What is the initial medication treatment for patients with Hypertension (HTN) and Type 2 Diabetes Mellitus (DM2)?

From the Guidelines

For patients with both hypertension and type 2 diabetes mellitus, the initial medication treatment should involve an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB), as they provide both blood pressure control and kidney protection. According to the most recent guidelines 1, combinations of ACE inhibitors and angiotensin receptor blockers are recommended first-line therapy for hypertension in people with diabetes and coronary artery disease. Specific medications include lisinopril, ramipril, or losartan, which are preferred due to their ability to lower blood pressure and provide kidney protection, particularly important for diabetic patients at higher risk for nephropathy.

Key considerations for treatment include:

• Monitoring kidney function and potassium levels when starting ACE inhibitors or ARBs, particularly in patients with existing kidney disease 1
• Adding a calcium channel blocker or a thiazide diuretic as a second agent if blood pressure remains above target (typically <130/80 mmHg for diabetic patients)
• Regularly checking blood pressure and adjusting medication doses as needed to reach target levels
• Considering the use of ACE inhibitors or ARBs in patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g) to reduce the risk of progressive kidney disease, as recommended by the 2022 standards of medical care in diabetes 1

It's essential to prioritize the use of ACE inhibitors or ARBs as first-line therapy, given their proven benefits in reducing cardiovascular events and providing renal protection in patients with diabetes, as supported by the most recent and highest quality study 1.

From the FDA Drug Label

Many patients will require more than 1 drug to achieve blood pressure goals. Relative risk reduction from blood pressure reduction is similar across populations with varying absolute risk, so the absolute benefit is greater in patients who are at higher risk independent of their hypertension (for example, patients with diabetes or hyperlipidemia), and such patients would be expected to benefit from more aggressive treatment to a lower blood pressure goal The recommended initial dose is 10 mg once a day. Lisinopril tablets, USP, may be administered alone or with other antihypertensive agents

The initial medication treatment for patients with Hypertension (HTN) and Type 2 Diabetes Mellitus (DM2) is lisinopril 10 mg once a day. This can be adjusted according to blood pressure response, and other antihypertensive agents may be added if necessary 2.

• Key points:
  • Patients with HTN and DM2 may require more than one drug to achieve blood pressure goals
  • The initial dose of lisinopril is 10 mg once a day
  • Lisinopril can be administered alone or with other antihypertensive agents
  • Patients with higher risk, such as those with diabetes, may benefit from more aggressive treatment to a lower blood pressure goal 2.

From the Research

Initial Medication Treatment for HTN and DM2

The initial medication treatment for patients with Hypertension (HTN) and Type 2 Diabetes Mellitus (DM2) involves several classes of antihypertensive drugs.

• Angiotensin-converting-enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are considered the ideal choice for initial or early treatment of hypertension in patients with DM2 and albuminuria 3.
• Thiazide and thiazide-like diuretics might be beneficial, alone or in a fixed-dose combination with ACE inhibitors or ARBs 3.
• Calcium channel blockers (CCBs) constitute an ideal option as a second- or third-line agent 3.
• Beta-blockers are not considered as first-line antihypertensive agents, except for those patients with heart failure or previous myocardial infarction 3.

Blood Pressure Goals

• A blood pressure target of <140/90 mmHg applies to most patients with HTN and DM2, but individualization is always important 3.
• A goal blood pressure of less than 130/80 mm Hg should be attained to reduce cardiovascular morbidity and mortality in patients with HTN and DM2 4.
• Target diastolic blood pressures of less than 80 mm Hg appear optimal, and systolic targets of 135 mm Hg or less are reasonable 5.

Choice of Agents

• ACE inhibitors, angiotensin II receptor blockers, and thiazide diuretics may be the preferred first-line agents for treatment of hypertension in diabetes 5.
• Beta-blockers and calcium-channel blockers are more effective than placebo, but they may not be as effective as diuretics, angiotensin-II receptor blockers, or ACE inhibitors 5.
• The combination of an ACE inhibitor and a calcium antagonist that lowers the heart rate might offer even greater advantages than either class of drug alone 6.