What are the treatment guidelines for a patient with both diabetes mellitus (DM) and hypertension (HTN)?

Treatment Guidelines for Diabetes Mellitus and Hypertension

Patients with both diabetes mellitus and hypertension should be treated with a regimen that includes either an ACE inhibitor or an ARB as first-line therapy, with a blood pressure target of <130/80 mmHg. 1

Blood Pressure Management

BP Targets

• Blood pressure should be measured at every routine diabetes visit, with elevated readings (≥130/80 mmHg) confirmed on a separate day 1
• Target blood pressure for patients with diabetes is <130/80 mmHg 1
• In elderly patients (>65 years), a more moderate systolic target of 130-139 mmHg is recommended to avoid complications 1

Treatment Algorithm

1. For BP 130-139/80-89 mmHg:

   • Start with lifestyle modifications alone for maximum 3 months 1
   • If targets not achieved after 3 months, initiate pharmacological therapy 1

2. For BP ≥140/90 mmHg:

   • Immediate initiation of both lifestyle modifications and pharmacological therapy 1

3. Pharmacological Approach:

   • First-line: ACE inhibitor or ARB (not both simultaneously) 1
   • If one class is not tolerated, substitute with the other 1
   • Add a thiazide/thiazide-like diuretic as one of the first two drugs 1
   • Add calcium channel blockers and/or β-blockers as needed to achieve target 1
   • Monitor renal function and serum potassium within first 3 months of starting ACE inhibitors, ARBs, or diuretics, then every 6 months if stable 1

4. For resistant hypertension:

   • Refer to a hypertension specialist if target BP not achieved despite multiple-drug therapy 1

Lifestyle Modifications

• Weight control if overweight/obese 1
• DASH-style dietary pattern with reduced sodium intake (1200-2300 mg/day) 1
• Increased consumption of fresh fruits, vegetables, and low-fat dairy products 1
• Physical activity: at least 150 minutes of moderate-intensity aerobic activity or 90 minutes of vigorous exercise weekly, distributed over at least 3 days 1
• Moderate alcohol intake (limit to one drink for women, two for men daily) 1

Lipid Management

• Obtain fasting lipid profile at diagnosis and annually thereafter 1
• For patients with diabetes at very high CV risk: LDL-C target <1.4 mmol/L (<55 mg/dL) with at least 50% reduction from baseline 1
• For patients with diabetes over age 40 with CV risk factors: LDL-C target <100 mg/dL (2.6 mmol/L) 1
• Statin therapy is recommended regardless of baseline lipid levels for diabetic patients with overt CVD or those over 40 years with one or more CV risk factors 1
• Consider adding ezetimibe if target LDL-C not achieved with maximal tolerated statin dose 1

Newer Antidiabetic Medications with CV Benefits

• SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin) are recommended for patients with T2DM and CVD or at high CV risk 1, 2
• GLP-1 receptor agonists (liraglutide, semaglutide, dulaglutide) are recommended for patients with T2DM and CVD or at high CV risk 1, 2
• Empagliflozin specifically recommended to reduce risk of death in patients with T2DM and CVD 1

Monitoring and Follow-up

• Monitor blood pressure at every routine diabetes visit 1
• Check orthostatic blood pressure measurements when clinically indicated 1
• Monitor renal function and serum potassium within 3 months of starting ACE inhibitors, ARBs, or diuretics, then every 6 months if stable 1
• Assess cardiovascular risk factors systematically at least annually 1

Special Considerations

• In patients with diabetic nephropathy, ACE inhibitors or ARBs have shown benefits in slowing disease progression 1, 3, 4
• Multiple-drug therapy is generally required to achieve blood pressure targets in most patients 1, 5
• ACE inhibitors and ARBs are contraindicated during pregnancy due to risk of fetal damage 1
• Hypertension and diabetes share common pathophysiological mechanisms including insulin resistance, endothelial dysfunction, and inflammation 6, 2