What's the next step for a patient with hypertension and hyperglycemia?

Next Step: Confirm Diabetes Diagnosis with Repeat Testing

A single fasting plasma glucose of 145 mg/dL requires confirmation with repeat testing before diagnosing diabetes, as recommended by the American Diabetes Association. 1, 2

Immediate Diagnostic Action

• Repeat fasting plasma glucose on a separate day to confirm the diagnosis, as a single elevated value (≥126 mg/dL) is insufficient for diagnosis without symptoms of hyperglycemia 1, 2
• Alternatively, obtain HbA1c testing (≥6.5% confirms diabetes) or perform a 2-hour oral glucose tolerance test (≥200 mg/dL confirms diabetes) 1, 2
• The patient's fasting glucose of 145 mg/dL exceeds the diagnostic threshold of 126 mg/dL, but confirmation prevents misdiagnosis in cases of stress hyperglycemia or laboratory error 1, 2

Once Diabetes is Confirmed

Blood Pressure Management Priority

• Measure blood pressure at this visit using proper technique with appropriate cuff size while patient is seated and relaxed 1, 2
• If BP is ≥140/90 mmHg, initiate both lifestyle modifications and pharmacological therapy immediately with an ACE inhibitor or ARB as first-line agent 2
• If BP is 130-139/80-89 mmHg, start lifestyle modifications and reassess in 3 months; if target not achieved, add pharmacological therapy 2
• Target BP <130/80 mmHg for patients with diabetes and hypertension 2

Initial Diabetes Management

• For incidentally diagnosed or metabolically stable patients (A1C <8.5% and asymptomatic), metformin is the initial pharmacologic treatment if renal function is normal 1
• If A1C ≥8.5% or blood glucose ≥250 mg/dL with symptoms (polyuria, polydipsia, weight loss), initiate basal insulin while starting metformin 1
• Measure A1C every 3 months to assess glycemic control 1

Comprehensive Cardiovascular Risk Assessment

• Obtain fasting lipid profile at diagnosis and annually thereafter 2
• For patients over age 40 with cardiovascular risk factors, target LDL-C <100 mg/dL (2.6 mmol/L) 2
• Initiate statin therapy regardless of baseline lipid levels for diabetic patients over 40 years with one or more CV risk factors 2
• Consider SGLT2 inhibitors or GLP-1 receptor agonists for patients with diabetes at high cardiovascular risk 2

Lifestyle Modifications (Start Immediately)

• DASH-style dietary pattern with sodium restriction to 1200-2300 mg/day 2
• At least 150 minutes of moderate-intensity aerobic activity weekly distributed over at least 3 days 1, 2
• Weight control if overweight or obese 2
• Increased consumption of fresh fruits, vegetables, and low-fat dairy products 2

Monitoring Schedule

• Renal function and serum potassium within 3 months of starting ACE inhibitors, ARBs, or diuretics, then every 6 months if stable 2
• Blood pressure at every routine diabetes visit 2
• HbA1c every 3 months until target achieved 1
• Annual screening for microalbuminuria once patient has had diabetes for 5 years (if age ≥10 years) 1, 2

Critical Pitfall to Avoid

• Do not delay confirmation testing - a single fasting glucose does not establish diagnosis, and premature treatment initiation without confirmation can lead to unnecessary medication burden and patient anxiety 1, 2
• Do not ignore the hypertension - the combination of diabetes and hypertension dramatically increases cardiovascular risk, with hypertension predicting both diabetes progression and cardiovascular events in patients with impaired glucose tolerance 3, 4
• Do not treat blood pressure too aggressively in the acute setting - if this represents new-onset severe hypertension (>180/120 mmHg), assess for target organ damage before deciding between emergency versus urgent management 5