1. Hypertension & diabetes: new guidelines Janice Douglas, MD Case Western University Cleveland, OH George L Bakris, MD Director of the Hypertension/Clinical Research Center at Rush Medical College Chicago, IL

2. What we know Hypertension and diabetes More than 11 million Americans have both diabetes and hypertension as comorbid diseases. Increases in: urinary albumin excretion hyperuricemia dyslipidemias left ventricular hypertrophy Diabetes is the leading cause of end-stage renal disease in the general population.

3. Basis of NKF guidelines Hypertension and diabetes Based on JNC VI guidelines: BP <130/85 Trials suggest linear relationship between lower BP and lower cardiovascular risk (HOT, UKPDS) NKF guidelines: <130/80 Bakris GL, et al. Am J Kidney Dis 2000;36(3):646-661

4. Achieving the goal Hypertension and diabetes If BP >145/90, 2 or more medications needed to reach goal ACE inhibitor/diuretic is ideal starting combination Titrate ACE to max, keep diuretic low dose Watch for pulse rates higher than 84

5. Medication Hypertension and diabetes An average of 3.2 different antihypertensives are needed to reach this goal. The worse the renal function, the more medications you need (4 or 5).

6. Importance of BP management Hypertension and diabetes Tight BP control stronger than tight glucose control for lowering risk of: stroke death by diabetes any diabetic endpoint microvascular complications (UKPDS) BMJ 1998 Sep 12;317(7160):703-13

7. Hypertension and diabetes “I think it is critically important that the goal blood pressure be achieved [and that] people not become wimpy in terms of their anti-hypertensive medication doses.” George L Bakris, MD Director of the Hypertension/Clinical Research Center at Rush Medical College Chicago, IL

8. Reaching the goal Hypertension and diabetes General hypertensive population reaching JNC VI goal of <130/85: <30% Patients with diabetes and hypertension reaching JNC VI goal of <130/85: 11% Patients with diabetes and hypertension reaching NKF goal of <130/80: ????

9. Critical issues Hypertension and diabetes 1)Team approach (physician, nurse clinician, nurse, dietician) 2)Timing of medication (once daily dosing, fixed-dose combinations) 3)Education (What is the goal and why? Enlist the patient as active participant.)

10. Hypertension and diabetes 1) CME programs (classes of drugs and BP control) 2) Recertification (test them on recertification exam) Physician outreach

11. Fear of a J-shaped curve Hypertension and diabetes Fear is preventing the achievement of these goals: 1) No study with aggressive blood pressure control shows a J-shaped curve in cardiovascular events. 2) Fear of renal dysfunction is preventing adequate use of ACE inhibitors.

12. ACE-inhibitors and CCBs Hypertension and diabetes In combination, these agents produce an additive reduction in blood pressure. There is a reduction in the incidence of edema and proteinuria. Adding a diuretic gives “more bang for your buck”.

13. Hypertension and diabetes How medical information is disseminated and how it is put forth have a huge impact on how the patient accepts the information. Physicians must become aware that cultural factors impact treatment. Socioeconomic factors

14. Hypertension and diabetes Hispanic community barriers: Language barrier Males reluctant to come in Preconceived notions about medication Attempted solutions: Translators from the same culture Build confidence and trust “Shortcut approach” doesn’t work Specific barriers

15. Hypertension and diabetes Diet and exercise go hand in hand with other approaches. DASH study reduced BP in hypertensive subjects: Systolic (mm Hg) -11.5 + 1.3 Diastolic (mm Hg) -5.7 + 0.9 Lifestyle Svetkey LP, et al. J Am Diet Assoc 1999; 99(s8): s96-104

16. Pocket guide Hypertension and diabetes Pocket-sized version of treatment algorithm Executive summary of the guidelines National Kidney Foundation 1.800.622.9010