Hypertension in Diabetes Mellitus

See Also

Management
Blood Pressure Goal

Continue adding agents until goal reached (2 or 3 at a time are the norm)
Small differences in Blood Pressure (5 mmHg) have large impact on outcomes
Adults: Hypertension goals parallel those for known cardiovascular disease
1. Blood Pressure target goals are volatile and differ between organizations
  1. ACC/AHA Guidelines are back to <130/80 mmHg for all patients
  2. ADA Guidelines are up to <140/90 mmHg unless criteria met for 130/80 (see below)
2. ADA Blood Pressure goals have been raised to <140/90
  1. Systolic Blood Pressure (SBP) <140 mmHg rationale (compared with intensive group <120 mmHg)
    1. Increased adverse effects (e.g. Hypotension, Hypokalemia) with intensive SBP lowering
    2. Cardiovascular events were NOT reduced with intensive SBP lowering
    3. Exception: CVA risk was reduced with intensive SBP lowering
      1. Number Needed to Treat: 89 for 5 years to prevent one CVA
  2. Diastolic Blood Pressure (DBP) <80 mmHg rationale
    1. Improved cardiovascular outcomes compared with DBP cutoff of 90
    2. However ADA returned to goal of <90 diastolic as of 2017
3. Summary of goal Blood Pressures in Diabetes Mellitus
  1. Indications for BP <130/80 (per ADA), whereas this is the goal for all patients per ACC/AHA
    1. Diabetic Nephropathy
    2. Increased Cerebrovascular Accident Risk
      1. See Cerebrovascular Accident Risk Factors
    3. Younger patients with Diabetes Mellitus
      1. Longer exposure to pressure burden
      2. Better tolerate lower Blood Pressure
    4. Diabetes Mellitus and meeting BP <130/80 goals without adverse effects
  2. Indications for BP <140/90 (per ADA) or <130/80 (per ACC/AHA)
    1. Diabetes Mellitus without other indications
4. Negotiate Blood Pressure goals with patient
  1. Balance potential benefits (cardiovascular event, Renal Function) with risks (e.g. Hypotension, Hypokalemia)
5. References
  1. (2018) Presc Lett 25(5):26-7
  2. (2013) Diabetes Care January 36(suppl 1): S11-S66
    1. http://care.diabetesjournals.org/content/36/Supplement_1/S11.full.pdf
Child: Average <95th percentile based on height, gender and age
1. See Pediatric Hypertension
2. See Hypertension Criteria
3. NIH Information on Hypertension in Children
  1. http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf

Complications
Hypertension adverse effects in Diabetes Mellitus

Microvascular Complications
1. Renal Insufficiency (and Proteinuria)
  1. ACE Inhibitors beneficial (except renal stenosis)
  2. Calcium Channel Blockers beneficial
  3. Angiotensin Receptor Blockers beneficial
2. Autonomic Neuropathy (e.g. Impotence)
3. Diabetic Retinopathy
Macrovascular Complications
1. Coronary Artery Disease
  1. ACE Inhibitors beneficial
  2. Thiazide Diuretics beneficial
  3. Long-acting Calcium Channel Blockers beneficial
    1. Nondihydropyridines (e.g. Verapamil) clearly are beneficial
    2. Mixed data on Dihydropyridines
  4. Beta Blockers beneficial
2. Cerebrovascular Disease
  1. ACE Inhibitors beneficial
  2. Thiazide Diuretics beneficial
3. Peripheral Vascular Disease

Management
Medications

First-Line Agents
1. ACE Inhibitor
  1. Increases Glomerular Filtration Rate (GFR)
  2. Decreases Proteinuria
2. Angiotension II Receptor Blockers
  1. Alternative to ACE Inhibitors
Second-Line Agents
1. Diuretics (especially in Isolated Systolic Hypertension)
Third-Line Agents
1. Beta Blockers
  1. Now thought to be a viable option for Hypertension control in Diabetes Mellitus
  2. Historically has been used only when other options have been exhausted
    1. Blunts hypoglycemic response (not seen in studies)
    2. Associated with increased weight gain
    3. Glucose and lipids less affected with Carvedilol
2. Calcium Channel Blockers
  1. Non-Dihydropyridine Calcium Channel Blockers
  2. Dihydropyridine Calcium Channel Blockers
Other Medications
1. Alpha Antagonists (use only as adjunctive agent)

Management
Algorithm

General
1. See Hypertension Management
2. See Nonpharmacologic Management of Hypertension
3. See DASH Diet
Protocol
1. Start with 2 medications if goal is >20 mmHg lower than current Blood Pressure
2. Anticipate needing as many as 3-4 Antihypertensives to reach goal
3. Adjust in specific populations (e.g. Black)
  1. See Antihypertensives for Specific Populations
  2. May require ACE Inhibitor for renal protection, but other agents for Blood Pressure control
Step 1: Start with ACE Inhibitor or Angiotensin Receptor Blocker (ARB)
1. Proteinuria present
  1. Evidence supports ACE/ARB as first line
2. Proteinuria absent
  1. No evidence for one Antihypertensive class over another
Step 2: Add Diuretic
1. Serum Creatinine >1.8: Loop Diuretic (e.g. Furosemide)
2. Serum Creatinine <1.8: Thiazide Diuretic
  1. Hydrochlorothiazide
  2. Chlorthalidone (may be preferred)
    1. Longer Half-Life (better 24 hour control)
    2. Approaches twice the potency of Hydrochlorothiazide
    3. Higher risk of Hypokalemia
Step 3: Add long-acting Calcium Channel Blocker
1. Dihydropyridine Calcium Channel Blocker (e.g. Norvasc, Nifedipine) or
2. Non-Dihydropyridine Calcium Channel Blocker (e.g. Verapamil, Diltiazem) or
  1. Do not use with Beta Blocker
Step 4: Add Beta Blocker
1. Use caution if Heart Rate <70-80 bpm
2. Avoid if on Non-Dihydropyridine Calcium Channel Blocker (e.g. Verapamil, Diltiazem)
Step 5: Add additional Antihypertensive (avoid these agents in the elderly, see Beers List)
1. Central Adrenergic Agonist (e.g. Clonidine)
2. Alpha Adrenergic Antagonist (e.g. Hytrin)
3. Reserpine (very effective per JNC7, but review Drug Interactions)

References