What is the recommended approach for managing common internal medicine conditions like hypertension and diabetes?

Management of Hypertension and Diabetes in Internal Medicine

For optimal management of hypertension and diabetes, a targeted approach focusing on blood pressure control, glycemic management, and cardiovascular risk reduction is recommended, with specific medication choices based on comorbidities and risk factors.

Hypertension Management

Blood Pressure Targets

• Blood pressure should be categorized as non-elevated BP, elevated BP, and hypertension to guide treatment decisions 1
• For patients with diabetes, a blood pressure target of <130/80 mmHg is recommended for those with high cardiovascular risk or established cardiovascular disease 1
• For patients with diabetes and lower cardiovascular risk (10-year ASCVD risk <15%), a blood pressure target of <140/90 mmHg is appropriate 1

Screening and Diagnosis

• Blood pressure should be measured at every routine clinical visit 1
• Hypertension is defined as systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg based on an average of two or more measurements obtained on two or more occasions 1
• Home blood pressure monitoring is recommended for all patients with hypertension and diabetes after appropriate education 1

Treatment Approach for Hypertension

• For patients with confirmed blood pressure 130-139/80-89 mmHg:

  • Begin with lifestyle modifications for up to 3 months 1
  • If targets not achieved, add pharmacological therapy 1

• For patients with confirmed blood pressure ≥140/90 mmHg:

  • Initiate both lifestyle modifications and pharmacological therapy promptly 1
  • Timely titration of medication is essential 1

• For patients with confirmed blood pressure ≥160/100 mmHg:

  • Initiate lifestyle modifications and prompt initiation of two drugs or a single-pill combination 1

Medication Selection for Hypertension

• First-line medications for patients with diabetes and hypertension include:

  • ACE inhibitors or ARBs (especially with albuminuria or coronary artery disease) 1
  • Thiazide-like diuretics (preferably long-acting agents like chlorthalidone and indapamide) 1
  • Dihydropyridine calcium channel blockers 1

• For patients with albuminuria (urine albumin-to-creatinine ratio ≥30 mg/g):

  • ACE inhibitors or ARBs are recommended as first-line therapy 1
  • Maximum tolerated dose should be used 1

• For resistant hypertension (BP ≥140/90 mmHg despite three medications including a diuretic):

  • Consider adding a mineralocorticoid receptor antagonist 1

• Avoid combination of ACE inhibitors with ARBs due to increased risk of adverse effects without additional benefit 1

Monitoring

• For patients on ACE inhibitors, ARBs, or diuretics, monitor serum creatinine/eGFR and potassium levels at least annually 1

Diabetes Management

Glycemic Control

• Individualize glycemic targets based on patient factors, with general HbA1c target <7% for most patients 1
• Consider SGLT2 inhibitors for patients with diabetes, especially those with high cardiovascular risk, as they reduce heart failure hospitalization and cardiovascular mortality 1

Comprehensive Risk Management

• Assess cardiovascular risk factors systematically at least annually in all patients with diabetes 1
• Use SCORE2 for assessing 10-year risk of fatal and non-fatal CVD among individuals aged 40-69 years with elevated BP 1
• Use SCORE2-OP for assessing cardiovascular risk in patients ≥70 years 1

Lifestyle Modifications for Both Conditions

Dietary Recommendations

• Recommend a DASH-style dietary pattern or Mediterranean diet 1
• Reduce sodium intake (<2,300 mg/day) and increase potassium intake 1
• Increase consumption of fruits and vegetables (8-10 servings per day) and low-fat dairy products (2-3 servings per day) 1
• Reduce saturated fat and trans fat intake 1
• Increase dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols 1

Physical Activity and Weight Management

• Encourage regular physical activity within the patient's limitations 1
• Recommend weight loss if overweight or obese 1
• Moderate alcohol intake (no more than 2 servings per day in men and no more than 1 serving per day in women) 1

Patient-Centered Care

• Conduct informed discussions about cardiovascular risk and treatment benefits tailored to patient needs 1
• Consider motivational interviewing to assist patients in controlling blood pressure and enhancing treatment adherence 1
• Encourage home blood pressure measurement and self-monitoring 1
• Consider multidisciplinary approaches in management 1

Common Pitfalls and Caveats

• Avoid excessive blood pressure reduction in patients with intracerebral hemorrhage (systolic BP ≥220 mmHg) - acute reduction >70 mmHg within 1 hour is not recommended 1
• Be cautious with intensive blood pressure control in elderly patients, those with chronic kidney disease, or frailty due to higher risk of adverse effects 1
• Monitor for orthostatic hypotension, especially in patients with diabetes who may have autonomic neuropathy 1
• Metformin (commonly used for diabetes) rarely causes hypoglycemia by itself but can do so if combined with other medications that lower blood sugar 2
• The presence of low diastolic blood pressure is not necessarily a contraindication to intensive blood pressure management in the context of otherwise standard care 1