What are the recommended antihypertensive medications for patients with diabetes mellitus (DM) and hypertension?

Recommended Antihypertensive Medications for Patients with Diabetes Mellitus and Hypertension

For patients with diabetes mellitus and hypertension, ACE inhibitors or angiotensin receptor blockers (ARBs) are recommended as first-line therapy, especially in those with albuminuria or coronary artery disease. 1, 2

First-Line Medication Selection

• ACE inhibitors or ARBs are recommended as first-line therapy for hypertension in people with diabetes, particularly those with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g) or established coronary artery disease 1, 2, 3
• For patients who cannot tolerate ACE inhibitors (e.g., due to cough or angioedema), ARBs provide similar cardiovascular and renal protection benefits without the same allergy risk 3, 4
• Thiazide-like diuretics, dihydropyridine calcium channel blockers, and ARBs are all effective first-line agents with proven efficacy in reducing cardiovascular events 1, 2
• For Black patients with diabetes, calcium channel blockers and thiazide diuretics may be more effective than ACE inhibitors or ARBs 2

Treatment Algorithm Based on Blood Pressure Level

• For blood pressure between 130/80 mmHg and 140/90 mmHg: Start with lifestyle modifications for a maximum of 3 months, then add pharmacologic therapy if targets are not achieved 1, 2
• For blood pressure between 140/90 mmHg and 160/100 mmHg: Begin with a single antihypertensive medication (preferably ACE inhibitor or ARB) plus lifestyle modifications 1, 2
• For blood pressure ≥160/100 mmHg: Initial treatment with two antihypertensive medications is recommended (ACE inhibitor or ARB plus either a thiazide-like diuretic or dihydropyridine calcium channel blocker) 1, 2, 3

Combination Therapy Considerations

• Multiple-drug therapy is generally required to achieve the blood pressure goal of <130/80 mmHg in patients with diabetes 1
• Preferred combinations include:
  • ACE inhibitor or ARB + calcium channel blocker 2, 5
  • ACE inhibitor or ARB + thiazide-like diuretic 2, 5
• Avoid combining ACE inhibitors with ARBs as this increases the risk of hyperkalemia without additional benefit 2, 3

Special Considerations for Diabetic Patients with Comorbidities

• For patients with diabetes and albuminuria: ACE inhibitors or ARBs are strongly recommended to reduce the risk of progressive kidney disease 1, 2, 4
• For patients with diabetes and established coronary artery disease: ACE inhibitors or ARBs are recommended as first-line therapy 1, 2
• For patients with resistant hypertension (not meeting blood pressure targets on three classes including a diuretic): Consider adding a mineralocorticoid receptor antagonist 1

Monitoring and Follow-up

• Monitor serum creatinine and potassium levels within 7-14 days after initiating ACE inhibitors or ARBs, and at least annually thereafter 2, 3
• Continue ACE inhibitor or ARB therapy even as kidney function declines to eGFR <30 mL/min/1.73 m² as this may provide cardiovascular benefit without significantly increasing the risk of end-stage kidney disease 1
• Watch for hyperkalemia when using ACE inhibitors or ARBs, especially in combination with mineralocorticoid receptor antagonists 2

Common Pitfalls to Avoid

• Underdosing medications before adding additional agents 2
• Failing to consider ethnicity in medication selection (ACE inhibitors and ARBs are less effective in Black patients) 2, 6
• Using ACE inhibitor + ARB combinations, which increases adverse effects without additional benefit 2, 3
• Overlooking the need for more aggressive initial therapy in patients with markedly elevated blood pressure 1, 2
• Discontinuing ACE inhibitors or ARBs prematurely when kidney function declines 1

Target Blood Pressure

• The recommended blood pressure target for patients with diabetes is <130/80 mmHg 1, 3
• This target has been shown to reduce the risk of cardiovascular events, particularly stroke, as well as diabetic nephropathy progression 5, 7