What are the primary aims for managing diabetes and hypertension?

Primary Aims for Managing Diabetes and Hypertension

The primary aims are to prevent cardiovascular disease and microvascular complications through comprehensive control of blood glucose, blood pressure, and lipids, with specific targets of HbA1c ≤7%, blood pressure <130/80 mmHg, and LDL-C <100 mg/dL for most patients. 1, 2, 3

Core Treatment Targets

Blood Pressure Management

• Target blood pressure <130/80 mmHg for all adults with diabetes and hypertension 2, 3, 4
• This target applies regardless of age for most community-dwelling adults, as patients ≥60 years achieve similar cardiovascular benefits as younger populations 2
• A less stringent target of <140/90 mmHg applies only to elderly patients with severe coronary heart disease or those at high risk of adverse effects from intensive control 1, 3
• Blood pressure should be measured at every routine diabetes visit using proper technique: 5 minutes of rest, seated with back supported, feet flat, arm at heart level 2, 3

Glycemic Control

• Target HbA1c ≤6.5% to 7.0% for most patients 3
• This target reduces microvascular complications (retinopathy, nephropathy, neuropathy) which are directly linked to hyperglycemia 1
• Monitor for hypoglycemia, particularly with insulin or sulfonylureas, with alert value at blood glucose ≤3.9 mmol/L 3

Lipid Management

• All diabetic patients over age 40 with hypertension require statin therapy regardless of baseline lipid levels 3
• Primary goal: LDL-C <100 mg/dL (2.6 mmol/L) for patients without overt cardiovascular disease 3
• For very high-risk patients or those with established cardiovascular disease: LDL-C <70 mg/dL (1.8 mmol/L) using high-dose statin 3
• Obtain fasting lipid profile at least annually 3

Prevention Framework

Primary Prevention

• The goal is to reduce risk factors and prevent the occurrence of type 2 diabetes through lifestyle intervention 1
• Lifestyle modifications include: healthy diet, weight control, physical activity ≥150 minutes per week distributed over at least 3 days, salt restriction to 1200-2300 mg/day, smoking cessation, and alcohol restriction 1, 3
• Lifestyle intervention can reduce the cumulative incidence of type 2 diabetes risk by 43% over 20 years 1

Secondary Prevention

• The goal is early detection, diagnosis, and treatment to prevent diabetic complications 1
• Screen high-risk populations through diabetes screening, with repeat screening at least every 3 years if initial results are normal 1
• Comprehensive control of blood glucose, blood pressure, and lipids in patients with diabetes 1

Tertiary Prevention

• The goal is to delay progression of diabetic complications, reduce morbidity and mortality, and improve quality of life 1
• This requires intensive management of all cardiovascular risk factors simultaneously 1, 5

Pharmacologic Strategy

Blood Pressure Medications

• For BP ≥140/90 mmHg: initiate pharmacologic therapy immediately along with lifestyle modifications 3
• ACE inhibitors or ARBs are the preferred first-line agents for diabetic patients with hypertension 3, 4
• Most patients require multiple-drug therapy (typically 3-4 drugs) to achieve blood pressure targets 3, 6
• Standard triple therapy: ACE inhibitor or ARB + calcium channel blocker + thiazide-like diuretic (chlorthalidone or indapamide preferred) 4
• If blood pressure remains uncontrolled after 2-4 weeks on triple therapy, add spironolactone 12.5-25mg daily with close potassium monitoring 4

Critical Monitoring Requirements

• Monitor serum creatinine/eGFR and potassium at least annually when using ACE inhibitors, ARBs, or diuretics 3
• Monitor eGFR and urine albumin-to-creatinine ratio every 3 months in patients with diabetic nephropathy 4
• Resistant hypertension is defined as BP ≥140/90 mmHg despite appropriate lifestyle management plus a diuretic and two other antihypertensive drugs at adequate doses 3

Special Population Considerations

End-of-Life Care

• Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity become the primary goals 1
• Strict blood pressure control may not be necessary, and withdrawal of therapy may be appropriate 1
• The intensity of lipid management can be relaxed, and withdrawal of lipid-lowering therapy may be appropriate 1
• Glucose targets should aim to prevent hypoglycemia and hyperglycemia rather than achieving tight control 1

Patients with Chronic Kidney Disease

• Target blood pressure <130/80 mmHg, as patients with CKD are automatically classified as high cardiovascular risk 2, 4
• Continue SGLT2 inhibitors (like dapagliflozin) as they provide renoprotection and cardiovascular benefit, although glucose-lowering efficacy diminishes with eGFR <45 mL/min/1.73m² 4
• Stop metformin immediately when eGFR <30-35 mL/min/1.73m² due to lactic acidosis risk 4

Critical Pitfalls to Avoid

• Never combine ACE inhibitors with ARBs or direct renin inhibitors 3
• Failure to monitor renal function and potassium when using renin-angiotensin system blockers can lead to dangerous hyperkalemia 3
• Most patients require multiple drugs to achieve blood pressure targets—delaying intensification of therapy when targets are not met contributes to poor outcomes 3, 6
• Diuretics and beta-blockers have prodiabetic effects, while ACE inhibitors and ARBs may prevent diabetes more effectively 7