Treatment of hypertension in patients with diabetes

Hypertension (HTN) is a common problem in diabetes, with an impact on long term health even more serious than it is in non-diabetic patients. Over time, uncontrolled HTN is associated with strokes, heart attacks, kidney disease and death.  The question of how aggressively to treat the condition is readdressed by the American Diabetes Association (ADA) in the January, 2013 issue of the journal Diabetes Care.

The results of several studies have made it clear that the treatment of HTN in diabetes is associated with significant clinical benefits.  Up to this point, major guidelines have suggested the goal should be a blood pressure of less than 130/80. However, this was brought into question by the ACCORD BP trial (Action to Control Cardiovascular Risk in Diabetes), which was specifically structured to address the question of optimal blood pressure control in diabetes.  This study compared patients in whom a systolic pressure (the “top” number in your blood pressure) of 120 was targeted to patients in whom the target was less than 140. After 5 years, the findings were that a) there was no difference in the rate of heart attacks or strokes in the two groups and b) serious side effects from medications were more frequent in the patients for whom a systolic blood pressure of 120 was targeted.

With these, and other, data in hand, the ADA has revised its prior recommendation of treating to a systolic blood pressure of less than 130 and now recommends a target of 140 or less. They acknowledge there is still some degree of uncertainty, and say that for certain patients a target of 130 or less may be appropriate as long as therapy can be maintained without side effects.

There are no new recommendations regarding the specific medication to be given to diabetic patients with high blood pressure. Angiotensin converting enzyme inhibitors (or ACE) agents, based upon their ability to prevent adverse cardiac outcomes and slow progression of early kidney disease, are the preferred therapy. However, many patients will require a second antihypertensive agent to adequately control their blood pressure. Options include calcium channel blockers, diuretics and beta blockers: this choice is often based on other health issues in the individual patient.

The combination of high blood pressure and diabetes also calls for active lifestyle management with attention to diet, exercise and tobacco cessation.  Your primary care physician will need to be both a provider and educator, and will advise on the role of other health care professionals (endocrinologist, cardiologist nutritionist, etc) in your care. To make an appointment to meet with a NuHealth endocrinologist or cardiologist, please call 516 572 4080.