Clinicians can consult a diagram to plan treatment of hypertension in diabetes patients as part of the new American Diabetes Association guidelines.
“Diabetes and Hypertension: A Position Statement by the American Diabetes Association” was published in the September 2017 issue of Diabetes Care, and online on Aug. 22. The statement updates the ADA’s previous statement on hypertension and diabetes published in 2003.
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“Numerous studies have shown that antihypertensive therapy reduces ASCVD [atherosclerotic cardiovascular disease] events, heart failure, and microvascular complications in people with diabetes,” wrote Ian H. de Boer, MD, of the University of Washington, Seattle, and his colleagues.
The statement is a collaboration between nine diabetes experts from the United States, Europe, and Australia whose specialties include endocrinology, nephrology, cardiology, and internal medicine (Diabetes Care. 2017 Sep.;40:1273-84).
The statement recommends that diabetes patients have their blood pressure checked at every routine clinical visit and that those with an elevated blood pressure on a clinical visit (defined as office-based measurements of 140/90 mm Hg and higher) have multiple measurements, including on a separate day to confirm the diagnosis.
In addition, during the initial evaluation, and then periodically, diabetes patients should be assessed for orthostatic hypotension “to individualize blood pressure goals, select the most appropriate antihypertensive agents, and minimize adverse effects of antihypertensive therapy,” according to the recommendations.
For most patients with diabetes and hypertension, the goal should be a blood pressure below 140/90 mm Hg, and even lower targets may be appropriate for patients at high cardiovascular disease risk, the researchers said.
The guidelines include recommendations for managing hypertension and diabetes through lifestyle modifications such as increasing physical activity, achieving and maintaining a healthy weight, and following a healthy diet with minimal sodium intake and an emphasis on fruits, vegetables, and low-fat dairy products.
The guidelines also emphasize the need for caution when treating older adults who are taking multiple medications. “Systolic blood pressure should be the main target of treatment,” for adults aged 65 years and older with diabetes and hypertension, the authors said.
In addition, the guidelines provide direction for clinicians treating pregnant women. “During pregnancy, treatment with ACE inhibitors, ARBs [angiotensin receptor blockers], or spironolactone is contraindicated, as [these medications] may cause fetal damage,” the authors wrote. Pregnant women with preexisting hypertension or with mild gestational hypertension with systolic blood pressure below 160 mm Hg, a diastolic blood pressure below 105 mm Hg, and no sign of end-organ damage need not take antihypertensive medications, they said. For pregnant women who require antihypertensive treatment, the aim should be a systolic blood pressure between 120 mm Hg and 160 mm Hg and a diastolic blood pressure between 80 mm Hg and 105 mm Hg.
The authors concluded that there currently is insufficient evidence to support blood pressure medication for diabetes patients without hypertension.
The recommendations reference several key clinical trials that compared intensive and standard hypertension treatment strategies: the ACCORD BP (Action to Control Cardiovascular Risk in Diabetes – Blood Pressure) trial, the ADVANCE BP (Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation – Blood Pressure) trial, the HOT (Hypertension Optimal Treatment) trial, and SPRINT (the Systolic Blood Pressure Intervention Trial).
Lead author Dr. de Boer reported serving as a consultant for Boehringer Ingelheim and Ironwood Pharmaceuticals, and his institution has received research equipment and supplies from Medtronic and Abbott. Study coauthors disclosed relationships with multiple companies including Merck, Abbott, Pfizer, and AstraZeneca.