What is the recommended treatment and management for hypertension in a diabetic person?

Management of Hypertension in Diabetic Patients

For patients with diabetes and hypertension, treatment should include an ACE inhibitor or ARB as first-line therapy, especially in those with albuminuria, along with comprehensive lifestyle modifications targeting a blood pressure goal of <130/80 mmHg. 1

Blood Pressure Targets

• Target blood pressure for diabetic patients: <130/80 mmHg 1
• Initiate pharmacologic therapy along with lifestyle modifications when BP ≥130/80 mmHg 1
• For BP ≥160/100 mmHg, start with two antihypertensive medications simultaneously 1

Pharmacological Management Algorithm

First-line Therapy:

• For patients with albuminuria (UACR ≥30 mg/g): ACE inhibitor or ARB 1
  • Strongly recommended for UACR ≥300 mg/g
  • Suggested for UACR 30-299 mg/g
• For patients with coronary artery disease: ACE inhibitor or ARB 1
• For patients without albuminuria or CAD: Any of the following classes:
  • ACE inhibitors (e.g., lisinopril)
  • ARBs
  • Thiazide-like diuretics (preferably chlorthalidone or indapamide)
  • Dihydropyridine calcium channel blockers (e.g., amlodipine) 1

If BP Target Not Achieved with First-line Therapy:

• Add a second agent from a different class among the four recommended classes 1
• Important: Do NOT combine ACE inhibitors with ARBs or with direct renin inhibitors 1

If BP Target Still Not Achieved:

• Add a third agent from the remaining recommended classes 1

For Resistant Hypertension:

• If BP remains uncontrolled on three medications (including a diuretic), consider adding a mineralocorticoid receptor antagonist (e.g., spironolactone) 1
• Consider referral to a specialist with expertise in BP management 1

Monitoring

• For patients on ACE inhibitors, ARBs, or diuretics:
  • Monitor serum creatinine/eGFR and potassium levels at least annually 1
  • Check these values 7-14 days after initiation or dose changes 1
• Regular BP monitoring to assess treatment efficacy

Lifestyle Modifications

All diabetic patients with BP >120/80 mmHg should implement the following lifestyle changes:

• Weight management: Caloric restriction for overweight/obese patients 1
• Dietary approach: DASH-style eating pattern 1
  • Reduce sodium intake (<2,300 mg/day)
  • Increase potassium intake
  • Consume 8-10 servings of fruits and vegetables daily
  • Include 2-3 servings of low-fat dairy products daily 1
• Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week 1
• Alcohol moderation: No more than 2 drinks/day for men, 1 drink/day for women 1
• Smoking cessation 2

Special Considerations

• Pregnancy: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated 1
• Chronic kidney disease: Continue ACE inhibitors or ARBs even as kidney function declines to eGFR <30 mL/min/1.73 m², as they provide cardiovascular benefit without significantly increasing end-stage kidney disease risk 1
• Beta-blockers: Not recommended as first-line agents unless the patient has specific indications such as coronary artery disease or heart failure 1

Common Pitfalls to Avoid

1. Inadequate dosing: Ensure timely titration of medications to reach target BP 1
2. Inappropriate combinations: Avoid combining ACE inhibitors with ARBs or with direct renin inhibitors 1
3. Overlooking lifestyle modifications: These should be implemented alongside pharmacotherapy, not as a substitute 1
4. Neglecting monitoring: Regular monitoring of kidney function and electrolytes is essential, especially with ACE inhibitors, ARBs, and diuretics 1
5. Failing to recognize resistant hypertension: Consider medication adherence issues, white coat hypertension, or secondary causes before diagnosing true resistant hypertension 1
6. Ignoring albuminuria: This is a critical factor in selecting first-line therapy 1

By following this comprehensive approach to hypertension management in diabetic patients, you can significantly reduce the risk of microvascular and macrovascular complications, including nephropathy, retinopathy, stroke, and myocardial infarction.