What is the best initial antihypertensive medication for a patient with newly diagnosed hypertension and type 2 diabetes mellitus (T2DM)?

From the Guidelines

For a newly diagnosed hypertensive patient with type 2 diabetes, an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) is typically the best first-line medication, as recommended by the most recent guidelines 1. Specific options include lisinopril (starting at 10mg daily) or losartan (starting at 50mg daily). These medications not only lower blood pressure but also provide kidney protection, which is particularly important for diabetic patients who are at higher risk for nephropathy. The target blood pressure for diabetic patients is generally <130/80 mmHg, as suggested by previous studies 1. These medications work by blocking the renin-angiotensin-aldosterone system, reducing vasoconstriction and fluid retention while decreasing proteinuria in diabetic patients. It's essential to monitor kidney function and potassium levels after starting these medications, particularly in diabetic patients, as recommended by the American Diabetes Association standards of medical care in diabetes 2018 1. If the patient cannot tolerate ACE inhibitors or ARBs (due to cough, angioedema, or hyperkalemia), calcium channel blockers like amlodipine (5-10mg daily) or dihydropyridine calcium channel blockers would be appropriate alternatives. Many patients will eventually require multiple medications to achieve adequate blood pressure control, and initial treatment for patients with diabetes depends on the severity of hypertension, with those having blood pressure ≥150/90 mmHg potentially starting with two antihypertensive medications 1.

Some key points to consider when treating hypertensive patients with type 2 diabetes include:

• The importance of achieving blood pressure targets to reduce cardiovascular risk
• The need for regular monitoring of kidney function and potassium levels
• The potential for multiple medications to be required to achieve adequate blood pressure control
• The consideration of alternative medications, such as calcium channel blockers, if ACE inhibitors or ARBs are not tolerated.

Overall, the goal of treatment is to reduce morbidity, mortality, and improve quality of life for patients with hypertension and type 2 diabetes, and the choice of medication should be guided by the most recent and highest-quality evidence available 1.

From the FDA Drug Label

2.3 Nephropathy in Type 2 Diabetic Patients The usual starting dose is 50 mg once daily. The dose should be increased to 100 mg once daily based on blood pressure response

The best medicine to start a newly diagnosed hypertension who is also type 2 diabetic is losartan, with a starting dose of 50 mg once daily. The dose can be increased to 100 mg once daily based on blood pressure response 2.

From the Research

Treatment Options for Hypertension in Type 2 Diabetics

The treatment of hypertension in patients with type 2 diabetes mellitus is crucial to prevent substantial morbidity and mortality. According to 3, the optimal blood pressure goals for these patients are less than 135/80 mm Hg.

First-Line Agents

Several studies suggest that thiazide diuretics, angiotensin-II receptor blockers, and angiotensin-converting enzyme (ACE) inhibitors may be the preferred first-line agents for treating hypertension in diabetes 3, 4.

Comparison of Agents

A head-to-head comparison of angiotensin receptor blockers with ACE inhibitors has shown similar cardioprotective and renoprotective properties of both medication classes 4. However, angiotensin receptor blockers have an improved safety profile with fewer episodes of cough and angioedema.

Combination Therapy

Combination antihypertensive therapy may be considered as initial treatment for newly diagnosed hypertension, especially in patients with stage 2 hypertension 5. The most common combinations used are a thiazide and a potassium-sparing diuretic, and a thiazide and an ACE inhibitor.

Key Findings

• Thiazide-type diuretics are superior in preventing one or more major forms of cardiovascular disease and are less expensive 6.
• Angiotensin-converting enzyme 2 (ACE2) counteracts renin-angiotensin system overactivity and may improve glycemia in diabetic patients 7.
• Restoration of ACE2 improves glycemia in diabetic mice by reducing oxidative stress and improving blood flow to the β-cells 7.

Potential Therapies

Strategies to restore ACE2 levels in type 2 diabetes seem to be a promising therapy for angiotensin-II-mediated type 2 diabetes 7. Novel therapeutic strategies, such as those that include a mineralocorticoid receptor blocker or a selective sodium-glucose cotransporter type 2 inhibitor, may further protect patients with diabetes from cardiovascular and renal complications 4.