What medications are recommended for patients with diabetes (Diabetes Mellitus) and hypertension (High Blood Pressure)?

Medication Management for Diabetes and Hypertension

For patients with diabetes and hypertension, first-line treatment should include an ACE inhibitor or ARB, particularly in patients with albuminuria, with addition of a thiazide-like diuretic and/or dihydropyridine calcium channel blocker when blood pressure targets are not met. 1

Blood Pressure Targets

• Target blood pressure for patients with diabetes: <130/80 mmHg 1, 2
• Prompt pharmacologic therapy should be initiated when:
  • BP ≥130/80 mmHg (along with lifestyle modifications) 1
  • BP ≥160/100 mmHg requires immediate initiation of two antihypertensive medications 1

Medication Selection Algorithm

First-Line Therapy:

• ACE inhibitor or ARB is the recommended first-line treatment, especially for patients with:
  • Albuminuria (UACR ≥300 mg/g creatinine - strong recommendation) 1
  • Moderate albuminuria (UACR 30-299 mg/g creatinine) 1
  • Coronary artery disease 1

Second-Line Therapy (if BP remains uncontrolled):

• Add one of the following:
  • Thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide) 1, 2
  • Dihydropyridine calcium channel blocker (e.g., amlodipine) 1, 2

Third-Line Therapy (if BP remains uncontrolled):

• Add the remaining class (if started with diuretic, add calcium channel blocker or vice versa) 2

Fourth-Line Therapy (if BP remains uncontrolled on three medications):

• Mineralocorticoid receptor antagonist (e.g., spironolactone) 1
• Consider referral to a hypertension specialist 1

Important Cautions and Monitoring

• Avoid combining ACE inhibitors with ARBs - increases risk of adverse effects without additional benefit 1, 2
• Avoid combining ACE inhibitors or ARBs with direct renin inhibitors 1
• For patients on ACE inhibitors, ARBs, or diuretics:
  • Monitor serum creatinine/eGFR and potassium levels at least annually 1
  • Check renal function and serum potassium within 3 months after initiating therapy 2
  • Assess blood pressure control within 2-4 weeks after adding a second agent 2

Special Considerations

• Patients with albuminuria: ACE inhibitors or ARBs are strongly recommended to reduce progression of kidney disease 1, 2
• Resistant hypertension: Consider mineralocorticoid receptor antagonist (spironolactone) when BP remains uncontrolled on three medications including a diuretic 1
• Beta-blockers: Not considered first-line except in patients with heart failure or previous myocardial infarction 1, 3
• Patients with BP ≥160/100 mmHg: Consider single-pill combination therapy to improve adherence 1

Lifestyle Modifications

Alongside pharmacological therapy, implement these lifestyle modifications:

• Weight loss if overweight or obese
• DASH dietary pattern
• Sodium restriction (<2,300 mg/day)
• Increased physical activity (at least 150 minutes/week)
• Moderation of alcohol intake 1, 2

Monitoring and Follow-up

• Assess BP control within 2-4 weeks after medication changes 2
• Monitor renal function and electrolytes within 3 months of initiating ACE inhibitors, ARBs, or diuretics 2
• Annual monitoring of renal function and potassium for patients on stable therapy 1

This approach to managing hypertension in patients with diabetes focuses on reducing cardiovascular and renal complications while maintaining quality of life through evidence-based medication selection and careful monitoring.