What is the best management plan for patients with diabetes mellitus (DM) and hypertension (HTN)?

Management of Diabetes Mellitus and Hypertension

For patients with diabetes and hypertension, initiate an ACE inhibitor or ARB as first-line therapy targeting blood pressure <130/80 mmHg, combined with DASH-style dietary modifications, sodium restriction to <2,300 mg/day, and at least 150 minutes of moderate-intensity aerobic exercise weekly. 1

Blood Pressure Targets and Monitoring

• Measure blood pressure at every routine diabetes visit, with any reading ≥130/80 mmHg confirmed on a separate day before initiating treatment 1
• Target blood pressure is <130/80 mmHg for all patients with diabetes and hypertension to reduce cardiovascular events and stroke risk 1, 2
• Perform orthostatic blood pressure measurements when clinically indicated, particularly in patients at risk for autonomic neuropathy 1, 2

Pharmacologic Management Algorithm

For BP 130-139/80-89 mmHg:

• Start lifestyle modifications immediately (detailed below) 1
• If BP targets not achieved after 3 months of lifestyle therapy alone, initiate pharmacologic therapy 1, 2

For BP ≥140/90 mmHg:

• Immediately initiate both lifestyle modifications AND pharmacologic therapy - do not delay drug treatment 1

For BP ≥160/100 mmHg:

• Promptly initiate two antihypertensive drugs simultaneously or use a single-pill combination to achieve rapid BP control 1

First-Line Pharmacologic Therapy

ACE inhibitors or ARBs are the mandatory first-line agents for all patients with diabetes and hypertension, as they reduce cardiovascular events and provide renal protection 1, 2, 3

• If one class is not tolerated, substitute with the other (ACE inhibitor ↔ ARB) 1
• Never combine ACE inhibitors with ARBs - this combination increases adverse events without additional benefit 1
• Never combine ACE inhibitors or ARBs with direct renin inhibitors 1

Special Considerations for Albuminuria:

• For urine albumin-to-creatinine ratio 30-299 mg/g: ACE inhibitor or ARB is suggested as first-line therapy 1
• For urine albumin-to-creatinine ratio ≥300 mg/g: ACE inhibitor or ARB is strongly recommended and should be titrated to maximum tolerated dose 1, 3

Additional Antihypertensive Agents

Most patients require multiple drugs to achieve BP targets - monotherapy is rarely sufficient 1, 2

Second and Third-Line Agents (add sequentially as needed):

1. Thiazide-like diuretics (chlorthalidone or indapamide preferred over hydrochlorothiazide due to superior cardiovascular event reduction) 1
2. Dihydropyridine calcium channel blockers 1
3. Beta-blockers (when indicated for other cardiovascular conditions) 1

For Resistant Hypertension:

• Add a mineralocorticoid receptor antagonist (e.g., spironolactone) when BP remains ≥140/90 mmHg despite three-drug therapy including ACE inhibitor/ARB, thiazide-like diuretic, and calcium channel blocker 1
• Refer to hypertension specialist if targets still not achieved 1

Lifestyle Modifications (Mandatory for All Patients)

Dietary Interventions:

• DASH-style eating pattern: 8-10 servings of fruits and vegetables daily, 2-3 servings of low-fat dairy products daily 1
• Sodium restriction to <2,300 mg/day (equivalent to 3,000-6,000 mg sodium chloride) 1
• Increase potassium intake through dietary sources 1
• Limit saturated fat to <7% of total calories and trans fats to <1% of energy intake 1
• Total dietary fat 25-35% of calories, emphasizing monounsaturated and polyunsaturated fats 1
• Dietary fiber intake of 14 g per 1,000 calories consumed 1

Alcohol Consumption:

• Limit to ≤2 drinks/day for men and ≤1 drink/day for women (1 drink = 12 oz beer, 4 oz wine, or 1.5 oz distilled spirits) 1
• Minimize alcohol if weight loss is needed or if triglycerides are elevated 1

Physical Activity:

• At least 150 minutes of moderate-intensity aerobic exercise per week OR 90 minutes of vigorous aerobic exercise weekly 1
• Distribute activity over at least 3 days per week with no more than 2 consecutive days without exercise 1, 2
• For major weight loss maintenance, increase to 7 hours of moderate/vigorous activity weekly 1

Weight Management:

• Reduce excess body weight through caloric restriction when overweight or obese 1

Monitoring Requirements

Renal Function and Electrolytes:

• Monitor serum creatinine, eGFR, and potassium within 3 months of initiating ACE inhibitor, ARB, or diuretic therapy 1, 2
• If stable, monitor every 6 months thereafter 1, 2
• Monitor at least annually as minimum frequency 1

Lipid Management:

• Obtain fasting lipid profile at diagnosis and annually 2
• Initiate statin therapy for patients >40 years with one or more cardiovascular risk factors, regardless of baseline LDL-C 2
• Target LDL-C <100 mg/dL for patients with cardiovascular risk factors 2
• Target LDL-C <55 mg/dL with ≥50% reduction from baseline for very high cardiovascular risk patients 2

Newer Antidiabetic Agents with Cardiovascular Benefits

Consider SGLT2 inhibitors or GLP-1 receptor agonists for patients with type 2 diabetes and established cardiovascular disease or high cardiovascular risk, as these agents reduce cardiovascular events and mortality beyond glycemic control 2

Critical Pitfalls to Avoid

• Do not delay pharmacologic therapy in patients with BP ≥140/90 mmHg - lifestyle modifications alone are insufficient at this level 1
• Do not use ACE inhibitor + ARB combinations - this increases hyperkalemia and acute kidney injury risk without benefit 1
• Do not underdose ACE inhibitors or ARBs - titrate to maximum tolerated doses, especially with albuminuria 1
• Do not use hydrochlorothiazide as first-choice diuretic - chlorthalidone and indapamide have superior cardiovascular outcomes 1
• In elderly patients, lower BP gradually to avoid complications from rapid reduction 1
• ACE inhibitors and ARBs are contraindicated in pregnancy - discontinue immediately if pregnancy occurs 2