Abington-Jefferson Health, Abington, Pa (Drs. Skolnik and Jaffa); Johns Hopkins University School of Medicine, Baltimore, Md (Dr. Kalyani); Altru Diabetes Center, Grand Forks, ND (Dr. Johnson); Touro University College of Osteopathic Medicine, Vallejo, Calif (Dr. Shubrook) nskolnik@comcast.net
This article was developed as part of the ADA Primary Care Advisory Group’s initiative to disseminate diabetes information to primary care physicians nationwide.
Drs. Jaffa and Kalyani reported no potential conflict of interest relevant to this article. Dr. Skolnik serves on the AstraZeneca Speakers’ Bureau and has served on advisory panels for AstraZeneca, Boehringer Ingleheim, Eli Lilly, Novartis, Sanofi, and Teva. Dr. Johnson serves on the Novo Nordisk and Medtronic Speakers’ Bureaus and on advisory panels for Novo Nordisk and Sanofi. Dr. Shubrook has received research support from Sanofi, Eli Lilly, AstraZeneca, and Takeda, and has served as a consultant for Novo Nordisk and Eli Lilly.
These recommendations are based on evidence suggesting the lack of superiority of ACE inhibitors and ARBs over other classes of antihypertensive agents for the prevention of CV outcomes in all patients with diabetes.18 However, in people with diabetes at high risk for ASCVD and/or with albuminuria, ACE inhibitors and ARBs do reduce ASCVD outcomes and the progression of kidney disease.19-24 Thus, ACE inhibitors and ARBs continue to be recommended as first-line medications for the treatment of hypertension in patients with diabetes and urine albumin/creatinine ratios ≥30 mg/g, as these medications are associated with a reduction in the rate of kidney disease progression.
The use of both an ACE inhibitor and an ARB in combination is not recommended.25,26 For patients treated with ACE inhibitors, ARBs, or diuretics, serum creatinine/estimated glomerular filtration rate (eGFR) and serum potassium levels should be monitored.
What are the recommended lifestyle modifications for patients with diabetes and hypertension?
Regular exercise and healthy eating are recommended for all people with diabetes to optimize glycemic control and lose weight (if they are overweight or obese). For patients with hypertension, the DASH diet (available at: https://www.nhlbi.nih.gov/health/health-topics/topics/dash/) is effective at lowering BP. The DASH diet emphasizes reducing sodium intake, increasing potassium intake, limiting alcohol intake, and increasing physical activity. Specifically, sodium intake should be restricted to <2300 mg/d and patients should consume approximately 8 to 10 servings of fruits and vegetables per day and 2 to 3 servings of low-fat dairy per day. Alcohol should be limited to 2 drinks per day for men and one drink per day for women.
People with diabetes who have hypertension should be treated with lifestyle modification and pharmacologic therapy to a target blood pressure of <140/90 mm Hg.
Most adults with diabetes should perform 150 minutes per week of moderate to vigorous exercise, spread over at least 3 days/week. In addition, it is recommended that resistance exercises be performed at least 2 to 3 days/week. Prolonged inactivity is detrimental to health and should be interrupted with activity every 30 minutes.27
Finally, as a part of lifestyle management for all patients with diabetes, smoking cessation is important, as is attention to stress, depression, and anxiety.
Is there an advantage to nighttime dosing of antihypertensive medications?
Yes. Growing evidence suggests that there is an ASCVD benefit to avoiding nocturnal BP dipping. A 2011 RCT of 448 participants with T2DM and hypertension showed a decrease in CV events and mortality during 5.4 years of follow-up if at least one antihypertensive medication was taken at bedtime.28 As a result of this and other evidence,29 consider administering one or more antihypertensive medications at bedtime, although this is not a formal recommendation in the ADA Standards of Care.
Are there any additional issues to be aware of when treating patients with diabetes and hypertension?
Yes. Sometimes patients who have had diabetes for many years have significant orthostatic hypotension secondary to autonomic neuropathy. Postural changes in BP and pulse may require adjustment of BP targets. Home BP self-monitoring and 24-hour ambulatory BP monitoring may indicate white-coat or masked hypertension.
Lipid management
What is the current evidence for lipid treatment in diabetes?
Lipid abnormalities are common in people with diabetes and contribute to the overall high risk of ASCVD in these patients. Subgroup analyses of patients in large trials with diabetes30 and trials involving patients with diabetes31 have shown significant improvements in primary and secondary prevention of ASCVD with statin use. A 2008 meta-analysis of 18,686 people with diabetes showed a 9% reduction in all-cause mortality and a 13% reduction in vascular mortality for each 39-mg/dL reduction in low-density lipoprotein (LDL) cholesterol.32 Absolute reductions in mortality are greatest in those with highest risk, but the benefits of statin therapy are clear for low- and moderate-risk individuals with diabetes, too.33,34 As a result, statins are the medications of choice for lipid lowering and CV risk reduction and should be used in addition to lifestyle management.
Who should get a statin, and how do I choose the optimum dosage?
Patients ages 40 to 75 years with diabetes but without additional ASCVD risk factors should receive a moderate-intensity statin, according to the ADA (see TABLES 12 and 22). For those with additional CV risk factors, a high-intensity statin should be considered. The American College of Cardiology/American Heart Association ASCVD risk calculator (available at: http://www.cvriskcalculator.com/) may be useful for some patients, but generally, risk is already known to be high for most patients with diabetes. For patients of all ages with diabetes and established ASCVD, high-intensity statin therapy should be added to lifestyle modifications.35-37
