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1999 Clinical Advisory: Treatment Of Hypertension and Diabetes
James R. Sowers MD, and James Reed, MD
James R. Sowers, MD
James Reed, MD
The purpose of this clinical advisory update is to alert clinicians about new information to be used in their clinical practice. Therapy in patients with hypertension and diabetes begins with weight reduction, increased physical activity and moderation of salt and alcohol intake.1,2 The goal blood pressure is 130/85 mm Hg. If it is not reached, then pharmacological intervention is indicated.1,2 Based on clinical trial results,4 classes of drugs are effective first-line therapy in these patients (Fig 1). Most hypertensive diabetic patients will require the use of more than one agent to achieve a therapeutic goal of 130/85.2
Because proteinuria is a harbinger for CVD and renal disease,3 ACE inhibitors may afford unique benefits in preventing CVD as well as diabetic nephropathy.1,2 The Appropriate Blood Pressure Control in Diabetes (ABCD) Trial4 showed cardioprotective effect of ACE inhibitors. Recently, the UK Prospective Diabetes Study Group reported5,6 blood pressure lowering with an atenolol based program was just as effective as a captopril based regimen in reducing the incidence of diabetic complications (both microvascular and macrovascular). Many required these drugs plus a diuretic to achieve "tight control of 144/82 mm Hg". In patients assigned to less tight control (154/87 mm Hg), there was less use of multiple antihypertensive agents. Risk reductions in the group assigned to tight blood pressure control were 24% in diabetes-related end points, 32% in deaths related to diabetes, 44% in strokes, and 37% in microvascular end points, predominantly diabetic retinopathy. These results suggest that combination therapy with either an ACE inhibitor or a beta blocker are very effective in reducing macrovascular and microvascular events providing blood pressure is adequately lowered.
Low dose thiazide diuretics (i.e., 25 mg or less of hydrochlorothizide or chlorthialidone daily), are effective and safe antihypertensive agents in type II diabetic patients.1,2 In the Systolic Hypertension in the Elderly (SHEP) study, elderly type II diabetic men had reductions in stroke and coronary heart disease similar to those without diabetes.7 Low dose diuretics are not associated with significant metabolic abnormalities.1,2 Lower dose diuretics in conjunction with ACE inhibitors usually produces substantial synergism in reducing blood pressure, and use of these agents together, further minimizes potential metabolic problems. Diuretics are important because of the salt sensitivity and expanded plasma volume that is often present in diabetic patients8 particularly in those requiring several drugs to control blood pressure levels of <130/85.
Results from the subset analysis of type II diabetics in the Hypertension Optimal Treatment (HOT) trial9 and a recent sub-analysis of this cohort in the Sys-Eur Trial10 suggest that further reduction in diastolic blood pressure below 85 mm Hg is beneficial. HOT also confirmed that multiple drug regimes are required to reach goal for most hypertensive diabetics. In the Sys-Eur trial, while systolic blood pressure was reduced by a comparable amount in each group (-22±16 mm Hg, nondiabetic vs. -22.1±14 mm Hg, diabetic group), the risk reduction in mortality from CVD was 13% for the nondiabetics and 76% for the diabetic patients.10 Thus, the benefit conferred per mm Hg blood pressure reduction appears to be greater in persons with type II diabetes than in those with hypertension but no coexistent diabetes mellitus. Data from a large trial that was recently reported also supported this notion.11
Acknowledgements: The authors with to thank Ed Roccella, Marvin Moser, Joe Izzo and Sheldon Sheps for their thoughtful input. We also wish to thank Paddy McGowan for her help in preparing this update.
TREATMENT GOAL < 130/85 MM HG
Algorithm for antihypertensive therapy in
the diabetic person.