What is the recommended treatment approach for a patient with hypertension and type 2 diabetes mellitus?

Treatment of Hypertension in Patients with Type 2 Diabetes

For patients with diabetes and hypertension, initiate an ACE inhibitor or ARB as first-line therapy targeting blood pressure <130/80 mmHg, with prompt addition of a thiazide-like diuretic as the second agent if needed. 1, 2

Blood Pressure Targets

• Target BP <130/80 mmHg for all patients with diabetes and hypertension 1, 2
• Blood pressure should be measured at every routine diabetes visit, with elevated readings (≥130/80 mmHg) confirmed on a separate day before initiating treatment 2
• For elderly patients (>65 years), a more moderate systolic target of 130-139 mmHg is acceptable to avoid complications 2

Treatment Algorithm Based on Initial Blood Pressure

BP 130-139/80-89 mmHg (Mildly Elevated)

• Start with lifestyle modifications alone for a maximum of 3 months 1, 2
• If target not achieved after 3 months, initiate pharmacologic therapy 1, 2

BP ≥140/90 mmHg (Confirmed Hypertension)

• Immediately initiate both lifestyle modifications AND pharmacologic therapy 1, 2
• Do not delay medication while attempting lifestyle changes alone 1

BP ≥160/100 mmHg (Severe Hypertension)

• Prompt initiation of two drugs or a single-pill combination demonstrated to reduce cardiovascular events 1
• This requires aggressive upfront treatment given the markedly elevated risk 1

First-Line Pharmacologic Therapy

ACE inhibitor or ARB is the mandatory first-line agent for the following reasons: 1, 2

• Proven cardiovascular event reduction in diabetic patients 1
• Slows progression of diabetic nephropathy 1, 3
• Reduces proteinuria and delays end-stage renal disease 4
• If one class is not tolerated, substitute the other 1, 2

Special Considerations for Albuminuria:

• UACR ≥300 mg/g creatinine: ACE inhibitor or ARB is strongly recommended at maximum tolerated dose 1
• UACR 30-299 mg/g creatinine: ACE inhibitor or ARB is suggested 1

Second-Line and Additional Agents

Most patients require multiple drugs to achieve target BP 1, 2

Preferred Second Agent:

• Thiazide-like diuretic (chlorthalidone or indapamide preferred over hydrochlorothiazide due to superior cardiovascular outcomes) 1
• Should be added as one of the first two drugs in the regimen 2

Third and Fourth Agents (as needed):

• Dihydropyridine calcium channel blocker (e.g., amlodipine) 1
• Beta-blocker if additional therapy needed 1, 2

Combinations to AVOID:

• Never combine ACE inhibitor + ARB (increased risk without benefit) 1
• Never combine ACE inhibitor or ARB + direct renin inhibitor 1

Resistant Hypertension Management

If BP remains ≥140/90 mmHg despite appropriate lifestyle management plus a diuretic and two other antihypertensive drugs at adequate doses: 1

• First exclude medication nonadherence, white coat hypertension, and secondary causes 1
• Add a mineralocorticoid receptor antagonist (spironolactone or eplerenone) to the regimen 1
• This is particularly effective when added to ACE inhibitor/ARB + thiazide-like diuretic + dihydropyridine calcium channel blocker 1
• Critical caveat: Monitor serum potassium closely due to hyperkalemia risk when combining with ACE inhibitor/ARB 1

Mandatory Lifestyle Modifications

Implement these interventions for all patients regardless of medication use: 1, 2

• Weight loss if overweight/obese through caloric restriction 1, 2
• Sodium restriction to <2,300 mg/day 1, 2
• DASH-style diet: 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy products daily 1
• Physical activity: At least 150 minutes of moderate-intensity aerobic activity per week 1, 2
• Alcohol moderation: Maximum 2 drinks/day for men, 1 drink/day for women 1

Monitoring Requirements

Initial Monitoring (First 3 Months):

• Serum creatinine/eGFR and serum potassium within first 3 months of starting ACE inhibitor, ARB, or diuretic 1, 2

Ongoing Monitoring:

• If stable, monitor renal function and potassium every 6 months 1, 2
• If adding mineralocorticoid receptor antagonist, increase monitoring frequency due to higher hyperkalemia risk 1
• Blood pressure measurement at every routine diabetes visit 1, 2
• Check orthostatic blood pressure when clinically indicated 1, 2

Common Pitfalls to Avoid

• Do not delay pharmacologic therapy in patients with BP ≥140/90 mmHg while attempting lifestyle modifications alone 1, 2
• Do not use ACE inhibitor + ARB combination despite both being individually beneficial 1
• Do not forget to monitor potassium when using ACE inhibitor/ARB, especially with diuretics or mineralocorticoid receptor antagonists 1, 2
• Do not use ACE inhibitors or ARBs in pregnancy due to fetal harm risk 2
• Do not undertitrate medications—most patients need 2-4 agents to reach target 1