Management of Hypertension with Treatment Goals in Diabetic Patient: ADA Recommendations
American Diabetes Association (ADA) Professional Practice Committee: Recommendations
Treatment Strategies
Lifestyle Intervention:
Recommendation
For patients with blood pressure >120/80 mmHg, lifestyle intervention consists of weight loss when indicated, a Dietary Approaches to Stop Hypertension (DASH)-style eating pattern including reducing sodium and increasing potassium intake, moderation of alcohol intake, and increased physical activity.
Lifestyle management is an important component of hypertension treatment because it lowers blood pressure, enhances the effectiveness of some antihypertensive medications, promotes other aspects of metabolic and vascular health, and generally leads to few adverse effects.
Pharmacologic Interventions:
Recommendations
Fig. 1: Recommendations for the treatment of confirmed hypertension in people with diabetes. *An ACE inhibitor (ACEi) or angiotensin receptor blocker (ARB) is suggested to treat hypertension for patients with coronary artery disease (CAD) or urine albumin-to-creatinine ratio 30–299 mg/g creatinine and strongly recommended for patients with urine albumin-to-creatinine ratio ≥300 mg/g creatinine. **Thiazide-like diuretic; long-acting agents shown to reduce cardiovascular events, such as chlorthalidone and indapamide, are preferred. ***Dihydropyridine calcium channel blocker (CCB). BP, blood pressure.
Patients with confirmed office-based blood pressure ≥140/90 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of pharmacologic therapy to achieve blood pressure goals.
Patients with confirmed office-based blood pressure ≥160/100 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes.
Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes.
ACE (Angiotensin Converting Enzyme) inhibitors or Angiotensin Receptor Blockers (ARB) are recommended first-line therapy for hypertension in people with diabetes and coronary artery disease.
Multiple-drug therapy is generally required to achieve blood pressure targets.
Note: However, combinations of ACE inhibitors and Angiotensin Receptor Blockers (ARB) and combinations of ACE inhibitors or ARB with direct renin inhibitors should not be used.
ACE inhibitors (eg. Enalapril. Lisinopril, Ramipril) or ARBs (eg. Telmisartan, Olmesartan, Losartan), at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine or 30–299 mg/g creatinine. If one class is not tolerated, the other should be substituted.
Monitoring: For patients treated with an ACE inhibitor, Angiotensin Receptor Blocker (ARB), or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored at least annually.
Doctors Liked to Read More
Initial treatment for people with diabetes depends on the severity of hypertension (Fig. 1). Those with blood pressure between 140/90 mmHg and 159/99 mmHg may begin with a single drug.
For patients with blood pressure ≥160/100 mmHg, initial pharmacologic treatment with two antihypertensive medications is recommended in order to more effectively achieve adequate blood pressure control.
Single-pill antihypertensive combinations may improve medication adherence in some patients.
Initial treatment for hypertension should include any of the drug classes demonstrated to reduce cardiovascular events in patients with diabetes: ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers.
In patients with diabetes and established coronary artery disease, ACE inhibitors or ARBs are recommended first-line therapy for hypertension.
For patients with albuminuria (urine albumin-to-creatinine ratio [UACR] ≥30 mg/g), initial treatment should include an ACE inhibitor or ARB in order to reduce the risk of progressive kidney disease (Fig. 1).
Recommendation
Patients with hypertension who are not meeting blood pressure targets on three classes of antihypertensive medications (including a diuretic) should be considered for mineralocorticoid receptor antagonist therapy (eg. Spironolactone).
Resistant hypertension is defined as blood pressure ≥140/90 mmHg despite a therapeutic strategy that includes appropriate lifestyle management plus a diuretic and two other antihypertensive drugs with complimentary mechanisms of action at adequate doses.
Comments
You must login to write comment