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blood pressure & hypertension in diabetes

Etiology: - primary hyperaldosteronism in 14% if diabetic patients with resistant hypertension Epidemiology: - target BP of < 130/80 (2023 ADA, ACC, AHA) [15] - blood pressure < 130/80 mm Hg is not associated with lower risk for 3.5-year all-cause mortality in patients with newly diagnosed type 2 diabetes. - blood pressure < 110/75 mm Hg is associated with excess mortality risk [6] Management: 1) choice of antihypertensives is the same as for patients without diabetes in the absence of diabetic nephropathy [13] - ACE inhibitors reduce proteinuria (1st line) - no benefit for patients with microabuminuria [7] - angiotensin II receptor antagonists (ARBs) also reduce proteinuria - no benefit for patients with microabuminuria [7] - olmesartan may be an exception [8] - thiazide diuretics - recommended as 1st line agents [3] - synergistic effect when used with ACE inhibitor or ARB - avoid in patients with history of gout - caution: may worsen glycemic control - calcium-channel blockers [13] - beta-blockers generally avoided in the absence of specific indication - carvedilol - less tendency to cause hyperglycemia & dyslipidemia than other beta blockers - may reduce risk of microalbuminuria [4] - beta-blockers may mask symptoms of hypoglycemia - beta-blockers may increase mortality 2) mortality, cardiovascular events & renal failure similar with ACE inhibitors, ARBs, calcium-channel blockers, thiazide diuretics, & beta-blockers [12] 3) target BP < 130/80 mm Hg (2023 ADA) [15] (formerly < 140/90 2018 ADA) a) for stage 1 hypertension (140-159/90-99 mm Hg, now 130-149/80-89 mm Hg?), start with single agent [13] b) no benefit to target systolic blood pressure lower than prior 2018 ADA standard therapy (< 140 mm Hg) see ACCORD trial & INVEST trial [5] c) systolic blood pressure target: < 130 mm Hg [2,15] d) diastolic blood pressure target: < 80 mm Hg [10] - diastolic blood pressure target: 60-80 mm Hg [2] - not supported by American Diabetes Association in 2015 & 2018 [10] e) < 130/80 mm Hg [9] - not associated with lower mortality or MI - associated with lower risk of stroke (absolute reduction 1%) - higher risk of adverse effects (3.3% vs 1.7%) relative to standard treatment (< 140/90 mm Hg) f) strict control < 120/70 mm Hg not recommended [2] g) < 135/80 mm Hg (American College of Physicians* h) each 10-mm Hg drop for systolic BP > 140 associated with a 13% reduction in mortality [11] * The American College of Physicians withdrew their guideline 'The evidence base for tight blood pressure control in the management of type 2 diabetes mellitus' in February of 2009

Related

diabetes mellitus hypertension (HTN, high blood pressure, HBP)

General

endocrinology

References

  1. Umpierrez GE et al, Primary aldosteronism in diabetic subjects with resistant hypertension. Diabetes Care 2007, 30:1699 PMID: 17429062
  2. Prescriber's Letter 17(4): 2010 Intensive Blood Pressure and Lipid Control for Patients with Diabetes: More from ACCORD Detail-Document#: 260404 (subscription needed) http://www.prescribersletter.com
  3. Journal Watch 23(10):78, 2003 Berl T et al, Cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial of patients with type 2 diabetes and overt nephropathy. Ann Intern Med 138(Apr 1):542, 2003 PMID: 12667024 http://www.annals.org/issues/v138n7/full/200304010-00017.html - Vijan S & Hayward RA, Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care. Ann Intern Med 138(Apr 1):593, 2003 PMID: 12667032 http://www.annals.org/issues/v138n7/full/200304010-00018.html
  4. Internal Medicine News, April 15, 2005
  5. The ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010 Apr 29;362(17):1575-85. Epub 2010 Mar 14. PMID: 20228401 http://dx.doi.org/10.1056/NEJMoa1001286
  6. Vamos EP et al. Association of systolic and diastolic blood pressure and all cause mortality in people with newly diagnosed type 2 diabetes: Retrospective cohort study. BMJ 2012 Aug 30; 345:e5567 PMID: 22936794
  7. Prescriber's Letter 19(11): 2012 Which Diabetes Patients Need an ACE Inhibitor or ARB, Aspirin, and Statin? Detail-Document#: 281124 (subscription needed) http://www.prescribersletter.com
  8. Haller H et al Olmesartan for the Delay or Prevention of Microalbuminuria in Type 2 Diabetes N Engl J Med 2011; 364:907-917March 10, 2011 PMID: 21388309 http://www.nejm.org/doi/full/10.1056/NEJMoa1007994
  9. McBrien K et al. Intensive and standard blood pressure targets in patients with type 2 diabetes mellitus: Systematic review and meta-analysis. Arch Intern Med 2012 Sep 24; 172:1296. PMID: 22868819 http://archinte.jamanetwork.com/article.aspx?articleid=1307572
  10. American Diabetes Association Standards of Medical Care in Diabetes-2015: Summary of Revisions Diabetes Care. Jan 2015. 38:S1-S2 http://care.diabetesjournals.org/content/38/Supplement_1
  11. Emdin CA et al Blood Pressure Lowering in Type 2 Diabetes. A Systematic Review and Meta-analysis. JAMA. 2015;313(6):603-615 PMID: 25668264 http://jama.jamanetwork.com/article.aspx?articleid=2108887 - Williams B Treating Hypertension in Patients With Diabetes. When to Start and How Low to Go? JAMA. 2015;313(6):573-574 PMID: 25668260 http://jama.jamanetwork.com/article.aspx?articleid=2108870
  12. Bangalore S, Fakheri R, Toklu B, Messerli FH Diabetes mellitus as a compelling indication for use of renin angiotensin system blockers: Systematic review and meta-analysis of randomized trials. BMJ 2016 Feb 11; 352:i438. PMID: 26868137 Free Article - Majumdar SR. Antihypertensive treatments for adults with type 2 diabetes. BMJ 2016 Feb 11; 352:i560. PMID: 26867645
  13. Medical Knowledge Self Assessment Program (MKSAP) 17, American College of Physicians, Philadelphia 2015
  14. Tucker ME Beta-Blockers May Raise Mortality in People With Diabetes Medscape - Apr 05, 2018. https://www.medscape.com/viewarticle/894878
  15. Tucker ME ADA Advises New BP, Lipid Targets for People With Diabetes. Medscape. Dec 13, 2022 https://www.medscape.com/viewarticle/985482 - ElSayed NA, Aleppo G, Aroda VR et al 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2023 Diabetes Care. 2023 Jan 1;46(Suppl 1):S158-S190. PMID: 36507632 PMCID: PMC9810475 Free PMC article