What are the guidelines for managing Diabetes Mellitus (DM) and Hypertension (HTN)?

Guidelines for Managing Diabetes Mellitus (DM) and Hypertension (HTN)

Blood Pressure Targets for Diabetic Patients

For patients with diabetes and hypertension, blood pressure should be targeted to a systolic BP of 130 mmHg (and lower if tolerated, but not below 120 mmHg) and diastolic BP below 80 mmHg (but not below 70 mmHg). 1

• In older diabetic patients (≥65 years), the systolic BP goal should be 130-139 mmHg if tolerated 1
• Optimal BP control significantly reduces the risk of both microvascular and macrovascular complications in diabetic patients 1
• BP targets should be adjusted based on comorbidities, duration of diabetes, and age 1
• Avoid hypoglycemia in all diabetic patients, as it may increase cardiovascular risk 1

First-Line Treatment Approach

• Lifestyle modifications are recommended for all patients with diabetes and hypertension 1

  • Reduced calorie intake for lowering excessive body weight 1
  • Moderate-to-vigorous physical activity (combination of aerobic and resistance exercise) for ≥150 minutes/week 1
  • Reduced sodium intake (to <100 mmol/day) 1
  • Increased consumption of vegetables, fruits, and low-fat dairy products 1
  • Smoking cessation with structured advice 1

• For pharmacological treatment, initiate with a combination of a RAAS blocker (ACE inhibitor or ARB) and a calcium channel blocker or thiazide-like diuretic 1

  • RAAS blockers (ACE inhibitors or ARBs) are strongly recommended as first-line therapy, particularly in patients with microalbuminuria, albuminuria, proteinuria, or left ventricular hypertrophy 1
  • The combination of an ACE inhibitor and an ARB is not recommended 1

Special Considerations for Diabetic Hypertensive Patients

• In black patients with diabetes, thiazide diuretics and calcium channel blockers are more effective as first-line agents 1
• For patients with stage 2 hypertension (≥160/100 mmHg), initiation with two antihypertensive agents from different classes is recommended 1
• BP control often requires multiple drug therapy, typically a combination of two or three agents 1
• Monthly evaluation of adherence and therapeutic response is necessary until control is achieved 1

Metabolic Syndrome Management

• For patients with metabolic syndrome, a RAAS blocker should be the first choice, followed by calcium antagonists or low-dose thiazide diuretics if needed 1
• Beta-blockers should be avoided in patients with metabolic syndrome unless specifically indicated, due to their adverse effects on insulin sensitivity, body weight, and lipid profile 1
• Newer vasodilating beta-blockers (carvedilol, nebivolol) may have fewer metabolic adverse effects 1

Monitoring and Follow-up

• Patients with diabetes on combined antihypertensive treatments should be encouraged to self-monitor BP 1
• Regular assessment for orthostatic changes is important, especially in elderly diabetic patients 2
• In elderly diabetic patients with low diastolic BP (<70 mmHg), careful monitoring is needed to prevent excessive BP lowering which can lead to falls and poor outcomes 2

Lipid Management in Diabetic Hypertensive Patients

• Statins are recommended as first-choice lipid-lowering treatment in patients with diabetes and high LDL-C levels 1
• For patients with T2DM at very high CV risk, an LDL-C target of <1.4 mmol/L (<55 mg/dL) and LDL-C reduction of at least 50% is recommended 1
• If target LDL-C is not reached with maximum tolerated statin dose, combination therapy with ezetimibe is recommended 1

Glycemic Control

• Target HbA1c <7.0% (<53 mmol/mol) to decrease microvascular complications 1
• HbA1c targets should be individualized according to diabetes duration, comorbidities, and age 1
• In elderly patients with multiple comorbidities, less stringent glycemic targets (7.5-8.0%) are appropriate 2

Cardiovascular Risk Reduction

• Hypertension and diabetes frequently coexist (in approximately 80% of patients with DM) and dramatically increase cardiovascular risk compared to either condition alone 1, 3
• The combination of lifestyle modifications and pharmacological interventions is essential for comprehensive cardiovascular risk management 4, 3
• Regular monitoring for microvascular (retinopathy, nephropathy, neuropathy) and macrovascular complications is necessary 3, 5