What is the recommended treatment for hypertension in patients with diabetes?

Treatment of Hypertension in Diabetes

ACE inhibitors or ARBs should be the first-line treatment for hypertension in patients with diabetes, particularly for those with albuminuria or coronary artery disease, with addition of thiazide-like diuretics and/or dihydropyridine calcium channel blockers when blood pressure targets are not met. 1, 2

Initial Treatment Approach

Blood Pressure Assessment and Goals

• Target blood pressure for patients with diabetes: <130/80 mmHg 2
• Prompt pharmacologic therapy should be initiated when BP ≥140/90 mmHg 1
• For BP between 140/90 mmHg and 159/99 mmHg: Start with a single drug 1
• For BP ≥160/100 mmHg: Immediate initiation of two antihypertensive medications 1

First-Line Medication Selection

1. For patients with albuminuria (UACR ≥30 mg/g creatinine) or coronary artery disease:

   • ACE inhibitor or ARB at maximum tolerated dose 1, 2
   • Strong recommendation for UACR ≥300 mg/g creatinine (A level evidence)
   • Recommended for UACR 30-299 mg/g creatinine (B level evidence) 1

2. For patients without albuminuria:

   • Any of these drug classes that have demonstrated cardiovascular event reduction 1:
     • ACE inhibitors or ARBs
     • Thiazide-like diuretics (preferably chlorthalidone or indapamide)
     • Dihydropyridine calcium channel blockers

Stepped Therapy Approach

Step 1: Initial Therapy

• Start with an ACE inhibitor or ARB (e.g., losartan) 3
• Monitor renal function and potassium within 2-4 weeks of initiation 2

Step 2: Dual Therapy

• If BP remains uncontrolled, add either:
  • Thiazide-like diuretic (preferably chlorthalidone or indapamide) 2 OR
  • Dihydropyridine calcium channel blocker (e.g., amlodipine) 4
• The combination of an ACE inhibitor/ARB with a calcium channel blocker may be preferred based on the ACCOMPLISH trial 5

Step 3: Triple Therapy

• If BP remains uncontrolled, use all three classes:
  • ACE inhibitor or ARB
  • Thiazide-like diuretic
  • Dihydropyridine calcium channel blocker 1

Step 4: Resistant Hypertension

• For patients not meeting BP targets on three classes (including a diuretic):
  • Add a mineralocorticoid receptor antagonist (spironolactone) 1, 2
  • Monitor potassium and renal function closely due to increased risk of hyperkalemia 1

Important Precautions

Medication Combinations to Avoid

• Do not combine ACE inhibitors with ARBs 1
• Do not combine ACE inhibitors or ARBs with direct renin inhibitors 1
• These combinations increase risk of adverse effects without additional benefit 2

Monitoring Requirements

• Check serum creatinine, eGFR, and potassium levels:
  • Within 2-4 weeks of initiating therapy 2
  • At least annually thereafter 1
• Annual quantitative assessment of urinary albumin (UACR) 2

Special Considerations

Dosing of ACE Inhibitors/ARBs

• Titrate to maximum tolerated dose indicated for blood pressure treatment 1
• Higher doses of ACE inhibitors or ARBs are more effective for reducing proteinuria 6

Resistant Hypertension Management

• Before diagnosing resistant hypertension, exclude:
  • Medication nonadherence
  • White coat hypertension
  • Secondary hypertension 1
• Consider medication adherence testing if BP remains uncontrolled despite multiple medications 2

Lifestyle Modifications

Implement alongside pharmacological therapy:

• Weight loss if overweight or obese
• DASH dietary pattern (high in fruits, vegetables, whole grains, and nuts)
• Sodium restriction (<2,300 mg/day)
• Physical activity (at least 150 minutes/week)
• Moderation of alcohol consumption 1, 2

Comprehensive Approach

Hypertension management in diabetes should be part of a comprehensive cardiovascular risk management strategy that includes:

• Lipid control (statin therapy)
• Diabetes management
• Smoking cessation
• Limited sodium intake 3, 4

This approach recognizes that hypertension and diabetes are "bad companions" that synergistically increase cardiovascular risk 7, and effective blood pressure control is crucial for reducing morbidity and mortality in this high-risk population.