin

7. European Guidelines on hypertension in T2DM 2002 Review BP if single reading >140/85 (130/75 if microalb) Consider HBPM or ABPM (cut-off ?130/75) 12-20/8-12mmHg less. Address all CV risk factors - statin, ASA NB Statins also reduce microalb excretion Target 140/85 Drugs

8. European Guidelines on hypertension in T2DM 2002 - Drugs Nephropathy - ACE, A2RA, CCBs, indapamide Hyperkalaemia - Loop diuretics or thiazides Angina - Beta block or CCB MI or LV dsyfunction - beta block and ACE ISH - thiazides and CCBs Not alpha blockers as first line Use once daily dosing to aid compliance

9. HbA 1c cross-sectional, median values

10. Blood Pressure : Tight vs Less Tight Control cohort, median values Less tight control Tight control

11. Bristol Integrated Care Pathway 140/80 In the presence of nephropathy: 135/75 or lower.

12. Bristol Integrated Care Pathway Step 1 Lifestyle Step 2 ACE (or A2RA if cough) Step 3 Diuretic (BFZ, Frusemide) Step 4 beta blocker

13. PANDIPP

14. Case 2 69 yr old woman with Type 2 diabetes diagnosed 7 years ago BMI = 33 Proteinuria ++ on 3 occasions BP = 160/95 Creatinine = 135 K+ = 5.9 HbA1c = 9.0% on Glibenclamide and Metformin

15. Case 3 28 yr old woman with Type 1 diabetes since age 12 Retinopathy - laser 2 years ago BP = 144/88 Alb/creat = 5.4 HbA1c = 10.1% Cholesterol = 5.3

16. Perkins, B. A. et al. N Engl J Med 2003;348:2285-2293 Microalbuminuria can disappear in 58% of cases

17. Case 4 74 yr old man with T2DM diagnosed 4 years ago BP = 140/80 Proteinuria + on 2 occasions Cholesterol = 4.9 HbA1c = 7.3%

18. The British Hypertension Society recommendations for combining Blood Pressure Lowering drugs Younger (e.g.<55yr) and Non-Black Older (e.g.  55yr) or Black Step 1 Step 2 Step 3 Step 4 Resistant Hypertension Add: either  -blocker or spironolactone or other diuretic A: ACE Inhibitor or angiotensin receptor blockerB:  - blocker C: Calcium Channel BlockerD: Diuretic (thiazide) A (or B) A A or B C or D + ++CD Adapted from : ‘Better blood pressure control: how to combine drugs’ Journal of Human Hypertension (2003) 17, 81-86

19. Treating Hypertension in Nephropathy Lewis et al 2001

20. Is home blood pressure monitoring useful?

21. Home BP vs clinic BP