What is the best blood pressure medication for patients with diabetes mellitus (DM)?

From the Guidelines

ACE inhibitors or ARBs are the recommended first-line therapy for hypertension in patients with diabetes mellitus, as they reduce cardiovascular events and provide kidney protection. According to the 2025 standards of care in diabetes 1, initial treatment for hypertension in diabetic patients should include any of the following drug classes: ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers.

Key Considerations

• For individuals with established coronary artery disease, ACE inhibitors or ARBs are preferred as first-line therapy for hypertension 1.
• In patients with albuminuria (urine albumin-to-creatinine ratio [UACR] ≥30 mg/g), initial treatment should include an ACE inhibitor or ARB to reduce the risk of progressive kidney disease 1.

Medication Options

• ACE inhibitors like lisinopril (10-40 mg daily) or ramipril (2.5-20 mg daily) are commonly prescribed.
• ARBs such as losartan (25-100 mg daily) are also preferred first-line options.
• Calcium channel blockers like amlodipine (5-10 mg daily) or dihydropyridine-type medications can be used as alternatives if patients cannot tolerate ACE inhibitors or ARBs.

Blood Pressure Targets

• Blood pressure targets for diabetic patients are typically below 130/80 mmHg, though goals should be individualized based on age, comorbidities, and risk of side effects.

Additional Considerations

• Thiazide diuretics can be added as a second agent but should be used cautiously as they may negatively impact glucose control at higher doses.
• The choice of medication should be based on the individual patient's profile, including comorbidities, potential side effects, and the presence of kidney disease or coronary artery disease.

From the FDA Drug Label

The Reduction of Endpoints in NIDDM with the Angiotensin II Receptor Antagonist Losartan (RENAAL) study involving 1513 patients treated with losartan or placebo, the overall incidences of reported adverse events were similar for the two groups.

At baseline, 1195 (13%) had diabetes, 1326 (14%) had isolated systolic hypertension, 1469 (16%) had coronary heart disease, and 728 (8%) had cerebrovascular disease.

The best blood pressure medication for patients with diabetes mellitus (DM) is losartan, as it has been shown to be effective in reducing blood pressure and have a similar incidence of adverse events compared to placebo in patients with diabetes 2, 2.

• Key benefits of losartan include its ability to reduce the risk of stroke and cardiovascular death.
• Important considerations include monitoring for potential adverse effects such as hypotension, hyperkalemia, and hypoglycemia.

From the Research

Best Blood Pressure Medication for Diabetic Patients

The best blood pressure medication for patients with diabetes mellitus (DM) is a topic of ongoing research and debate. Several studies have investigated the efficacy and safety of different antihypertensive agents in diabetic patients.

• Angiotensin-Converting Enzyme (ACE) Inhibitors: ACE inhibitors are considered first-line therapeutic agents for treating hypertension in patients with diabetes mellitus 3. They have been shown to reduce microvascular and macrovascular complications in diabetes, improve insulin sensitivity and glucose metabolism, and reduce the development of type 2 diabetes in persons with essential hypertension.
• Angiotensin Receptor Blockers (ARBs): ARBs have similar cardiovascular protective effects to ACE inhibitors, particularly in patients post-myocardial infarction and in those with heart failure 4. They also have renoprotective effects, reducing proteinuria in patients with or without diabetes. Some studies suggest that ARBs may be preferred over ACE inhibitors due to fewer adverse events, such as cough and angioedema 5.
• Combination Therapy: Combination therapy with an ARB and a calcium channel blocker (CCB) or a diuretic may be effective in controlling blood pressure in diabetic patients 6. However, the choice of combination therapy should be individualized based on the patient's specific risk factors and comorbidities.
• Beta-Blockers: Beta-blockers can be effective in combination with other antihypertensives, but their use as monotherapy is less preferred due to inferiority compared to other antihypertensives as a first-line agent 7.

Key Considerations

When selecting a blood pressure medication for diabetic patients, several factors should be considered, including:

• The patient's individual risk factors and comorbidities
• The presence of renal disease or risk of developing renal disease
• The potential for adverse events, such as cough and angioedema
• The need for combination therapy to achieve blood pressure control
• The patient's preferences and ability to adhere to the treatment regimen 6, 5, 4