ADA Officials Make Therapeutic Recommendations for Diabetes Patients With Hypertension

Patients with diabetes who have hypertension should, at a minimum, be treated to blood pressure targets of less than 140/90 mmHg, and even lower targets for some patients at higher risk of cardiovascular disease, according to a position paper released recently by the American Diabetes Association (ADA).¹

The ADA's recommendations, which include a newly added pictorial algorithm for the treatment of confirmed hypertension in people with diabetes, are featured in the the September issue of Diabetes Care.

The Association recommends that people with diabetes have blood pressure measurements taken at every routine clinical visit and, for people with diagnosed hypertension, taken at home as well. Patients with an elevated blood pressure should have their blood pressure confirmed with multiple readings, including measurements on a separate day, to diagnose hypertension, according to the panel.

Lifestyle management plans for lowering blood pressure are also highlighted in the guidelines and include suggestions on weight loss, nutrition, and increased physical activity. The statement also details, step-by-step, the recommended approach for the use of medication in the treatment of hypertension in people with diabetes, which depends on initial blood pressure, kidney health, response to treatment and adverse effects.

The guidelines recommend that:

• "patients with a confirmed blood pressure ≥160/100 mmHg should have prompt initiation and timely titration of 2 drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes, in addition to lifestyle therapy (Grade A recommendation).
• Treatment include drug classes demonstrated to reduce cardiovascular events in patients with diabetes: ACE inhibitors, angiotensin receptor blockers (ARBs), thiazide-like diuretics, or dihydropyridine calcium channel blockers. Multiple-drug therapy is generally required to achieve blood pressure targets (Grade A recommendation).
• An ACE inhibitor or ARB is the recommended first-line treatment for hypertension in patients with diabetes and urine albumin-to creatinine ratio ≥ 300 mg/g creatinine (Grade A recommendation) or 30—299 mg/g creatinine (Grade B recommendation). If one class is not tolerated, the other should be substituted. (Grade B recommendation).
• For patients with an ACE inhibitor, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored (Grade B recommendation)."

The Association provides detailed information regarding pregnancy, diabetes, and hypertension. The statement emphasizes that women with preexisting hypertension or mild gestational hypertension (blood pressures less than 160/105 mmHg), and no evidence of end-organ damage, should not be treated with antihypertensive medications, as there is no benefit that clearly outweighs the potential risks. Blood pressure targets and potential medication guidelines are also included for pregnant patients with diabetes who do require treatment for hypertension.

Antihypertensive treatment for people with diabetes in the absence of hypertension is addressed, with the position statement indicating there is little evidence that blood pressure medication improves health outcomes in this group of patients. Additionally, the statement offers recommendations for adults who are 65 years of age and older who have diabetes and hypertension.

“In the past two decades, we have seen a decrease in ASCVD morbidity and mortality in people with diabetes, and evidence indicates that advances in blood pressure control are likely the key to such improvements,” the Association’s Chief Scientific, Medical & Mission Officer William T. Cefalu, MD, said in a press release.² “As medical and pharmacological developments occur, it is imperative that medical providers, diabetes educators and patients stay abreast of the most current care recommendations that can lead to improved cardiovascular health for people with diabetes and will ultimately result in better overall health and fewer diabetes-related complications.”

Reference

1. ADA. Diabetes and Hypertension: A Position Statement by the American Diabetes Association. Diabetes Care. 2017; 40(9): 1273-1284. http://care.diabetesjournals.org/lookup/doi/10.2337/DCi17-0026. Accessed Sept. 11, 2017.

2. American Diabetes Association Issues Updated Diabetes and Hypertension Position Statement [news release]. Arlington, Virginia. ADA website. Aug. 22, 2017. http://www.diabetes.org/newsroom/press-releases/2017/american-diabetes-association-updated-diabetes-and-hypertension-position-statement-2017.html. Accessed Sept. 11, 2017.