Hypertension is a common comorbidity of diabetes that increases risks for cardiovascular disease (CVD) and microvascular complications. Most patients with diabetes have hypertension, but the prevalence can vary depending on the type of diabetes, age, obesity, and ethnicity. For example, in type 1 diabetes, hypertension is often the result of underlying nephropathy. In type 2 diabetes, hypertension usually coexists with other cardiometabolic risk factors.
Each year, the American Diabetes Association updates its Standards of Medical Care in Diabetes. In the 2013 update, the standards revised recommendations to include changing the treatment goal for high blood pressure (BP) from less than 130 mm Hg to less than 140 mm Hg (Table 1). “This change to the standards of medical care was made based on several new meta-analyses that showed there is little additional benefit to achieving the lower BP targets,” explains Richard W. Grant, MD, MPH.
Clinical trials have shown that the health benefits to targeting a BP goal of less than 140 mm Hg—including the reduction of CVD events, stroke, and nephropathy—offered little benefit with more intensive BP treatment. Research has shown that such approaches do not significantly reduce mortality rates or the rate of non-fatal heart attacks. There is a small but statistically significant benefit in terms of reducing the risk of stroke, but this comes at the expense of needing more medications and higher rates of side effects.
According to Dr. Grant, the change in the “default” systolic BP target is not meant to downplay the importance of treating hypertension in patients with diabetes. “Untreated hypertension can be very dangerous,” he says. “The change also doesn’t imply that lower targets are generally inappropriate. These lower targets may be appropriate for some patients, particularly those who are younger and have a longer life expectancy, or for those who have a higher risk of stroke. It will depend on the characteristics of each patient. The risks and benefits of using a lower BP goal must be weighed based on whether patients can achieve these goals without excessive amounts of treatment and without a heavy burden of medication side effects.”
The updated Standards of Medical Care in Diabetes also provides important general recommendations for treating patients with diabetes who have hypertension. “Lifestyle therapies are among the most important to emphasize to patients,” says Dr. Grant (Table 2). Several lifestyle therapies are recommended, including reducing sodium intake to below 1,500 mg/day and decreasing excess body weight. The consumption of fruits, vegetables, and low-fat dairy products should be increased, while alcohol consumption should be decreased and monitored closely. Increasing activity levels is also paramount. “In addition to helping with hypertension, non-pharmacologic strategies may also positively affect glycemia and lipid control,” adds Dr. Grant.
“The key is to individualize treatments based
on each person’s specific profile.”
According to the update, non-pharmacologic therapy is reasonable in people with diabetes with mildly elevated blood pressure (systolic BP >120 mm Hg or diastolic BP >80 mm Hg). If the BP is confirmed to be 140 mm Hg systolic or higher and/or 80 mm Hg diastolic or higher, pharmacologic therapy should be initiated along with non-pharmacologic therapy.
ACE inhibitors, angiotensin receptor blockers, b-blockers, diuretics, and calcium channel blockers are available to treat patients with diabetes who have high BP. Inhibitors of the renin-angiotensin system may also be advantageous for some with diabetes who require initial or early hypertension therapy. “We have a wide arsenal of agents that can effectively reduce cardiovascular events in patients with diabetes,” Dr. Grant says. “The key is to individualize treatments based on each person’s specific profile.” It is also important to titrate medications when appropriate and consider adding BP medications in a timely manner, if necessary, to overcome clinical inertia.
Health information technology continues to grow by leaps and bounds, and research suggests it can be used safely and effectively to help patients reach their BP goals. For example, telemonitoring interventions have been used to direct the titration of antihypertensive medications between office visits. Studies suggest that these interventions can significantly impact BP control. “Most patients with hypertension will need multiple drugs to reach their BP treatment goals,” says Dr. Grant. “Using technology to improve medication adherence and overcome barriers to using drugs is an important step to decreasing the burden of hypertension among patients with diabetes.”
Readings & Resources (click to view)
American Diabetes Association. Standards of Medical Care in Diabetes—2013. Diabetes Care. 2013;36:S1-S110. Available at: http://care.diabetesjournals.org/content/36/Supplement_1/S11.full
McBrien K, Rabi DM, Campbell N, et al. Intensive and standard blood pressure targets in patients with type 2 diabetes mellitus: systematic review and meta-analysis. Arch Intern Med. 2012;172:1296-1303. Available at: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/archinternmed.2012.3147.
O’Connor PJ, Vazquez-Benitez G, Schmittdiel JA, et al. Benefits of early hypertension control on cardiovascular outcomes in patients with diabetes. Diabetes Care. 2012 Sep 10 [Epub ahead of print]. Available at: http://care.diabetesjournals.org/content/early/2012/09/06/dc12-0284.abstract.
Schrier RW, Estacio RO, Mehler PS, Hiatt WR. Appropriate blood pressure control in hypertensive and normotensive type 2 diabetes mellitus: a summary of the ABCD trial. Nat Clin Pract Nephrol. 2007;3:428-438.
Cooper-DeHoff RM, Gong Y, Handberg EM, et al. Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease. JAMA. 2010;
ACCORD Study Group, Cushman WC, Evans GW, Byington RP, et al. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med. 2010;362:1575-1585.