What medications are recommended for a patient with diabetes mellitus (DM) and hypertension (HTN)?

From the Guidelines

For patients with diabetes mellitus and hypertension, first-line antihypertensive therapy should include an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB), as these medications lower blood pressure and provide kidney protection for diabetic patients. The most recent and highest quality study, 1, recommends initial treatment for hypertension to include any of the drug classes demonstrated to reduce cardiovascular events in people with diabetes: ACE inhibitors, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers.

Key considerations for medication selection include:

• The presence of albuminuria, where an ACE inhibitor or ARB is recommended to reduce the risk of progressive kidney disease 1
• The presence of established coronary artery disease, where ACE inhibitors or ARBs are recommended as first-line therapy for hypertension 1
• The need for multiple-drug therapy to achieve blood pressure targets, with combinations of a RAAS blocker, and a calcium channel blocker or diuretic being recommended 1

Medication options may include:

• ACE inhibitors like lisinopril (10-40 mg daily)
• ARBs like losartan (50-100 mg daily)
• Calcium channel blockers like amlodipine (5-10 mg daily)
• Thiazide diuretics like hydrochlorothiazide (12.5-25 mg daily) For diabetes management, metformin is the preferred first-line agent unless contraindicated, with additional medications like SGLT-2 inhibitors or GLP-1 receptor agonists offering cardiovascular benefits 1. Regular monitoring of blood pressure, blood glucose, kidney function, and electrolytes is essential when using these medications.

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

Losartan is recommended for a patient with diabetes mellitus (DM) and hypertension (HTN), as it has been shown to be effective in reducing blood pressure in patients with hypertension, including those with diabetes.

• The recommended starting dose is 50 mg once daily, which can be increased to 100 mg once daily based on blood pressure response 2.
• Losartan has been studied in patients with nephropathy in Type 2 Diabetic Patients, and the usual starting dose is 50 mg once daily 2.
• The LIFE study compared losartan and atenolol in hypertensive patients with left ventricular hypertrophy, and found that losartan resulted in a 13% reduction in risk of the primary endpoint compared to the atenolol group 2.

From the Research

Medications for Diabetes and Hypertension

The following medications are recommended for a patient with diabetes mellitus (DM) and hypertension (HTN):

• ACE inhibitors, such as lisinopril, which lower blood pressure and produce a renoprotective effect in patients with IDDM and NIDDM without detriment to glycaemic control or lipid profiles 3
• Diuretics, which are potent hypotensive drugs with clearly demonstrated clinical benefit, and should form part of the antihypertensive regimen of most diabetic hypertensives 4, 5
• Angiotensin-receptor antagonists (ARBs), such as losartan, which represent a valuable new class of drugs in the treatment of diabetic nephropathy 6
• Calcium channel blockers (CCBs), which may lower blood pressure but not albuminuria in patients with type 2 diabetes 7
• Beta-blockers, which can be used in combination with other agents to reduce blood pressure and albuminuria in patients with type 2 diabetes 4

Combination Therapy

Combination therapy with an ACE inhibitor and a diuretic may be more effective in reducing albuminuria than combination therapy with an ACE inhibitor and a CCB 7 Combination therapy with an ACE inhibitor and a CCB may be more effective in reducing blood pressure than combination therapy with an ACE inhibitor and a diuretic 7

Dosage

The optimal dose of losartan for renoprotection and blood pressure reduction in diabetic nephropathy is 100 mg daily 6 The optimal dose of lisinopril for renoprotection and blood pressure reduction in diabetic patients is not specified in the provided evidence, but it is recommended as a first-line agent for reducing blood pressure and preventing or attenuating nephropathy in hypertensive diabetic patients with IDDM or NIDDM and microalbuminuria or overt renal disease 3