What are the pharmaceutical options for an adult patient with diagnosed hypertension or diabetes and abnormal lab results, considering their age, medical history, and potential comorbidities?

Pharmaceutical Management for Adult Patient with Hypertension and/or Diabetes

Blood Pressure Management

For this patient with hypertension, initiate treatment with an ACE inhibitor (such as lisinopril 10 mg daily) or ARB as first-line therapy, particularly if diabetes or chronic kidney disease is present. 1, 2

Initial Antihypertensive Therapy

• Start with a RAAS blocker (ACE inhibitor or ARB) as the preferred first-line agent, especially in the presence of microalbuminuria, albuminuria, proteinuria, or left ventricular hypertrophy 1
• Lisinopril should be initiated at 10 mg once daily in adults with hypertension, with dosage adjusted according to blood pressure response up to 20-40 mg daily 3
• Target blood pressure should be <130/80 mmHg (systolic <130 mmHg and diastolic <80 mmHg but not <70 mmHg) 1, 2
• For patients aged >65 years, target systolic blood pressure to 130-139 mmHg 1

Combination Therapy Strategy

• If blood pressure is not controlled with monotherapy, add a calcium channel blocker (such as amlodipine 5-10 mg daily) or thiazide/thiazide-like diuretic 1, 2
• The combination should be initiated with a RAAS blocker plus either a calcium channel blocker or thiazide diuretic 1
• For patients requiring triple therapy, use ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic 2, 4
• If blood pressure remains uncontrolled on triple therapy, add spironolactone 25-50 mg daily as the preferred fourth-line agent 2, 4

Special Considerations for Race

• For Black patients with hypertension without heart failure or CKD, initial therapy should include a thiazide-type diuretic or calcium channel blocker rather than an ACE inhibitor alone 1
• Black patients typically require two or more antihypertensive medications to achieve target blood pressure <130/80 mmHg 1

Diabetes Management

Glycemic Control

• Target HbA1c <7.0% (<53 mmol/mol) to decrease microvascular complications, with individualization based on duration of diabetes, comorbidities, and age 1
• Tight glucose control is essential but must be balanced against hypoglycemia risk 1

Cardiovascular Risk Reduction in Diabetes

• For patients with type 2 diabetes and established cardiovascular disease or at very high/high CV risk, add an SGLT2 inhibitor (empagliflozin, canagliflozin, or dapagliflozin) to reduce cardiovascular events 1
• Empagliflozin specifically reduces risk of death in patients with type 2 diabetes and CVD 1
• GLP-1 receptor agonists (liraglutide, semaglutide, or dulaglutide) are recommended to reduce cardiovascular events in patients with type 2 diabetes and CVD or at very high/high CV risk 1

Renal Protection in Diabetes

• SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) are recommended if eGFR is 30 to <90 mL/min/1.73 m² to reduce renal endpoints 1
• Annual screening for kidney disease by assessment of eGFR and urinary albumin:creatinine ratio is mandatory 1

Lipid Management

LDL-C Targets

• For patients with type 2 diabetes at very high cardiovascular risk, target LDL-C <1.4 mmol/L (<55 mg/dL) with at least 50% reduction from baseline 1
• Secondary goal: non-HDL-C <2.2 mmol/L (<85 mg/dL) in very high-CV risk patients 1

Lipid-Lowering Therapy

• Statins are the first-choice lipid-lowering treatment in patients with diabetes and high LDL-C levels 1
• If target LDL-C is not reached on maximal tolerated statin, add ezetimibe 1
• For patients at very high CV risk with persistent high LDL-C despite maximal statin plus ezetimibe, add a PCSK9 inhibitor 1
• Statins are contraindicated in women of childbearing potential 1

Monitoring and Follow-up

• Recheck blood pressure in 2-4 weeks after initiating or adjusting medication 2
• Monthly visits until blood pressure target is achieved, then every 3-6 months once controlled 2
• Home blood pressure monitoring should be encouraged (target <135/85 mmHg at home) 2
• Monitor serum creatinine, eGFR, and potassium when initiating RAAS blockers, especially in combination with diuretics 1, 2
• Annual screening for diabetic complications including retinopathy, nephropathy, and neuropathy 1

Critical Pitfalls to Avoid

• Never combine ACE inhibitors with ARBs - this increases adverse events (hyperkalemia, acute kidney injury) without additional cardiovascular benefit 1
• Do not use aspirin for primary prevention in patients with diabetes at moderate CV risk 1
• Avoid vitamin or micronutrient supplementation to reduce CV risk - not recommended 1
• Do not delay treatment intensification in patients with Grade 2 hypertension (≥160/100 mmHg) - immediate pharmacologic intervention is required 2